Monthly Archives: March 2015

JMT Editorial : Outreach of Journal of Medical Thesis

Vol 2 | Issue 3 | Sep - Dec 2014 | page 1-2 | Shyam AK

Author: Dr. Ashok K Shyam

MS Orthopaedics
Editor - Journal of Medical Thesis

One of the most important issues related to any journal is about its outreach and number of people the journal reaches to and is of interest to. Since Journal of Medical Thesis (JMT) started publication two years back, the circulation of the journal is grown exponentially. Also the number of different medical specialities that have shown interest in publishing in JMT has grown. Earlier we used to get many thesis from orthopaedic faculty, now we have started receiving thesis from cardiology, gynaecology and other branches. This shows that Journal is slowly but surely picking up with the academic world.

JMT is a unique experiment and one of its kind journal in the world. The idea of JMT was to pool data from all thesis and make it available in public domain for all to access [1]. Something like a clinical trial registry, this was an attempt to make a registry for Medical Thesis. This is aimed at reducing the number of duplicate thesis and also prevent plagiarism. With thesis getting recognition by being published in JMT, the students also feel responsible to execute a good thesis. Over a period of time all these factors will help improve the quality of thesis that are published. Also providing this platform we aim to motivate the thesis guide who get adequate academic credit by publishing in JMT. The idea has been appreciated by many head of departments and deans that I have spoken to and we have received quite a few suggestions to improve the format and also the review process. We currently have more than 200 reviewers with us and the number is steadily growing. This will in turn improve the review process although time to publication will also increase.

JMT has been a bit delayed due to change in format and also technical modification we needed with new indexes. In attempt to increase the outreach of the Journal, head of departments and deans of medical colleges are being send invitations to be a part of the JMT Network and also submit their thesis to us for publications. This will help them create an e-library of their thesis with us which will be permanent and in public domain. This will help in developing the academic character of the institute or the college and also will encourage some competitiveness among the colleges. These factors will again help in improving the dedication with which the students will undertake their thesis and also develop an interest in the institute to promote good and relevant research. We will request the departments and the medical colleges to participate and collaborate with JMT to make this a successful model nationally and then internationally.
In line with our aim to improve the thesis quality, the Journal of Medical thesis is also conducting workshops on how to write a thesis and what all is needed to convert it to a publication [2]. We have been regularly conducting these workshops and last one was in Sir JJ Group of Government Hospitals in Mumbai.

These courses are one full day course and we talk about a lot of practical issues that student face while they do their thesis, especially for busy clinical branches. There were around a 100 students who attended the workshop and many are still in touch with JMT Team. We will also try and run symposia in every issue of JMT where a team of post graduate teachers will write about what they want their students to know about doing a post graduate thesis and how to do it in the right manner. This may take some more time but the process has already started and probably a department wise invitation will be extended. We would like the head of departments of medical colleges to join the JMT Editorial board and form a collective pool of intellectuals who can decide on the format of the journal and also help in provide suggestions for improving Thesis in the country.

Lastly the idea of JMT has been a bit of revolutionary in terms of being the first of its kind journal and has been taken up by other faculties too. A Journal of Engineering Thesis is already in discussion and will soon be launched for students of engineering and similar discussions are ongoing in field of business management too. I feel this is a good initiative and this shows the potential of idea of JMT to increase its outreach and have a cross faculty impact. We wish the new journals and their teams a very best luck for their endeavours.

Finally I would like to extend an appeal to all post graduates in medicine and allied branches to please submit their work in JMT. The journal already has a huge outreach and soon the number of people accessing JMT will exceed manifold. The special focus would be submission of thesis protocol or synopsis in the hypothesis format. This is most useful in terms of 'patenting' the intellectual property and avoiding misuse of your idea or hypothesis [3]. With this appeal I will leave you to enjoy the new issue of JMT.

Dr Ashok Shyam
Editor – JMT


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

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

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

How to Cite this Article:  Shyam AK. Editorial: Outreach of Journal of Medical Thesis. Journal Medical Thesis 2014 Sep - Dec; 2(3):1-2

Download Full Text PDF  | Download Full Thesis




Phobia about Thesis in Medical Postgraduate student

Vol 2 | Issue 3 | Sep - Dec 2014 | page:3-4 | Dr. Dhiraj Sonawane[1].

Author: Dr. Dhiraj Sonawane[1]

[1]J.J Hospital Mumbai.


