Monthly Archives: September 2014

Fracture Healing and Wound Healing in HIV infected individuals


Vol 2 | Issue 2 | May - Aug 2014 | page 42-44 | Gavhale S V,Gawhale S K,Gavai P V, Dash K K, Yeragi B S


Author: Piyush V Gavai[1], Sangeet K Gawhale[2], Kumar Kaushik Dash[1], Bhakti S Yeragi[3]

[1]Department of Orthopedics, St. George Hospital, Shahid Bhagat Singh Road, Fort, Mumbai India.
[2]Sir JJ Group of Hospitals & GMC, Mumbai-India
[3]Department of Radiology, BYL Nair Hospital, Dr. A. L. Nair Road, Mumbai India.

Institute at which research was conducted: Dept. of Orthopaedics, Grant Medical College,Sir JJ Group of Hospitals,Byculla – 8.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2004

Address of Correspondence
Dr. Piyush V Gavai1
Department of Orthopedics, St. George Hospital, Shahid Bhagat Singh Road, Fort, Mumbai - 400001, India.
Email: dr_piyushgavai@yahoo.com


Abstract

Backgrounds: Acquired Immunodeficiency Syndrome caused by the Human Immunodeficiency Virus (HIV) is today one of the most common cause of secondary immunodeficiency. Fracture and soft tissue healing rates and risk of postoperative infections may differ in HIV infected patients.
Materials and Methods: A retrospective comparative study was conducted with of 40 randomly chosen cases of HIV infected patients and a control group of 40 patients.
Results: Thirty-one (77.5 %) patients presented with trauma, seventeen (42.5 %) due to motor vehicle accident, 13 (32.5 %) cases secondary to fall and one (2.5%) patient due to firearm injury. The average fracture healing time in closed fractures treated conservatively was found to be normal / comparable to healthy individuals in this study according to radiological and clinical parameters. The wound healing time and rate of infection in HIV infected individuals was comparable to normal individuals. For patients not in ARC, the post-operative infection rates are comparable with those for non-HIV patient population.
Conclusions: Fracture healing and wound healing rates doesn't differ significantly in HIV patients. However, the surgeon must be aware of the risk of late-onset hematogenous infections in HIV patients with ARC.
Keywords: HIV, infection, wound healing, fracture healing.
Thesis Question: 1. Is healing of wounds and fractures different between HIV infected individuals and normal counterparts?
2. What is the incidence of infection in these treated HIV infected patients?
Thesis Answer: 1. Wound healing and fracture healing in HIV infected individuals was comparable to healthy individuals.
2. Rate of infection in HIV positive Stage 2 was comparable to normal individuals. But patients in ARC (AIDS Related Complex) tend to develop late-onset implant related                                                    hematogenous infections.

                                                        THESIS SUMMARY                                                             

Introduction

Acquired Immunodeficiency Syndrome caused by the Human Immunodeficiency Virus (HIV) is today one of the most common cause of secondary immunodeficiency. The AIDS pandemic is fast spreading across the globe. In India, 40,00,000 people have AIDS / HIV with a prevalence of 0.8 %33. AIDS is the end result of a progressively decreased immunological competence caused by HIV. The Human immunodeficiency virus damages and progressively destroys the immune system by interacting with the CD4 subset of helper T- cells and using them for replication. This results in an immunocompromised state in an individual infected with HIV and renders him susceptible to a variety of infections and diseases. It is highly likely that like any other illness of chronic nature, HIV infection may affect or actually retard the healing process necessary for convalescence. Fracture and soft tissue hjhjhnealing rates may be expected to suffer in HIV infected patients, more so in those with signs of AIDS-related complex. Owing to its immunosuppressive nature, the possibility or likelihood of postoperative infections should logically increase.

Aims and Objectives

  • To study the healing of soft tissue injuries / open wounds in orthopedic patients infected with HIV.
  • To study the rate of fracture healing in HIV infected patients.
  • To study the incidence of infections in these treated HIV positive patients:
    1.In the immediate post-op period.
    2.In the follow up period.

Methods

A retrospective study was conducted at our institute in order to assess the response of HIV infected patients, treated for orthopedic conditions including trauma and other conditions. A total of 40 randomly chosen cases of HIV infected patients and a control group of 40 randomly chosen cases of non-HIV infected patients admitted in the orthopedics wards were selected for this study.
Patients were clinically assessed for any symptoms and signs of AIDS Related Complex (ARC) to determine the stage of the HIV infection by the Center For Disease Control (CDC) system of USA. Patients were examined on the second and tenth postoperative day to assess the wound healing and to rule out infection. The postoperative follow up of these patients was mainly in the form of clinical examination and X Rays with routine hemograms. The absolute lymphocyte count was calculated as a prognostic factor for fracture healing.

Results

The present study included 40 cases of HIV infected individuals compared with a study of 40 randomly chosen non- HIV infected patients. Thirty-one (77.5 %) patients presented with trauma, seventeen (42.5 %) due to motor vehicle accident, 13 (32.5 %) cases secondary to fall and one (2.5%) patient due to firearm injury. The average fracture healing time in these patients with closed fractures treated conservatively in casts or in traction was comparable to the study group. Eighteen (45%) trauma cases and eight (2.5%) cold cases were taken up for elective surgery strictly following the WHO guidelines for surgical precautions.68% trauma and 69% cases in the control group were taken up for surgery. Operative intervention in the symptomatic HIV infected individuals did not accelerate the rate of development of AIDS in any of the cases.

Conclusion

1. The average fracture healing time in closed fractures treated conservatively was found to be normal / comparable to healthy individuals in this study according to radiological and clinical parameters. This finding is consistent with the literature review.
2. In open fractures the rate of wound infection was higher (71.4 %) in seronegative individuals.
3. For patients not in ARC, the post-operative infection rates are comparable with those for non-HIV patient population. Patients who are in ARC tend to develop late-onset implant related hematogenous infection, which is probably similar to the mechanism of opportunistic infection.
4. The wound healing time and rate of infection in HIV + ve individuals in Stage 2 of CDC classification is comparable to normal individuals.

Clinical Message

Fracture healing and wound healing rates doesn't differ significantly in HIV patients. However, the surgeon must be aware of the risk of late-onset hematogenous infections in HIV patients with ARC.

Keywords

HIV, infection, wound healing, fracture healing.

Bibliography

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4. Lemaire Rogers ; Masson Jean-Bernard : Risk of transmission of blood borne viral infection in orthopedic trauma JBJS (Br) 2000 Apr 82(3)313-323.
5. J J Behrans Prevelance of seropositivity for HIV patients who have severe trauma .JBJS 1992 ;74 ,64 641-645.
6. Lehmann Christopher Infection after Total Joint Arthroplasty in patients with HIV or intravenous drug abuse AAOS 1999 Poster Board No. 308.
7. AAOS 1996 Annual meeting – Scientific Program Relative rate of perioperative surgical infections in asymptomaic HIV positive Orthopedic patients.
8. Luck J V Jr, Instructional course lecture Orthopedic surgery on HIV positive patients –complications and outcomes 1994 ; 43: 543-549.
9. Norain John N TKR in hemophilic arthropathy JBJS 2002 ; 84 : 1138-1141.
10. Ragni M V The effect of antiviral therapy on the natural history of HIV infection. J of AIDS 1992 ;5:120-126.
11. Palement Postoperative infection in asymptomatic HIV positive patients J Trauma 1994 ;37:545-550.
12. Edelsiten HIV positive hemophilics and implant surgery JBJS 1992 Vol 74 ( Br) Supp 2 : 196.
13. Carl A , Sodersstorm HIV infection rates in a trauma center treating predominantly rural blunt trauma victims J Trauma 1989; 29 : 1526-1530.
14. Frochle Prevelance of HIV in trauma emergency room ArchivesOrtho.Trauma Surgery 1996 ; 115:337-338.
15. Hernigou HIV virus and orthopedic surgery Rev. Chir. Orthop. 1993 ;79:5-12.
16. Edward P Sloan Human Immunodefiency Virus and Hepatitis B virusseroprevelance in an urban trauma population The Journal of Trauma :Injury, Infection and Critical Care 1995 ;38 : 736-741.
17. Ellis S Caplan Seroprevelance of Human Immunodefiency Virus and Hepatitis B virus,Hepatitis C virus , and Rapid Plasma Reagin in a trauma population The Journal of Trauma :Injury, Infection and Critical Care 1995;39:533-538.
18. Palement Guy D Postoperative infections in asymtomatic HIV positive orthopedic patients The Journal of Trauma 1994 ; 37: 545-550.
19. Palement Guy D . Relative rate of perioperative surgical infections in asymptomatic HIV positive orthopedic patients AAOS 1994 Paper No. 520.
20. Mineriro J The risk of seroconversion in surgeons of the Hepatitis B,Hepatitis C and HIV in a specific surgical population Acta Med Port1997 Jun – Jul ; 10 (6-7) : 455-461.
21. Gakuu L N Postoperative pyrexia in orthopedic unit East Afr Med J 1997 Aug ;74(8) :530-532.
22. Sanchez L P Seroprevelance of blood borne transmissible diseases in trauma orthopedic surgical patients P R Health Sci J 1998 Jun ; 17(2) :113-116.
23. Haseltine W A Molecular biology of HIV type . FASEBJ 1991 ;5:2349-2360.
24. Fauci A S The HIV infectivity and mechanisms of pathogenesis. Science 1991; 239:617-622.
25. Fauci A S Immunopathogenic mechanisms in HIV infection . Ann Intern Med 1991; 114:678-693.
26. Volberding P A ; Kochs M A et al. Zidovudine in asymptomatic HIV infection a controlled trial in persons with fewer than 500 CD 4 positive cells /mm3. New Eng J Med 1990; 322:941-949.
27. Graham N H M , Parle L P et al Effect of Zidovudine and pneumocystis carini pneumonia prophylaxis on progression of HIV –1 infection to AIDS . Lancet 1991;338:265-269.
28. Lemp G F , Neal D Survival trends in patients with AIDS JAMA 1990;263: 402-402.
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30. Daor E S Meyer R D Transient high level of viremia in patient with primary HIV type I of infection N Eng J Med 1991 ; 324: 961-964.
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peripheral blood versus lymphoid organ of the same patient Clin Res 1992 ; 40: 333 abstract.
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musculoskeletal allografts JBJS (Am)1995 ; 77 A : 1742- 1754.
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How to Cite this Article: Gavai P V, Gawhale S K, Dash K K, Yeragi B S: Fracture Healing and Wound Healing in HIV infected individuals. Journal Medical Thesis 2014 May-Aug; 2(2):42-44

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A Prospective Study of Functional Outcome of Tibial Condylar Fractures Treated with Locking Compression Plates


Vol 2 | Issue 2 | May - Aug 2014 | page 23-27 | Gavhale S V,Gawhale S K,Gavai P V, Dash K K, Yeragi B S


Author: Sandeep V Gavhale[1], Sangeet K Gawhale[1], Piyush V Gavai [2], Kumar Kaushik Dash[2], Bhakti S Yeragi[3]

[1]Grant Govt. Medical College & Sir J. J. Group of Hospitals, Mumbai.
[2]Department of Orthopedics, St. George Hospital, Shahid Bhagat Singh Road, Fort, Mumbai India.
[3]Department of Radiology, BYL Nair Hospital, Dr. A. L. Nair Road, Mumbai India.

Institute at which research was conducted: Dept. of Orthopaedics,Grant Medical College,Sir JJ Group of Hospitals.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2004

Address of Correspondence
Dr. Sandeep V. Gavhale
Sir JJ Group of Hospitals & GMC, Mumbai-400018, India.
Email: dr.svgavhale@gmail.com


Abstract

Background: There is a wide range in treatments for proximal tibial fractures. Functional outcome of tibial condylar fractures managed with locking plate and the importance of anatomical reduction and physiotherapy in obtaining good results needs to be evaluated.
Materials and Methods: Prospective descriptive study was carried out including all patients having proximal tibial metaphyseal fractures (both open and closed). Patients unfit for surgical management, and those less than 18 years old were excluded.
Results: In our series, the majority of the patients are found to be between the age group of 18-29 years (8) & 30-39 years (6). 90% of patients were male. Road traffic accident was the most common cause. Wound infections (superficial and deep) were the most common complications. According to Rassmussen's scoring system, 56.67% patients had excellent results, 30% had good results and 13.33% had fair results.
Conclusions: Locking plates gives excellent results in tibial condylar fractures with minimum complications. Achieving and maintaining anatomical reduction becomes easy with locking plates, which helps in early mobilization and hence obtaining good functional outcome in tibial condylar fractures and there is no substitute for early physiotherapy.
Keywords: Tibia condyle fracture, locking plate, anatomic reduction, physiotherapy.
Thesis Question: 1.What is the functional outcome of tibial condylar fractures managed with locking plate?
2.What is the importance of anatomical reduction and physiotherapy in obtaining good results?
3. What is the complication rate in tibial condylar fractures managed with locking plate?
Thesis Answer: 1.Tibial condylar fractures managed with locking plate gives good functional outcome.
2. Anatomical reduction combined with early physiotherapy is crucial in obtaining good results.
3. Complication rates are minimal in tibial condylar fractures managed with locking plate.

