Vol 2 | Issue 2 | May - Aug 2014 | page 50-53 | Ubale T, Ranganath N, U H, Kumar S, Shah K

Author: Tushar Ubale[1], N.Ranganath[2], Harish U[1], Sunil Kumar[3], Kunal Shah[1]

[1]R.N .Cooper Municipal Hospital,Mumbai.
[2]General Hospital Alur Hassan District , Karnataka State.
[3]Mysore Medical College And Hospital Mysore.

Institute at which research was conducted: Mysore Medical College And Institute,Mysore.
University Affiliation of Thesis: Rajiv Gandhi University Of Health Sciences Karnataka.
Year of Acceptance: 2012

Address of Correspondence
Dr. Harish U
No.3 ,2nd Main 7th Crossm Amarjyothinagar,Vijayanagar Bangalore,Karnataka 560040.
E-Mail : 77harish36@Gmail.Com

 Abstract

Background:Supracondylar and intercondylar femoral fractures are serious injuries and difficult to treat and have potential to produce significant long term disability with poor results. It is now recognized that distal femoral fractures are best treated with open/closed reduction and surgical stabilization. Many studies show retrograde intramedullary nailing is the best option.Our aim in this study is to evaluate surgical and functional outcome of retrograde intramedullary nailing in treatment of distal femoral fractures.
Methods: 20 patients,13 male, 7 female, The mean age was 39.7 years. 15 supraacondylar and 5 intercondylar fractures were treated with RIN and evaluated. Closed technique was used in 15 case and open technique in 5 cases.
Results: Results were evaluated by Lysholm knee score rating system. EXCELLENT-40% GOOD-40% FAIR -15% POOR-05%. Complications of 1 case of varus deformity of less than 10°, 1 case of superficial infection and 2 case of delayed union.
Conclusion: In surgical management of distal femoral fractures retrograde intramedullary nailing is one of the better options with good functional outcomes and less complications.
Keywords: Distal femur,Supracondylar,intercondylar, retrograde intramedullary nail.

Introduction

This is an era of rapid industrialization and fast pace of life which has led to concomitant rise in road traffic accident (RTA), as well as increased life expectancy, old age population, carrying dangers of osteoporosis and fractures. So these major factors contribute to such complex fractures of distal femur. The incidence of distal femoral fractures is approximately 37/I,00,000 person-years.1
The osteosynthesis in the distal femur could be difficult because of thin cortex, communition, osteopenia, complex injuries associated soft tissue injuries, a distal wide medullary canal and involvement of the knee joint. Most surgeons agree that distal femoral fractures need to be treated operatively to achieve optimal outcomes.2
Supracondylar and intercondylar femoral fractures are serious injuries and difficult to treat and have potential to produce significant long term disability with poor results.[3]
In early 1960s, studies of non-operative skeletal traction4 of distal femoral fractures alongwith principle of Watson Jones5 resulted in increased incidence of many complications, like angular deformity, delayed patient mobilization, joint integrity, knee stiffness and post-traumatic osteoarthritis. [6,7]
The options for surgical treatment are open reduction and internal fixation with Dynamic condylar screw, 95 degrees angled blade plate, locking condylar buttress plate, minimally invasive percutaneous plate osteosynthesis (MIPPO), Liss invasive stabilization technique (LISS plate technique), Ante-grade and Retrograde intramedullary interlocking nailing. Most commonly used implant for fixation of distal femoral fractures are 95 degrees angled blade plate, dynamic condylar screw fixation allows correction only in sagittal planes However plating requires extensive stripping of soft tissue structures, which affect soft tissue and osseous healing. The use of plates & screws in the fixation of these fractures has the inherent drawback of producing a load shielding device. The resultant osteopenia creates a substantial risk of refracture proximal to the plate.[ 9,10]
Intramedullary nails offer potential biomechanical advantages over plates and screws because their intramedullary location results in less stress on the implant, they have the potential for load sharing, and can be inserted with minimal stripping of soft tissue. Given the appropriate fracture patterns, ante grade IM nailing in the treatment of distal femoral fractures has been associated with angular deformities because of inability of distal interlock of the antegrade nail to achieve control of the small and often osteoporotic distal fracture fragment. [11]
So Retrograde intramedullary interlocking nailing is best in terms of decreased operative time, blood loss, anatomical reduction of articular surface, restoration of limb alignment, early mobilization and good functional outcome, have been shown to be effective ways of managing notorious distal femoral fractures.
Distal femoral fractures tend to collapse into varus. In surgical fixation of these fractures with AO blade plate or dynamic condylar screw, the shaft of femur is pulled laterally displacing the mechanical axis lateral to anatomical axis of the limb. This creates rotational movements at the fracture site causing pull of blade plate or condylar screws leading to fatigue fracture of the plates, also presence of osteoporotic bones leads to fixation failures with plates and screws traumatic surgeries.
The advantages of intramedullary device is that it aligns the femoral shaft with condyles decreasing the tendency to varus movement of fracture site. Also advantageous in osteoporotic bone stabilization, Retrograde intramedullary nail has got distinct advantage of preservation of fracture haematoma, minimal soft tissue dissection and hence decrease operative blood loss, decreased operative time and reduced incidence of infection, early mobilization and good functional outcome.
The purpose of this study is to evaluate the results of supracondylar and intercondylar fracture of distal femur treated by closed/open reduction and internal fixation using Retrograde intramedullary nail.

