Category Archives: Vol 2 | Issue 3 | Sep- Dec 2014

JMT Editorial : Outreach of Journal of Medical Thesis


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


Author: Dr. Ashok K Shyam

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


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

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

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

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

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

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

Dr Ashok Shyam
Editor – JMT

References

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

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

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


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

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Editorial


 

 

Phobia about Thesis in Medical Postgraduate student


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


Author: Dr. Dhiraj Sonawane[1]

[1]J.J Hospital Mumbai.

Email: dvsortho@gmail.com


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

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

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

Reference

1. Originally, the word compounds "dissertation" and "thesis" (plural, "theses") were not interchangeable. When, at ancient universities, the lector had completed his lecture, there would traditionally follow a disputation, during which students could take up certain points and argue them. The position that one took during a disputation was the thesis, while the dissertation was the line of reasoning with which one buttressed it. Olga Weijers: The medieval disputatio. In: Hora est! (On dissertations), p.23-27. Leiden University Library, 2005.
2. Post Graduate Medical Education. Regulations on the Medical Council of India. New Delhi: Medical Council of India; 2000. http://www.mciindia.org.
3. Thesis writing and journal publication course. http://www.iorg.co.in/2012/02/second-iorg-basic-course-thesis-writing-journal-publication.
4. Publish and flourish. http://www.bombayorth.org/?s=publish+and+flourish.
5. David W. Ramey, DVM. How to Read a Scientific Paper. AAEP Proceedingspg.1999,45:280-84.
6. Charles W. Van Way, III, MD. Writing a Scientific Paper. Nutrition in Clinical Practice December 2007,22: 636-40.
7. Timothy M. Johnson, Ann Arbor, Michigan. Tips on how to write a paper. J AM Acad Dermatol.2008,59:1064-69.


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

Download Full Text PDF   |  Download Full Thesis


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


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


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

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

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

Address of Correspondence
Dr. Komal Jakhotia
Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, 12, Thube Park, Shivaji Nagar, Pune – 411005, Maharashtra, India.
Email: komal.jakhotia183@gmail.com


 Abstract

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

                                                        THESIS SUMMARY                                                             

Introduction

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

Materials and Methods

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

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

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

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

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

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

Observation and Results

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

Discussion 

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

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

Clinical Message

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

Conclusions

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

Bibliography

1. Gandevia SC, Killian KJ, Campbell EJM. The effect of respiratory muscle fatigue on respiratory sensations. Clin Sci 1981;60:463-6.
2. Amonette, WE & Dupler, TL, The Effects of Respiratory Muscle Training on V ̇O2max, The Ventilatory Threshold and Pulmonary Function. J Exerc Physiol. 5 (2), 48-55, 2002.
3. Power SD, Coombes J, & Dermirel H. Exercise training-induced changes in respiratory muscles.Sports Med 1997;1(1):120-131.
4. Steinhaus LA, Dustman RE, Ruhling RO, Emmerson RY, Johnson SC, Shearer DE, Shigeoka JW, Bonekat WH. Cardio-respiratory fitness of young and older active and sedentary men. Br J Sports Med. 1988 Dec;22(4):163-6. PubMed PMID: 3228686; PubMed Central PMCID: PMC1478744.
4. Par q Goodman JM, Thomas SG, Burr J. Evidence-based risk assessment and recommendations for exercise testing and physical activity clearance in apparently healthy individuals. ApplPhysiolNutrMetab. 2011 Jul;36Suppl 1:S14-32. PubMed PMID: 21800940.
5. Green M. Respiratory muscle testing. Bull Eur Physiopathol
Respir 1984; 20: 433–436
6. Jonathan D. Witt, Jordan A. Guenette, Jim L. Rupert, Donald C. McKenzie & Sheel Inspiratory muscle training attenuates the human respiratory muscle metaboreflex.The Journal of Physiology2007; 584, 1019-1028
7. Sonetti DA, Wetter TJ, Pegelow DF & Dempsey JA (2001). Effects of respiratory muscle training versus placebo on endurance exercise performance. RespirPhysiol 127, 185–199
8. Vicente-Rodríguez G, Rey-López JP, Ruíz JR, Jiménez-Pavón D, Bergman P, Ciarapica D, Heredia JM, Molnar D, Gutierrez A, Moreno LA, Ortega FB; HELENA Study Group. Interrater reliability and time measurement validity of speed-agility field tests in adolescents. J Strength Cond Res. 2011 Jul;25(7):2059-63. PubMed PMID: 21499136.
9. Mahar MT, GuerieriAM, Hanna MS, Kemble CD. Estimation of aerobic fitness from 20-m multistage shuttle run test performance. Am J Prev Med. 2011 Oct;41(4 Suppl 2):S117-23. PubMed PMID: 21961611.
10. Ramsbottom R, Brewer J, Williams C. A progressive shuttle run test to estimatemaximal oxygen uptake. Br J Sports Med. 1988 Dec;22(4):141-4. PubMed PMID: 3228681; PubMed Central PMCID: PMC1478728.
11. Hagberg JM, Yerg JE Jr, Seals DR. Pulmonary function in young and older athletes and untrained men. J Appl Physiol. 1988; 65:101–10
12. Womak CJ, Harris DL, Katzel LI, et al. Weight loss, not aerobic exercise, improves pulmonary function in older obese men. J Gerentol A BiolSci Med Sci. 2000;8:M453–M457.
13. Verges S, Lenherr O, Haner AC, Schulz C, Spengler CM. Increased fatigue resistance of respiratory muscles during exercise after respiratory muscleendurance training. Am J PhysiolRegulIntegr Comp Physiol. 2007Mar;292(3):R1246-53. Epub 2006 Oct 26. PubMed PMID: 17068160.
14. Inbar O, Weiner P, Azgad Y, Rotstein A, Weinstein Y. Specific inspiratory muscle training in well-trained endurance athletes. Med Sci Sports Exerc. 2000;32:1233–1237.
15. Verges S, Sager Y, Erni C, Spengler CM. Expiratory muscle fatigue impairs exercise performance. Eur J ApplPhysiol 101: 225–232, 2007
16. Mador MJ, Acevedo FA. Effect of respiratory muscle fatigue on subsequent exercise performance. J ApplPhysiol 70: 2059–2065, 1991.
17. Leddy JJ, Limprasertkul A, Patel S, et al. Isocapnichypernea training improves performance in competitive male runners. Eur J Appl Physiol. 2007;99:665–676.
18. Edwards AM, Wells C, Butterly R. Concurrent inspiratory muscle and cardiovascular training differentially improves both perceptions of effort and 5000 m running performance compared with cardiovascular training alone [erratum in: Br J SportsMed. 2009;310–311]. Br J Sports Med. 2008;42:823–827.
19. Wijkstra PJ, TenVergert EM, van der Mark TW, Postma DS, Van Altena R, Kraan J, Koëter GH. Relation of lung function, maximal inspiratory pressure, dyspnoea, and quality of life with exercise capacity in patients with chronic obstructive pulmonary disease.Thorax. 1994 May;49(5):468-72. PubMed PMID: 8016768; PubMed Central PMCID: PMC474868.
20. Markov G, Spengler CM, Knopfli-Lenzin C, Stuessi C, BoutellierU.Respiratory muscle training increases cycling endurance without affecting cardiovascular responses to exercise. Eur J ApplPhysiol 85: 233–239, 2001.
21. McMahon ME, Boutellier U, Smith RM, Spengler CM. Hyperpnea training attenuates peripheral chemosensitivity and improves cycling endurance.JExpBiol 205: 3937–3943, 2002.
22. RuizJR, OrtegaFB, GutierrezA, et al. Health-related fitness assessment in childhood and adolescence: a European approach based on the AVENA, EYHS and HELENA studies. J Public Health.2006;14:269–277.
23. Womak CJ, Harris DL, Katzel LI, et al. Weight loss, not aerobic exercise, improves pulmonary function in older obese men. J Gerentol A BiolSci Med Sci. 2000;8:M453–M457.
24. Mayhew, J. L., 1977 "Oxygen cost and energy expenditure of running in trained runners". British Journal of Sports Medicine 11 (3): 116-121
25. Ramsbottom R, Brewer J, Williams C. A progressive shuttle run test to estimatemaximal oxygen uptake. Br J Sports Med. 1988 Dec;22(4):141-4. PubMed PMID: 3228681; PubMed Central PMCID: PMC1478728.
26. A D Flouris, G S Metsios, Y Koutedakis Enhancing the efficacy of the 20 m multistage shuttle run test Br J Sports Med 2005;39:166–170. doi: 10.1136/bjsm.2004.012500
27. Brown PI, Sharpe GR, Johnson MA. Inspiratory muscle training reduces blood lactate concentration during volitional hyperpnoea.Eur J ApplPhysiol 104: 111–1117, 2008
28. Brown PI, Sharpe GR, Johnson MA. Inspiratory muscle training reduces blood lactate concentration during volitional hyperpnoea.Eur J ApplPhysiol 104: 111–1117, 2008.
29. Mayhew, J. L., 1977 "Oxygen cost and energy expenditure of running in trained runners". British Journal of Sports Medicine 11 (3): 116-121
30. St Croix CM, Morgan BJ, Wetter TJ, Dempsey JA. Fatiguing inspiratory muscle work causes reflex sympathetic activation in humans. J Physiol 529: 493–504, 2000.
31. Harms, CA., Wetter, T. J., St. Crois, C.m. Pegelow, D. F. and Dempsey, J.A. (2000) Effects of respiratory muscle work on exercise performance. J. Appl. Physiol. 89, 131-138
32. Verges S, Sager Y, Erni C, Spengler CM. Expiratory muscle fatigue impairs exercise performance. Eur J ApplPhysiol 101: 225–232, 2007
33. Suzuki S, Yoshiike Y, Suzuki M, Akahori T, Hasegawa A., & Okubo T. Expiratory muscle training and respiratory sensation during treadmill exercise. Chest. 1993;104(1):197-202.