                                                        THESIS SUMMARY                                                             

Introduction

Low and high-energy tibial plateau fractures present a variety of soft tissue and bony injuries that can produce permanent disabilities and their treatment is often challenged by severe fracture comminution. Potential complications vary with the degree of trauma energy and include soft tissue injuries requiring coverage procedures, compartment syndrome, peroneal nerve injury and vascular injury. Associated injuries include cruciate and collateral ligament injuries and meniscal tears. Complex fractures include significant articular comminution and depression, condylar displacement, metaphyseal fracture extension and open or closed soft tissue injuries. New implants and surgical techniques have provided new options for the treatment of tibial plateau fractures. These include techniques of limited incision reduction for joint surface restoration, the ring and hybrid external fixators, percutaneous plates (LISS) and fixed angle plate and screw designs (LCP). High-energy tibial plateau fractures present a spectrum of soft tissue and bonny injuries that can produce permanent disabilities. Their treatment is challenged by fracture comminution, instability, displacement and extensive soft tissue injuries. New implants and surgical techniques have provided new options for the management of these fractures. The goals of treatment are restoration of joint congruity, normal limb alignment, knee stability and a functional range of knee motion. There is a wide range in treatments for proximal tibial fractures. Surgical treatment of low-energy unicondylar tibial plateau fractures can usually be carried out at early stage. In most closed high-energy tibial plateau fractures temporary knee bridging external fixation is needed to allow soft tissue recovery. Delayed definitive surgical treatment can be carried out once optimal soft tissue conditions exist (7-21 days). Locking plates may decrease the need for dual plating in certain bicondylar fracture patterns. Locking plate in the lateral side in bicondylar tibial fractures might be a stable enough fixation when medial condyle is not comminuted and there is no separate posteromedial fragment. Dual plating is needed in bicondylar tibial plateau fractures with a separate posteromedial segment, complete separation of the entire medial plateau and medial articular comminution.

Aims and Objectives

1.To study functional output of tibial condylar fractures managed with locking plate.
2.To study importance of anatomical reduction and physiotherapy in obtaining good results and functional outcome.
3.To study fracture patterns.
4.To study complication rates.

Methods

A prospective study was conducted at Sir J J Group of Hospitals,Mumbai after obtaining the ethical clearance, to study functional output of tibial condylar fractures managed with locking plate and to study importance of anatomical reduction and physiotherapy in obtaining good results. We studied 30 cases of tibial condylar fractures during the period May 2010 – Nov 2012

Inclusion Criteria of our study was:
All Proximal Metaphyseal Fractures of Tibia
Both Closed and Open fractures
Patient above Age of 18 years

Exclusion Criteria of our study was:
All Diaphyseal Fractures
Patient Less than 18 Yrs of Age
Patients who are medically unfit for the surgery.

Patients were given plaster slab for temporary immobilization and surgery was planned after subsidence of swelling. As soon as the operation was planned, certain routine procedures were regularly followed.
1.Use of antibiotics – 1 preoperative & 4 post-operative doses of first generation cephalosporin (cefuroxime)
2. Shaving & preparing the part for surgery always done
3. Selection of proper size of implants
4. Assessment of the joint instability under anaesthesia.
5. To verify if any other associated procedures might be required like bone grafting.

Rassmussen's Knee Score was used for evaluation of result.

Results

Observation and analysis of results was done in relationship to age, sex, mode of injury,type of fracture, complications and the remarks of different age groups in details as follows
AGE DISTRIBUTION:
In our series, the majority of the patients are found to be between the age group of 18-29 years (8) & 30-39 years (6). The least number of cases are found in the age group between 70-79(0) and 80-89years(1). The youngest being 19 years and the eldest being 81 years.average age being 40.47 yrs
SEX INCIDENCE :
There were 27 males (90%) and only 3 females (10%) in our series. This incidence of sex versus upper tibial fractures can be attributed to an over-
whelming large proportion of male patients, because in our Indian setup, the female population largely working indoors or in the agricultural fields and do not indulge themselves in travelling or out door activities.
MODE OF VIOLENCE :
In this series, the majority of the patients treated are due to road traffic accidents
or automobile accidents [25 out of 30, 83.33 %]. There were 2 case of domestic fall and 3 case of fall from height
TYPE OF FRACTURE AND CORRELATION WITH MODE OF INJURY :
SCHATZKER'S CLASSIFICATION :
There was 1 case of Schatzker type I, 8 cases of Schatzker type II, no case of Schatzker type III, 3 cases of Schatzker type IV, 6 cases of Schatzker type V and 12 cases of Schatzker type VI.
Range of Motion
Range of motion of 120 to 140 degrees was achieved in all patients of which 7 achieved it at 3 months follow up, 14 achieved it at 4 months follow up and 16 achieved it at 6 months follow up

ASSOCIATED INJURIES :
Compound fracturess were found in 2 patients which were managed by external fixator and plastic surgery intervention and final fixation with locked plates . One patient had distal end radius fracture which was managed by closed reduction and K wire fixation.
One patient had left humerus fracture who underwent plating for the same.
One patient had Patella fracture, managed by ORIF with TBW
Two patients had fracture of ipsilateral Lateral femoral condyle, fixed with two 4.5 mm CC screws
Three patients had fracture of tibia shaft treated with Interlock nailing
Two patients had fracture shaft femur treated with Interlock nailing
One patient had compression fracture of D12 Vertebra, managed conservatively.
One patient had ipsilateral Popliteal artery thrombosis ,managed with embolectomy by CVTS doctors
One patient had Head injury, managed by Neurosurgeons.
COMPLICATIONS :
Complications are divided into pre-operative & post operative ; and post operative complications are further divided into septic and non septic types.
Pre operative –
Out of 30 patients 2 patients had compound fracture grade IIIB (Pt 27) and grade IIIC(Pt.19). Both patients were schatzker type VI. External fixator was applied to 2 patients. The aim of temporary spanning external fixation was, soft tissue healing. Local flaps used to cover the wound at a later date and final fixation with locked plates was done after complete wound healing (pt 21-154 days & pt 27 – 60 days)
Popliteal artery thrombosis was diagnosed in one patient (pt -21).External fixator was applied in this patient. Time taken from the trauma to definitive fixation in this patient was 154 days
The decision to proceed with definitive fixation was based on the patient's medical fitness and recovery of the soft-tissue envelope. This staged treatment was individualized and based on the attending surgeon's experience and judgment in identifying satisfactory soft-tissue recovery. Specific clinical signs aiding in this decision included resolution of edema and fracture blisters and the return of skin wrinkling .Final results was excellent in one patient(pt.27) & fair in 1 patient(pt.21)
Post operative complications
Nonseptic Complications
Complications requiring surgical interventions due to implant failure/breakage was not seen in our study.
Septic Complications
Six patients developed superficial wound complications that responded to daily dressing and antibiotics. Deep wound infections occurred in 6 patients. Three patients (pt 10,20,26) responded to intravenous antibiotics as per culture and senility report & plastic surgery intervention ; and implant removal was required in other 3 patients(pt.13,24,28). Using the Fisher exact test, patient gender, age, use of temporary spanning external fixation, and compound fractures were not found to be statistically associated with the development of infection. The time delay to definitive surgery and patient age were similarly not found to be significantly associated with the development of deep infection.
CLINICAL RESULTS (According to Rassmussen's Knee Scoring System):
In our series Excellent results were achieved in 17 cases (56.67%), Good results in 9 cases (30%) and Fair in 4 cases (13.33%).

Discussion

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic and metaphyseal bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation[51]. High energy, complex bicondylar tibial plateau fractures, however,typically present with an associated severe soft-tissue injury. Extensive dissection through the tenuous soft-tissue envelope to achieve reduction and apply conventional stabilizing implants, particularly through a midline incision, may significantly increase postoperative infection rates and implant failure leading to loss of fracture reduction, hindering long-term successful outcome . There are two major problems for the operative treatment of tibial head fractures: On the one hand there is a highly elevated infection rate for the treatment of bicondylar tibial head fractures, caused by the frequently necessary vast exposition of the fracture and its fragments for the placement of double-plate osteosynthesis. These double-plate osteosynthesis are affiliated with an overall infection rate of up to 50%. Therefore many authors point out that, if possible, only one plate should be used. Separate screws from the opposite side can help to provide sufficient stability. If double-plate osteosynthesis can not be avoided it is strictly recommended to use two separate skin incisions. The Y-shaped approach is not used and recommended anymore, due to the high rate of skin necrosis 6,8,9,10,15,16,17. On the other hand, during the last decades, older patients suffer from tibial head fractures due to a change of the age structure and activity level in our population. In contrast to younger patients the reason for tibial head fractures of older patients is usually a minor trauma, which leads to plateau-fractures of the tibial head. Reason is the usually pre-existing osteoporosis [2,3,18].  Our own collective consisted of 18 patients with a bicondylar Schatzker type – V(6) & VI (12) tibial head fracture. Out of 18 patients for the 13 patients suffering from a bicondylar fracture we used a unilateral osteosynthesis with a locked screw plate with or without supportive scew fixation from the opposite side. All these cases would have required a bilateral conventional double-plate osteosynthesis, if treated without locking plate & screws. No statistically significant wound infection and no secondary loss of reduction, especially of the contralateral tibial head, occurred.  Our results show, that a unilateral plate fixation of the bicondylar tibial fracture is sufficient. With the use of locked-screw plates also the contralateral tbial head fragment can be held in position. We did not observe severe complications like deep wound necrosis or osteitis, which are well known after bilateral incisions. Rasmussen-score of our group showed a result comparable to the results of other authors treating bicondylar tibial head fractures.
Main problem for the treatment of tibial head split depression fractures or gap-fractures, where the reason is usually a minor trauma, is not infection but secondary loss of reduction due to the missing stability of conventional implants especially in osteoporotic bone[2,3,7,12,13,22,23]. The all 30 patients( 9 patients with osteoporotic bone) suffering from tibial plateau fractures, which we treated with angular stable implants, showed no loosening or failure of the osteosynthesis. Unilateral plate fixation for the treatment of bicondylar tibial head fractures, as well as the treatment of osteoporotic tibial plateau fractures with angular stable implants, seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures.
The indications and uses for locking plate technology continue to be defined. One important problem to avoid is the creation of an overstiff construct by placing locked screws when not needed (or more than what is needed). The resultant relative lack of motion at the fracture site can, in some situations, be too stiff to allow fracture healing. This has led some to refer to locking plates as “nonunion generators.”
Thus, the indications and correct utilization of locking plates is important to understand so they are not used inappropriately and compromise fracture healing. In addition, newer techniques such as “hybrid” plating (use of both locking and nonlocking screws in a single construct) and far cortical locking (obtaining purchase in far cortex while bypassing proximal cortex) have evolved to combat these problems sometimes seen with locking plate[52]

Conclusion

1.Tibial condylar fractures are common in males than in females.
2.Road traffic accidents were the commonest cause of mode of injury in tibial condylar fractures.
3.Locking plates gives excellent results in tibial condylar fractures with minimum complications.
4.Anatomical reduction is of utmost importance in obtaining good functional outcome in tibial condylar fractures.
5.Early and vigorous physiotherapy is required in obtaining good result in tibial condylar fractures.

Clinical Message

Tibial condylar fractures are most difficult fractures to be managed even in experienced hands. Achieving and maintaining anatomical reduction becomes easy with locking plates, which helps in early mobilization and hence obtaining good functional outcome in tibial condylar fractures and there is no substitute for early physiotherapy.

