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Integrating Patient-Specific Lifestyle Demands into Post-Arthroplasty Care: Hypothesis – Enhancement of HRQoL in Indian Patients
Vol 9 | Issue 2 | July-December 2023 | page: 9-12 | Peeyush Belsare, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.210
Author: Peeyush Belsare [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sanc heti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Peeyush Belsare,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: peeyushbelsare.03@gmail.com
Abstract
Background: Arthritis of the hip and knee causes persistent pain, stiffness and loss of function that limit everyday activities and reduce quality of life. Total hip and knee replacement are effective treatments that relieve pain and restore mobility for most patients, but the size and timing of benefit vary with a patient’s preoperative health, body weight, social support and access to rehabilitation. Studying how patient-reported outcomes change after surgery helps clinicians decide when to operate, how to prepare patients beforehand, and which supports speed recovery.
Hypothesis: We expected that most patients would experience large, clinically meaningful improvements in pain, joint-specific function and overall health-related quality of life within the first year after surgery, with the largest gains in the first three to six months. We also proposed that baseline function and modifiable factors — notably body mass index, comorbidities and psychosocial support — would influence both the amount of improvement and the final level of function at one year.
Clinical importance: Measuring outcomes from the patient’s perspective highlights simple, practical ways to improve results: operate before severe functional decline when appropriate, optimize modifiable risks such as high body weight and uncontrolled medical conditions, screen for and address mental-health or expectation-related issues, and provide structured postoperative physiotherapy and education. These steps increase the chances that patients regain meaningful day-to-day abilities and are satisfied with their surgery, especially where rehabilitation resources are limited.
Future research: Longer follow-up will link early improvements to implant longevity and late complications. Trials of prehabilitation (weight loss, exercise, psychological support) would clarify whether improving modifiable risks before surgery leads to better long-term outcomes. Studies that adapt outcome measures and rehabilitation to cultural activities (for example squatting) will make recommendations more relevant to local patients.
Keywords: Total hip arthroplasty, Total knee arthroplasty, Quality of life, Patient-reported outcomes, Preoperative optimization, Rehabilitation.
Background
Arthritis of the hip and knee is a common and often disabling problem. Pain, stiffness and reduced mobility make everyday tasks — walking, climbing stairs, sitting and squatting — difficult, and they take a real toll on quality of life. Over the years the goals of treatment have moved beyond simply keeping implants in place: we now measure success by how patients feel and function after surgery. Preoperative function strongly predicts what patients experience after joint replacement; those who are less disabled before surgery generally reach a higher final level of function, while those with worse baseline scores often show larger absolute improvements but may still lag behind in absolute terms. (1) Long-term follow-up studies show meaningful gains in patient-reported health for many years after arthroplasty, confirming durable benefit for appropriately selected patients. (2)
Most published series find that the greatest relief from pain and the biggest functional gains happen early — within the first three to six months — with further smaller improvements or stabilization up to a year and beyond. (3) Age affects outcomes in complex ways: older patients may carry more comorbidity but can still enjoy large relative improvements, while younger patients often have different expectations tied to higher activity levels. (4) Appropriateness of surgery matters too; selecting patients who are likely to benefit improves both resource use and outcomes. (5) Alongside patient selection, implant survival and complication rates remain important, but these technical metrics alone do not capture how much better a patient’s life has become after surgery. (6)
Total knee and hip replacement have evolved over decades, and improvements in implant design, surgical technique and perioperative care have broadened the pool of patients who can safely undergo these operations. (7) Contemporary practice increasingly emphasizes a multidisciplinary approach — coordinated perioperative care, better pain control, early mobilization, physiotherapy and clear patient education — to speed recovery and improve longer-term outcomes. (8) Shared decision-making, where patients understand realistic goals and risks, is now central to planning arthroplasty and is linked to higher satisfaction after surgery. (9)
Despite a strong international evidence base, differences in lifestyle, cultural expectations and activity demands mean that outcomes observed elsewhere may not map perfectly to every population. In countries where activities like squatting and sitting cross-legged remain important, the functional priorities after surgery differ from those emphasized in many western studies. This reality underscores the importance of studying health-related quality of life (HRQoL) in local patient groups, using validated patient-reported outcome measures that capture pain, stiffness, function and broader health domains. The thesis on which this synopsis is based addresses these questions by prospectively following patients undergoing primary total hip and knee arthroplasty and measuring changes in PROMs over the first postoperative year. The aim is practical: to describe the magnitude and timing of improvement, and to identify the patient and treatment factors that most strongly influence recovery in our setting. (1–9)
Hypothesis
This study grew out of three practical hypotheses that reflect what surgeons and patients commonly observe and what previous research suggests.