A thesis or dissertation is a document submitted in support of candidature for an academic degree or professional qualification presenting the author's research and findings (1) As per the Regulations of Medical Council of India, M.D. thesis has been made an essential part of the degree course as this gives training in research methodology.(20)
Is it so? Not at least for most medical post graduate students. Thesis is usually seen by different aspect by students, guides and institutes.
For most guides it is some work given by university that has to be completed by the postgraduate student during his training which he has to approve some day before final day of submission. For institute/ university it is 'must do' for appearing in MD/MS exams without completing and approving it, the candidate won't be allowed to appear for exams. The past and present scenario had not changed much; thesis completion had been seen as obligation for passing exam. Most medical post graduate student (MPGS) looks at it as an “unknown creature” which he has never exposed throughout his medical education, and he doesn't know what to do with this. He only knows that this is a passport which will allow him to appear for the course completion exam and somehow he has to win over this unknown creature. As the time passes this creature grows bigger and complex. These students are unaware of the fact that this unknown creature is going to help them to fly high in their career. Education & awareness about research, thesis writing, and publishing should be given to the medical student at various levels for improvement of the present scenario.
Thesis being the first and for most the last research work, of the medical post graduate student. In the present world where every country, every university, institute are focusing towards research and publication, our first research of most medical student is just become copy and paste of others research work. Few medical speciality students give the reasons for this that they have no time during busy residency, thesis topic is given late, they don't know how to make thesis, less time left for submission of thesis, guides not giving enough time etc. which is not completely true. All this reasons are mostly to avoid meeting this unknown creature and monster. The guide has most important role in teaching his student to carry out research. Many guides themselves have lost interest in research project while few do not know how to carry out it.
Students are usually given topic by the guide as per the interest of the guide. No effort are usually been taken to take challenging or new research topic. The easiest way for student is to select topic is to ask seniors, few try to find already done thesis, some search on Pubmed. After the topic is finalised which is mostly the repetition of same research work already studied many times; the thesis is send for ethical committee clearance where some are asked queries, few given modification & rarely any getting rejected. The final hunt for this unknown is started just few months before the final date of submission. The candidate has to finish this within this time frame or the candidate won't be allowed to appear for the qualifying exams. Most guides usually give some correction and later sign before the last date of thesis submission. Some give multiple corrections before approval, and few are notorious of not giving approval easily.
Most students find the way of thesis completion like
· Copying from previous year's thesis, published articles, books, internet etc.
· Manipulating the data to support the hypothesis.
· Sometimes running behind the guide for approval or giving gifts to guides
This all is fixed in the format given by the respective university. Final product delivered out is a good looking thesis decorated with images and colourful charts and diagram. Most of us must have gone through this phase doing similar thing. Since decades it is mostly unchanged and if it is going in same way; in long term will yield poor research and minimal progress in our speciality. Thesis being the first research is for training the student in research work. After completing their post graduation some join teaching institute, few start private practise, few continue with further education. Research work done during completion of thesis is of great help for everyone. One with research and publications is pushed much ahead at every stage than the other without it. For practising doctor, it helps to understand and analyse the journal research articles which help him to update his knowledge and practicing style, build his curriculum vitae and for affiliation to major institutes as lecturers/consultants as research and published work is asked during interviews. For consultants/ faculties in teaching institutes it helps to carry out research work in future, reducing years of eligibility of PG guide, getting further promotions in designation, to guide their students as PG guides in research, understanding others research work and teaching to students and trainee under him. For students continuing with further education; candidate with research and publication are given preferences for fellowships as this helps the guide to carry their research project; while candidates opting for superspeciality has to complete another thesis during their training.
In recent years few steps have been taken by universities like assessment and reviewing of thesis by a PG guide outside universities & cancellation of repeating thesis topic. Due to this many thesis are getting correction, while few thesis are getting rejected. Institutes are sanctioning some funds to carry out research though not enough for few researches.
Also teaching MPGS with courses and work shop like 'Thesis Writing Course'(6) and 'Publish and Flourish'(7) are being conducted by speciality organisations and research groups.
Many good articles available to guide students to write manuscript are available. The common ones are 'how to read a scientific paper'(2), 'art of scientific writing'(3), 'tip for how to write a paper'(4), 'scientific writing a fun'(5) etc.

More steps for promoting research should be taken by institute/ university. This can be done by
- Training programmes like thesis writing and research study work shop for refreshing PG guides knowledge and teaching medical students.
- Including research and research methodology in more details during undergraduation.
- Weekday meets for discussion on research and thesis.
- Giving grants for carrying out research.
- Providing free access to various research articles to carry out research projects.
- Reducing duties hours of residents in institutes with huge patient load.
- Awards for the best 10 thesis in university with preference given to challenging/ new research topics.

Thesis phobia in MPGS is mainly due to lack of knowledge to do research and in writing thesis. The solution to this is by providing knowledge about research and thesis writing during undergraduation and post graduation.
It the inclusive responsibility of all student, guide, university, organisation to take out specialities to next level, which can be done mainly by education and awareness of research.