Keywords

Tibia condyle fracture, locking plate, anatomic reduction, physiotherapy

Bibliography

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14. Ries MD, Meinhard BP. Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury. Clin Orthop Relat Res 1990:215-23.
15. Murphy CP, D'Ambrosia R, Dabezies EJ. The small pin circular fixator for proximal tibial fractures with soft tissue compromise. Orthopedics 1991;14:273-80.
16. Benirschke SK, Agnew SG, Mayo KA, Santoro VM, Henley MB. Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol. J Orthop Trauma 1992;6:78-86.
17. Itokazu M, Matsunaga T. Arthroscopic restoration of depressed tibial plateau fractures using bone and hydroxyapatite grafts. Arthroscopy 1993;9:103-8.
18. Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res 1993:87-100.
19. Georgiadis GM. Combined anterior and posterior approaches for complex tibial plateau fractures. J Bone Joint Surg Br 1994;76:285-9.
20. Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens FF. Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma 1994;8:455-61.
21. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg Am 1995;77:661-73.
22. Bendayan J, Noblin JD, Freeland AE. Posteromedial second incision to reduce and stabilize a displaced posterior fragment that can occur in Schatzker Type V bicondylar tibial plateau fractures. Orthopedics 1996;19:903-4.
23. Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg Br 1996;78:710-7.
24. Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop Relat Res 1996:203-10.
25. Mikulak SA, Gold SM, Zinar DM. Small wire external fixation of high energy tibial plateau fractures. Clin Orthop Relat Res998:230-8.
26. Watson JT, Coufal C. Treatment of complex lateral plateau fractures using Ilizarov techniques. Clin Orthop Relat Res 1998:97 -106.
27. Kumar A, Whittle AP. Treatment of complex (Schatzker Type VI) fractures of the tibial plateau with circular wire external fixation: retrospective case review. J Orthop Trauma 2000;14:339-44.
28. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma 2001;15:312-20.
29. Mills WJ, Nork SE. Open reduction and internal fixation of high-energy tibial plateau fractures. Orthop Clin North Am 2002;33:177-98, ix.
30. Weiner LS, Kelley M, Yang E, et al. The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures. J Orthop Trauma 1995;9:244-50.
31. Koval KJ, Sanders R, Borrelli J, Helfet D, DiPasquale T, Mast JW. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma 1992;6:340-6.
32. De Boeck H, Opdecam P. Posteromedial tibial plateau fractures. Operative treatment by posterior approach. Clin Orthop Relat Res 1995:125-8.
33. Horwitz DS, Bachus KN, Craig MA, Peters CL. A biomechanical analysis of
internal fixation of complex tibial plateau fractures. J Orthop Trauma 1999;13:545-9.
34. Borrelli J, Jr., Ellis E. Pilon fractures: assessment and treatment. Orthop Clin North Am 2002;33:231-45, x.
35. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma 1999;13:85-91.
36. Sirkin M, Sanders R, DiPasquale T, Herscovici D, Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84.
37. DUWAYNE A. CARLSON, M.D.f, PHOENIX, ARIZONA;Bicondylar Fracture of the Posterior Aspect of the Tibial Plateau;1998 by The Journal of Bone and Joint Surgery.
38. CC Chan, MRCS (Ed), J Keating, FRCS Orth (Ed);Comparison of Outcomes of Operatively Treated Bicondylar Tibial Plateau Fractures by External Fixation and Internal Fixation ;Malaysian Orthopaedic Journal 2012 Vol 6 No 1.
39. Charlie Lewis; Does the mode of fixation of tibial plateau fractures, i.e. external fixation versus internal fixation influence the time to union? A systematic review of the literature.
40. B. Kienast, A. Paech, C. Queitsch, U. Schümann, R. Oheim, C. Jürgens, A. Schulz: Complex Tibial Head Fractures: Is there an Advantage in Locked Implants?. The Internet Journal of Orthopedic Surgery. 2008 Volume 8 Number 1. DOI: 10.5580/c00
41. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK ;Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.;J Orthop Trauma. 2004 Nov-Dec;18(10):649-57.


How to Cite this Article:Khobragade A,  Patel S, Deokate M, Bhagat S, Patil N: A Prospective Study of Functional Outcome of Tibial Condylar Fractures Treated with Locking Compression Plates. Journal Medical Thesis 2014 May-Aug; 2(2):23-27

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Journal of Medical Thesis: Perspectives of an Arthroscopy Surgeon


Vol 2 | Issue 2 | May - Aug 2014 | page 7 |  Sundarrajan S R


Author: Dr S R Sundarrajan

Senior Consultant Arthroscopy And Sports Medicine Ganga Hospital, Coimbatore
Email: sundarbone70@hotmail.com


I have an immense pleasure to give a guest editorial for journal of medical thesis. For the past 15 years I have been a guide for DNB students, guiding them for the their thesis projects. I request all postgraduates to think twice before taking thesis topic.They should take this golden opportunity to learn how to read, write, find an article. Collecting, analysis of the data and also to form a basic framework in their mind about how to go ahead to write a research paper.
Because it is an opportunity for them to know everything about research. As they have three years time, it is possible to do Level 1 study so that it can be easily publized without struggle. Once they make it in a hardway further publications will follow through…
I congratulate team of journal of medical thesis for giving all such a wonderful opportunity as your 3 years work can be published that too in an indexed journal. Mind you all your hard work which has been put shouldn't go waste. Grab this with both hands and spread this to all your friends so that in this era of 'Publish or Perish' you have a publication in your pocket.
As an arthroscopy surgeon going through different eras starting from PTB graft to hamstring grafts, from titanium interference screws to endobutton to tight rope, from 11'o clock position of the graft to 9'0 clock position, from transtibial technique to anteromedial portal , from single bundle reconstruction to double bundle reconstruction. Is one better than the other ?
Question still unanswered , still the techniques have evolved implants have changed and after doing 600 odd arthroscopy surgeries every year I look back to see what have I did and what could be done better. I am proud to say that we have record of every arthroscopy patient we have operated and we make a point to analyse them. Friends we can also match up to the standards of western world only thing is that the effort should be there. That's all !


How to Cite this Article:  Sundarrajan S R. Journal of Medical Thesis: Perspectives of an Arthroscopy Surgeon. Journal Medical Thesis 2014 May-Aug; 2(2):7

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Perspective of a Thesis Guide in Allotment of Thesis Topic


Vol 2 | Issue 2 | May - Aug 2014 | page 3-4 | Jagtap S, Sonawane D, Saraogi A.


Author: Dr. Sanjay Jagtap[1], Dr. Dhiraj Sonawane[1], Dr. Akash Saraogi[1]

[1]J.J Hospital Mumbai.
Email: dvsortho@gmail.com


A thesis may be defined as a statement of the writer's opinion (or judgment) on a limited topic, a clearly stated view that can be supported by REASON and CONCRETE EVIDENCE. In present circumstances, the spectrum of thesis work ranges from a formal document with repetition of previous ideas to a research work with potential of formulating a guideline. With increasing importance of research work done by a medical professional, particularly for strengthening the curriculum vitae of the researcher, thesis activity during the course of post-graduation and later has become the subject of interest once again. This article will enlighten upon the point of view of a thesis guide upon formulation of a thesis topic.
A thesis is more than just a long paper. It requires a great deal of time and understanding from the researcher. It is an unfortunate circumstance to see that the purpose of dissertation is limited as a statutory document for the sake of eligibility for the qualification attainment. The main purpose of any thesis is different from any research. A purpose of a research is to “answer the unanswered”. A thesis whereas is a learning process for the student on which he not only aims to obtain answer for a particular question but also learns the process of formulation of a research topic, execution of the methodology, knowledge of the entire spectrum of the topic in question & derives at a conclusion out of own personal experience. It also serves as a tool to skill development in the form of specific procedure to be performed. It goes unsaid that thesis topic is individual's understanding to its highest level than any other concept/topic, in his lifetime.
The postgraduate guide is rightly the “mentor” for the student. He serves as a guide for learning in all aspects, right from becoming a researcher to gaining practical experience clinically to developing skills. “Dissertation” is not just a subject of learning between the guide and the student, but practically serves as a niche for development of bond between the two. As a thesis guide, the teacher has huge role to play. It starts right from selection of a thesis topic, right up to the publication of the same. He acts as a constant qualified, skilled supervisor for the smooth ongoing of the study. He not only directs guidance to the researcher for the difficulties the researcher faces but also provides a timely feedback for him to make appropriate modifications in the research process when required.
How does one opt for a dissertation topic? A highly vague and non-standardized subject with a huge spectrum of factors! However, from the point of view of a research guide, there are many factors taken into account while finally concluding upon one. Even after years of practice in the field of Orthopaedics, the Orthopaedic doctor faces with certain situations in practice as a clinician or surgeon, the questions to which there is no answer available to, either in the reference textbooks, internet or any of the guidelines. Such questions act as a catchment most commonly for the purpose of research topic. To summarize, “answer the unanswered”. The Question that is to be answered at the end of the research cannot be vague. It has to be very specific with less number of variables involved, so as to avoid confounding. Thesis is not a perception of a researcher but Evidence based scientific medicine. So the topic of a dissertation has to specifically put forward a query that can be answered. If too many variables are involved, the conclusions become less reliable affecting statistical significance of many variables.
Not only the question, but also the choice of answers to be obtained from the research shall be specific and non-overlapping. For e.g., in comparison between two methodologies of treatment for a particular condition say Treatment A v/s B. The following outcomes are acceptable: A better than B or B better than A or A equivalent to B. The grey area of “Slightly better”, “little” is excluded when we apply a statistical test of significance over those variables. This forms the basis of the evidence-based medicine. Needless to say, this virtue is the most magnetic of all in selection of a dissertation topic. Any form of new diagnostic procedure, surgery, implant, treatment protocol, drug etc. serves as a hotspot for researchers to opt it as a research topic. This provides them with an opportunity to adopt something new and advanced, compare it with the previous modules & extrapolate the results to their population. This also provides the researcher to incept an original work on a topic in which not much work has ben done earlier. The drawback associated with it is that not much of literature is available for the researcher to review and may pose some hindrance in ethical approval.
No dissertation guide will want the study to be like the same old stuff packed in a new outfit. The true satisfaction of researcher and the guide is in when something significant is being contributed to the existing knowledge pool. It not only helps making a study unique but also helps other practitioners in refining their existing knowledge, which ultimately helps in improving patient care. In existing circumstances, where an orthopaedic surgeon's success is quantified by the number of papers he has published and upon the impact factor of the journal in which it is published, every researcher opts for a topic of study, which has high chances of future acceptance in a journal for publication. Considering This factor in mind, the topic is selected in most circumstances. The trend is shifting more towards the fate as publication than towards the inquisitiveness for a particular concept in question.
No guide is interested to suggest a topic, which answers a common question about a common problem. There are hundreds of studies already available all over the globe. So, the topic of interest is most commonly either an uncommon query about a common problem or an uncommon problem in the first place. The latter is less preferred by most journals. It is highly undesirable to select a topic/disease that is not very common in the study population involved. It will not only be difficult on the part of the researcher to find the number of cases for the study, but also the study wont prove beneficial later for the study population later as the problem in the first place is not the priority problem of that study population.
It is natural that a surgeon who has an inclination or practice of a particular subspecialty is more likely to allot a topic of that particular field. It helps in candidate having an in-depth exposure to knowledge as well as practical experience under that guide. However, it restricts the researcher from other fields. It is mandatory on the part of the guide as well as the researcher to foresee that the topic involved is well within the boundaries of ethical law. No study should ever be done which has a potential risk of causing harm to the patient. Sometimes, the topic itself might be unintentionally ethical. However, it can be well avoided by doing an appropriate review of the literature and by scrutiny carried out by Institutional Ethics Committee.
Pilot study is a very helpful tool in assessing the correctness, feasibility of a study. Whether or not the topic selected for study is likely to be useful can be pre-judged by doing a pilot study. It helps in saving time, cost and energy significantly. It usually always involves reviewing literature by the student on various topics suggested the guide or by self-exploration. After reviewing a certain number of topics, the student can participate significantly in contributing inputs while selecting a particular topic for dissertation. A newly joined postgraduate student is not a professional researcher to begin with. Therefore, it is obligatory on the part of the guide to regulate the financial costs and expenditure, a study is likely to incur. A study requiring research funds from various organizations has to be pre-planned and funds should be well utilized. The feasibility of the study should be focused upon.
There are various practical limitations in selection of a thesis topic. These include disinterest on the part of researcher due to lack of knowledge, motivation & time, lack of training in research methodology, ease of availability of ready-made material online (Plagiarism), disinterest on part of the research guide, limited specialization of the research guide.
Dissertation, the concept primarily designed to train the post graduate students in research methodology, to develop leadership, to develop expertise in a particular field is losing its importance as a tool to add to the pool of knowledge in orthopaedics. It's either treated as a document of statutory importance for sake of academic completion or as means to improvise curriculum vitae by means of publication. Its time that we recognize it as means of improvising skills, knowledge & research methodology qualities in the student & by keeping the above mentioned virtues in mind, add significantly to the knowledge pool which helps in patient care.