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

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


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


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

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

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

Address of Correspondence
Dr. Yogesh Savliram Gangurde
Assistant Professor In Dept. Of Orthopaedic
At Govt.Medical College, Aurangabad-431001
Email: dryogeshg18@gmail.com


 Abstract

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

                                                        THESIS SUMMARY                                                             

Introduction

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

Methods

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

Observation and Result

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

Discussion

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

Conclusion

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

Bibliography
1. Campbell: Operative OrthopaedicsTenth edition page no. 3126-3149.
2. Aronson James-Histology of distraction osteogenesis using different external fixators Clinical orthopedics- 1989 (241) 106 – 116.
3. The ASAMI Group,Operatibe principles of Ilizarov. 1991 .
4. Boyd H.B. :- 'Obserbation on nonunion of shaft of Long Bone' JBJS.1961 [43 A] 159-170.
5. Christian D. et al Bone regenerate formation in cortical bone during distraction and Lengthening.Clinical Orthopaedics, 1990 [250] 34-43.
6 . Ilizarov Tension stress effect on genesis and growth of tissus part – 1 : Influence Of stability of fixator and soft tissue preservation Clinical Orthopaedics 1989 [238] 249 – 258.
7 . Morandi M et al.Infected tibialpseudoarthoses: A 2 year follows up of patients treated by Ilizarov technique Orthopaedics. 1989 [12/4] 497 – 504.
8. Dror Paley et al. Ilizaov Treatment of Tibial nonunion with Bone Loss Clinical Orthopaedics – 1989[241] 146 – 153. 23 .
9. Shitin V.P. et al Basing the term of beigning of distraction operationes in lengthening of l leg. Orthopaedics Traumotology Protez.1974 [35] 48 -59.
10. Dr. L. Celentano et al.Radionucleide Research in distraction osterogenesis ASAMI Group – [1991] 60 -62.
11. Vladimir Schwartzman et al. - 'Corticotomy'.Clinical Orthopaedics 1992 [280] 37 – 46.
12. Vladimir Schwartzman et al.Treatment tractics with Ilizarov Method, Tibia nonunion Orthoppaedics Clinics in North America.1990 [21/4] 639 - 641.
13. Young Teremy et al.Sonographic evaluation of bone productions of the distraction site in Ilizarov units lengthening procedure.
14. Gorden L. , E. chiu et al Treatment of ifecgted nonunion and segmental defects of Tibia JBJS - 1988 [ 70/A] 337 – 355.
15. Catahoun J.H. et al. Treatment of infected nonunion with PMMA Beads Clinical Orthopaedics 1993. [295] 23 – 27. 24
16. James Aronson et al. Local Bone Transportation for treatment of intercalary defects by Ilizarov Clinical Orthopaedics1989 [243] 71 – 80 .
17. Brunner U. H. et al. Force required for Bone segment transport in treatment of Large Diaphyseal defects using intramedullary devices. CORR - 1994 [301] 147 -155.
18. Stuart A Green, et al. Skeletal Defects: Comparision of Bone grafting and Bone Transport for segmental skeletal defects. CORR 1994 [301] 111 -117.
19. H. R. song et al. Tibial Bone defects treated by internal Bone Transport using Ilizarov Method.
20. Treatment of malunion and nonunion of femur and tibia by detailed preoperative planning and Ilizarov technique. OCNA 1990 [21] 667 – 691.
21. J. L. Marsh et al.Chronic infected tibial nonunion with Bone Loss. "Conventional technique vs. Bone Transport" CORR 1995 [301] 139 -146.
22. F. Dagher et al. Compound tibialfracures with Bone Loss treated by ilizarov technique. JBJS. [BR] 1991 [73B] 316 – 321. 25 .
23. M.A. Cattagni et al. Distraction osteogenesis in the treatment of stiff Hypertrophic nonunion using Ilizarov principles. CORR – 1994 [301] 159 – 163.
24. G. K. Dendrinos, et al. Use of Ilizarov Technique for treatment of nonunion of Tibia associated with Infection.
25. Atesalp A. S. et al. Treatment of Tibial bone defects with Ilizarov circular external fixator in high velocity gun shot wounds. International Orthopaedics 1998 [22] n343 -347.
26. Choon La Toh, Jesse B et al. "Infected nonunion or Tibia". CORR - 1995. [315] 176 -191.
27. Person RL, Perry CR. Et al. The ilizarov technique in treatment of infected Tibial nonunion Orthopaedics Rev .1989 [815] 609 – 617.
28.Harry L. et al. Tibial defects: Reconstruction using the method of Ilizarov an alternative. OCNA.1990 [21] 629 -637.
29.Lesle Nagar, et al.Treatment of large bone defects with Ilizarov technique Kpirmal pf trai,a – USA. March 93 [34/3] 390 – 392 26
30.Hoffman C.O. et al. Segment Transport employing intramedullary devices in Tibial bone defects following trauma and infections. Journal of OrthopaedicsTrauma 1999 [13/3] 170 -177.
31.Andrew J. We iland et al."Vascularised Bone autografts". CORR 1983 [174] 87 -95.
32.LalitMaini, Manish Chanddhaeg al. Ilizarov method in infected nonunion of
fractures. Injury – 2000 [31] 509 – 517.
33. Green S.A. et al. Ilizarov method of managing segmental skeletal defects
CORR 1992 [280] 136 – 143.
34. Kenneth R et al. Management of Resistant pseudoarthosis of Long bones.
CORR 1988 [233] 242 – 249.
35.S A Green et al. Open Bone graft for septic nonunion,
Clinical Orthopaedics and Relaated Research. 1983 [180] 117 -124.
36.Tuschiya. Et al Limb salvage using distraction osteogenesis
JBJS [BR] 1997 [79/B] 403 -411. 27
37.EduradoGracio. Et al. Ilizarov technique : Results and difficulties.
Clinical Orthopaedics 1992 [283] 116 – 123.


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

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Study on Surgical Management of Intertrochanteric Fractures of Femur with 95 Degrees Angle Blade Plate


Vol 2 | Issue 3 | Sep - Dec 2014 | page:12-16 | Kiran Kalaiah, Vivek N Savsani,  Harish U,  Sunil Kumar P C, Kaladagi P S


Author: Kiran Kalaiah[1], Vivek N Savsani[1],  Harish U[2],  Sunil Kumar P C[1], Kaladagi P S[1]

[1] Mysore Medical College & Research Institute

[2] Registrar,R.N Cooper Hospital,Mumbai.

Institute at which research was conducted: Mysore Medical College And Research Institute,Mysore.
University Affiliation of Thesis: Rajiv Gandhi University Of Health Sciences Karnataka.
Year of Acceptance: 2013.

Address of Correspondence
Dr. Harish U
S/o NO.3 2nd Main 7th Cross Amarjyothinagar, Vijayanagar, Bangalore, Karnataka - 560040
Email: 77harish36@gmail.com


 Abstract

Background: Intertrochanteric fractures are seen more commonly in the elderly. They occur commonly in osteoporotic bone. They are 3-4 times more common in women than in men. Although relatively uncommon, intertrochanteric fractures also occur in the young, most commonly in men after high energy injuries. By definition, Intertrochanteric fracture includes any fracture from the extra capsular part of the neck of the femur to a point 5 cm distal to the lesser trochanter. In the earlier days, intertrochanteric fractures were treated conservatively as these fractures unite invariably. Internal fixation of trochanteric fractures is a life saving measure in the elderly.There are many options available for internal fixation of trochantric fractures like dynamic hip screw(DHS),dynamic condylar screw(DCS),GAMMA nail,proximal femoral nail,95 degree angle blade plate etc. Our aim in this study is to evaluate surgical and functional outcome of 95° angle blade plate in treatment of , intertrochanteric fractures.
Methods: 20 patients,13 male,7 female. The mean age was 59 years with intertrochanteric fracture of femur were treated by open reduction and internal fixation with 95 degrees angle blade plate.
Results: Evaluation of cases using Kyle Criteria: Results were evaluated by Kyle criteria. 30% (6 patients) scored excellent results, 45% (9 patients) had good results, 15% (3 patients) had fair results and 10% (2 patients) had poor results. 2 patients had implant failure which needed re-doing.
Evaluation of cases according to anatomical outcome: 75% patients had a good result and 25% had fair result. Shortening of more than 1 cm was noted in 2 patients, varus angulation was noted in 4 patients, restriction of hip movements was noted in 5 patients and knee movement restrictions were noted in 1 patient.
Conclusion: The 95 degrees angle blade plate is a suitable option for the treatment of intertrochanteric fractures and subtrochanteric fractures.
Keywords: Intertrocantric fracture, 95 degrees angle blade plate.