1. Originally, the word compounds "dissertation" and "thesis" (plural, "theses") were not interchangeable. When, at ancient universities, the lector had completed his lecture, there would traditionally follow a disputation, during which students could take up certain points and argue them. The position that one took during a disputation was the thesis, while the dissertation was the line of reasoning with which one buttressed it. Olga Weijers: The medieval disputatio. In: Hora est! (On dissertations), p.23-27. Leiden University Library, 2005.
2. Post Graduate Medical Education. Regulations on the Medical Council of India. New Delhi: Medical Council of India; 2000.
3. Thesis writing and journal publication course.
4. Publish and flourish.
5. David W. Ramey, DVM. How to Read a Scientific Paper. AAEP Proceedingspg.1999,45:280-84.
6. Charles W. Van Way, III, MD. Writing a Scientific Paper. Nutrition in Clinical Practice December 2007,22: 636-40.
7. Timothy M. Johnson, Ann Arbor, Michigan. Tips on how to write a paper. J AM Acad Dermatol.2008,59:1064-69.

How to Cite this Article: Sonawane D. Phobia about Thesis in Medical Postgraduate student. Journal Medical Thesis 2014 Sep-Dec ;  2(2):3- 4.

Download Full Text PDF   |  Download Full Thesis

Effect of Inspiratory Muscle Training (IMT) On Aerobic Performance in Young Healthy Sedentary Individuals

Vol 2 | Issue 3 | Sep - Dec 2014 | page:12-16 | Komal Jakhotia, Neha Jain, Seemi Retharekar, Apurv Shimpi, Savita Rairikar,  Ashok Shyam, Parag Sancheti.

Author: Komal Jakhotia[1], Neha Jain[2],  Seemi Retharekar[1], Apurv Shimpi[1],  Savita Rairikar[1],  Ashok Shyam[3], Parag Sancheti[3]

[1]Sancheti Institute College of Physiotherapy, Thube Park, Shivajinagar, Pune .
[2] M.A Rangoonwala College of Physiotherapy and Research, KB Hidayatullah road, Pune.
[3] Sancheti Institute Of Orthopaedics and Rehabilitation, Shivajinagar, Pune

Institute at which research was conducted: Sancheti Healthcare Academy, Sancheti Institute College Of Physiotherapy, Thube Park, Shivajinagar, Pune.
University Affiliation of Thesis: Mumbai Universityof Health Sciences, Nashik.
Year of Acceptance: 2013.

Address of Correspondence
Dr. Komal Jakhotia
Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, 12, Thube Park, Shivaji Nagar, Pune – 411005, Maharashtra, India.


Background: Respiratory muscles like all other skeletal muscles improve their function in response to training. The principles of progressive overload and specificity of training apply to respiratory muscles also. Inspite so many studies on effect of RMT (respiratory muscle training) on athletes and other respiratory conditions, there is lack of literature on RMT in healthy individuals.
Methods: 50 subjects were divided in 2 groups (25 each): training and control group. The training group was given 4-week inspiratory muscle training program while the control group did not participate in any form of training. IMT was given with an elastic resistant band tied around the thorax at the xiphisternal level. 30 breaths twice a day, 6 days a week for 4 weeks was given. Outcome measures: shuttle run test (SRT) and estimated .
Conclusion: Specific inspiratory muscle training shows significant improvement in aerobic capacity.
Keywords: Inspiratory muscle training, aerobic capacity.
Thesis Question: Does specific Inspiratory muscle training improves aerobic performance
Thesis Answer: Specific training of the inspiratory muscles enhanced aerobic capacity and exercise performance in healthy individuals. However there was no significant improvement in exercise tolerance.

                                                        THESIS SUMMARY                                                             


Maximal aerobic capacity of an individual is evaluated on the basis of maximal oxygen uptake (V ̇O2max). It is dependent on the optimum functioning of various systems such as the respiratory system, circulatory system & neuromuscular system. Respiratory system also has been identified as a limiting factor in aerobic capacity of an individual; which is clinically observed as respiratory muscle fatigue and/or hyperventilation (Boutellier U & Büchel R et al,1992; Boutellier U, Piwko P,1992) During high intensity exercise fatigue of respiratory muscles have a cumulative effect along with already fatigued peripheral muscles contributing to increased perception of breathlessness i.e. how hard the exercise feels further limiting the exercise performance. Apart from the respiratory system, the musculoskeletal system plays a crucial role in aerobic conditioning including lung ventilation. Respiratory muscles like all other peripheral muscles are skeletal muscles. They improve in their function in response to training. At the same time lack of activity also deconditions them. The cardiovascular fitness reflected by aerobic capacity in sedentary individuals is reduced than normal.Hence, we proposed that IMT (inspiratory muscle training) in normal healthy sedentary individuals can be used as one of the ergogenic aids in improving aerobic performance. Hence, we hypothesized that during increased demand in ventilation such as when exercising; there is high probability that improved respiratory muscle strength would improve the aerobic capacity and exercise tolerance. To examine this hypothesis we assessed the aerobic capacity & exercise tolerance during a progressive exercise test before & after a 4 week of respiratory muscle training program.