How to Cite this Article:  Jagtap S, Sonawane D, Saraogi A. Perspective of a Thesis Guide in Allotment of Thesis Topic. Journal Medical Thesis 2014 May-Aug; 2(2):5-6

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Guest Editorial: Authorship woes: Guidance for Postgraduate residents and Research fellows


Vol 2 | Issue 2 | May - Aug 2014 | page 3-4 | Harshavardhana N S, Dabke H V.


Author: Mr NS Harshavardhana[1], Mr HV Dabke[2]

[1]Sr. Clinical Fellow in Tr & Orth, Inverclyde Royal Hospital, Greenock; Scotland
[2]Consultant Orthopaedic Surgeon, Salisbury District Hospital, Salisbury; England
Email: nharsha@outlook.com


Undertaking a short-term research constitutes a key part of trainee physician's training and may be mandatory for some specialties. Contracted research workers / Clinical research fellows contribute to major bulk of research conducted in higher education institutes & university hospitals. An opportunity to report the results and publish an article of a project is an important milestone in a trainee's career progression. It may be a stepping stone for that elusive higher degree / entry into higher surgical training. Fifty one cases of research misconduct were reported to COPE in 2001.
However the authorship of research comes with its own woes that a young investigator may not have an insight of. Discrepancy between who actually does the research and who gets the credit is not uncommon. In a survey of 809 authors, Flanagin A et al observed 7-16% incidence of 'ghost authorship' in full-text articles published in 6 peer-reviewed journals. A ghost author is usually an individual who made a significant contribution to a study but fails to be listed as an author. The international committee of medical journal editors (ICJME) observes this to be professional misconduct and condemns such a practice. It may also mean a professional writer who is assigned / hired to write up an article and subsequently becomes an author on a research project. Such individuals do not meet the ICMJE criteria for authorship.
A 'gift author' (also known as honorary author) is usually a senior figure (Dean / Departmental chair / Professor) who gets listed as a author without significant contributor by virtue of his / her position. The common reason for such a practice may be either to obtain favour in terms of career advancement or enhance the chances of a publication. Another commonly observed practice is to add a colleague as an author with an understanding they would reciprocate the same to increase one's list of publications.
Enumerated below are some of ethical / professional set of guidelines to help such individuals:-
I)Prior to taking up the job – Preparing to practicising ethical authorship
Prior to job interview at the pre-interview visit, discuss with current research fellows to get the vibe of the department. Spend a few minutes on internet reviewing the recent publication of the department its authors comparing with scientific programme proceedings where they were presented prior to publication as a full-text article.
Ask if the department has a policy on authorship and obtain a copy of that document for personal use.
Read at least one book on 'publication ethics' familiarising oneself as to what is likely to come / what to expect. Donate a copy to the departmental library at the time of leaving from the job (if it doesn't have one) to benefit newer colleagues.

II)Once in the job – Taking up research projects
Start discussing about authorship when you undertake a research project. Know the individuals involved and their roles from the beginning to avoid misunderstandings.
Have a face-to-face meeting with all concerned and sort out differences / address issues – record the minutes of the meeting.
Discuss about authorship as the project evolves and you begin to draft a conference abstract. Show it to all the authors involved – so that all are in agreement with results / conclusions / recommendations prior to its submission.
Do not accept a new project or procrastinate – until the full-text first draft of the current research project is written-up keeping the journal in mind you wish to submit to (preferably done before your job contract ends).
In-addition to the ICMJE universal authorship criteria, educate oneself with individual journals' authorship criteria ensuring they are all met.
Always run the final manuscript with all authors before submitting it to a journal staking claim for first authorship (if you rightfully deserve). There should be a consensus on all issues relating to the manuscript at this stage to avoid future embarrassments.
Repeat the whole process when you take-up another new research project.
There is no substitution to diligent maintenance of records and communication.
It may not always be possible to observe above procedures at all times given the power dynamics and senior colleagues / Consultants feeling uncomfortable when pinned down. Equally difficult is to have a written authorship agreement prior to undertaking research as the golden rule is 'The one with the gold makes the rules'. Some may even argue this to be not a sensible approach in real life.
The disagreement about authorship can be classified to be of two types:-
I)Disputes - What constitutes 'significant contribution' may be perceived as a matter of subjective interpretation. The best approach is to negotiate with people involved and attempt to reach an acceptable solution to all parties involved. If you are omitted from authorship on a research project that you rightfully deserved, then:-
i)Ask for an opportunity to be heard and vent your unhappiness to the senior author. Seek an explanation listing the facts and avoid being emotional. Many a times a deal is struck here.
ii)If you still disagree with the supervisor's decision, the COPE (Commission on professional ethics) recommends appealing against this decision to someone more senior. It could be your Departmental chair / Professor or Clinical director.

II)Professional misconduct - If you are asked / being forced to do something that you perceive as being unethical with authorship list, handling this could be challenging as:-
Maintaining silence – could mean one being complicit to unethical practice and against GMC's good medical practice on probity.
Assuming the role of 'Whistleblower' – may have dire implications on your career / short-term goals.
The COPE recommendation again is to be as objective as possible sticking to facts citing the journal editor's authorship recommendations and how executing the requested / ordered act contravenes / violates it.
Occasionally it may also happen wherein you may be named in a publication against your wishes or being unaware of it. Again the key is liaising with co-authors at an early stage expressing one's wish to be removed from a particular research. If you discover this after publication, a formal letter should be written to journal editor (with permission of all authors) to amend the publication.
It is also important to cultivate the habit of acknowledging all contributors who have helped one with a research project and may not satisfy the authorship criteria. It could be that statistician who performed the complex calculation and help you derive meaningful conclusion from numbers or secretary who performed word processing / type-setting the manuscript. Be lavish in your praise – whatever goes out comes back in some form. Familiarise with contributorship guidelines of individual journals.
The following are merely guidelines only. A foundation of trust and honesty is of paramount importance to any publication exercise as observed by Lederberg – “The act of publication is an inscription under oath, a testimony…”
Undertake research with probity & integrity adhering to GMC's good medical practice.
Good luck in your research career…………..

References
i)A Neuman, R Jones. Authorship of research papers: ethical and professional issues for short-term researchers - J Med Ethics 2006; 32: 420-23.
ii)Flanagin A, Carey LA, Fontanarosa PB et al. Prevalence of articles with honorary and ghost authors in peer-reviewed medical journals - JAMA 1998; 280 (3): 222-24.
iii)The commission on professional ethics (COPE) report, 2003.
iv)Drummond R, Yank V, Emanuel L. When authorship fails - JAMA, 1997; 278(7): 579-85.
v)R Jones. Research misconduct - Family Practice 2002; 19: 123-24.

Recommended reading
1)Lundberg GD, Glass RM What does authorship mean in a peer-reviewed medical journal. JAMA, 1996; 276 (1): 75.
2)A Sheikh. Publication ethics and RAE (Research assessment exercise): Reflections on the troubled question of authorship. J Med Ethics 2000; 26: 422-26.


How to Cite this Article:  Harshavardhana NS, Dabke HV. Guest Editorial: Authorship woes: Guidance for Postgraduate residents and Research fellows. Journal Medical Thesis 2014 May-Aug; 2(2):1-2

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Research Education and Journal of Medical Thesis


Vol 2 | Issue 2 | May - Aug 2014 | page 1-2 | Shyam A K


Author: Dr. Ashok K Shyam

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


Thesis is an essential document for a medical curriculum [at least in India] and this has been the rule since many many years. Again thesis has been written and rewritten in the same formats since a long time, however times are changing rapidly. Importance of research is rising in geometric proportion with each passing year and now 'Thesis' which was meant to be our first exposure to research is gaining additional importance.
The perception about thesis has certainly undergone rapid changes in last few years. There are two main reasons, one is change in attitude towards research and the other is change in university policies. There has been directive from universities that thesis will also undergo peer review before acceptance. This practice has been started since last two years and many students have received corrections and revisions for their theses. This has forewarned the next batch to make better thesis and to avoid major errors in research methodology. The other aspect is change in attitude towards research. In our country 'Research Apathy' has existed for a long time. Apathy towards conventional form of research in terms of collecting data and writing and publishing manuscripts. In last few years this has changed and we at the Indian orthopaedic research group (IORG) are fortunate, not only to witness this change but also contribute to the change. We see many students and trainees taking initiate in publishing in journals and also presenting their research in conference. As thesis is the first line of our exposure to research, many students are now interested in publishing and presenting their thesis. To do this successfully we are now in desperate need for research education. Although university has started research methodology courses and we are been part of some of these courses, we find them much too dry and much generalised. We feel needs for thesis for various faculties of medicine is quite different. What is needed for an orthopaedic thesis may not be the requirement for a paediatric thesis. We feel each faculty should be addressed separately and in small group where individual attention can be given to these candidates. With this in mind Journal of Medical Thesis along with IORG has decided to conduct 'Thesis Writing Workshops' every two month at various places in India. Many medical colleges have shown interest in supporting us in this venture and the first course is done with the help of Sir JJ Medical College, Mumbai. We feel such courses will help students realise the right way of doing there thesis and also help them in publishing it.
The format of the thesis writing courses will include the standard university guidelines and information about any recent updates and changes. Speakers from IORG will be speaking on how to design the studies, how to do a literature review and how to write various parts of thesis. A detailed account of basic statistical method will also be given in this course. This will help students to learn basics about statistics and also help them understand statistics while reading literature. Special lecture on use of End note and formatting of references is one of the key features of the Course. Along with writing a good thesis the second major emphasis of the course will be conversion of this thesis into a publication. With this respect the entire program is been formulated with background of journal guidelines and a separate lecture on how to convert your thesis into a publication is included in the schedule. No meeting related to research can be complete without discussion of Evidence based medicine and in this course too we have included a short introduction on EBM and how to use it for thesis and publications. In the end we will be going through an ideal template thesis where students can identify the format and also revise what they have learned from the course. Additional lecture on journal guidelines of Journal of Medical Thesis and submission process of JMT is also added to the course. Thus the course is designed to provide a complete overview of Research and specifically of Thesis writing. We believe more such courses should be organised and are looking for collaboration from medical colleges. For the first two of these courses we found tremendous response from students with both programs exceeding maximum registration. We also hope the medical associations would also contribute by organising such workshops and helping the next generation of professionals to be more educated in research methodology and publications.
Journal of Medical thesis will also be starting symposiums on thesis writing for different faculties which will be published in the journal. This will be compiled to address subject wise articles and experts from editorial board of JMT will be invited to write these articles. In coming years research education will be one of the main focus on JMT and we will be taking more initiatives to this end. JMT hopes to contribute to research education in a very positive way and invites opinions from our readers on how we can do this in a more effective way. This will help us achieve our goals and realise our vision put forth in the first issue [1]. On another note we are also starting a series of guest editorial which will focus mostly on current perspective of medical thesis and how to add positivity to perception of thesis. First hypothesis is published in this issue of JMT and we hope to invite more students in publishing there hypothesis with us [2,3]. With this I leave our readers to enjoy the new issue of Journal of Medical thesis.

References
1. Shyam AK. Editorial: Journal of Medical Thesis: Creation of AUnique Paradigm - Principles and Vision.Journal Medical Thesis 2013 July-Sep; 1(1):1-3.
2. 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.
3. Shyam AK. Editorial: Journal of Medical Thesis: Hypothesis, Intellectual Property and Journal of Medical Thesis: Concept of Defensive Publication. Journal Medical Thesis 2014 Jan-Apr; 2(1):1-2.


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

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Evaluation of the results of arthroscopic repair of rotator cuff tears: A prospective study


Vol 2 | Issue 2 | May - Aug 2014 | page 24-30 | Menon A, Sheikh I.


Author: Aditya Menon, Irfan Sheikh

[1]DNB Ortho K B Bhabha Municipal General Hospital, Mumbai.
Institute at which research was conducted: K.B.Bhabha Municipal General Hospital, Bandra (w), Mumbai.
University Affiliation of Thesis: National  Board of  Examinations.
Year of Acceptance:  2013.