                                                        THESIS SUMMARY                                                             

Introduction

Intertrochanteric fractures are seen more commonly in the elderly. They occur commonly in osteoporotic bone.1 Most of them result from a simple fall from standing height.  They are 3-4 times more common in women than in men. Though the energy is low, comminution of the fracture is usually seen due to osteoporosis. Although relatively uncommon, intertrochanteric fractures also occur in the young, most commonly in men after high energy injuries. A cadaver study has shown that the energy required to break this tough bone is very high in young adults. By definition, Intertrochanteric fracture includes any fracture from the extra capsular part of the neck of the femur to a point 5 cm distal to the lesser trochanter. Osteoporotic hip fracture is increasingly recognized as a growing problem in Asia as per the Asian Audit Report, 2009. It is estimated that the incidence of hip fracture will rise from 1.66 million in 1990 to 6.26 million by 2050. Also by 2050, more than 50% of all osteoporotic fractures will occur in Asia. Among elderly patients, hip fractures are associated with an in-hospital mortality of 7-14 %.10,11 In the earlier days, intertrochanteric fractures were treated conservatively as these fractures unite invariably. But this method is associated with high mortality and morbidity rates, 30% of elderly patients die within 1 year of fracture. After 1 year, patients resume their age-adjusted mortality rate. Current guidelines recommend that surgeons perform hip fracture surgery within 72 hours of injury as observational studies suggest earlier surgery is associated with better functional outcome and lower rates of non-union, shorter hospital stays and duration of pain and lower rates of complication and mortality. Internal fixation of trochanteric fractures is a life saving measure in the elderly. Proper precautions are to be taken during surgery to prevent complications like coxa vara deformity, shortening, limited hip movements and secondary osteoarthritic changes in the hip. Post-fracture rehabilitation is equally necessary. Early post-operative ambulation and physiotherapy is crucial and the best approach for the patient. The overall goal is returning of patient to pre-morbid level of function.

Materials and Methods

The present study includes 20 cases of intertrochanteric fracture of femur in adult patients above 16 years of age irrespective of sex treated by open reduction and internal fixation with 95 degrees angle blade plate, in the Department of Orthopaedics at K.R Hospital, Mysore, attached to the Mysore Medical College & Research Institute, Mysore, from November 2011 to October 2013, selected on the basis of purposive sampling (Judgment sampling) method. The average age incidence was 59 years. 13 males and 7 females. Among them the minimum age was 17 years and maximum age noted was 80 years. 45% of the patients were in the age group of 61 - 70 years with the mean age of 54 years for males and 67 years for females. Predominantly males were affected. Fall from standing height was the most common mechanism of injury. Type II fractures were the most common. The average duration of hospital stay was 20.15 days. 12 patients had fracture on the right side. And 8 patients had a fracture on the left side. In our study 7 fractures were Boyd and Griffin's type II fractures, followed by 6 cases of type III, 4 cases of type I and 3 cases of type IV. . The final results were evaluated by  Kyle criteria, anatomical outcome.

Results

Results were evaluated by Kyle criteria, anatomical outcome.
Evaluation of cases using Kyle Criteria: In our study, 30% (6 patients) scored excellent results, 45% (9 patients) had good results, 15% (3 patients) had fair results and 10% (2 patients) had poor results. 2 patients had implant failure which needed re-doing.

Evaluation of cases according to anatomical outcome:
In our study, 75% patients had a good result and 25% had fair result. Shortening of more than 1 cm was noted in 2 patients, varus angulation was noted in 4 patients, restriction of hip movements was noted in 5 patients and knee movement restrictions were noted in 1 patient.

Conclusion

Hip fractures are the leading cause of morbidity and mortality in the elderly. Intertrochanteric fractures are a common injury, more commonly seen in elderly females and arising out of trivial fall. Patients with trochanteric fractures are bed-ridden, which leads to severe health problems and reduced quality of life which increases the burden on the care-givers. Patients with trochanteric fractures undergoing early surgery have an improved ability to return to independent living and prevention of complications of prolonged immobilisation. The 95 degrees angle blade plate can be used for both stable and unstable intertrochanteric fractures, but the final outcome is dependent on various factors such as the type of fracture, the condition of the medial wall, the bony architecture, and the co-morbid conditions of the patient, the operative technique, implant position and post-operative care. The position of the implant should be such that the tip of the blade should be in the lower half of the femoral head and the blade should pass below the superior cortex of the neck. This study shows that the 95 degrees angle blade plate offers a reliable and effective alternative for the treatment of trochanteric fractures.
The 95 degrees angle blade plate is a stable and acceptable implant for the treatment of intertrochanteric fractures.

Bibliography

1. Cleveland M, Bosworth DM, Thompson FR, Wilson Hj Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959 Dec;41-A:1399–1408.
2. Courtney AC, Wachtel EF, Myers ER, Hayes WC. Age-related reduction in the strength of the femur tested in a fall-loading configuration. J Bone Joint Surg Am. 1995 Mar;77(3):387–395.
3. Laros GS. Intertrochanteric fractures. In: Evarts CM. Surgery of the musculoskeletal system. 1st ed., New York: Churchill Livingstone. 1983;2(5):123-148.
4. Hwang LC, Lo WH, Chen WM, Lin CF, Huang CK, Chen CM. Intertrochanteric fractures in adults younger than 40 years of age. Arch Orthop Trauma Surg. 2001;121(3):123-6.
5. Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures in adults younger than 50 years of age. Epidemiology and results. Clin Orthop Relat Res. 1995 Mar;(312):238-46.
6. Boyd HB, Griffin LL. Classification and Treatment of Trochanteric Fractures. Arch Surg. 1949;31B:190-203.
7. Mithal A, Dhingra V, Lau E. The asian audit: Epidemiology, costs and burden of osteoporosis in Asia. Beijing, China: An International Osteoporosis Foundation (IOF) publication. 2009.
8. Dhanwal DK, Dennison EM, Harvey NC, Cooper C. Epidemiology of hip fracture: Worldwide geographic variation. Indian J Orthop. 2011 Jan;45(1):15-22.
9. Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: A world-wide projection. Osteoporos Int. 1992 Nov;2(6):285-9.
10. Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. Br Med J. 2006;332:947-51.
11. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br 2005;87:361-6.
12. Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics, 11th ed. Elsevier; 2007.
13. Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, McLaughlin M, Halm EA, Wang JJ, Litke A, Silberzweig SB, Siu AL. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004 April;291(14):1738-43.
14. Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med 1997;103:51-63.
15. Simunovic N, Devereaux P J, Bhandari M. Surgery for hip fractures: Does surgical delay affect outcomes?. Indian J Orthop 2011;45:27-32.
16. Ganz R, Thomas RJ & Hammerle CP: Trochanteric fracture of the femur. Treatment and results. Clin Orthop Relat Res. 1979;138:30-40.
17. Peltier LF. Orthopedics: A History and Iconography.
18. Rajasekaran S, Kamath V, Dheenadhayalan J. Intertrochanteric fractures. In: Sivananthan S, Sherry E, Warnke P, Miller MD, editors. Mercer's Textbook of Orthopaedics and Trauma.10th ed. Hodder Arnold; 2012.
19. Ponseti IV. History of Orthopaedic Surgery. Iowa Orthop J. 1991;11:59–64.
20. Jewett EL. One- piece Angle Nail for Trochanteric Fractures. J Bone Joint Surg Am. 1941;23:803-810.
21. Moore AT. Blade-plate internal fixation for intertrochanteric fractures. J Bone Joint Surg Am, 1944 Jan 01;26(1):52-62.
22. Jaslow IA. Blade-plate fixation Report of a case. J Bone Joint Surg Am, 1947 Jul 01;29(3):814-816.
23. Wilson JN. Chapter 29. Fractures and Joint Injuries. Watson – Jones. 6th ed. B.I. Churchill Livingstone 1992;2:878-973.
24. Evans EM. The Treatment of Trochanteric Fractures of the Femur. J Bone Joint Surg Am, 1949;31B:190-203.
25. Murray RC, Frew JFM. Trochanteric Fractures of the Femur. J Bone Joint Surg Am, 1949;31B:204-219.
26. Arden GP, Walley GJ. Treatment of Intertrochanteric Fractures of the Femur by Internal Fixation. Br Med J. 1950;2:1094-1097.
27. Taylor GM, Neufeld AJ, Nickel VL. Complications and failures in the operative treatment of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1955;37-A(2):306-316.
28. Sahlstrand T. The Richards Compression Screw and Sliding Hip Screw System in the Treatment of Intertrochanteric Fractures. Acta Orthop. Scand. 1974;45:213-219.
29. Dimon JH, Hughston JC. Unstable Intertrochanteric Fractures of the Hip. J Bone Joint Surg Am. 1967;49A:440-450.
30. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am. 1970;52(3):457-67.
31. Mann RJ. Avascular necrosis of the femoral head following intertrochanteric fractures. Clin Orthop Relat Res. 1973;(92):108-15.
32. Sarmiento A. Unstable Intertrochanteric Fractures of the Femur. Clin Orthop Relat Res. 1973;92:77-85.
33. Sgarbi G, Salvatore P, Zangrando A, Gemmati U. Osteosynthesis using the blade-plate method and early weight-bearing in pertrochanteric fractures. Chir Organi Mov. 1977;63(6):621-6.
34. Whatley JR, Garland DE, Whitecloud T 3rd, Wickstrom J. Subtrochanteric Fractures of the Femur: Treatment with ASIF Blade Plate Fixation. Southern Medical Journal 1978;71:1372-1375.
35. Jacobs RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip fractures: a clinical and biomechanical study. Clin Orthop Relat Res. 1980;146:62-70.
36. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989 ;238:122-30.
37. Senter B, Kendig R, Savoie FH. Operative stabilization of subtrochanteric fractures of the femur. J Orthop Trauma. 1990;4(4):399-405.
38. Brien WW, Wiss DA, Becker V Jr, Lehman T. Subtrochanteric femur fractures: a comparison of the Zickel nail, 95 degrees blade plate, and interlocking nail. J Orthop Trauma. 1991;5(4):458-64.
39. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation. Injury. 1994 Mar;25(2):99-104.
40. Vanderschot P, Vanderspeeten K, Verheyen L, Broos P. A review on 161 subtrochanteric fractures--risk factors influencing outcome: age, fracture pattern and fracture level. Unfallchirurg. 1995 May;98(5):265-71.
41. Van Meeteren MC, van Rief YE, Roukema JA, van der Werken C. Condylar plate fixation of subtrochanteric femoral fractures. Injury. 1996 Dec;27(10):715-7.
42. Siebenrock KA, Müller U, Ganz R. Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures. Injury. 1998;29 Suppl 3:C7-15.
43. Skoták M, Behounek J, Krumpl O. Solution of Intertrochanteric Fractures of Proximal Femur by 130 degrees Angled Blade Plate - Longterm Results. Acta Chir Orthop Traumatol Cech. 1999;66(6):336-41.
44. Lundy DW, Acevedo JI, Ganey TM, Ogden JA, Hutton WC. Mechanical comparison of plates used in the treatment of unstable subtrochanteric femur fractures. J Orthop Trauma. 1999 Nov;13(8):534-8.
45. Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta-analysis of 14 studies. Injury. 1999;30:157–63.
46. Becker CE, Keeler KA, Kruse RW, Shah SA. Complications of Blade Plate Removal. Journal of Pediatric Orthopaedics. 1999;19(2):188-193.
47. Segal LS. Custom 95 degree condylar blade plate for pediatric subtrochanteric femur fractures. Orthopedics. 2000 Feb;23(2):103-7.
48. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001 May;83-A(5):643-50.
49. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of Reverse Oblique and Transverse Intertrochanteric Fractures with Use of an Intramedullary Nail or a 95° Screw-Plate: A Prospective, Randomized Study. J Bone Joint Surg Am. 2002; 84:372-381.
50. Neher C, Ostrum RF. Treatment of subtrochanteric femur fractures using a submuscular fixed low-angle plate. Am J Orthop (Belle Mead NJ). 2003 Sep;32(9 Suppl):29-33.
51. SuriyajakyuthanaW. Intertrochanteric fractures of the femur: results of treatment with 95 degrees Condylar Blade Plate. J Med Assoc Thai. 2004 Dec;87(12):1431-8.
52. Yoo MC, Cho YJ, Kim KI, Khairuddin M, Chun YS. Treatment of unstable peritrochanteric femoral fractures using a 95 degrees angled blade plate. J Orthop Trauma. 2005 Nov-Dec;19(10):687-92.
53. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2005 Jan;19(1):63-6.
54. Bredbenner TL, Snyder SA, Mazloomi FR, Le T, Wilber RG. Subtrochanteric fixation stability depends on discrete fracture surface points. Clin Orthop Relat Res. 2005 Mar;(432):217-25.
55. Giannoudis PV, Schneider E. Principles of fixation of osteoporotic fractures. J Bone Joint Surg Br. 2006 Oct;88(10):1272-8.
56. Rahme DM, Harris IA. Intramedullary nailing versus fixed angle blade plating for subtrochanteric femoral fractures: a prospective randomised controlled trial. J Orthop Surg (Hong Kong). 2007 Dec;15(3):278-81.
57. Yong CK, Tan CN, Penafort R, Singh DA, Varaprasad MV. Dynamic Hip Screw Compared to Condylar Blade Plate in the Treatment of Unstable Fragility Intertrochanteric Fractures. Malaysian Orthopaedic Journal 2009;3(1):13-18
58. Kesemenli CC, Memişoğlu K, Necmioğlu S, Kayıkçı C. Treatment of intertrochanteric femur fractures with 95° fixed-angle blade plate in elderly patients. European Journal of Orthopaedic Surgery & Traumatology 2010 Dec;20(8):629-634.
59. Forward DP, Doro CJ, O'Toole RV, Kim H, Floyd JCP, Sciadini MF, Turen CH, Hsieh AH, Nascone JW. A Biomechanical Comparison of a Locking Plate, a Nail, and a 95° Angled Blade Plate for Fixation of Subtrochanteric Femoral Fractures. J Orthop Trauma 2012;26(6):334-340.
60. Laghari MA, Makhdoom A, Pahore MK, Memon A. Subtrochanteric Femoral Fractures Treated by Condylar Plate, A study of 56 cases. JLUMHS 2012;11:2.
61. Parker MJ, Das A. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2013 Feb 28;2:CD000339.
62. Chaurasia BD. Human Anatomy Volume 2. 4th ed. CBS; 2004.
63. Standring S, editor. Gray's Anatomy. 39th ed. Elsevier; 2005.
64. Netter FH. Atlas of Human Anatomy. 5th ed. Elsevier; 2010.
65. Crock HV. An Atlas of the Arterial Supply of the Head and Neck of the Femur in Man. Clin Orthop. 1980;152:17-27.
66. Chung SMK. The Arterial Supply of the Developing Proximal End of the Human Femur. J Bone Joint Surg Am. 1976;58:961-965.
67. Trueta J, Harrison MHM. The Normal Vascular Anatomy of the Femoral Head in Adult Man. J Bone Joint Surg Br. 1953;35:442-460.
68. Hayes WC. Biomechanics of Falls and Hip Fracture in the Elderly. In: Apple DF, Hayes WC, editors. Prevention of Falls and Hip Fractures in the Elderly. Rosemont, Illinois: American Academy of Orthopaedic Surgeons; 1994.
69. Cummings SR, Nevitt MC. A Hypothesis: The Causes of Hip Fractures. J Gerontol 1989;44:107-111.
70. Kaufer H, Matthews LS, Sonstegard D. Stable Fixation of Intertrochanteric Fractures. J Bone Joint Surg Am. 1974;56A:899-907.
71. Yong CK, Tan CN, Penafort R, Singh DA, Varaprasad MV. Dynamic Hip Screw Compared to Condylar Blade Plate in the Treatment of Unstable Fragility Intertrochanteric Fractures. Malaysian Orthopaedic Journal 2009;3(1):13-18
72. Singh AK. Management of Trochanteric Fractures. Indian J Orthop 2006;40:100-102.
73. Babulkar SS. Management of Trochanteric Fractures. Indian J Orthop 2006;40:210-218.