Methods

In this prospective study of 20 cases of distal femoral fractures who were treated in K.R.Hospital, MMCRI, Mysore between the period of August 2009 and September 2011 are included. The method used for the fracture fixation was RIN. The duration of follow up ranged from 2 to 24 months.The distal femoral fractures studied included the supracondylar and intercondylar fractures. Twenty patients with fifteen SC and five IC of the distal femoral fracture were treated with RIN and evaluated.The mean age of patients in our study was 39.7 years maximum number of patients were between 20-29 years of age. 13 patients were male and 7 were females. The fracture occurred on right side in 8 (40%) patients and in left side 12 (60%) patients. RTA was the main cause of fracture accounting to 80%. Among these fractures, 15 were of closed type and 5 were of open type In our study Mullers type A fractures were more in number i.e. 15 out of which, 6 were of type A1, 6 was of type A2 and 3 were of type A3. There were 5 type C fractures out of which 3 was C1 type and 2 was C2 type.Out of 20 patients closed technique was used in 15 case and open technique in 5 cases. All static locking done. The final results were evaluated by functional evaluation scale developed by Lysholm  knee score rating system.

Results

Results were evaluated by functional evaluation scale developed by Lysholm knee score rating system. According to Lysholm knee scoring system, EXCELLENT-40% GOOD-40% FAIR -15% POOR-05% Comparing our results with standard studies of
1.Emmet Lucas et al.34(1993)
2.Richard. E Gellman et al.45(1996)
3.Patel.K et al. 48 (2004)
4.Present study (2012)
In Lucas study number of cases was 33 with average ROM was 100°, with 1 bent and broken nail and infection with septic knee and average union time of five months.
In Gellman study number of cases was 24 with average ROM was 104°, results were 16 good, 2 fair and 2 poor results and average union time was 4 months.
In Patel K study number of cases was 25, open cases were 28% and closed were 72%. AO classification was used. All cases were operated by percutaneous RIN. Average union time was 3.1 months and average ROM was 117°. 84% showed excellent, 8% showed good and 8% showed fair results correspondingly.
In our study 20 cases were studied with 15 closed and 5 open cases, average age was 39.7 years, 16 cases were due to RTA and 4 due to fall.
In our study we found average union time 3.6 months comparatively less than Lucas and Gellman study and slightly more than Patel case study.
In our study average ROM was 111.25% which is more than Lucas and Gellman study and less than Patel K case study.
We had complications of 1 case of varus deformity of less than 10°, 1 case of superficial infection and 2 case of delayed union.
In our study functional results are better than Lucas and Gellman study and comparatively less better than Patel K case study. We attribute this less better result because we operated five cases by open technique compared to all percutaneous RIN in Patel K case study.

Conclusion

The study was conducted to assess fracture pattern, management treatment evaluating the results of RIN in the treatment of supracondylar and intercondylar fractures of distal femur. Analysis of our study showed that this is good method of treating type A and C fractures. In type C fractures good articular congruity was achieved by fixing the fragments with cannulated cancellous screws first and then inserting RIN. Retrograde insertion of nail stabilized the fracture below isthmus and interlocking neutralized the rotational stresses and restricted telescoping of fragments, there by preventing angulation, rotational instability and shortening. This stability allowed us to mobilize the knee early and improve the range of motion and quadriceps power.
So we conclude that in surgical management of distal femoral fractures retrograde intramedullary nailing is one of the best options.

