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.

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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.

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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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.

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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22. Chang W S,Zuckerman J D,Kummer F J.Frankel V H:Biomechanical evaluation of anatomical reduction vs medial displacement osteotomy in unstable intertrochanteric fractures.clinical orthop relat res 1987;225:141-146.
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24. Davis T R , Sher J L , Horsman A , Simpson M , Porter B B : Intertrochanteric femoral fracture. Mechanical failure after intemal fixation. J B J S —B 1990 ;72 : 26-31.
25. Levy R N , Siegel Mark , Sedlin E D , Siffert R S : Complications of Ender-pin fixation in Basicervical , intertrochanteric and subtrochanteric fracture of the hip . J B J S. JAN 1983 ;65-A: 66-69.
26. Sherk H H , Foster M D : Hip fractures: Condylocephlic rod vs Compression screw .Clin Orthop . 1985 ; 192 : 255-259.
27. Stem M B , Angerman A: Comminuted intertrochanteric fractures treated with a Leinbach prosthesis. Clinical Orthop relat Res ,l987 ; 218 : 75-80.
28. Haentjens P , Casteleyn P P , Deboeck H , Handelberg F and Opdecam P : Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with intemal fixation . J B J S Am 1989 ;l2l4-1225.
29. Rosenfeld R T , Schwartz D R and Alter A H : Prosthetic replacement for trochanteric fractures of the femur. J B J S Am 1973 ; 55;420.
30. Elberg J F , Peze W : La prothese dia-cephalique. Une nouvelle approche des fractures de la region cervico-trochanterienne chez le vieillard, Acta Orthop Belbica. 1982 ;48 :823 -830.
31. Saragaglia D , Carpentier E , Gordrff A , Legrand J J , Faure C and Butel J : Les fractures de la region trochantrienne du vieilled ; clous de Ender , protheses ou osteosyntheses directes. A propos d'une se'rie contune de 265 cas .Rev . chir .Orthop .1985;71:179-186.
32. Chamley John : Low friction principle and clean air operating —Theory. In low friction Arthroplasty of the hip .Theory and practice . 1979 New york , Springer pp. 3-15: 152-168.
33. Sarmiento A: Intertrochanteric fractures of the femur . 150 degree angle nail plate fixation and early rehabilitation . A primary report of 100 cases. J B J S ,1963 ; 45A : 706-772.
34. Clawson D K : Trochanteric fractures treated by the sliding screw plate fixation method . J Trauma ,l964; 4: 737-756.
35. Dimon J H and Hughston J C: Unstable intertrochanteric fractures of the hip. J B J S 1967 ;49A : 440 — 450.
36. Tranzo R G : Intertrochanteric fiactures. Special consideration in management. Orthop clin . north Am .1974 ; 5: 571- 583.
37. Baetels W: The treatment of intertrochanteric fractures. J B J S . 1989 ; 21: 773- 775.
38. Flores LA, Harrington IJ, Martin H. The stability of intertrochanteric fractures treated with a sliding screw plate. J Bone Joint Surg Br. 1990;72:37–40. [PubMed]
39. Hall G, Ainscow DA. Comparison of nail-plate fixation and Ender's nailing for intertrochanteric fractures. J Bone Joint Surg Br. 1981;63:24–8. [PubMed]
40. Sernbo I, Fredin H. Changing methods of hip fracture osteosynthesis in Sweden: An epidemiological enquiry covering 46,900 cases. Acta Orthop Scand. 1993;64:173–4. [PubMed]
41. Larsson S, Friberg S, Hansson LI. Trochanteric fractures: Mobility, complications, and mortality in 607 cases treated with the sliding-screw plate. Clin Orthop Relat Res. 1990;260:232–41. [PubMed]
42. Kim WY, Han CH, Park JI, Kim JY. Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. Int Orthop. 2001;25:360–2. [PubMed]
43. Richman, proximal femoral reconstruction around a cemented hemiarthroplasty for intertrochanteric fractures AAOS 1998 scientific Program.
44. Eksioglu et al ,Good results and lesser complications with the use of hemiarthroplasty in unstable intertrochantric fractures and faster return to pre-fracture status. Ankara university turkey 99
45. Casey Chan and Gill et al ,Cemented hemiarthroplasty was a reasonable alternative to the sliding screw device for treatment of intertrochantric fractures. clinical orthopedics and related research 2000
46. Domingo L J ,Cecilia D , Herrera A ,unstable trochanteric fractures showed cut out rate of 0.6%-I .4% whereas tendency to vams displacement was low in comparison with other implants. 2001
47. Haidukewych c j, Israel T A, Berry, 95*fixed angle fixation performed sign better than did sliding hip screws I reverse oblique fracture J B J S 2001
48. Sanowaki c , Lubbelte , sauden m , Am study support the use of an intramedullary nail rather than 95*screw plate for fixation of reverse oblique and Imcrtrochanteric fractures in elderly patients. J B J S 2002
49. Rodip O , Kiral A , Kaplan obtained 17 excellent results 14 good results after 12 mths according to harris hip score .Observed inner motion of bi polar decreased over times. Int orthop 2002 50. Eren OT, Kucukkaya concluded in that Enders nail may be appropriate in stable, non displaced IT fractures in elderly pts. Acta orthop traumatol ture 2003
51.Paprota B ,Krol R , Wiatrak A obtained 29 good results , 21 good and 17 satisfactory results in hip arthroplasty after failed internal fixation.2004
52.Grimarud, Monzon R J, Richman J arthroplasty treated unstable IT with cemented hip arthoplasty with novel cerclage .Allows early wt bearing and have relatively low rate of complications.
53.Kim SY ,Kim YG , Hwang J K proximal femoral nailing provide superior clinical outcome but no advantage with regard to functional outcome when compared with a long stem cement less calcar replacement arthroplasty. J B J S 2005.
54.Chong kw Wong MK, Rakiraj used computer navigation in performing minimally invasive surg for intertrochanteric fracture. INJURY 2006 AUG.
55. Kyle RF, Cabanela ME, Russell TA, Swiontkowski MF, Winquist RA, Zuckerman JD, Schmidt AH, Koval KJ. Fractures of the proximal part of the femur. Instr Course Lect. 1995;44:227–253. [PubMed]
56. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83:643–650. [PubMed]
57. Broos PL, Rommens PM, Deleyn PR, Geens VR, Stappaerts KH. Pertrochanteric fractures in the elderly: Are there indications for primary prosthetic replacement? J Orthop Trauma. 1991;5:446–51. [PubMed]
58. Haentjens P, Casteleyn PP, De Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg Am. 1989;71:1214–25. [PubMed]
59. Stappaerts KH, Deldycke J, Broos PL, Staes FF, Rommens PM, Claes P. Treatment of unstable peritrochanteric fractures in elderly patients with a compression hip screw or with the Vandeputte (VDP) endoprosthesis: A prospective randomized study. J Orthop Trauma. 1995;9:292–7. [PubMed]
60. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev. 2006;2:CD000086. [PubMed]
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62. Broos PL, Rommens PM, Geens VR, Stappaerts KH. Pertrochanteric fractures in the elderly.Is the Belgian VDP prosthesis the best treatment for unstable fractures with severe comminution? Acta Chir Belg. 1991;91:242–249. [PubMed]
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64.Geerts, Heit, Clagett, Pineo, Colwell, Anderson, & Wheeler, 2001) .