First, elective primary hip and knee arthroplasty produce large, clinically meaningful improvements in pain, joint-specific function and overall quality of life within a year after surgery, with most gains appearing early (by three to six months) and then stabilizing. This expectation is supported by multiple reports showing early, marked improvement in PROMs followed by sustained benefit at medium-term follow up. (10–12) Measuring patients at baseline and again at 3, 6 and 12 months allows us to capture both the speed and size of recovery and to confirm whether the same pattern holds in our patient population.
Second, preoperative clinical status influences both the amount of improvement and the final functional level. Patients who present with worse pain and poorer function often achieve large absolute improvements, but they may not reach the same final level as those who started with better function. This has implications for timing: operating earlier, before severe decline, may increase the chance that a patient returns to desired activities. (13–16) The study therefore examines how baseline WOMAC, SF-36 and joint-specific scores correlate with one-year outcomes, and whether practical thresholds exist that should inform when to recommend surgery.
Third, characteristics such as body mass index, presence of other medical problems, psychosocial status and expectations act as modifiers of outcome and are, in several cases, at least partly modifiable. Obesity is frequently associated with more complications and less favourable functional recovery after joint replacement, and psychological factors such as depression or unrealistic expectations can dampen perceived benefit even when objective measures improve. (16–17) Socioeconomic context and access to rehabilitation resources similarly shape recovery. (14–17) By testing the relationships between these variables and outcomes, the study aims to identify targets for preoperative optimization (for example weight management or treating depression) and perioperative interventions (structured rehabilitation, education) that can improve both objective recovery and patient satisfaction.
Taken together, these hypotheses address a straightforward clinical question: who benefits most from arthroplasty, when is the best time to operate to maximize improvement, and which modifiable factors should clinicians address before and after surgery to improve results? The thesis tests these ideas using standard statistical approaches — paired comparisons to evaluate within-subject change over time, regression analyses to find independent predictors of outcomes, and subgroup comparisons between hip and knee patients — while using a mix of disease-specific and general health instruments to give a rounded, patient-centred view of recovery. (10–17)
Discussion
The findings from this study fit comfortably with what many earlier, patient-focused reports have shown: people tend to feel markedly better after hip or knee replacement, especially in the early months after surgery. Pain relief and improvements in daily function are often the most noticeable changes patients describe, a pattern reported in large cohorts of arthroplasty patients. (18, 19)
How patients start—how much pain and disability they have before surgery—still matters a great deal. Those who come to surgery with better function generally end up with higher function at follow-up, while those who are more disabled can show large absolute gains but may not reach the same final level. That pattern highlights a practical dilemma: waiting longer often means the chance to regain full function is smaller. (20)
Social and practical supports clearly shape recovery. Patients with stronger social networks, stable finances and easy access to physiotherapy tend to recover more quickly and report higher satisfaction in the early months after surgery. Where rehabilitation is limited or follow-up is inconsistent, recovery can lag even when the operation itself is technically successful. (21, 22)
Body weight emerged as an important, and at times modifiable, factor. Higher body mass index was associated with slower functional recovery and a higher risk of complications in this cohort. That finding supports programs that help patients reduce weight and optimize fitness before surgery, not as reasons to deny care but to improve the chance of a smoother recovery. (23)
When we look specifically at hip replacement, many patients report durable improvements in quality of life across physical and social domains. These gains translate into better mobility and fewer restrictions in daily activities for a large proportion of patients. Still, there is variation between individuals—how much people return to specific cultural or lifestyle activities (for example deep squatting or sitting on the floor) can differ, and standard outcome tools may not capture those nuances completely. (24)
Finally, prospective follow-up—measuring patient-reported outcomes at set intervals—proved invaluable. Tracking patients at baseline, three, six and twelve months gives a clear picture of the speed and scale of recovery, reveals who needs additional support, and helps clinicians and patients set realistic expectations. Short- and mid-term follow-up studies like this one are useful for guiding immediate care decisions and for designing targeted interventions to improve recovery. (25)
There are limitations to keep in mind. This was a single-center, observational study with one-year follow-up: it tells us a lot about early and intermediate recovery but not about long-term implant survival or very late complications. Cultural differences in daily activities mean some standard questionnaires may under- or over-estimate the functional limitations that matter most to patients here. Despite these limits, the results point toward clear, actionable steps clinicians can take to improve outcomes.
Clinical importance
Joint replacement for the hip or knee reliably eases pain and restores everyday function for most people — often within the first few months after surgery. Using patient-reported measures to assess pain and function before surgery helps decide the right timing: operating before a person’s abilities fall too far often leads to a better final result. Simple, practical steps make a big difference: help patients optimize weight and control medical problems, screen and support mental health, give clear education about what to expect, and ensure access to basic physiotherapy and follow-up. In settings with limited resources, prioritizing patients who are likely to gain the most and making sure they receive focused rehab and support offers the best value for both patients and the health system.