How to Cite this Article: Kalaiah K, Savsani V N,  Harish U, Kumar S, Kaladagi P S. Study on Surgical Management of Intertrochanteric Fractures of Femur with 95 Degrees Angle Blade Plate. Journal Medical Thesis 2014  Sep-Dec ; 2(3):12-16

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A Comparative Study Of The Management Of Fracture Neck Femur By Dynamic Hip Compression Screw With Derotation Screw Versus Three Cancellous Screws


Vol 2 | Issue 3 | Sep - Dec 2014 | page:5-8 | Azhar A Lakhani, Neetin Mahajan, Dhiraj V Sonawane


Author: Azhar A Lakhani[1], Neetin Mahajan[1], Dhiraj V Sonawane1[1]

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

Institute at which research was conducted: GGMC and Sir JJ group of hospitals, Mumbai.
University Affiliation of Thesis: Maharashtra University of Health Sciences, Nashik.
Year of Acceptance: 2014.

Address of Correspondence
Dr. Azhar A Lakhani
S/o Azizuddin Lakhani,
A-2, Flat-2, Salimabad society, sandeep talkiz road,
Yavatmal-445001
Maharashtra
Email: lakhaniazhar@gmail.com


 Abstract

Background: Intracapsular fractures of neck femur have always presented a great challenge to orthopaedics surgeons and remain in many ways the unsolved fracture as far as treatment and results are concerned.
Methods: Cases included in this study are transcervical and subcapital fracture neck femur in patients less than 60 yrs of age managed in Sir JJ Hospital, Mumbai -08.
Results: Fracture type, anatomical reduction and proper implant selection are the most important factor affecting the outcome of management of fracture neck femur whereas age, time interval, method of reduction, and capsulotomy play a less important role.
Conclusion: Dynamic Hip Screw (DHS) is a better implant in management of most of the cases of fracture neck femur. High subcapital fractures are an exception to this rule.
Keywords: Fracture neck femur, transcervical/ subcapital fracture, canulated cancellous screw, dynamic hip screw, avascular necrosis, non union.

                                                        THESIS SUMMARY                                                             

Introduction

Fractures of the femoral neck are devastating injuries that most often affects the elderly and have a tremendous impact on the health Care system and society in general. The worldwide incidence of femoral neck fractures has continued to increase. From an estimated 1.3 million hip fractures in 1990. This number is predicted to rise to 2.5 million by 2025 and 4.5 million by 2050, assuming there is no age specific increase. Amongst these the fractures occurring in young patients are particularly troublesome. The fracture is regarded as a vascular injury to the bone's blood supply[3-8]. The degree of vascular compromise is thought to directly correlate with the displacement of the fracture which affects fracture union and leading to complications. Hence intracapsular fracture neck of femur is regarded as an orthopaedic emergency[9] and needs to be reduced with rigid internal fixation which is believed to improve the circulation of femoral head and prevent the non union and avascular necrosis. Internal fixation with cannulated cancellous screws after good anatomical reduction has the advantages of decreased blood loss and operative time, lower transfusion requirements and decreased length of hospital stay[9]. Richards et al has quoted basic advantages of using sliding hip screws in terms of strength greater than multiple cancellous screws, minimization of risk of subsequent subtrochanteric fracture secondary to a stress riser effect, and placement of compression across the fracture at the time of reduction. Disadvantages of the sliding hip screw for femoral neck fracture stabilization include a larger surgical exposure and the potential to create rotational malalignment of the femoral head at the time of screw insertion [10]. However inspite of available modalties and techniques there is high rate of compliations particularly in young patients suffering from fracture neck femur. We have undertaken this comparative study to assess the outcome of both fixation modalities as well as factors influencing the results of these fixations in our population and attempt to fill in the lacunae in our understanding of management of fracture neck femur.