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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.

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.

Bibliography

1. Robert Steinbrook M.D. Tuberculosis and HIV in India, NEJM 2007; 356:12 1198-1199.
2. AIDS epidemic update Geneva, Joint United Nations Programme on HIV/AIDS and World Health Organization, 2007 (UNAIDS/07.27E/JC1322E).
3. Tuli S. M. Treatment of TB spine, Indian Journal Surgery 1978; 3: 195-213.
4. Youmans G.P. et al. Increase in resistance of TB bacilli to streptomycin, A preliminary report mayo clinic 1947; 22: 457-79.
5. Crofton J. Mitchison D.A. Streptomycin resistance in pulmonary tuberculosis, BMJ 1948 ; 2: 1009.
6. American review of Tuberculosis 1951; 63: 295-311.
7. Barnes P.F. Davidson P.T. Tuberculosis in patients with HIV, Infection Med. Clinics of North America 1993; 77:6 1369-1390.
8. Journal of Medical microbiology, 1989; 3 of 3: 175-181.
9. Michael D. Iseman. M.D. Rapid Detection of Tuberculosis and Drug-Resistant Tuberculosis, NEJM 2006; 355: 15 1606-08.
10. Unaids. T.B. in the era of HIV, Geneva unaids 1996.
11. Iseman M.D. Treatment Multidrug resistant TB, NEJM 1998; 329: 784-91.
12. Mario C. Raviglione, M.D. and Ian M. Smith. XDR Tuberculosis Implications for Global Public Health, NEMJ 2007 356; 7: 656-659.
13. Wikipedia.
14. Steward T. Cole et al. Tuberculosis and the tubercle bacillus, ASM Press Washington .D.C. 2005; 547-555.
15. CPCSEA Guidelines for laboratory animal facility, Indian Journal of Pharmacology 2003; 35: 257-274.
Rodrigues CS, Shenvi SV, Almeida DVG, Sadani MA, Goyal N, Vadher C, Mehta AP. Use of BACTEC 460 TB system in the Diagnosis of Tuberculosis, Indian Journal of Medical Microbiology 2007; 2591:32-6.