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


 Abstract

Background: Rotator cuff tear is most troublesome issue in shoulder surgery we tried to assess the functional outcome of arthroscopic repair of rotator cuff tears in patients and to evaluate the influence of a variety of factors on the outcome of rotator cuff repairs, including the age and sex of the patient, side affected, dominant shoulder and duration of symptoms.
Method: 30 cases of Rotator Cuff tear between the age of 18 and 70 years were primarily treated with arthroscopic repair from February 2009 to June 2011. Data was collected by direct observations as per the proforma prepared accordingly. Patient was assessed for UCLA score at pre- operative and post-operative 3, 6, 12, 18 and 24 months. Assessment of the final outcome was done at 24 months. Inclusion criteria : Presence of tear in any of the rotator cuff tendons,Patient between 18 and 70 years of age, Cuff repair performed solely with the use of arthroscopic techniques. We excluded Patients having associated shoulder lesions like SLAP etc, revision rotator cuff repair patients, irreparable tears, patients with associated symptomatic acromioclavicular arthritis and Patients with cuff tear arthropathy. Pre-operative and post-operative UCLA scores were compared using paired t-test. One way ANOVA was also used to compare more than two variables.
Results : There were 14 males(46.67% ) and 16 females(53.33%) with average age was 52.43(30- 68) years. 27(90%) were right hand dominant and 3(10%) were left hand dominant. There was involvement of right rotator cuff in 18(60%) and left in 12(40%). Average duration of symptoms was 8.4 months (3- 24 months). 22(73.33%) patients had symptoms for less than 1 year and 8(26.67%) had symptoms for more than 1 year. All patients were treated with arthroscopic debridement and repair with bone suture anchor. Subacromial decompression was done as and when required. Average pre- operative UCLA score was 14.60(5- 25) and post- operative was 30.83(28- 35). There was a 100% satisfaction in this study at the end of 24 months according to UCLA score with 25(83.33%) patients having good and 5(16.67%) having excellent scores. There were no complications in this study.
Conclusion: Arthroscopic rotator cuff repair offered good results and enabled the same reconstruction as with open technique and avoided the latter's complications. Advantages of arthroscopic rotator cuff repair include, a small cosmetic scar, the ability to perform the procedure on an outpatient basis, reduced early postoperative pain, availability to diagnose any intraarticular pathology that can affect the end results and deltoid muscle preservation that allows earlier and easy postoperative rehabilitation.
Keywords: Rotator cuff tear, arthroscopic, UCLA Score.
Thesis question : Whether arthroscopic repair of rotator cuff tears is functionally better than open repair. And to evaluate that age and sex of the patient, side affected, dominant shoulder and duration of symptoms influence the outcome of rotator cuff repairs.
Thesis answer : Arthroscopic rotator cuff repair offered good results and enabled the same reconstruction as with open technique and avoided the latter's complications. Age, sex, dominant arm and side involved do not affect the post- operative result.

                                                        THESIS SUMMARY                                                             

Introduction

Rotator cuff injuries or disease can be particularly troubling to patients by causing pain, weakness, and dysfunction of the shoulder. The Rotator Cuff undergoes progressive degenerative changes with increasing age and may lead to partial tear of cuff and finally to complete rupture of the rotator cuff.The spectrum of these disorder ranges from inflammation to massive tearing of the rotator cuff musculotendinous unit. Rotator cuff repair is one of the most frequent procedures performed in the shoulder joint. In 1911, Codman first did the open surgical repair of a supraspinatus tendon rupture that he identified as one of the major causes of the painful shoulder. Over the next three decades, operative treatment of rotator cuff tears became increasingly popular, with many different techniques being described. However, the results were variable and a high percentage of unsatisfactory results were reported in some series.The treatment of symptomatic rotator cuff tears has travelled a long way, starting with complete open repair, to arthroscopic assisted mini open techniques to complete arthroscopic repair. Neer reported the results of anterior acromioplasty in combination with cuff mobilization and repair in 1972. The surgical fundamentals emphasized in that report substantially improved the reliability of the outcomes of repairs of rotator cuff tears.
The fundamentals include
(1) Preservation or meticulous repair of the deltoid origin.
(2) Adequate decompression of the subacromial space by resection of any anteroinferior osteophytes.
(3) Surgical releases as necessary to obtain freely mobile muscle-tendon units.
(4) Secure fixation of the tendon to the greater tuberosity.
(5) Closely supervised rehabilitation including early passive motion within a protected range.
The first arthroscopic cuff repairs were reported by Johnson using a staple technique in 1992 .The treatment of Rotator Cuff tear has changed dramatically during the recent past as there is, progression towards less invasive procedures like arthroscopy to obtain equivalent or better results to the traditional open procedures. As of today, arthroscopic cuff repair is technically demanding as most of the patients are elderly and tissue quality is poor. It is still in its developmental phase, with innovative techniques and suture materials being designed such as double row anchors to overcome past inadequacies. Although the best procedure for repairing a full thickness Rotator Cuff tear is still controversial, results with most of the studies of complete arthroscopic Rotator Cuff repair have been promising and evolving as a future alternative to traditional open and mini open techniques. Arthroscopic rotator cuff repair has several advantages. With this technique it is possible to use a much smaller incision and to protect the deltoid muscle. It provides to diagnose and to treat the intraarticular lesions. Rotator cuff may be released and mobilized with this technique, soft tissue damage minimized, thus postoperative pain decreases and rehabilitation is facilitated decreasing the risk of adhesive capsulitis. In 2001, Burkhart SS, Danaceau SM, Pearce CE Jr. concluded that results of arthroscopic rotator cuff repair are independent of tear size, but most of the recent studies state that post repair, large and massive rotator cuff tears result in more postoperative weakness than small tears do. This study has been undertaken to assess the short term functional outcome of arthroscopic repair of rotator cuff tears by using the University of California, Los Angeles (UCLA) score.

Aims and Objectives

1.To assess the functional outcome of arthroscopic repair of rotator cuff tears in patients.
2.Evaluate the influence of a variety of factors on the outcome of rotator cuff repairs, including the age and sex of the patient, side affected, dominant shoulder and duration of symptoms.

Methods

“Evaluation of the results of arthroscopic repair of rotator cuff tears: a prospective study” was conducted from February 2009 to June 2011 for a period of 29 months
SOURCE OF DATA:
The present study was conducted at Khorshedji Behramji Bhabha Municipal General Hospital, (K B Bhabha Municipal General Hospital-KBBH), Mumbai-400050, which is a secondary care multispecialty hospital under Municipal Corporation of Greater Mumbai and affiliated to Seth G S Medical college and King Edward Memorial hospital, Parel, Mumbai. It caters to a suburban population of the metropolitan area of Mumbai covering 4 suburban areas with total population of around 5-10 lakhs. These suburban areas are Santacruz, Khar road, Bandra, and Mahim.
STUDY POPULATION:
1)All male/female patients attending out-patient department between the age of 18 and 70 years.
2)All male/female patients admitted in in-patient ward between the age of 18 and 70 years.
3)Population includes both urban/rural/slum dwellers.

STUDY PERIOD: February 2009 to June 2011

SAMPLE SIZE: 30 cases of Rotator Cuff tear were primarily treated with arthroscopic repair.

TYPE OF STUDY: Prospective continuous and non-randomized study.

INCLUSION CRITERIA
1.Presence of tear in any of the rotator cuff tendons.
2.Patient between 18 and 70 years of age
3.Cuff repair performed solely with the use of arthroscopic techniques
4.Consent to participate and follow up in post-operative rehabilitation
EXCLUSION CRITERIA
1. Patients having associated shoulder lesions like SLAP etc.
2. Revision rotator cuff repair patients
3. Irreparable tears
4.Patients with associated symptomatic acromioclavicular arhritis.
5. Patients with associated biceps brachii tendon pathology.
6. Patients with cuff tear arthropathy.
DATA COLLECTION:
Data was collected by direct observations as per the proforma prepared accordingly.
Patient was assessed for UCLA score at pre-operative and post-operative 3, 6, 12, 18 and 24 months.
Assessment of the final outcome was done at 24 months.

DATA ANALYSIS:
Arithmetic mean, standard deviation, chi square test, Pearson's correlation and t-tests were used to examine continuous variables. Pre-operative and post-operative UCLA scores were compared using paired t-test. One way ANOVA was also used to compare more than two variables.
PATIENTS
History was elicited from patients regarding age, sex, duration of pain, involved side, hand dominance and loss of function. Patients were clinically examined for range of movement, strength of rotator cuff muscles, etc. Pre- operative UCLA score was documented of all the patients.
Physical Examination
Physical examination consisted of measurements of the range of motion and a manual muscle-strength test. The range-of-motion assessment included measurement of forward flexion in sagittal plane and strength of forward flexion.

JOBE' S Empty can test was used for assessment of Supraspinatus.
In this test the arm is placed in 30 degrees of forward flexion and 90 degrees of abduction in the plane of the scapula with the elbow fully extended and thumb pointing down (Empty can test) towards the floor. The patient is asked to raise the arm against resistance applied by the examiner over the forearm. If the arm flops down with pain, it is indicative of a rotator cuff tear. This is often referred to as Drop arm sign and though diagnostic of a full thickness cuff tear, it can be occasionally seen in the presence of severe cuff inflammation or large partial tears. The empty can position eliminates most of the deltoid action but patients with weak supraspinatus may recruit the biceps by flexing the elbow.
JOBE'S Full can test was also used for assessment of Supraspinatus.
In this the same test is repeated with the thumb pointing up towards the ceiling. The deltoid shares the load of the Supraspinatus and it is performed with ease. In the presence of a full thickness tear both the empty can and the full can tests will be positive. In Supraspinatus tendonitis, calcific tendonitis or partial tears of the rotator cuff the full can test will be negative whereas the empty can test may be positive. The full can test is more specific for the diagnosis of a full thickness tear.
Resisted external rotation tests were used for the Infraspinatus and the Teres minor together. In this test the patient is asked to tuck the elbow near his waist in 90 degrees of flexion at the elbow and rotate the forearm externally against resistance.
Napoleon or Belly Press test.
It is a new test for Subscapularis .With both palms resting on the abdomen, when patients exerted pressure on the abdomen, patients were not able to maintain the elbow anterior to the midline of the trunk, as viewed from the side, instead, the elbow dropped back behind the trunk. The test can be performed with the examiner's hand inserted between the patient's hand and stomach to assess the pressure exerted on the stomach compared with that exerted by the hand on the uninjured side.

Radiological evaluation
Pre-op radiological evaluation involved true AP views and MRI of involved shoulder. Final diagnosis was done on the basis of intra-op findings.
Patients were investigated pre operatively for fitness for undergoing surgery under general anesthesia.
Patients were properly counseled and explained regarding the operative procedure and post-operative rehabilitation protocol.

SCORING SYSTEM
UCLA54 scoring system was used in this study to evaluate the patients. It evaluates the pain, function, range of active forward flexion, strength of active forward flexion and patient satisfaction. Pain and function have a maximum value of 10 and the other components have a maximum value of 5. The UCLA score has almost a 15% component related to patient satisfaction and it is either yes or no – meaning if patient is satisfied full 5 points are added to the score. If the patient is not satisfied then the contribution to the score is zero. The component values are added to achieve the total score, which has a maximum of 35. In this case, a higher score indicates better shoulder function
PRE-OPERATIVE MANAGEMENT
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)
Random blood sugar level.
HIV \ HBsAg.
Radiograph of the chest.
Pre-operative anesthesia fitness was obtained and a minimum fasting period of eight hours was taken into account, before taking up the patient for surgery.
On the day of surgery patients were prepared with shaving of local parts and scrubbing with chlorhexidine for two minutes. Third generation cephalosporin (ceftriaxone 1 gm) and aminoglycoside (amikacin 500 mg) was administerd intravenously about 30 min prior to surgery.

OPERATIVE TECHNIQUE
Arthroscopic rotator cuff repair was performed using the suture anchor technique of repair with subacromial decompression.
The technique performed in our study was as follows:
Anaesthesia: General anaesthesia
Position: Lateral position
Procedure:
The arm was left free on a draped support. Hypotensive anaesthesia was used to facilitate intra – operative visualization.
Four portals were used. Posterior and lateral portals were used mainly for standard 4 mm arthroscope (the viewing portals), while anteromedial and anterolateral portals were used for the instruments (the working portals).The subacromial space was cleared of adhesion, bursal tissue and reactive synovitis. Tendon mobility was improved by releasing superficial adhesions between the cuff and acromial arch. A superior capsular release and rotator interval-coracohumeral ligament release were performed when needed to allow a low tension reduction of supraspinatus tendon to its anatomical position. Limited debridement of degenerated tendon margins was performed with the use of the shaver or a basket punch. After adequate visualization, preparation and release of tendon, upper surface of Greater Tuberosity was abraded with a burr, removing all soft tissue and cortical bone, to create a bleeding cancellous bone bed. However trough was not created.
In order to perform a tendon to bone repair, tension band suture technique using inverted horizontal mattress sutures and placing the anchor's in the lateral cortex of the humerus was done. The anterolateral portal was used to drill the anchor holes approximately 10 mm distal to the tip of greater tuberosity and at 5mm to 7mm intervals. Drill was kept perpendicular to the lateral humeral cortex. An arthroscopic clamp was then inserted through the same anterolateral portal in order to grasp the tendon and allow the assistant to place it under tension by pulling laterally on the clamp. A suture hook was inserted through the anteromedial portal and was used to pass the suture some distance medial to the tendon edge, close to the musculotendinous junction in an inverted mattress fashion.
A grasping clamp was used to retrieve one of the suture limbs through the anterolateral portal. The anchor was threaded onto the retrieved limb of the suture and was inserted back through the anterolateral cannula and the previously drilled anchor hole. Sutures were tied immediately with the use of simple sliding knot with three reversed additional half hitches. Two or three such horizontal mattress sutures were used in most of the patients.
A subacromial decompression with acromioplasty was performed as needed, such as patients with evidence of anterosuperior impingement of cuff with the acromial arch. Biceps tenotomy was performed as per requirement.