Materials and Methods

Study Design:
This was a randomized controlled study. Fifty healthy college students of both sexes (17 males, 33 females) of mean age 22.3+2 were selected in this study. All participants were informed of the nature of the study and written consent was taken prior to the study. At the initial screening, physical activity status of all individuals was determined through Physical Activity Readiness Questionnaire (PAR- Q).The participants were equally divided into 2 groups. The training group of 25 participants was required to complete a 4-week supervised program of IMT. The participants performed no other form of exercise training during this study period. The control group did not participate in any form of training (n=25). The independent variables were age & gender and were equally distributed between the 2 groups. The dependent variables measured were inspiratory muscle strength, aerobic capacity, exercise performance & exercise tolerance levels. The study was approved by the ethical committee of the institution & according to the Helsinki Declaration prior to beginning.

The participants were divided randomly in 2 groups by random number table. 25 participants in training group and control group respectively. Participants between the age of 18-25 years & within normal PI max values of 91+25cm H2O were included. Participants with any history of chronic airflow limitation like asthma or any neuromuscular condition were excluded. All participants were non smokers. The training was mainly focused on young healthy individuals to avoid influence of any age- related degenerative changes or associated respiratory conditions.

PI max equipment. The reliability & validity was checked at the institutional level.

This study was conducted at a tertiary care centre. The sample size was calculated before starting the study. The random allocation sequence was generated by the random number table. This was a single blinded study. A care provider enrolled the participants and assigned participants to the respective interventions. The researcher assessing the outcome measures was blinded after assignment to interventions.
Prior to the intervention, the inspiratory muscle strength was determined by the MIP values. Following this, the training group was given IMT for 4 weeks.

Inspiratory muscle strength- The simplest scientific measurement of the inspiratory muscle strength is maximum inspiratory (PImax) mouth pressures. Each participant’s MIP was determined using PI Max equipment. Participants were instructed to exert maximal inspiratory effort against a closed valve gradually after a forced expiration and to maintain it for 1 second. The nose was plugged during the test procedure to avoid leakage of exhaled air. The participant was asked to look at the needle of the device for a visual feedback. Three consecutive efforts were recorded allowing 1- minute pause between each effort. The mean value of the three readings was taken as the final measurement.

IMT Protocol- IMT was given with an elastic resistant bands (theraband) tied firmly circumferentially around the thorax at the xiphisternal level. The xiphisternal level was selected as the thoracic expansion at this level of the ribcage is maximum. The subject was advised to take deep breaths and expand the chest against the resistance of the theraband. When MIP readings were taken, the participants were asked to remember the feel of it. They were also given adequate number of trails before starting IMT. The participants were asked to exert their MIP and sustain the MIP for 5 seconds. The resistance was gradually increased depending on perception of individuals’ inspiratory muscle effort by progressing from yellow to green theraband. 5 sets of 6 breaths each with a rest period of 4-6 seconds after each set was given twice a day, 6 days a week for 4 weeks.
Figure I: Anterior view of the elastic band (theraband) tied to lower thoracic cage at the xiphisternal level. The participant was asked to expand the ribcage maximally against the resistance of the band at this level.
Figure II. Lateral view of elastic band tied to the lower thoracic cage to resist the bucket handle movement of ribs & hence strengthening the inspiratory muscles.
Exercise test- A progressive incremental multistage 20m shuttle run test was performed before & after IMT. The exercise test was continued till the stage of exhaustion. The estimated V ̇O2max correlating to the shuttle run test performance was calculated.
Respiratory effort during exercise: At completion of the shuttle run each participant score of breathlessness on a modified Borg scale of 6-20 was measured. The subject was told to estimate the perception of breathlessness on the scale
at the end of the test performance.
Primary outcome measures: Shuttle run test, estimated VO2max and Borg scale.
Secondary outcome measures: Peak heart rate & respiratory rate.
Statistical analysis: All the baseline values (table I) reported as mean difference (SD) of MIP, SRT & estimated V ̇O2max, RR, HR were comparable between the two groups and hence analyzed using t-test. Paired t-test was used to analyze pre and post values after 4 weeks (intra group). Unpaired t-test was used to analyze the difference between training and control group (inter group). 12th version of SPSS software was used. A p value of less than 0.05 was considered significant.