Methods

Cases included in this study are transcervical and subcapital fracture neck femur in patients less than 60 yrs of age. The cases studied for this dissertation were managed in Sir J J Group of Hospitals, Mumbai-08. The ethical clearance for this study has been obtained from this institutions ethical Committee.
The total number of cases studied were 62
The total patients were divided into two subgroups
1. Patients treated with multiple cancellous screws (31 )
2. Patients treated with dynamic hip screw and derotation screw (31).
All the patients were followed up with radiological and functional assesement.

Discussion

Age, sex and laterality of fracture: We have found no studies suggesting the role of these variables in the outcome of fracture treatment. In our study as well, we have not found these factors to play any role in the outcome of fracture treatment. Modality of treatment: On assessment of patients on follow up with Harris hip score, w e found excellent result in 61.3 % of our patients managed with DHS while only 25.8 % of patients managed with CC screw showed excellent result. On the other hand 9.7 % patients managed with CC screw showed poor results while none of the patients managed with DHS showed poor result. This difference is statistically significant with p value of 0.024 as calculated by Chi-square test. Also overall Harris hip score of patients managed with DHS was higher as compared to the score in patients managed with CC screw. We have found DHS not only to be to be more stable but also allows better compression across the fracture, allowing early mobilization and early union. There was no complication of non-union in patients managed with DHS while 3 patients managed with CC screw progressed to non-union. Average time for union in our study was 14 weeks for patients managed with DHS while it was 18 weeks for patients managed with CC screw. We recommend use of DHS with derotation screw for managing all the patients of fracture neck femur i/v/o early mobilization, early union and reduced risk of non-union. Fracture type: Pauwel's type-3 femoral neck fractures are problematic to treat, with non-union rates higher than those reported for historical controls. In one of the studies on Pauwel's type III fractures [11] non-union rate of 16% was reported with cannulated screws and 8 % with fixed angle device and supports the theory that these type-3 fractures experience shear and may demonstrate a higher rate of varus, shortening, and non-union. In our study, 8 patients had Pauwel's type III fracture of which 5 patients were managed with DHS while 3 patients were managed with CC screw. Complications like delayed union and varus were seen in patients managed with CC screw. However no patients with type III fracture ended up in non-union. Biomechanically, it has been shown that a sliding hip screw device is stronger than three parallel cancellous screws for the treatment of Pauwel's type III intracapsular neck femur fractures. Stability and the quality of reduction appeared to influence the rates of adverse outcomes in our series. We recommend use of DHS with derotation screw in Pauwel's type III fractures as adequate compression is achieved intraoperatively by placing 5 mm shorter lag screw in inferior quadrant of the neck and placing the derotation screw wider apart in superior quadrant. We have found limitation of this construct in high subcapital fracture where DHS threads won't have enough purchase in femoral head[12 ]. Time interval between injury and surgery: Advocates of early surgery suggest that the main advantages of prompt reduction of a displaced femoral neck fracture are unkinking of the vessels and performance of an intracapsular decompression to remove the hematoma that increases intracapsular pressure [13,14,15]. This improves and restores blood flow to the femoral head, minimizing the risk of femoral head osteonecrosis. In our study majority of our patients were treated within twenty-four hours after the injury. However, the exact time to treatment is difficult to ascertain. In our study however higher risk of non-union was seen in patients managed with CC screw who underwent surgery more than 72 hrs after trauma. The probable reason is that when surgery is delayed for more than 72 hrs there is resorption at fracture ends and compression across the fracture site is poor, more so with CC screw as compared to DHS.[16 ]. Method of reduction (open vs. closed): In our study only 13 % (8 patients) required open reduction of which 1 patient developed Avascular Necrosis. Hence we do not consider open reduction as a risk factor for AVN. Role of Capsulotomy: The role of capsulotomy in the treatment of femoral neck fractures remains controversial, and the practice varies by trauma program, region, and country. Clinical studies [17-21] have shown that decompressing the intracapsular hematoma by means of a capsulotomy or aspiration reduces the intracapsular pressure. This decrease in the intracapsular pressure results in improved blood flow to the femoral head and may reduce femoral head Ischemia [17-23]. In our study the difference in the rate of osteonecrosis between those who had and those who had not received a capsulotomy was small; however, our sample size was too small for us to make definitive conclusions about the value of capsulotomy. Capsulotomy was not done in patients managed with DHS as reaming for lag screw placement was considered to decompress the femoral head. Post-operative radiological reduction: Portzmann RR et al [24] and Lee ch et al [25] and several others have found increased complications like non-union and AVN in patients with non- anatomical post operative reduction. Complications like non-union, AVN, shortening and post operative poor functional outcome were seen more commonly in patients who were fixed in malalignment. Hence it is recommended by us to reduce the fractures anatomically or in valgus impacted position. Positioning of Lag screw and type of barrel: Screw position26 can be assessed with implant-cortical bone purchase by evaluating the distance from the implant to the cortex. Baumgaertner et al.[27] proposed what has become the well-known concept of the tip-apex distance (TAD). In our study the exact distance was not measured due to variable magnification of available x-rays and lack of proper scaling of the x rays and hence the stability of reduction and the relation of TAD with the outcome could not be commented. Similarly, we have found that placement of DHS lag screw in the inferior quadrant along the calcar and use of long barrel plate increases the stability of fixation and hence is recommended by us. We have also found Dynamic Hip Screw with derotation screw to have greater ability to compress across the fracture site as compared to Canulated Cancellous screw. However, further biomechanical studies are recommended for confirmation. Duration of surgery and blood loss: Average duration of surgery in patients managed with CC screw was 50 mins while that in DHS group was 90 mins. Incision for CC screw group was smaller as compared to DHS group. Average blood loss for CC group was 50 cc while that of DHS group was 150 cc. Complications: In this study, the risk factors for fracture non-union after internal fixation of intracapsular femoral neck fractures, we found that a displaced fracture, borderline and unacceptable reduction, and more centralized screw position were risk factors for non-union and implant failure. The factors that have been most consistently found to be predictive of non-union after fixation of intracapsular femoral neck fractures are poor reduction and fracture displacement. Age and sex are not risk factors for non-union in most studies, including our study. Fracture site, fracture level, and bone density were not found to be related. Of the 3 patients managed with CC screw that went into non-union, 2 patients were fixed in borderline retroversion and 1 was fixed in varus. [28] In our study we have achieved union rate of 100 percent with DHS while it is 90 % in patients managed with CC screw. High rate of union in DHS group was due to significant compression and impaction achieved across the fracture site. Avascular Necrosis : AVN was seen in 6 cases (9.7 %) in our series. Of this 4 cases were managed with DHS while 2 patients were managed with CC screw. Of the patients who developed AVN, none of the patients required further surgical management in the form of hip replacement till follow-up. Further collapse was prevented in these patients with the use of bisphosphonates. Union was confirmed radiologically by corticalization across the fracture site in AP and lateral views and filling of earlier bone defects with remodelling of bone. Minor complications like superficial infection and bursitis were encountered but these complications were managed with oral/ IV medications. None of these minor complications were found to affect the overall functional outcome.

Clinical Message

The aim of this study was to study various factors related to the anatomical and functional outcome in the management of fracture neck femur. With the increasing incidence of fracture neck femur in young adults this study aims in providing precise management protocols and thereby reducing the incidence of complications in young patients. Anatomical reduction is of prime importance for any fracture neck femur to unite. All cases of fracture neck femur in patients less than 60 years of age should be managed with DHS with Derotation screw with the exception of high subcapital fracture which should be managed with Canulated cancellous screws.

Bibliography

1. David g lavelle, fractures and dislocations of the hip in : campbells operative orthopaedics. Terry canalle s, beaty JH : editors. Pennsylvania. 2008; mosby Elsevier. 11th edition, volume -3 : p3237-308
2. Ross k Leighton, fractures of neck of femur in rockwood and greens fractures in adults. Bucholz R W heckman J D, courtbrown C M. Editors Philadelphia. 2006, lippincot Williams and Wilkins, 6th edition, vol 2, p 1753-92
3. Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am. 1976;58:689-95.
4. Thuan V. Ly and Marc F.Swiontkowski. Treatment of Femoral Neck Fractures in Young Adults. J Bone Joint Surg Am. 2008;90:2254-2266.
5. Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma. 1986 ;26:932-7.
6. Zetterberg CH, Irstam L, Andersson GB. Femoral neck fractures in young adults. Acta Orthop Scand. 1982;53:427-35.
7. Swiontkowski MF, Winquist RA, Hansen ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837-46.
8. . Luice RS, Fuller, Stephen, Burdick DC and Johnston RM,: ―Early prediction of avascular necrosis of the femoral head following femoral neck fractures‖. Clinical Orthopaedics. 1981; 161: p207-14. 9. Ross K Leighton. Fractures of the Neck of Femur. In: Rockwood and Green's Fractures in Adults. Bucholz RW, Heckman JD, Court-brown CM: editors. Philadelphia. 2006; Lippincott Williams & Wilkins. 6th ed,vol-2; p1753-92.
10. Behr JT, Dobozi WR, Badrinath K. The treatment of pathologic and impending pathologic fractures of the proximal femur in the elderly. Clin Orthop 1985;198:173â€―178.
11. Liporace F, Gaines R, Collinge C, Haidukewych GJ.: Results of internal fixation of Pauwels type-3 vertical femoral neck fractures.: J Bone Joint Surg Am. 2008 Aug;90(8):1654-9. doi: 10.2106/JBJS
12. MP Singh, Aditya N Aggarwal, Anil Arora, Ish K Dhammi, and Jagjit Singh:Unstable recent intracapsular femoral neck fractures in young adults: Osteosynthesis and primary valgus osteotomy using broad dynamic compression plate: Indian J Orthop. 2008 JanMar; 42(1):43-48.
13. Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837-46.
14. Claffey TJ. Avascular necrosis of the femoral head. An anatomical study. J Bone Joint Surg Br. 1960;42:802-9.
15. Swiontkowski MF, Tepic S, Rahn BA, Cordey J, Perren SM. The effect of fracture on femoral head blood flow. Osteonecrosis and revascularization studied in miniature swine. Acta Orthop Scand. 1993;64:196-202.
16. George J. Haidukewych, Walter S. Rothwell, David J. Jacofsky, Michael E. Torchia and Daniel J. Berry: Operative Treatment of Femoral Neck Fractures in Patients Between the Ages of Fifteen and Fifty Years: J Bone Joint Surg Am. 2004;86:1711-1716.
17. Bonnaire F, Schaefer DJ, Kuner EH. Hemarthrosis and hip joint pressure in femoral neck fractures. Clin Orthop Relat Res. 1998;353:148-55.
18. Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg Br. 1991;73:73-5.
19. Holmberg S, Dalen N. Intracapsular pressure and caput circulation in nondisplaced femoral neck fractures. Clin Orthop Relat Res. 1987; 219:124-6.
20. Crawfurd EJ, Emery RJ, Hansell DM, Phelan M, Andrews BG. Capsular distension and intracapsular pressure in subcapital fractures of the femur. J Bone Joint Surg Br. 1988;70:195-8.
21. Str¨omqvist B, Nilsson LT, Egund N, Thorngren KG, Wingstrand H. Intracapsular pressures in undisplaced fractures of the femoral neck. J Bone Joint Surg Br. 1988;70:192-4.
22. Swiontkowski MF, Tepic S, Perren SM, Moor R, Ganz R, Rahn BA. Laser Doppler flowmetry for bone blood flow measurement: correlation with microsphere estimates and evaluation of the effect of intracapsular pressure on femoral head blood flow. J Orthop Res. 1986;4:362-71.
23. Woodhouse CF. Dynamic influences of vascular occlusion affecting the development of avascular necrosis of the femoral head. Clin Orthop Relat Res. 1964;32:119-29.
24. Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am. 1976;58:689-95.
25. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. 2003;123:527-33.
26. Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques.J Orthop Trauma. 2007;21:544-8
27. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64.
28. Bonnaire FA, Weber AT. Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck. Injury. 2002;33 Suppl 3:C24-32. .