Keywords

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

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

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

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

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

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

Abstract

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

Introduction

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

Aims and Objectives

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

Methods

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

Results

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

Conclusion

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

Clinical Message

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

Keywords

HIV, infection, wound healing, fracture healing.

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40. Gregory K Johnson Progress towards new safer latex gloves to reduce HIV I transfer by needle stick AAOS 1994 Paper 509.
41. Klemens Trieb Risk of infection after TKR in hemophilic in HIV positive patients (letters to editors) JBJS May 2003 Vol. 85 A:969.
42. Briggs J A , Wilk T Structural organization of authentic ,mature HIV virions and cores EMBO J 2003 Apr 1; 22 (7): 1707 –1715.
43. Mark A Jacobson Absolute or Total Lymphocyte count as a marker for the CD 4 positive T lymphocyte criteria.San Francisco – Gladstone Center for AIDS Research.
44. Giuseppe Pantaleo The immunopathogenesis of Human Immunodefiency Virus Infection The New Eng J Med Feb 1993 ; Vol 328 No 5 327-335.
45. W Roder ,H Muler HIV infection in human body JBJS (Br) Mar 1992 Vol 72 B 2 :179-180.
46. Osmond Dennis H . Revised CDC Classification System for HIV .infection HIV InSite Jun 1998.
47. Schmidt B., Kearns G., Perrott D., and Kaban LB. (1995) . Infection following treatment of mandibular fractures in Human Immunodeficiency Virus sero positive patients: J Oral Maxillofac Surg. 1995 Oct;53(10): 1134-9.
48. P. Hoekman et al: Lecture Notes.Department of Orthopaedics and Traumatology, center Hospitalier de Kigali, Rawanda.
49. O'Brien ED et al : Open tibial fracture infections in asymptomatic HIV positive patients : Orthop Rev. 1994 Aug 23(8):662-4.
50. Philips AM et al : orthopaedic surgery in hemophiliac patients with HIV Clin Orthop. 1997 Oct; (343) : 81-7.
51. M Eriguchi, Y Takeda et al : Lecture Notes : Surgery in patients with HIV infection : indications and outcome.
52. Harrison WJ., Lewis CP et al : Wound healing after implant surgery in HIV positive patients.: J Bone Joint Surg Br. 2002 Aug; 84(6):802-6.

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

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

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

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

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

Abstract

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

Introduction

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

Aims and Objectives

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

Methods

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

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

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

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

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

Results

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

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

Discussion

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

Conclusion

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

Clinical Message

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

Keywords

Tibia condyle fracture, locking plate, anatomic reduction, physiotherapy

Bibliography

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10. Waddell JP, Johnston DW, Neidre A. Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods. J Trauma 1981;21:376-81.
11. Bowes DN, Hohl M. Tibial condylar fractures. Evaluation of treatment and outcome. Clin Orthop Relat Res 1982:104-8.
12. Jensen DB, Rude C, Duus B, Bjerg-Nielsen A. Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg Br 1990;72:49-52.
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14. Ries MD, Meinhard BP. Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury. Clin Orthop Relat Res 1990:215-23.
15. Murphy CP, D'Ambrosia R, Dabezies EJ. The small pin circular fixator for proximal tibial fractures with soft tissue compromise. Orthopedics 1991;14:273-80.
16. Benirschke SK, Agnew SG, Mayo KA, Santoro VM, Henley MB. Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol. J Orthop Trauma 1992;6:78-86.
17. Itokazu M, Matsunaga T. Arthroscopic restoration of depressed tibial plateau fractures using bone and hydroxyapatite grafts. Arthroscopy 1993;9:103-8.
18. Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res 1993:87-100.
19. Georgiadis GM. Combined anterior and posterior approaches for complex tibial plateau fractures. J Bone Joint Surg Br 1994;76:285-9.
20. Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens FF. Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma 1994;8:455-61.
21. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg Am 1995;77:661-73.
22. Bendayan J, Noblin JD, Freeland AE. Posteromedial second incision to reduce and stabilize a displaced posterior fragment that can occur in Schatzker Type V bicondylar tibial plateau fractures. Orthopedics 1996;19:903-4.
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31. Koval KJ, Sanders R, Borrelli J, Helfet D, DiPasquale T, Mast JW. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma 1992;6:340-6.
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internal fixation of complex tibial plateau fractures. J Orthop Trauma 1999;13:545-9.
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Vol 2 | Issue 2 | May - Aug 2014 | page 7 |  Sundarrajan S R

Author: Dr S R Sundarrajan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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