Observation and Results

All the subjects repeated the shuttle run test after 4 weeks. All the subjects in training group completed the study. A confidence interval (CI) of 95% was considered for all the outcome measures & both the groups. The effectiveness of muscle training was demonstrated by increase in the MIP values in the training group significantly. (p<0.05). The estimated effect size (EES) for this group was 0.64.
Intra-group pre and post training values of Shuttle run test (SRT) performance in training group showed significant improvement.(p<0.05) (0.54 EES). The V ̇O2max increased from significantly (p<0.05) (0.55 EES) in training group. But even in the control group SRT significantly increased (p<0.05) (0.01 EES), but the associated V ̇O2 max did not show a statistically significant change (p>0.05) (0.00 EES).
However, inter-group analysis of SRT and estimated V ̇O2max between the training & control group using unpaired t test demonstrated a statistically significant improvement in SRT in the training group as compared to control group (p<0.05). At SRT completion, Borg scale of rate of perceived exertion (RPE) was not influenced by IMT. The RPE values remained significantly unchanged in training group (0.31 EES) and control group (p>0.05) (0.08 EES). The peak respiratory rate i.e. RR and heart rate in the training group reduced (p<0.05) (1.01 EES), (p<0.05) (0.16 EES) which showed significant cardiovascular conditioning. There was no significant improvement seen in the control group in RPE, maximal heart rate & respiratory rate.


In the above study effect of IMT on inspiratory muscle strength and aerobic performance was assessed. The participants were given 4 weeks of IMT. Pre and post training, aerobic capacity, exercise performance and exercise tolerance was assessed by estimated V ̇O2max, shuttle run test and Borg scale respectively. After the IMT, aerobic capacity and exercise performance significantly improved however the exercise tolerance (RPE) did not show significant improvement. In our study, IMT training improved respiratory muscles strength significantly in the training group. We expected the increase in inspiratory muscle strength to allow us to examine the effects of respiratory muscle strengthening on aerobic capacity, exercise performance & tolerance. During inspiration, with the descent of diaphragm, first the vertical diameter increases. As the descent continues, the transverse & A-P diameter increases; thus making 3-dimensional expansion. The circumferentially tied theraband uniformly resisted the act of inspiration indirectly resisting the action of diaphragm & associated synergists like the intercostals thus helping in its strengthening. The post training improvement in MIP reflected the improvement in strength of the inspiratory muscles. Strengthening of any skeletal muscle is primarily based on the overload principle. Hence we expected that progressive resistive strengthening of the inspiratory muscles will improve the lung ventilation influencing the ventilatory system to efficiently contribute in overall increase in aerobic capacity. Previous papers have shown that the respiratory system is not stimulated by whole body exercise. Recent evidences suggests that inspiratory muscle training along with limb exercise can be more effective in reducing rate of perceived exertion and improving exercise performance in athletes, increase inspiratory muscle strength and endurance and improved pulmonary function. IMT training improved aerobic capacity which was reflected by improvement of post training SRT. SRT reflects the overall aerobic capacity of the cardiovascular and respiratory systems and the ability to carry out exercise for prolonged time. Maximal oxygen uptake (V ̇O2max) reflects the oxygen delivery to the exercising muscles by the cardiovascular system. Because of the linear relationship between oxygen consumption and running velocity strong correlations exist between running performance in SRT and V ̇O2max .V ̇O2max based on the SRT performance also showed a statistically significant improvement. The delay in reaching peak threshold of lactate concentration & improved channelization of oxygenated blood flow to the limb muscle from cardiovascular & respiratory system can be the contributing factors. IMT may potentially reduce metabolic requirements of the inspiratory muscles during intense exercise thereby reducing lactate accumulation. This reduces the stimulation of diaphragm metaboreceptors and increases the threshold for activation of the metaboreflex. . As a result the vasoconstrictor effect of the metaboreflex diminishes, directing the blood flow & improved O2 availability to the limbs. During the progressive exercise test, the minute ventilation & the work of breathing increases resulting in increased effort of breathing. With IMT we expected a reduction in this sensation of respiratory effort and hence exercise tolerance. However in the present study Borg Scale for Rating of Perceived Exertion (RPE) scores the training group or the control group remained unchanged. This can be contributed to a short duration of training of 4 weeks. In fact, hyperventilation commonly occurs over time during prolonged heavy exercise because of accessory respiratory muscles recruitment .The changes in muscle recruitment patterns may lead to mechanical inefficiency of breathing. This may significantly limit exercise performance and increase may the work of breathing. During high-intensity exercise; the respiratory muscles consume ~10-15% of the total V ̇O2max which suggest that the respiratory system could potentially limit V ̇O2 max . Thus, respiratory effort adds to the peripheral working muscles fatigue. The sensation of breathlessness further prevents the individuals’ exercise tolerance. In contrast to our results, in a study at a given work load while IMT did decrease RPE while expiratory muscle training did not decrease RPE. The cardiovascular adaptations or conditioning such as reduction in the peak heart rate and respiratory rate were observed in this study. A short duration of 4 weeks of training also has shown apparent cardiovascular conditioning.