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

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

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

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

Abstract

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

Introduction

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

Aims and Objectives

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

Methods

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

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

Results

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

Discussion

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

Clinical Message

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

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

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

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

 Abstract

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

Introduction

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

Aims and Objectives

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

Methods

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

Results

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

Conclusion

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

Clinical Message

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

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

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

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

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

 Abstract

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

Introduction

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

Hypothesis

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

Discussion

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

Clinical Importance

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

Future Direction

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

Bibliography

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

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

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

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

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

 Abstract

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

Introduction

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Bibliography

1] Chartered Society of Physiotherapy. Curriculum framework for qualifying programmes in physiotherapy. London CSP; 2002.
2]Eckersley P., Grimley A.M.D. Trent Regional Health Authority Physiotherapy. The Physiotherapist in Pediatrics, Roles & Responsibilities 1989: 9-15.
3] Greathouse DG, Sweeney JK, Hartwick AM. Textbook of Military Medicine, Volume 1. Washington, DC:1989: 19-30.
4]Dastoor D. Looking back at 50 years of Physiotherapy. Physiotherapy Publication of School & Centre of Physiotherapy, Seth GSMC & KEMH. 2003: 9- 10.
5] Sheppard L. Public perception of physiotherapy: implications for marketing'. Aust J Physiother 1994; 40: 265- 271.
6] Hendriks HJM, Wagner C, Brandsma JW, Oostendorp RAB, Dekker J. Experiences with physiotherapists' consultation. Results of a feasibility study. Physiother Theory Pract 1996; 12: 211-220.
7]Kersons J.J. and Groenewegen P.P. Referrals to physiotherapy: the relation between the number of referrals, the indication for referral and the inclination to refer. Soc Sci Med 1990: 30; 797–804.
8]Stanton PE, Fox FK, Francois KM, Hoover DH, Spilecki GM. Assessment of resident physicians' knowledge of physical therapy. Phys Ther 1985: 65; 27-30.
9]Clemence ML, Seamark DA. GP referral for physiotherapy to musculoskeletal conditions--a qualitative study. Fam Pract. 2003: 20; 578-82. 10]Ritchey FJ, Pinkston D, Goldbaum JE, Heerten ME Perceptual correlates of physician referral to physical therapist: Implications for role expansion. Soc Sci Med 1989: 28; 69-80.
11]Houge NH. Physiotherapy in certain aspects of psychosomatic medicine. Psychother Psychosom. 1979: 32; 302-5.
12]Wong WP, Galley PM, Sheehan MC. Changes in medical referrals to an outpatient physiotherapy department. Aust J Physiother 1994: 40; 9- 14. 13] Archer KR, Mackenzie EJ, Castillo RC, Bosse MJ. LEAP Study Group.Orthopedic surgeons and physical therapists differ in assessment of need for physical therapy after traumatic lower-extremity injury. Phys Ther. 2009: 89; 1337-49.
14]Lamb M. Referral: General practitioners perceptions and contract needs within an outcome audit of a hospital out- patient Physiotherapy department. Physiother. 1995: 81; 222- 228.
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16]Ferguson A., Griffin E., Mulcahy C. Patient self referral to Physiotherapy in general practice – A model for the new NHS?' Physiotherapy 1999: 85; 13-20.
17]Holdsworth LK, Webster VS. Direct access to physiotherapy in primary care: now and into the future. Physiotherapy 2004: 90; 64-72. 18]Twomey L and Cole L. The changing face of Australian physiotherapy. Physiother Theory Pract 1985: 1; 77-85.
19]Archer KR, MacKenzie EJ, Bosse MJ, Pollak AN, Riley LH 3rd. Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: results of a national survey of orthopedic trauma surgeons. Phys Ther. 2009: 89; 893-905.

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

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

[1]Himalayan institute of medical sciences

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

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

Abstract

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

Introduction

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

Review of Literature

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

Aims and Objectives

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Keywords

Hip, unstable, intertrochanteric fracture, cephalomedullary implant.

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