POST OPERATIVE MANAGEMENT
All patients were given shoulder arm pouch. Immediate post op. I.V antibiotics would be given for 2 days i.e on the day of the surgery and 1st post op day. They were discharged on the next day after dressing.

Rehabilitation
Physiotherapy was started on post op day 1 or 2. Elbow, wrist movement, scapular retraction and finger grip was started at post op. day 2. Passive pendulum exercise was started at 3- 4 weeks. Passive extension and abduction was started at 4- 6 weeks. At 6- 7 weeks forward flexion with wall support was started. Abduction with wall support was started at 7- 8 weeks. Active assisted forward flexion and abduction were started at 8- 12 weeks. Full range of motion was initiated at 12 weeks.

Obervation and Results

46.67% of cases were male and 53.33% were female in study group.
53.33% of study cases were maximum in age group of 40- 60 years followed by 30% cases in age group of >60 years and the remaining minimum cases of 16.67% in age group of 20- 40 years. Range is from 30 to 68 years.
In this study, the percentage of cases with right shoulder involved was 60% and with left shoulder involved was 40%.
Pre operatively, 93.33 % had poor, 6.67 % fair, 0 % good and 0 % excellent scores.
At 3 months post-operative, 50 % had poor, 46.67 % fair, 3.33 % good and 0 % excellent scores.
At 6 months post-operative, 13.33 % had poor, 70 % fair, 16.67 % good and 0 % excellent scores.
At 12 months post-operative, 0 % had poor, 46.67 % fair, 53.33 % good and 0 % excellent scores.
At 18 months post-operative, 0 % had poor, 23.33 % fair, 66.67 % good and 10 % excellent scores.
At 24 months post-operative, 0 % had poor, 0 % fair, 83.33 % good and 16.67 % excellent scores.
The average age of the males was 54.35 and that of the females was 50.75 and they were not significantly different. The average duration of symptoms among men was 10 months and among women was 7 months; this difference was also not statistically significant. Similarly, the pre-operative and post-operative UCLA scores at 3,6,12, 18, and 24 months did not show any statistical differences. Mean 24 months UCLA score had no significant relation with sex of patient.Among men, duration of symptoms shows a statistically significant (p<0.05) negative correlation with post-operative UCLA scores while pre-operative UCLA scores show a statistically significant positive correlation with post-operative UCLA scores. Age is negatively correlated with post-operative UCLA scores, but the correlation is not significant. On the other hand among women, none of the correlations acquired statistical significance.
The involvement of right or left arms did not affect the post-operative UCLA scores.In both men and women pre and post-operative UCLA scores were significantly different from each other (p < .0001).
There is 100% satisfaction at post operative 24 months in the 30 patients in our study.
There is no statistically significant difference in pre operative and post operative UCLA score across the various age groups in either men or women.
There is no statistically significant relation between hand dominance and mean post- operative UCLA score at 24 months.
There were no complications in this study.

Discussion

Rotator cuff tears are among the most common conditions affecting the shoulder. Despite their ubiquity, there is substantial debate concerning their management.
Arthroscopic repair of rotator cuff tears is technically demanding and is still in the developmental phase, with only short and intermediate-term studies available. The results of arthroscopic repair have not been as thoroughly studied as those after open repair.
Despite its prior reputation as an impractical operative technique, recent reports of arthroscopic rotator cuff repair have shown promising results that appear to be as good as, if not superior to, the results of open rotator cuff repair. The clinical success rate in patients included in our study was 100%. Rebuzzi et al. showed satisfactory results of 81.4 %, whereas, Boileau et al. showed satisfactory results of 92 %. The clinical results reported in our study are similar to those of previously published reports on open and mini-open techniques. Outcome studies after open repair of the rotator cuff showed an 88% to 90% success rate14. In 1990, Levy et al. reported a preliminary one-year follow up study of twenty five patients with rotator cuff tears who had been treated with an arthroscopic subacromial decompression and then a mini-open lateral deltoid-splitting repair. Twenty of the patients (80%) had a good or excellent result according to the shoulder-rating system of the University of Californiaat Los Angeles. Youm et al. performed a comparison of clinical outcomes and patient satisfaction following arthroscopic and mini-open rotator cuff repair. They found that, at greater than two years of follow-up, arthroscopic and mini-open rotator cuff repairs produced similar results for small, medium, and large rotator cuff tears with equivalent patient satisfaction rates. Similarly Ide et al. performed a comparison between arthroscopic and open rotator cuff repairs in 100 cases. They concluded that the arthroscopic repair of small-to-massive tears had outcomes equivalent to those of open repair.63 In the study published by Boileau et al, they concluded that the results of arthroscopic repairs were comparable with those obtained with open or mini-open techniques, and that has given them the confidence to continue performing arthroscopic cuff repair. In a long-term follow-up study (2-14 years) of rotator cuff tears repaired arthroscopically, Wilson et al. concluded that the arthroscopic techniques for rotator cuff repair achieved results comparable to the results of traditional open repair. Similarly Jones and Savoie showed success rate of 88% in cases with arthroscopic repair of large and massive cuff tears. They concluded that the arthroscopic management of such tears could obtain results comparable to the reported outcomes following open repairs. Moreover, Buess et al. performed a comparative study between open versus arthroscopic repair of rotator cuff tears in 96 cases. The authors reported that the arthroscopic repair had yielded equal or better results than open repair, even at the beginning of the learning curve. They found that the patients with an arthroscopic repair had a significantly better decrease in pain and a better functional result concerning mobility. The authors concluded that the arthroscopic repair is successful for large and small tears and biomechanically, large tears might even benefit more than small ones.
Factors affecting the results of surgery
The outcome of rotator cuff repairs may be influenced by a variety of factors.
1. Age:
The average age of the patients in our study was 52.43 years. Although in this study there was no limitation concerning the age, we found no statistical significant relation between the age of the patient and the postoperative net results. Similarly, Bennet reported no difference in the outcome based upon the age as a variable. Stollsteimer and Savoie showed also no difference in the outcome noted among patients of different ages, suggesting that the arthroscopic repair is equally effective in all age groups. On the other hand, Boileau et al. reported that the age was clearly a factor influencing tendon healing. They found that the patients who had a healed tendon were, on the average, ten years younger than those in whom the tendon did not heal. They concluded that the chance of tendon healing decreased to 43% when the patient was more than sixty five years old. However, they stated that the absence of tendon healing (or only partial healing) did not necessarily compromise pain relief and patient satisfaction.
2. Sex:
There is little commentary in the literature with respect to sex for outcomes of rotator cuff disease. This study included 14 males and 16 females. The almost equal sex distribution was also shared between this study and other studies carried out by Kim, Boileau, and Galatz. They also shared that there was no significant relation between the sex of the patient and the postoperative net results. On the other hand, in the study performed by Watson et al, they identified a small, but statistically significant difference between male and female patients with regard to overall satisfaction, improvement in the functions of activity of daily livings (ADLs) and performance of usual work. However they stated that “what does exist does not support a sex difference”. Harryman et al evaluated patient satisfaction, functional outcome, and ultrasonographic cuff integrity after 105 rotator cuff repairs and found no significant correlation of patient sex with the outcomes.
3. Dominant shoulder & Side involved:
In the present study we found no significant relation between the dominant shoulder or side involved and the postoperative outcome. Cofield et al reported similar result.
4. Duration of symptoms:
Our study showed that the earlier the timing of the rotator cuff repair, the better was the postoperative net results as there was a statistically significant negative correlation between duration of symptoms and post-operative result in men but not significant in women. Clinical data from studies by Goutallier et al. supported the concept that the longer a patient had symptoms of a rotator cuff tear, the more extensive the fatty degeneration of the torn rotator cuff muscle. The authors also reported that surgical intervention when there is minimal fatty degeneration of the muscle reduces the rate of retears. These data suggest that early operative intervention would facilitate improved outcomes for patients. Additional support for this statement was reported in the study done by Harryman et al. In contrast, Cofield et al. reported that the time from the beginning of symptoms to surgery did not have a significant effect on the outcome. Similarly, Burkhart et al reported that the delay from injury to surgery, even of several years, did not adversely affect the surgical outcome and was not a contraindication to arthroscopic rotator cuff repair.

Conclusion

1. Arthroscopic rotator cuff repair offered good results and enabled the same reconstruction as with open technique and avoided the latter's complications.
2. Advantages of arthroscopic rotator cuff repair include, a small cosmetic scar, the ability to perform the procedure on an outpatient basis, reduced early postoperative pain, availability to diagnose any intraarticular pathology that can affect the end results, and deltoid muscle preservation that allows early and easier postoperative rehabilitation.
3. Every cuff tear is unique and requires individual planning.
4. Diagnosis of rotator cuff tears is made mainly by history, clinical examination and confirmed by ultrasonography or magnetic resonance imaging.
5. The potential for structural failure should not be considered to be a formal contraindication to an attempt of rotator cuff repair if optimal functional recovery is the goal of treatment.
6. Age, sex, dominant arm and side involved do not affect the post- operative result, but a larger clinical trial would be needed to prove the same.

Clinical Message

1.Arthroscopic rotator cuff repair is technically demanding procedure that needs prerequisite skills such as diagnostic shoulder arthroscopy, arthroscopic subacromial decompression and arthroscopic knot tying.
2.Thorough debridement of the tear should be done arthroscopically.
3.A subacromial decompression must be done in indicated cases.
4.Bone anchor suture technique is a good and proven technique for successful repair of rotator cuff tear.
A planned and well monitored post- operative physiotherapy protocol is essential for best optimization of the surgery.

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How to Cite this Article: Sheikh I, Menon A. Evaluation of the results of arthroscopic repair of rotator cuff tears: A prospective study. Journal Medical Thesis 2014 May-Aug ; 2(2):24-30

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Intertrochantric femur fracture in elderly treated with bipolar vs dhs – a prospective study


Vol 2 | Issue 2 | May - Aug 2014 | page 45-49 | Sheikh I


Author: Irfan Sheikh

[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:  2014

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


 Abstract

Background:Intertrochantric femur(IT) fracture is a common fracture in old age. The cause of morbidity and mortality in IT femur is malunions, nonunions, respiratory tract infection and bed sores etc. treatment modality like DHS is time tested but with availability of better hemiarthroplasty techniques and implant mortality and morbidity can be reduced. We aimed at evaluating the advantages and disadvantages of hemiarthroplasty over dynamic hip screw for management of IT fracture femur.
Methods: 60 yrs and above patients who were admitted and operated between feb 2010 to feb 2012 and had fulfilled the inclusion criteria were enrolled for this study
case selection was random
BIPOLAR Hemiarthroplasty:Total numbers of patient 16 of mean age of 80.2 yrs and F:M ratio is 9:7. Mean follow up period of 1.1 yrs
And DHS:Total numbers of patients 21 of mean age of 70.1 yrs and F:M ratio of 6:15.mean follow up period of 1.2 yrs
Harris Hip Scoring System: formulated by W.H.Harris post operativly.
Results: Bipolar group:1 had superficial wound infection, no one had deep infection or pulmonary infection.1 had bed sore . After 6 months fair result in 2 patients, good result in 4 patients and excellent result in 10 patients. Eventually all had good to excellent result after 1 yr.
DHS Group :3 had bed sore,.1 had lacunar infract.1 was admitted for physiotherapy at 6th month for gait training and muscle strengthening.1 had palpable implant and pain in hip, implant removal was done after 1 yr,. After 6 months,2 had poor results, 2 had fair results,13 had good results and 2 had excellent result at the end of 1 yr patient who follow up all had good to excellent results.
Conclusion: Functional recovery was delayed with internal fixation group.
Early post operative harris hip score were good in patients treated with hemiarthroplasty as compared to internal fixation group but at the end of 1 year score was comparable.Post operative complications were more internal fixation group than hemiarthroplasty group and were comparable with other studies.
Thus in conclusion, primary hemiarthroplasty does provide a stable, pain-free, and mobile joint with acceptable complication rate as seen in our study; however a larger prospective randomised study comparing the use of dynamic hip screw devices against primary hemiarthroplasty for unstable intertrochantric fractures will be needed.
Keywords: IT fracture in elderly, bipolar hemiarthroplasty, DHS, successful, decrease morbidity .
Thesis question : How can mortality and morbidity in elderly patient having IT femur fracture can be reduced ?
Thesis answer : The use of bipolar hemiarthroplasty meticulously can reduce the morbidity and mortality in elderly.