Study limitations: The amount of resistance applied to the inspiratory muscles through the elastic bands is very subjective. It depends on the individuals’ effort to take a deep breath. Also, the sample size was small when done on normal healthy individuals. The study can be further done to generalize the effect to a bigger population.

Clinical Message

Inspite of the limitations stated above, the technique of IMT is very simple and can be used in various clinical settings without requiring any specific training equipment. IMT can be applicable to a vast population including long term bed ridden patients, as part of general fitness program & rehabilitation program to improve the cardiopulmonary endurance of the people. The focus on IMT is still not into vogue & needs to be emphasized.


The above results showed that specific training of the inspiratory muscles enhanced aerobic capacity and exercise performance in healthy individuals. However there was no significant improvement in exercise tolerance.


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How to Cite this Article: Jakhotia K, Jain N, Retharekar S, Shimpi A, Rairikar S, Shyam A, Sancheti P. Effect Of Inspiratory Muscle Training (Imt) On Aerobic Performance In Young Healthy Sedentary Individuals. Journal Medical Thesis 2014  Sep-Dec ; 2(3):21-25.

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A Study of Non-Union of Tibia Treated with Bone Transport

Vol 2 | Issue 3 | Sep - Dec 2014 | page:26-30 | Neetin Pralhad Mahajan, Yogesh Savliram Gangurde,  Sangeet Keshav Gawhale

Author: Neetin Pralhad Mahajan[1], Yogesh Savliram Gangurde[1],  Sangeet Keshav Gawhale[1]

[1] GGMC and Sir JJ group of hospitals, Mumbai-08.

Institute at which research was conducted: GGMC and Sir JJ group of hospitals, Mumbai-08.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2005.

Address of Correspondence
Dr. Yogesh Savliram Gangurde
Assistant Professor In Dept. Of Orthopaedic
At Govt.Medical College, Aurangabad-431001


Background: Our study is planned to access closure of intercalary defect non union with segment transport over nail and without nail with ring fixator and problems during the procedure and complications of the procedure.
Methods: 32 Cases of nonunion of tibia following compound injury were taken into consideration for present study.
Results: In our series we achieved excellent results in 60 % cases,good to fair in 37 % and poor results only in 3% cases.We found that due to incorporation of tibia interlocking nail in the ring fixator construct Ilizarov fixation was only required for transportation of middle fragment. It avoided prolonged treatment with fixator. This gave patient high comfort and allowed to perform good Knee and ankle function.
Conclusion: Bone transport technique for treating nonunions in tibia though technically very demanding and with potential complications has emerged as most effective single treatment modality for management of all kinds of nonunions in Tibia.
Keywords: Ilizarov, bone transport ,tibia -nonunion.

                                                        THESIS SUMMARY                                                             


Non-Union of Tibia following compound injury is one of the challenging problems to Orthopaedicians. One may come across difficulties like Bone loss, Deformity, Infection, draining sinuses and osteomyelitis,Limb length discrepancy, Joint stiffness and non-union. Conventional methods of treating such problems are extensive debridement, local soft tissue rotation flap. Illizarov's techniques(distraction neohistiogenesis) has been beneficial in infected defect nonunion as it allows simultaneous treatment of bone loss, infection, nonunion and deformity. Bone transport has been one of the good techniques for treating difficult post-traumatic tibial defects.During this procedure, the various difficulties are encountered like Axial deviation, Deformities, Anatomical malalignment, Soft tissue invasion at docking site ,Prolonged fixator time, Pin tract sepsis, Longer hospital stay and associated antecedent psychological problems. Incorporation of tibial nail in the fixator construct and using fixator only to transport bone segment over the nail is an alternative to avoid above difficulties, provided infection is under control for smaller defects, acute docking and subsequent lengthening of tibia is an alternative for reconstruction.Our present study is being conducted to study different levels of bone transport in post traumatic non unions of tibia.


32 Cases of nonunion of tibia following compound injury in road traphic accident from 1995 to 2004 admitted in the J. J. Group of Hospitals, Mumbai were taken into consideration for present study. All the patients were assessed on admission for level of non-union in tibia, shortening of extremities, neurovascular deficit, deformity, previous surgical procedure performed, extent of infection, conditions of soft tissue over the anteromedial aspect tibia, function in the knee and ankle joints on clinical examination, the nonunion was classified as stiff or mobile and limb length discrepancy calculated. Preoperative radiological evaluation was done to determine level of nonunion in tibia, deformity, assessment of alignment, classification of nonunion as atrophic or hypertrophic and to look for evidence of osteomyelitis. The patients with soft tissue defects on the anteromedial side (shin of tibia) were subjected to soft tissue coverage. The patients with active draining sinuses and wound were subjected to a. Curettage / sinus excision b. Debridement accompanied by resection of non-viable necrotic bone until punctuate bleeding from the cortex was seen.
Infected material was sent for culture sensitivity and antibiotics were administered for at least for 3 weeks as per sensitivity. Radiographic evaluation was done to determine level of nonunion, deformity and defect in cms with or without shortening. In smaller defects less than 5 cm acute docking of the fragments and subsequent lengthening after Corticotomy and fibular Osteotomy was planned,bifocal osteosynthesis was planned for tibial defects requiring more than 5 cm of bone transport. Trifocal osteosynthesis was planned using proximal and distal corticotomies for tibial defect requiring larger transport (more than 12 cm) to reduce the time of distraction. In larger defects, tibia-interlocking nail was planned in fixator construct to get normal alignment of tibia and reduce the fixator time.Preplanned custom-made tibia interlocking nail was ordered with provision for proximal and distal locking and with provision for the locking of transport fragment near docking site.