How to Cite this Article: Lakhani A A, Mahajan N, Sonawane D V. A Comparative Study Of The Management Of Fracture Neck Femur By Dynamic Hip Compression Screw  With Derotation Screw Versus Three Cancellous Screws. Journal Medical Thesis 2014  Sep-Dec ; 2(3):5-8

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Comparison Between Various Modalities of Treatment of Distal End Radius Fractures


Vol 2 | Issue 3 | Sep - Dec 2014 | page:9-11 | Saraogi Akash Ashok, Sonawane Dhiraj V, Chandanwale Ajay, Jagtap Sanjay A,  Shah Nadir Z, Bhoyar Rahul P


Author: Saraogi Akash Ashok[1], Sonawane Dhiraj V[1], Chandanwale Ajay[1], Jagtap Sanjay A[1],  Shah Nadir Z[1], Bhoyar Rahul P[1]

[1] J.J. Hospital, Byculla, Mumbai-08

Institute at which research was conducted: Grant Government Medical College & Sir J.J. Group Of Hospitals, Byculla, Mumbai-08.
University Affiliation of Thesis:Maharashtra University Of Health Sciences, Nashik.
Year of Acceptance: 2014

Address of Correspondence
Dr. Saraogi Akash Ashok
Assistant Professor, M.S. (Ortho.), J.J. Hospital, Byculla, Mumbai-08.
Email: saraogiakash@gmail.com


 Abstract

Background: Management of distal radius fractures has changed significantly since Colle's proclamation in 1814. Our study is intended to find out both conceptual and practical guidance for precision treatment with an expectant favorable result.
Method: 120 patients of distal end radius fractures were treated with Cast immobilization, Augmented External fixation, Volar locking plate fixation, Percutaneous Pinning and plaster immobilization. A.O. classification was used. Functional outcomes were assessed using “Demerit point rating system” of Gartland & Werley (modified).
Results: The most common fracture type was A2. 63.3% excellent results were obtained in the plating group as compared to 46.7% in the cast group and the k-wiring group. 63 patients had excellent result outcome, 31 patients had good, 23 patients had fair and 3 patients had poor result outcome.
Conclusion: Functional outcome depends upon patient's age, fracture anatomy, displacement, reducibility, stability and articular incongruity of fractures. They are related more to the quality of anatomical reduction than to the method of immobilization. Volar locking plating is a safe and effective treatment for unstable fractures. Specially locking implants provide advantages in fractures with metaphyseal comminuted zones (A3 and C2 fractures).
Keywords: Distal Radius Fracture, Functional Outcome, Colle's Fracture, Volar Plating.

Thesis Question: Which is best modality of treatment of Distal End Radius Fracture?
Thesis Answer: Depends upon patient's age, fracture anatomy, displacement, reducibility, stability and articular incongruity of fractures, however, volar locking plating is a safe and effective treatment for unstable fractures.

                                                        THESIS SUMMARY                                                             

Introduction

The management of distal radius fractures has changed significantly since Colle's proclamation in 1814. Distal radius fractures have an approximate incidence of 1:10,000 people and represent 16% of skeletal and 74% of forearm fractures. They are more prevalent among females. The most common trauma mechanism is falling over the outstretched hand. The desire for anatomical restoration of the distal radial joint is the rationale for operative treatment. The extent of displacement, the degree of articular disruption, the stability and the reducibility of each fracture, as well as any concurrent injury to adjacent nerves, tendons or carpal structures must be assessed carefully in the planning of logical treatment. More than 1000 peer-reviewed studies have been published on the subject, yet there is no consensus on which treatment is superior or firm guidelines for treatment decisions. Distal End Radius fracture is frequently comminuted & this is responsible for slipping of the reduction, which is a rather common late feature. It is observed, therefore, that this fracture possesses little or no stability following closed reduction & it goes on for gradual collapse.

Aims & Objectives

1. To study fracture patterns of distal radius fractures & compare the results of different methods of treatment of fracture distal end radius.
2. To find out relationship between articular incongruity or perfect anatomical restoration of distal radius fractures and functional results & find out basis for selecting the method of treatment.

Materials and Methods

Study Design:
In this study 120 patients were treated for fractures of distal end radius in a tertiary care centre in a metropolitan city.
Inclusion criteria:
· Age - 15 to 65 years.
· The patient presented within two weeks of the injury.
Exclusion criteria:-
· Immature skeleton
· Congenital Deformity
· Compound cases
Study Period:
May 2011 to Oct 2013

Method Of Study:
After the approval from Institutional Ethics Committee, 120 patients of distal end radius fractures were enrolled in the study after obtaining informed written consent. A.O. classification was used for classification of fractures.
Techniques used:
1. Conservative — Cast immobilization
2. Operative —
a) External fixation
b) Internal Fixation - Volar locking plate fixation.
c) Percutaneous Pinning and plaster immobilization.
Intervention was done within a week after presentation.
Scoring System
Functional outcomes were assessed at final follow up visit using “Demerit point rating system” of Gartland & Werley {modified by Sarmiento et al (1975) & further modified by Lucas & Sachtjen(1981)} [2]

Results

The most common fracture type treated by Casting was A2 type, by Augmented external fixation was C2 type & by K-wiring was A2 type. The most common fracture type in this study was A2 followed by C2 & A3. The mean age of the study participants was 37 years. Age range was 18-65 years. Males were more commonly affected with M:F ratio of 3.3 : 1. Non-dominant side was more commonly involved than the dominant side. The mean volar tilt in the augmented external fixation group was -0.30 degrees whereas the median of the same group is 4 degrees. The mean for plating group is 3.43 degrees. The mean radial angle is highest in the plating group i.e. 19.13 degrees whereas it is lowest in K-wiring group i.e. 16.33 degrees. Mean value of Modified Gartland & Werley Total Demerit Score was 4.23 for the plating group whereas it was 6.37 for the K-wiring group. One patient developed pin tract infection in the k-wire group whereas 2 patients developed pin tract infection in the exernal fixator group. 2 patients in the Volar LCP group developed superficial infection, which resolved with antibiotics and dressings. 63.3% excellent results were obtained in the plating group as compared to 46.7% in the cast group and the k-wiring group. Overall, 63 patients had excellent result outcome, 31 patients had good, 23 patients had fair and 3 patients had poor result outcome.