                                                        THESIS SUMMARY                                                             

Introduction

There were an estimated 1.66 million hip fractures worldwide in 1990.
Intertrochanteric fractures are common problem in the elderly population and are associated With high rate of morbidity and mortality. Increased rate of these fractures is due to increased life expectancy of the people and due to increased incidence of osteoporosis in the old age. Before the advent of the term osteoporosis sir Astley cooper wrote “that regular decay of nature which are easily detected in the dead body and one of the principal of these is found in the bones, for they become thin in their shell and spongy in their texture.”
This osteoporosis is the main feature leading to this fracture. Usually people affected are between 60 and 80 years of age. John Buchwald in 1923 said “we
all come into this world under the brim of the pelvis but quite a few of us will leave through the neck of the femur. 90% of the intertrochanteric fractures in the elderly result from a simple fall.
Some of the factors found to be associated with a patient include-
Advancing age
Increased number of comorbidities
Increased dependency in activities of daily living
A history of other osteoporosis related (“fragility”) fracture
In the early days these fractures was treated with conservative treatment in traction or non - rotating boot for 6-8 weeks as fracture surface is large and the wide area of bone involved is cancellous. But there are certain complications of conservative treatment:
Hazards of immobilization
External rotation deformity
Varus deformity
Shortening
This led to the era of internal fixation of inter-trochanteric fracture. It is now ® accepted that internal fixation is the best method because it allows early mobilization and prevention of complications due to prolonged immobilization Osteoporosis and instability are one of the most important factors leading to unsatisfactory results Treatment with primary bipolar hemiarthroplasty rather than internal fixation could perhaps return these patients to the pre-injury level of activity more quickly thus obviating the postoperative complications caused by immobilization or failure of the implants6. I am doing the study of cases of intertrochanteric fracture managed with hemi-arthoplasty or internal fixation using dynamic hip screw as routinely DHS is used in our institute and it is already established modality of treatment for intertrochantric femur fractures and compare the results. , the role of the intramedullary devices in unstable. osteoporotic and severely comminuted intertrochanteric fractures is still to be defined.

Aims and Objectives

l) To study results of internal fixation in unstable intertrochanteric fracture.
2) To study results of hemiarthroplasty in unstable intertrochanteric fracture.
3) To compare the results of internal fixation and hemiarthroplasty in unstable intertrochanteric fracture.
4) To study complications of internal fixation and hemiarthroplasty in unstable intertrochanteric fracture.

Methods

STUDY AREA:
The present study was conducted at kharshetji behiramji municipal general hospital,bandra,Mumbai-400050,which is the secondary care multispeciality hospital under municipal corporation of greater Mumbai and affiliated to King Edward Memorial hospital,parel,Mumbai. It caters to suburban population of metropolitan area of Mumbai covering 4 sub-urban with total population of around 5-10 lakhs.these sub-urban areas are Santacruz,Khar road,Bandra and Mahim.
STUDY POPULATION:
All male and female patients aged at least 60 yrs and above with type 3,type 4 evans intertrochantric fracture femur
SAMPLE SIZE:
60 yrs and above patients who were admitted and operated between feb 2010 to feb 2012 and had fulfilled the inclusion criteria were enrolled for this study.
Type of study : Prospective cum Retrospective,comparative study.
Inclusion Criteria –
1. Age of patient at least 60 yrs and older.
2.Femoral intertrochanteric fracture confirmed on antero-posterior and lateral hip radiographs.
3. Should be unstable fracture (Evans type 3, 4, 5). Reverse oblique type
4. Patient ambulatory prior to fracture, though they may have used an aid like a cane or a walker.
5. No other major trauma in patient.
Exclusion Criteria -
1. Age less than 60 yrs
2. Associated major injuries of lower extremity.
3 Any infection around the affected hip (soft tissue or bone).
4 Stable fracture (Evans type 1, 2).
The patients fitting into the criteria were included in the study.

CASE SELECTION PROCESS WAS RANDOMLY

Clinical diagnosis of unstable intertrochanteric fracture was done with external rotation, shortening, and history of inability to get up after fall. Emergency treatment in form of analgesics is given. Antero-posterior x-ray of pelvis with both hips with opposite hip in maximum internal rotation and lateral view of the injured joint taken and 100mm scale views of the injured side taken for head size templating. Chest x-ray taken at the same time.
Injured limb is kept in a Thomas' splint with skin traction with adequate splintage to correct flexion deformity if any and to prevent overriding whenever present. Preoperative routine blood and urine investigations done.
Operative protocol:
Pre-operative templating done before surgery for identification of size of prosthesis.
Anesthesia: Spinal + Epidural
Antibiotics Protocol: 1 dose of Inj. Cefuroxime axetil 1.5 gm + Inj. Amikacin 500mg on previous night and same dose repeated just before starting surgery.
lnj. Cefuroxime axetil 750 mg IV 8 hrly +Inj. Amikacin 500mg IV 12 hrly for 5 days and Oral 2"“ generation cephalosporin for 8 days.
Position: lateral or fracture table
Preparation: With betadine scrub, saline, betadine solution, spirit and sterilium. Later draped using stockinet and sterile disposable adhesive drapes to minimize contamination from surrounding skin.
Approach: Postero-lateral for hemiarthroplasty and lateral for dynamic hip screw closure in layers over negative suction drains.
Postoperative protocol
In well equipped intensive care room pre-fumigated with attendant inside for partial hip replacement or medically unstable patient and foot end elevation for one day.
DVT prophylaxis given only if patient is high risk.
High Risk for DVT:divided into procedure specific and patient specific
Procedure > 1hour,Prolonged Immobility, Major Surgery (abdomen, pelvis procedures).
Increasing Age ,Stroke,Paralysis,Previous VTE,Cancer,Obesity,Varicose Veins,Cardiac Dysfunction
Indwelling Central Venous Catheters,Inflammatory Bowel Disease,Nephrotic Syndrome,Estrogen Use
For surgical patients, the incidence of DVT is affected by the preexisting factors listed
above and by factors relating to the procedure itself, including the site, technique, and
duration of the procedure, the type of anesthetic, the presence of infection, and the degree
of postoperative immobilization (Geerts, Heit, Clagett, Pineo, Colwell, Anderson, &
Wheeler, 2001)
Post-operative antero-posterior x-ray of Operated hemiarthroplasty and antero posterior and lateral for DHS. Post-operative hemogram and Serum Electrolytes done immediate postoperative and 24 hrs post operative static exercises in bed for glutei, hamstrings and quadriceps with regular ankle pump exercises started if pain permits. Drain removal after 48 hrs. Sitting started on 2nd day with quadriceps exercises in bed. Non weight bearing walking on operated side after 2 days. ROM exercises actively after 5 days.
Partial weight bearing started in hemiarthroplasty when pain permits. In internal fixation group, partial weight bearing started depending on stability of fixation. Postoperative dressings done on 2"“, 5"' and 8"' day.
Suture removal done on or after 14 days. Patient discharged after rehabilitation.
Prior to discharge check done for late clinical sepsis and Deep Venous Thrombosis.

Follow up: 6 wks
3 months
6 months
1 year
1 '/2 years.

SYSTEMIC GRADING OF PATIENTS

Harris Hip Scoring System: formulated by W.H.Harris .
It incorporates all important variables into single reliable figure, which is both reproducible and reasonably objective.
Statistical analysis
Data were reported as mean, standard deviation (SD), median (range) or number (percentage). T-test was used to assess significant difference among all numerical parameters of the study within the two surgical groups. Whereas, Chi square test was used for statistical analysis among all studied categorical variables such as gender, pre-morbid conditions and postoperative complications. P–values < 0.05 were considered statistically significant.

Obervation and Results

There were no significant differences between the 2 groups in terms of demographic data (age, sex), fracture type, hospital stay, operating time, metabolic diseases and associated diseases. Full weight bearing started significantly earlier in patient who fixation had more early complication than those with hemiarthroplasty mean follow up period for internal fixation is 1.2 years. Patient who underwent internal fixation had more early complication than those with hemiarthroplasty.
osteoporosis evaluation was not done by tests like dexa scan et. only x rays were done and as patients where selected randomly no uniformity of osteoporosis was noted in select group
Hemiarthroplasty (BIPOLAR group): Total numbers of patient in this group are 16 of mean age of 80.2 yrs and female to male ratio is 9:7. Mean follow up period of 1.1 yrs. Of total 16 patients, 7 are type 3 fractures, 7 are type 4 fractures, 1 Of type 5 and l of type reverse oblique. Mechanism of injury in this group was mainly trivial trauma in the form of slip and fall, only one patient had road traffic accident. All were ambulatory pre-fall either community or household. Average trauma admission time was 2.2 days with average stay of 15.53 days in hospital. All were operated with cemented prosthesis bipolar prosthesis. Complete wt bearing was started after average period of 7.46 days. 1 patient had superficial wound infection which was treated with meticulous wound care and antibiotics no patient had deep infection or pulmonary infection.1 had bed sore which was treated with air bad and wound dressing. 1 patient had post-operative constipation and abdominal distention (known operated case of carcinoma stomach) GI scopy was done and treated accordingly, this increased stay in hospital. After 6 months of follow up fair result in 2 patients, good result in 4 patients and excellent result in 10 patients. Eventually all had good to excellent result after 1 yr. There was no dislocation, acetabular protrusion or aseptic loosening of the stem.
Internal fixation(DHS GROUP) : Total numbers of patients in the group are 21 of mean age of 70.1 yrs and female to male ratio of 6:15.mean follow up period of 1.2 yrs of total 21 pts,10 are of type 3,8 are of type 4 and 3 are of type 5.mechanism of injury in this group was also trivial trauma in the form of slip and fall,3 had road traffic accident and had fall from height all patients were ambulatory pre fall except 1 who had hemiplegia on same side. average trauma admission time was 3.57 days and inpatient duration was 14.95 days all fractures were fixed using DHS in this group bone wires, k wires and screws were used to provide additional stability in some fractures.complete weight bearing was started after average period of 10.3 wks.3 patients had bed sore,treated with air bed and wound dressing.1 had lacunar infract in lentiform nucleus and rt frontal area postoperatively, and was treated accordingly.1 patient was admitted for physiotherapy at 6th month for gait training and muscle strengthening.1 had palpable implant and pain in hip, implant removal was done after 1 yr, fracture was united after collapse, no patient had deep infection. After 6 months of follow up,2 had poor results, 2 had fair results,13 had good results and 2 had excellent result at the end of 1 yr patient who follow up all had good to excellent results no implant cut out was seen, and no revision surgery was required.