Observation and Result

There were 32 tibial non-unions following compound injury in vehicular accident of them 28 males and 4 females. The mean length of segmental defects following sequestrectomy in tibia or removal of nonviable diseased bone was 7.7 cm [3.5 to 14 cms]. In all cases, the defect was successfully reconstructed using bone transport either by biofocalosteosynthesis or trifocal osteosynthesis. The mean latency period in our series was 7 days [7-10days]. The patient was allowed to weight bear as soon as pain subsided. Knee and ankle mobilization exercises was started preferably on 2nd day of surgery The mean duration of external fixator was 7.56 months [3 months-21 months]. The mean time required for consolidation of regenerate bone was 4.5 month [2 months-6 months].
The mean distraction gap was 7.7 cm [3-14cm] The mesn external fixation index was 1.13 month/cm [0.38-3.7 months/cm] The mean distraction index was found to be 34 days/cm [5.53-93 days/cm] The mean distraction consolidation index [maturation index] was 21/6 days/cm [1.08-102 days /cm]
All the patients in our series united successfully except in 2 patients A] In one, union could not be achieved using proximal corticotomy and needed revision of fixator and corticotomy distally and union was achieved at 7.5 months. B] In one patient with bilateral nonunion, tibia failed to unite on one side. He was treated with removal of assembly and open interlocking nailing and bone grafting, is still undergoing treatment for delayed union.
Infection was effectively controlled by debridement, sequestrectomy and preoperatively antibiotics for at least 3 weeks as per culture and sensitivity of material. In all cases, discharging sinuses healed completely. But in only one patient, there was recurrence of infection one year after removal of fixator, with a sequestrum formation. He was treated successfully with sequestrectomy and curettage.
All patients had fairly good range of movements in knee and ankle.
• Except in five patients, in whom average loss of movement was found to be around 50-60 % when compared to normal side but this existed before the above treatment was started.
• Knee and ankle movements were fairly good in cases that have undergone transport over nail.
• One patient needed triple arthrodesis for uncorrectable foot deformity.
• The fixator time was longer in patient with transport without nail from 4-18 months. It was significantly reduced by performing bone grafting at docking site
[5-8 months]
• The fixator time was found to be less [3 months to 14 months] in transport over the nail.
• The fixator time in acute docking and lengthening was found to be 10 to 13 months.
• There were on an average 3 episodes of pin site infection which were treated with dressings.
• One patient developed pin site abscess was treated with incision and drainage and antibiotics.
• Malalignment and axial deviation of transporting fragment was noticed in four patients at distraction site and this was successfully controlled by adjustment of the Ilizarov assembly.
• No malalignment was seen cases with transport over nail. ..
• Poor quality regenerate was seen on x-ray in 3 patients and needed reduction in rate of distraction.[0.5mm/day]
• Hypertrophic regenerate was seen in one patient required increase in rate of distraction to two folds. [2mm/day].
• Normotrophic regenerate was seen rest 28 patients.
• There was no evidence of immediate neurovascular injury due to placement of pins.
• No patient suffered from any delayed neurovascular injury during distraction phase.
The limb length discrepancy was not significant in our series. With the proper preoperative planning, it was almost corrected in the segment transport. It ranges from 0.5 to 2 cm.
• Refracture was seen in only one patient who sustained direct blow on united tibia with a heavy stone after 6 months of union. He was treated with Bone grafting and plaster cast. Union was achieved after 4 month.
• In our series, on patient suffered from any psychiatric illness after thorough counselling about the treatment.
• There was no evidence of compartment syndrome after syndrome.
• No patient developed hypertension during treatment period.
• There was no evidence of any stress fracture during removal of fixator.
• The hospital stay in our series ranges from 4 months to 6 months.
• It was found be less in patients with transport over nail from 2 to 3.5 months.