Discussion

The demerit point system was chosen over other functional scoring systems as it takes into consideration not only objective evaluation but also the subjective parameters and complications associated with treatment like poor finqer function, nerve complication and pain due to arthritis. The cast immobilization was done in non-articular undisplaced, non-articular displaced reducible and stable and articular displaced reducible and stable fractures (A.O. type- A2, B1 & C1 in this study). It has given Excellent to Good results in 80% cases treated conservatively. The results were better than in a series presented by Gartland and Werley (1951) (Excellent to Good results in 68.3%) due to proper selection of treatment in present series whereas in other series cast were given in all cases.
Indications for operative management were:
Displaced intra-articular fractures with (either of them):
1.Post reduction articular step of > 2 mm,
2.Post reduction radial shortening of > 3 mm,
3.Post reduction > 15 degrees of saggital plane angulation (as measured from the anatomical volar tilted position).
The type of operative treatment was selected was according to the fracture anatomy.
Augmented External fixator with ligamentotaxis was used in non-articular irreducible displaced fractures; articular, displaced fractures which were reducible but unstable; irreducible and complex fractures (A.O.Type- A3, C2, C3 in this study). Excellent to Good results were obtained in 76.6% cases, Fair in 20% eases. The results were comparable to other series (Good 85%, Fair 12% - Cooney WP et al 1979).
Trans-fixation with k-wire and immobilization in cast was done for non-articular displaced reducible but unstable fracture and articular displaced reducible and stable fractures (A.O.Type – A2, A3, B1, C1, C2, C3 in this study). In the present series, results were Excellent to good in 70%, fair in 23.3% and poor in 6.7% cases. In a series presented by Suman R.K. (1983) Excellent to Good results were in 81.1% and Fair to Poor results in 18.9% cases.
Internal fixation with volar LCP system was used in 30 patients (A.O.Type- A2, A3, B2, B3, C1, C2, C3]. In the present series, results were excellent in 63.3%, good in 23.3%, fair in 13.3% as compared to study by Murakami K. et al who treated 24 patients (Chiba, Japan) showed 83.3% excellent results & 16.7% good results with volar LCP. An advantage of volar plating technique is the comfort that it provides to patient in initiating early finger & wrist motion. Despite, our use of an early motion rehabilitation protocol, the distal end radius fracture reduction was maintained at the follow- up periods. Early rehabilitation had the additional advantage of enabling the patient to regain independence in daily activities rather quickly. In a present series, 6.7% patients developed arthritis, in whom, 80% had articular incongruity of 1-2 mm. In a retrospective study by Knirk J.L.et al (1986), it was concluded found that accurate articular restoration was the most critical factor in achieving a successful result. While interpreting the results it may be said that articular incongruity, loss of radial length and angular deviation were the most significant influences in that order, on the development of post-traumatic arthritis and overall end result

Conclusion

The treatment goal for fractures of the distal end of the radius is fully functional recovery of the wrist and prerequisites are restoration of the anatomy and early mobilization. Extra-articular fractures give better results than intra-articular fractures. Functional outcome depends upon patient's age, fracture anatomy, displacement, reducibility, stability and articular incongruity of fractures. It has also been shown that functional results are related more to the quality of anatomical reduction than to the method of immobilization. Volar locking compression plating is a safe and effective treatment for unstable fractures of the distal radius. It can also stabilize dorsally unstable distal radius fractures with least complications. Specially locking implants provide advantages in the treatment of distal radius fractures with metaphyseal comminuted zones (A3 and C2 fractures).

Bibliography

1. Belloti JC, Tamaoki MJ, Franciozi CE, Santos JB, Balbachevsky D, Chap Chap E, Albertoni WM, Faloppa F. Are distal radius fracture classifications reproducible? Intra and interobserver agreement. Sao Paulo Med J. 2008 May 1;126(3):180-5 PubMed PMID: 18711658.
2. Vaughan PA, Lui SM, Harrington IJ, Maistrelli GL. Treatment of unstable fractures of the distal radius by external fixation. J Bone Joint Surg Br. 1985 May;67(3):385-9. PubMed PMID: 3997946.
3. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951 Oct;33-A(4):895-907. PubMed PMID: 14880544.
4. Phadnis J, Trompeter A, Gallagher K, Bradshaw L, Elliott DS, Newman KJ. Mid-term functional outcome after the internal fixation of distal radius fractures. J Orthop Surg Res. 2012 Jan 26;7:4. doi: 10.1186/1749-799X-7-4. PubMed PMID: 22280557; PubMed Central PMCID: PMC3398340.
5. Cooney WP 3rd, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles' fractures. J Bone Joint Surg Am. 1979 Sep;61(6A):840-5. PubMed PMID:479230.
6. Suman RK. Unstable fractures of the distal end of the radius (transfixion pins and a cast). Injury. 1983 Nov;15(3):206-11. PubMed PMID: 6642635.
7. Murakami K, Abe Y, Takahashi K. Surgical treatment of unstable distal radius fractures with volar locking plates. J Orthop Sci. 2007 Mar;12(2):134-40. Epub 2007 Mar 30. PubMed PMID: 17393268.
8. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986 Jun;68(5):647-59. PubMed PMID: 3722221.


How to Cite this Article: Saraogi A A, Sonawane D V, Chandanwale A, Jagtap S A,  Shah N Z, Bhoyar R P. Comparison Between Various Modalities of Treatment of Distal End Radius Fractures. Journal Medical Thesis 2014  Sep-Dec ; 2(3):9-11

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Tobacco, Oxidative stress and Otorhinolaryngological diseases


Vol 2 | Issue 3 | Sep - Dec 2014 | page-17-20 | Reshma P Chavan, Shivraj M Ingole, V. W. Patil , Shubhangi M Dalvi , Dhiraj V Sonawane


Author: Reshma P Chavan[1], Shivraj M Ingole[1], V. W. Patil[1], Shubhangi M Dalvi[1], Dhiraj V Sonawane[1]

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

Institute at which research was conducted: GGMC and Sir JJ group of hospitals, Mumbai-08.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2014

Address of Correspondence
Dr Reshma Prakash Chavan.
Flat No-14, Building no-4 “Swastik” Sir J. J. Hospital Campus, Byculla. Mumbai-08
Email: entproblem@gmail.com


 Abstract

Background: Tobacco chewing and smoking are leading preventable causes of death. Researchers have rated nicotine as even more addictive than heroin, cocaine, marijuana or alcohol (Worldwide trends in tobacco consumption and mortality, WHO). The disrupted oxidative-reductive milieu proceeds a lipid per oxidation, altered antioxidative enzyme activities and depletion of non-enzymatic endogenous antioxidants, several of which can be detected in the pre-symptomatic phase of many diseases. So the association between oxidative stress and tobacco consumption in disease condition is studied.
Conclusion: Tobacco consumption causes increased oxidative stress. In tobacco chewing and smoking oral cavity lesions were more common. Allergic factor and hearing loss was not seen in tobacco chewing and smoking. There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions.
Keywords: Tobacco, Oxidative stress, Otorhinological diseases.

                                                        THESIS SUMMARY                                                             

Introduction

Oxidative stress is tied to mitochondrial oxidation of foodstuff and the generation of the energy necessary to sustain life occupies a place of central importance. Oxidative stress is a state of altered physiological equilibrium within a cell, tissue, or organ. It is a condition arising when there is a serious imbalance between the levels of free radicals in a cell and its antioxidant defences. It is estimated that 1-3 billion reactive oxygen species (ROS) are generated/cell/day. Therefore the body's antioxidant defence system for the maintenance of health is important.  Tobacco also causes increase in oxidative stress. Tobacco products have no safe level of consumption. It is not only tobacco related products alone, but also local Indian products like bidis, gutkas and pan masalas, which are the culprits. The role of tobacco in alteration of enzymatic activity (SOD, GTR, GTP, and MAD) and their association with development of benign and malignant condition was studied.

Aims and Objectives
1) To study the activity of enzymes melanodealdehyde (MDA) superoxide dismutase (SOD), glutathione peroxidise, catalyse activity of patients with and without tobacco consumption.
2) To study whether there is significant correlation between biochemical parameters and ENT parameters.
3) To study clinical conditions like allergic rhinitis, nasal polyposis, sensorineural hearing loss, leukoplakia, melanoplakia, erythroplakia, submucous oral fibrosis, oral cavity malignant tumour, nose and throat malignancy seen in tobacco consumers.

Methods

A Group of people was selected and both tobacco consumers and non consumers were compared for biochemical parameters. Exclusion criteria were patients with diabetis mellitus, hypertension, pancreatic diseases, liver diseases, kidney diseases and heart diseases, H.I.V. positive patients, and genetic disorders. Patients were selected between 18-60 yrs age group.

Sampling:-
Venous Blood samples were collected after overnight fasting.

1.Hemolysate prepared from heparinised blood specimens were used for estimation of activities of catalase (CAT), Superoxide dismutase (SoD), glutathione peroxidise (GHS-PX), glutathione reductase (GR) and Melondialdehyde (MDA).

2.Citrated blood collected was utilized for estimation of blood glutathione (GSH).

All samples were stored in refrigerator and the estimations were done within 24 hours of specimen collection.

A)Serum malondialdehyde:-

Method: Buege and Aust
Malondialdehyde (MDA) is a highly reactive three carbon dialdehyde, produce from lipid hydroperoxide. It can, however, also be derived by the hydrolysis of pentose's, deoxyribose, hexoses, from some amino acids and from DNA. MDA has most frequently been measured by thiobarbituric acid reaction.MDA is measured as an index of lipid Peroxidation.

Principle:- Serum sample is first treated with TCA for protein precipitation and then treated with thiobarbituric acid. The mixture is heated for 10 minutes in boiling water bath. One molecule of MDA reacts with two molecules of thiobarbituric acid. The resulting chromogen is centrifuged and intensity of colour developed in supernatant is measured spectrophotometrically at 530nm.MDA levels are expressed in nmol /mL.
Reagents:-
a) 40% Trichloroacetic acid (TCA).-40 gms of TCA in 100 mL of distilled water.
b) 0.67 % Thiobarbituric acid (TBA) 0.67 gm of TBA in 100 ml of distilled water in boiling water bath.
c) Standard Malondialdehyde (MDA).
Stock MDA is Prepared from the 1,1,3,3 tetraethoxy propane by acid hydrolysis. A solution containing 0.1105 ml 1,1,3,3 tetraethoxy propane in 50 mL distilled water and 0.5mL 0.1 M HCl is warmed at 500C for 1 hour and volume adjusted to 100 mL with distilled water. The concentration of free MDA was determined spectrophotometrically at 267nm, using a molar absorption coefficient of 31,800.

Sample processing:-

The above reaction mixture was heated in boiling water bath for 10 minute. It was then cooled at R.T. and centrifuge. The absorbance of supernatant ar 530 nm was noted. The result was calculated from standard graph.