Discussion

Surgical outcome in elderly patient is unsatisfactory with associated co morbid conditions like medical illness, osteoporosis and fracture instability. Elderly patients, even if they are in good general health cannot be mobilized without some weight being borne on the involved limb. Early mobilization may decrease the risk of mortality and morbidity. In patients with osteoporotic fractures, and major comminution, maintenance of reduction can be a major problem, so many surgeons recommend hip to be protected throughout the healing period5 '9 2° 2'. To reduce the healing time, dynamic devices are replaced with the static ones. Dynamic implants have more weight bearing capacity than static implants. Partial weight bearing creates a micro movement in dynamic system which increases union rate. The weak and porotic bone tolerates screws poorly so cut out is the major problem in internal fixation. Central position of the screw in the femoral neck is the recommendable position“. Use of intemal fixation has decreased the mortality rate but rate of complications are high bearing, many surgeons prefer arthroplasty for the treatment of unstable intertrochanteric fractures. The patient's rapid return to the prefacture level of activity has essentially prevented post-operative complications such as bed sores, pulmonary infections and atelectasis.
Stern and Angerman” reported 94% good and excellent results afier mean follow up period of 8 months with 1% cases of pneumonia and 3 % cases of deep infection. Haentj ens et al 28 compared results of bipolar arthroplasty and intemal fixation and reported 75% satisfactory results with less post operative complications in arthroplasty group.
Rosenfeld et al 29 reported 86% of satisfactory results in early period using arthroplasty.
failure rates of as high as 56% have been noted in association with unstable fractures, comminution, suboptimal fracture fixation, or poor bone quality treated by DHS in elderly patients.
No differences in postoperative mortality in two groups.
The Cochrane database analysis of relevant studies concluded that there is insufficient evidence to prove that primary arthroplasty has any advantage over internal fixation.However, they also mentioned that there were only two randomized trials studied and both had methodological limitations, including an inadequate assessment of the longer term outcome.
Harwin et al. reported on fifty-eight elderly patients with osteoporosis in whom a comminuted intertrochanteric femoral fracture had been treated with a bipolar Bateman-Leinbach prosthesis and who were followed for an average of twenty-eight months. The average patient age was seventy-eight years, and 91% walked prior to discharge. Two patients had a nonunion of the greater trochanter. There were no deep infections, dislocations, acetabular erosions, or cases of stem loosening.
Broos et al. reported on ninety-four elderly patients treated with a bipolar Vandeputte prosthesis. They found that the average operating time was shorter, the mortality rate was lower, and the functional results were better in the group treated with the bipolar hemiarthroplasty than in groups treated with Ender nailing, an angled blade-plate, or a dynamic hip screw.
Recently, Rodop et al. reported on fifty-four elderly patients who had been treated with a bipolar Leinbach hemiprosthesis (Protek; Sulzer Orthopedics, Baar, Switzerland). A good to excellent result, as assessed with the Harris hip-scoring system, was reported in 80% of the patients. There were no dislocations or cases of stem loosening.
In the current study, 86.6% patient had excellent to good results after follow up period of 1 yrs.
In patients with intemal fixation, advised to put minimal weight on the affected limb.
Despite the advice patient bear more weight. It is difficult to teach them to bear weight only on normal limb.
The most serious complication in arthroplasty is deep infection, rate reported to range from 0 to 3% 27 3° 3 ' . In the current study rate of deep infection is 0% in arthroplasty.
It should be remembered that even in the conventional total hip replacement, the rate of deep infection is higher in patients who have a previous operation on the hip”.
In the current study, rate of postoperative complications are higher in internal fixation as compared to arthroplasty, full weight bearing was delayed in internal fixation. No dislocation was seen in this study. 0 to 7 % dislocations were seen in other studies 27 3°. The rate of dislocation is aggravated by improper prosthesis length, larger the femoral component greater the tendency to dislocate.

Conclusion

1.Patients treated with internal fixation started full weight bearing (avg.10.3 wks) late as compared to hemiarthroplasty (avg. 7.46 days), hence the functional recovery was delayed with internal fixation group.
2.Early post operative harris hip score were good in patients treated with hemiarthroplasty as compared to internal fixation group but at the end of 1 year score was comparable.
3.Post operative complications were more internal fixation group than hemiarthroplasty group and were comparable with other studies.
4.Most of the fractures occure above 50 years were due to trivial trauma. As age advances there is weakning of bones due to osteoporosis and decreased mineralization and deterioration of general condition due to which cancellous bones are prone to fracture with trivial trauma.
5.It is a always advisable since elderly patients with multiple medical problems are prone for hazards of immobilization.
6.Small sample size is one of the limitations of our study. Further, inhomogeneous population in terms of existing co-morbidity is the other limitations.
7.Thus in conclusion, primary hemiarthroplasty does provide a stable, pain-free, and mobile joint with acceptable complication rate as seen in our study; however a larger prospective randomised study comparing the use of dynamic hip screw devices against primary hemiarthroplasty for unstable intertrochantric fractures will be needed

Clinical Message

Although the clinical outcomes were comparable at the end of one year in both groups,arthroplasty patient had lower post-operative complications like bed sores,,pulmonary infection and atelectasis..Major difference was in the duration after which full weight bearing was started,which was significantly early in arthroplasty group.in the end we conclude that hemiarthroplasty is a better option in patients with unstable intertrochanteric fractures.

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How to Cite this Article: Sheikh I. Intertrochantric femur fracture in elderly treated with bipolar vs dhs - a prospective study. Journal Medical Thesis 2014 May-Aug ; 2(2):45-49

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Study of in Vivo and in Vitro Growth of Mycobacterium Tuberculosis From the Intra-operative Samples of Patients of Osteoarticular Tuberculosis


Vol 2 | Issue 2 | May - Aug 2014 | page 39-41 | Agrwal D P, Sonawane D V


Author: Deepak Prakash Agrawal[1], Dhiraj Vithal Sonawane[2].

[1]Seth G.S Medical College And K.E.M Hospital.
[2]GMC & J. J. group of Hospital

Institute at which research was conducted: Seth G.S Medical College And K.E.M Hospital Parel Mumbai.
University Affiliation of Thesis: Maharashtra University of Health Science ( MUHS).
Year of Acceptance: 2009.

Address of Correspondence
Dr. Deepak Prakash Agrawal
Shree Gurukripa, Plot no 133 CIDCO N-3,Near High Court Aurangabad 431003.
Email: dr_dpa@yahoo.com


Abstract

Background: “Study of in vivo and in vitro growth of mycobacterium tuberculosis from the intra-operative samples of patients of osteoarticular tuberculosis”.
Methods: Study was carried out in patients volunteers of osteoarticular tuberculosis . Experimental animal was Swiss albino mice .Pus samples for the study was be obtained from osteoarticular kochs patients intraoperatively. One part was send for BACTEC 460 TB for culture and the other was used for the inoculation in study animal.
Comparison of the final reports of Z-N staining, L-J medium for culture, HPE, BACTEC 460 TB was done between the patient sample and the mice peritoneal lavage sample.
Conclusion: The Z-N staining and LJ medium though cheaper and freely available are not a good method for diagnosis of tuberculosis. The study reflected an outcome of 30% growth by TB - BACTEC method,there is more possibility for isolating the bacilli by TB – BACTEC method from pus sample than that of granulation tissue.As the TB – BACTEC was negative from all mice samples the use of murine model is not suitable for isolation and culture of Mycobacterium tuberculosis.
Keywords: Osteoarticular tuberculosis, murine model.

                                                        THESIS SUMMARY                                                             

Aims and Objectives

The principle aim and objectives of this study are as follows:
1. To grow bacilli in the peritoneum of mice from intra operative pus samples of Koch's patients.
2. To isolate and identify the bacilli and do culture sensitivity against 1st & 2nd line anti tubercular drugs.
To correlate these with clinicoradiological follow up of patients.

Methods

Institutional Ethics committee permission was obtained prior to start of the study.
A) Volunteer selection:
Study was carried out in patients (male / female) volunteers of osteoarticular tuberculosis. After taking written informed consent, all patients with suspected clinicoradiological tuberculosis were included in the study.
B) Inclusion criteria:
· Volunteers of all age group
· Willing to give written informed consent

C) Study procedure:
The study was done to fulfill above-mentioned objectives. The study methodology is given below.
D) Experimental animal:
1) Animal: Mice
2) Strain: Swiss albino mice of either sex
3) Randomization: Randomly selected at the time of delivery.
4) Animal Identification: By cage number and individual marking on tail
5) Weight at the start of study: 20-25 gm.
Animals were handled according to the CPCSEA guidelines for laboratory animal facility15
E) Husbandry conditions:
1) Environment:
Air conditioned with 12-15 filtered fresh air changes per hour, temperature: 22 30C, relative humidity: 30-70%. The temperature in the experimental room was recorded once daily and the humidity in the experimental room was calculated daily from the dry and wet bulb temperature recordings.
2) Accommodation:
A mouse (1 per cage) was housed in separate cages during acclimatization and study (approximate size of cage: 1.290 x W220 x H140 mm). The cage will be of stainless steel top grill having facilities for food and drinking water in glass bottles with stainless steel sipper tube.
3) Diet and water:
Rodent food of Chakan Oil Mills Ltd. Maharashtra given ad libitum. Aqua guard pure water in glass bottle ad libitum.
4) Acclimatization:
Seven days prior to initiation of the treatment for adult mice.
F) Collection of pus sample:
Pus samples for the study was be obtained from osteoarticular kochs patients intraoperatively at Orthopedic Surgery Department. The sample was collected in sterile air tight containers. This pus samples was divided in two parts. One part was send for BACTEC 460 TB for culture and the other was used for the inoculation in study animal at Central Animal house. Sample was also send for Z-N staining, L-J medium for culture and HPE
All the samples were sent immediately for testing to respective laboratories. In case of delay they were refrigerated in OT refrigerator (2-80 C) as advised by concerned microbiologist.

G) Procedure of BACTEC 460 TB16:
Semi automated radiometric BACTEC 460 TB (Becton Dickinson, Sparks, MD, USA) liquid media is used. The detection of mycobacterium growth in BACTEC 12B medium is carried out quantitatively by measuring of the 14CO2 liberated by the metabolism of 14C – labelled substrate present in the medium. Specimen is first decontaminated from normal bacterial flora by using standard N-acetyl-L-cysteine-NaOH method.
All inoculated 12B vials will be tested twice for first three weeks and then once a week for remaining three weeks. Positive vials will be subjected to smear microscopy. Final identification of M. tuberculosis complex (MTB) will be done by the BACTEC NAP (r-nitro-α-acetyl amino-β- hydroxy propiophenone) differentiation test.

H) Inoculation in study animals:
The study animal of either sex was included in the study and injected in two divided doses with pus specimen intraperitoneally (40 ml/kg). At the end of 28 days, all the animals were sacrificed by euthanasia, laparotomy was performed, the viscera was irrigated gently with saline and washings was collected. This irrigated sample was sent for identification and isolation MTB by BACTEC 460 TB. Sample was also send for Z-N staining, L-J medium for culture and HPE.
Comparison of the final reports of Z-N staining, L-J medium for culture, HPE, BACTEC 460 TB was done between the patient sample and the mice peritoneal lavage sample.

I) Parameters of assessment:
1. activity level, feeding (average 10 to 15 gram/week).
2. serial weekly weight monitoring.
3. fur coat- luster and appearance.
J) Disposal of animals:
All the sacrificed animals were disposed taking standard precautions.

K) Implication of the study:
The peritoneal lavage collected during the study was used for culture and sensitivity testing against 1st line and 2nd line AKT. Depending upon the sensitivity pattern the therapy for tuberculosis on the patients can be modified. Many times we come across situations where clinicoradiologically patient does not improve to the expectation, laboratory culture might not be positive for bacteria but if it grows in vitro then sensitivity testing can help us change the drug regime accordingly.

Results

1)Total Patients: 22
2)Ziehl Nelson staining positivity---Human : None
Ziehl Nelson staining positivity--- Mice : None
3)AFB Culture in L-J Medium--- Human : None
AFB Culture in L-J Medium --- Mice : None
4)AFB Culture with Tb-Bactec Method—Human : Six
AFB Culture with Tb-Bactec Method--- Mice : None
5)Scab: Staph. aureus in three specimen in both Human & Mice
6) HPE---Human : Seven S/O of TB
One of NHL
HPE ---Mice : Three S/O of TB
7)MDR Cases: None
8)HIV Positive: None
9)Clinicoradiological inprovement : ALL
10)No. of Death : Two (Died of unrelated causes)
11) TB BACTEC Positive results from tissue : One
TB BACTEC Positive results from pus : Five.

Conclusion

The conclusions of the study came out to be from the 22 samples of osteoarticular tuberculosis are as follows. The Z-N staining and LJ medium though cheaper and freely available are not a good method for diagnosis of tuberculosis.
Out of 22 cases 3 cases turned out to be Staph. aureus which was confirmed with the help SCAB and experimental model of mice with patients responded to routine antibiotics. One patient was diagnosed as NHL. Rest of the patients responded to 1st line AKT with clinicoradiological improvement. 6 patients showed growth on TB – BACTEC culture which was found sensitive to 1st line AKT confirming the clinicoradiological picture.
The study reflected an outcome of 30% growth by TB - BACTEC method. Out of the six samples 5 were pus sample and only 1 sample was granulation tissue sample.
So there is more possibility for isolating the bacilli by TB – BACTEC method from pus sample than that of granulation tissue.
Histopathological examination came out positive in 7 human samples and three mice samples supporting the diagnosis of tuberculosis.
As the TB – BACTEC was negative from all mice samples the use of murine model is not suitable for isolation and culture of Mycobacterium tuberculosis.

 Keywords

Osteoarticular tuberculosis, murine model.

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How to Cite this Article: Agrwal D P, Sonawane D V. Study of in Vivo and in Vitro Growth of Mycobacterium Tuberculosis From the Intra-operative Samples of Patients of Osteoarticular Tuberculosi. Journal Medical Thesis 2014 May-Aug ; 2(2):39-41

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