The Illizarov method of bone transport is an ideal treatment for all kinds of tibial nonunion with bone loss, which presents with many perplexing problems to the treating surgeon. This method is advantageous in treating infected nonunions, reconstructions of tibial defects, correction of deformities, maintaining limb length and allows early weight bearing with fixator. Conventional methods as stated have limited application in treating defects and taking years to corticalise and function. In our study, we have experienced good results following radical debridement and restoring medullary canal and bone grafting at docking site. Similar results were obtained in the study of F. Dagheret al. In our study, bone grafting at docking site reduced the fixator time. But only single radical debridement of diseased bone exposing vascular cortex and good antibiotic coverage before application of ring fixator was good alternative for complete eradication of infection from Tibia. No patient in our study required PMMA beads at nonunion site for eradication of infection. They united completely without any residual infection. Where as multiple debridements were required for treating infection in the study of LesleNeggaret al. In our experience, we found that bone grafting at docking site definitely reduces the fixator time and helps in achieving early union. But for longer defects, trifocal osteosynthesis using proximal and distal corticotomies are ideal to fill the defect early, achieve good consolidation and avoiding bone grafting at regenerate site and further chances of refracture of regenerate bone. Malalignment was not significant in our study with use of 2 halfshanz pins in the transporting fragment in addition to single ring. No malalignment was seen in patients with transport over nail. Functional result, joint functions, malalignment and deformity etc.complications were prevented using nail in the construct. One patient required recorticotomy and multiple adjustment. In our series also, 2 hypertrophic nonunion treated with acute docking and corticotomy [lengthening] achieved union after 6 months. Bone grafting at docking significantly achieved early union in one patient and reduced duration of fixation. In remaining 6 patients union was achieved with segment transport only. No bone grafting was performed at docking site. Similar results were seen in study of M, Cattagniet al. We state the corticotomy is alone a potent stimulus for union in Hypertrophic nonununion once the stable fixation is achieved.In our series of 8 patients treated with transport over nail, we found that incorporation of tibia interlocking nail in the ring fixator construct compared to study of Hoffman G.O. et al. In fact, Ilizarov fixation was only required for transportation of middle fragment. Once the transport was complete and fragments were locked, fixator was removed. It avoided prolonged treatment with fixator. This gave patient high comfort and allowed to perform good Knee and ankle function. The most common problem in our series was pin site infection associated with wire loosening. This was adequately tackled with frequent for tension at weekly interval was must for success of bone transport. There was no evidence of deep sepsis or intramedullary infection in cases of transport over nail. The time required for transport and external fixation in trifocal osteosynthesis was comparatively less as that for bifocal osteogenesis.


Internal bone transport using Ilizarov's principles of distraction and transformational osteogenesis for nonunion of long bones especially tibia is an ideal method to achieve union, simultaneously correct the deformity and restore the normal limb length and maintain function in knee and ankle joint. We conclude that,
• For defects less than 5 cm, acute docking and subsequent lengthening of the corticotomy serves better alternative for treating smaller defects and hypertrophic nonunion.
• Bone grafting at docking site helps to reduce external fixation time and achieve union early.
• For defects more than 5 cm, with or without shortening, bifocal osteosynthesis using segment transport is an ideal method.
• Segment transport in cases requiring transport more than 18% of the original bone length in tibia has problems mainly due to long duration of transport and fixator.
• Bone transport over unreamed intramedullary interlocking nails in such situations significantly reduces external fixation time and complications.
• Use of nail in the construct neither compromises quality nor quantity of the regenerate.
• Its prevents complications such as Missed target and malalignments Deep pin tract infections Fracture of the regenerate bone 20.
• Bone transport over nail can be performed in infected nonunions of tibia after thorough debridement of necrotic bone and preoperative treatment with antibiotics for at least 3 weeks.
• thorough primary debridement and early good soft tissue coverage are mandatory for good results in such patients.
• Maintaining fixator till consolidation of regenerate is mandatory to achieve union without secondary procedures in transport without nail.
• Supplementation of autologous cancellous bone grafting after clearing of fibrous tissue from ends of bone two weeks prior to docking accelerates and facilitates healing.
• Distraction alone acts as a potent stimulus for union in hypertrophic nonunions of tibia as after corticotomy blood supply increases.
• Functional loading of leg and knee and ankle joint mobilization within first few days of fixator application helps in long-term functional rehabilitation of patient.
• Preoperative psychological counselling regarding long treatment and support throughout treatment is necessary for successful completion of treatment.
• Problems, obstacles and complications can be prevented and corrected by good preoperative planning and patient motivation.
Thus, Bone transport technique for treating nonunions in tibia though technically very demanding and with potential complications has emerged as most effective single treatment modality for management of all kinds of nonunions in Tibia.

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How to Cite this Article: Mahajan N P, Gangurde Y S, Gawhale S K. A Study of Non-Union of Tibia Treated with Bone Transport. Journal Medical Thesis 2014  Sep-Dec ; 2(3):26-30

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