B) Superoxide-Dismutase Activity (SOD)
Method:- Arthur JR, Boyne R
Principle:-The role of superoxide dismutase (SOD) is to accelerate the dismutation of the toxic superoxide radical (02), produced during oxidative energy processes, to hydrogen peroxide and molecular oxygen.This method employs xanthine and xanthine oxidase (XOD) to generate superoxide radicals which react with,
2‑(4‑iodophenyl)‑3‑(4‑nitrophenol)‑5‑phenyltetrazolium chloride (I.N.T.) to form a red formazan dye. The superoxide dismutase activity is then measured by the degree of inhibition of this reaction. One unit of SOD is that which causes a 50% inhibition of the rate of reduction of INT under the conditions of the assay.
XanthineXODUric acid + O2.I. N. TO2.Formazan DayO2. + O2. + 2 H+ O2 + H2O2SODOR

C) Glutathione Peroxidase(GSH-PX)

Method: - Paglia Donald E & Valentine William N.

Principle:-This enzyme has been shown to catalylase with high specificity the invitro detoxification of hydrogen peroxide by the oxidation of reduced glutathione according to following reaction:

Reaction Principle
GPX
2GSH + ROOH ROH + GSSG + H2O

GR
GSSG + NADPH + H NADP+ + 2GSH
It measures the rate of GSH Oxidation by H2O2 as catalyzed by the GSH; however, this substrate is maintained at 2 constant concentrations by the addition of exogenous GSSG-R and NADPH, which immediately convert any GSSG convert any GSSG produced to the reduced form.
The rate of GSSG formation was then measured by following decrease in absorbance of the reaction mixture of 340nm as NADPH is converted to NADP.

D) Glutathione Reductase

Method: - Goldberg DM. & Spooner RJ
Principle:- Glutathione reductase (E.C.1.6.4.2) catalyses the reduction of glutathione (GSSG) in the presence of NADPH, which is oxidized to NADP+. The decrease in absorbance at 340 nm is measured.

GR
NADPH + H+ + GSSG NADP+ + 2GSH

Centrifuge 0.5 ml of whole blood for 5 min at 2000 rpm. Remove the plasma and buffy coat, Wash the erythrocytes three times by in 0.9% NaCl, centrifuging for 5 min at 2000 rpm after each wash. Lyse the cells by resuspending in cold redistilled H20, back up to 0.5 ml. Leave for 10 min at +2 - +8"C. Centrifuge lysate for 5 min at 2000 rpm to remove stroma. Dilute 100 µl of lysate with 1.9 ml of 0.9% NaCl solute on for assay.

E) Catalase (CAT)
Method:- Aebi
Principle:- In the UV range H2O2 shows a continual increase in absorption with decreasing wavelength. The decomposition of H2O2 can be followed directly by the decrease in extinction at 240nm.

Reagents:-
1. Phosphate buffer (50 mM, pH 7.0)
a) Dissolved 6.81 gms of potassium dihydrogen phosphate (KH2PO4) IN glass distilled water and volume made to 1 liter.
b) Dissolved 8.90 gms of disodium hydrogen phosphate (Na2HPO4) in glass distilled water and volume made to 1 liter. Mix solution A and B in the proportion of 1:1:55
2. Hydrogen Peroxide (30mM)
Diluted 0.34 ml of 30% H2O2 solution with phosphate buffer to 100ml which was prepared just before use.
Assay system
Calculation:
1 Unit = 2.3 Log A1 1000 1
_______ X ______ X ______ X ______ X 10
0.693 Log A2 6.93 Co
C0 = Concentration of the original enzyme sample in assay system. A1A240 at t=0 and A2 --A240 at t=15 sec.
Result was expressed by converting in Units/gm of Hb.
Observations-
Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in control and different categories of ENT lesions were studied.. Glutathione ReductaseU/gHb was significantly lower in diseased states.In control group Glutathione ReductaseU/gHb was 11.49973±1.972828.In benign conditions the Glutathione ReductaseU/gHb values were 5.8068 ±0.876812 while in cancer patients Glutathione ReductaseU/gHb was 3.8948±0.735391. Correlations between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions were studied. In benign Otorhinolaryngologicalogical conditions R values for MDA/Glutathione Reductase, MDA/ Glutathione Peroxidase, MDA/ SODU and MDA/ Catalase for were between -0.925 and -0.981. In cancer group R –value was between -0.784 and- 0.965. P values for correlation between MDA/Glutathione Reductase, MDA/ Glutathione Peroxidase, MDA/ SODU and MDA/ Catalase in benign and cancer group was 0.00. There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions.

Discussion

Tobacco contain carcinogens like polycyclic aromatic hydrocarbons, aldehydes, benzo[alpha]pyrene, ethylene oxide, 4-aminobiphenyl and nitrosamines which are metabolically activated by hydrolysis, reduction, or oxidation by xenobiotic metabolism through phases I and II enzymes.[8] Therefore in tobacco consumer there are elevated levels of enzymes indicative of increased oxidative stress. Oxidative stress (OS) can also result from conditions like excessive physical stress, exposure to environmental pollution and xeno-biotics. Oxidative stress, as a pathophysiological mechanism, has been linked to numerous pathologies, poisonings, and the ageing process. Accordingly, from the point of view of routine clinical-diagnostic practice, it would be valuable to routinely analyze OS status parameters to earlier recognize potential disease states and provide the basis for preventative advance treatment with appropriate medicines. The role of tobacco in alteration of enzymatic activity (SOD, GTR, GTP, and MAD) is associated with development of carcinoma in the oral sub mucus fibrosis. Tobacco also causes increase in oxidative stress which is duration dependent. Reactive oxygen species and reactive nitrogen species, endogenously or exogenously produced, can readily attack all classes of macromolecules (protein,DNA, unsaturated fatty acid).The disrupted oxidative-reductive milieu proceeds via lipid per oxidation, altered antioxidative enzyme activities and depletion of non-enzymatic endogenous antioxidants, several of which can be detected in the pre-symptomatic phase of many diseases. These biochemical parameters can be used as biomarkers for certain diseases states. Different ear, nose, throat diseases were studied in detail according to staging and biochemical parameters. During the study it is observed that the ENT diseases seen in tobacco consumers were dose and duration dependant. Also there are certain factors like addition of lime, betal nuts along with use of tobacco were more prone for the disease process Also alcohol intake along with tobacco increases disease severity and staging. There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions. Chronic exposure to tobacco smoke aggravated eosinophilic inflammation and promoted airway remodeling and nasal polyp formation in a murine model of ERSwNPs. [11] But there was no significant allergic complaints and hearing loss seen in tobacco consumers. The malignant transformation rate of OSF has been reported to be around 7.6% over a 17-year period.

Conclusion

Oxidative stress parameters were increased in tobacco chewers and both benign and malignant conditions of ear, nose and throat.
There is significant negative correlation between Malondialdehyde (MDA) and Glutathione Reductase, Glutathione Peroxidase, Superoxide-Dismutase (SOD), Catalase in ENT lesions. There were no significant allergic complaints and hearing loss seen in tobacco consumers.
Further study is required to see the malignant transformation of these benign lesion with continued and discontinuation of tobacco consumption.

Keywords

Distal femoral fractures,retrograde intramedullary nail,supracondylar,intracondylar.

Bibliography

1). Halliwell B, Gutteridge JM. 2nd ed. Oxford, UK: Oxford University Press; 1989. Free Radicals in Biology and Medicine.

2). Ames BN, Shigenaga MK, Hagen TM. Oxidants, antioxidants, and the degenerative diseases of aging. Proc Natl Acad Sci U S A. 1993;90:7915–22.

3) Buege JA, Aust SD. Microsomal lipid peroxidation. Methods Enzymol.1978;52:302-10.

4) Arthur JR, Boyne R. Superoxide dismutase and glutathione peroxidase activities in neutrophils from selenium deficient and copper deficient cattle. Life Sci. 1985 Apr 22;36(16):1569-75.

5) Paglia DE, Valentine WN. Studies on the quantitative and qualitative
characterization of erythrocyte glutathione peroxidase. J Lab Clin Med. 1967
Jul;70(1):158-69.

6)Goldberg DM, Spooner RJ (1983) Glutathione reductase. In Methods of Enzymatic Analysis. ed. Bergmeyer, H. Vol. 3,pp. 258 - 265. Basel: Verlag Chemie.

7) Aebi H. Catalase in vitro. Methods Enzymol. 1984;105:121-6.
8) Dwivedi S, Goel A, Khattri S, Mandhani A, Sharma P, Pant KK. Tobacco Exposure by Various Modes May Alter Proinflammatory (IL-12) and Anti
Inflammatory (IL-10) Levels and Affects the Survival of Prostate Carcinoma Patients: An Explorative Study in North Indian Population. Biomed Res Int. 2014;2014:158530.

9) Dukic M, Ninkovic M, Jovanovic M. Oxidative Stress – Clinical Diagnostic Significance. JMB. 2008; 27 (4):409–425.

10)Gupta, P.C. and Nandakumar, A. Oral cancer scene in India. Oral Dis. 5(1999) 1-2.

11 ) Lee KI, Kim DW, Kim EH, Kim JH, Samivel R, Kwon JE, Ahn JC, Chung YJ, Mo JH.Cigarette smoke promotes eosinophilic inflammation, airway remodeling, and nasal polyps in a murine polyp model. Am J Rhinol Allergy. 2014 May-Jun;28(3):208-14.

12) Trivedy CR, Craig G, Warnakulasuriya S. The oral health consequences of chewing areca nut. Addict Biol. 2002 Jan;7(1):115-25.


How to Cite this Article: Chavan R P, Ingole S M, Patil V W, Dalvi S M, Sonawane D V. Tobacco, Oxidative stress and Otorhinolaryngological diseases. Journal Medical Thesis 2014  Sep-Dec ; 2(3):17-20

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