Future directions
Future work should follow patients beyond one year to link early HRQoL improvements with implant longevity and late revisions. Randomized or controlled studies of prehabilitation, weight-reduction programs and focused psychosocial interventions would clarify whether improving modifiable risks before surgery translates into better long-term outcomes. Comparative studies of implant choices and fixation strategies that account for cultural activity demands (deep flexion, squatting) will help tailor surgery to local needs. Finally, qualitative research that explores patient expectations and day-to-day functional priorities can inform adaptation of PROMs and preoperative counseling so that measures and messages match what patients value most.
References
1. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999; 42(8):1722–8.
2. Nilsdotter A-K, Isaksson F. Patient relevant outcome 7 years after total hip replacement for OA - a prospective study. BMC Musculoskelet Disord. 2010; 11:47.
3. Neuprez A, Neuprez AH, Kaux J-F, Kurth W, Daniel C, Thirion T, et al. Early clinically relevant improvement in quality of life and clinical outcomes 1 year postsurgery in patients with knee and hip joint arthroplasties. Cartilage. 2018;9(2):127–39.
4. Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med. 2001; 161(3):454–60.
5. Quintana JM, Escobar A, Arostegui I, Bilbao A, Azkarate J, Goenaga JI, Arenaza JC. Health-related quality of life and appropriateness of knee or hip joint replacement. Arch Intern Med. 2006; 166(2):220–6.
6. Berry DJ, Scott Harmsen W, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements. J Bone Joint Surg Am. 2002; 84:171–7.
7. Patel NG, Waterson HB, Phillips JRA, Toms AD. 50 years of total knee arthroplasty. Bone Jt 360. 2019; 8:3–7.
8. Feng JE, Novikov D, Anoushiravani AA, Schwarzkopf R. Total knee arthroplasty: improving outcomes with a multidisciplinary approach. J Multidiscip Healthc. 2018; 11:63–73.
9. Slover J, Alvarado C, Nelson C. Shared decision making in total joint replacement. JBJS Rev. 2014; 2(3).
10. Barlow T, Griffin D, Barlow D, Realpe A. Patients’ decision making in total knee arthroplasty: a systematic review of qualitative research. Bone Joint Res. 2015;4(10).
11. Shan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and long-term quality of life after total knee replacement. J Bone Joint Surg Am. 2015; 97:156–68.
12. Bruyère O, Ethgen O, Neuprez A, Zégels B, Gillet P, Huskin JP, et al. Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study. Arch Orthop Trauma Surg. 2012; 132(11):1583–7.
13. Dowsey MM, Choong PF. The utility of outcome measures in total knee replacement surgery. Int J Rheumatol. 2013; 2013:353726.
14. Xie F, Lo NN, Pullenayegum EM, Tarride JE, O’Reilly DJ, Goeree R, et al. Evaluation of health outcomes in osteoarthritis patients after total knee replacement: a two-year follow-up. Health Qual Life Outcomes. 2010; 8:87.
15. Fujita K, Makimoto K, Higo T, Shigematsu M, Hotokebuchi T. Changes in the WOMAC, EuroQol and Japanese lifestyle measurements among patients undergoing total hip arthroplasty. Osteoarthritis Cartilage. 2009; 17(7):848–55.
16. Núñez M, Núñez E, Del Val JL, Ortega R, Segur JM, Hernández MV, et al. Health-related quality of life in patients with osteoarthritis after total knee replacement: factors influencing outcomes at 36 months of follow-up. Osteoarthritis Cartilage. 2007; 15(9):1001–7.
17. Petrie K, Chamberlain K, Azariah R. The psychological impact of hip arthroplasty. ANZ J Surg. 1994; 64:115–7.
18. Wiklund I, Romanus B. A comparison of quality of life before and after arthroplasty in patients who had arthrosis of the hip joint. J Bone Joint Surg Am. 1991; 73(5):765–9.
19. O'Boyle CA, et al. Individual quality of life in patients undergoing hip replacement. Lancet. 1992; 339(8801):1088–91.
20. Kauppila AM, Kyllönen E, Ohtonen P, Leppilahti J, Sintonen H, Arokoski JP. Outcomes of primary total knee arthroplasty: impact of patient-relevant factors on self-reported function and quality of life. Disabil Rehabil. 2011; 33(17-18):1659–67.
21. Clement ND, Muzammil A, Macdonald D, Howie CR, Biant LC. Socioeconomic status affects the early outcome of total hip replacement. J Bone Joint Surg Br. 2011; 93(4):464–9.
22. Rissanen P, Aro S, Sintonen H, Slätis P, Paavolainen P. Quality of life and functional ability in hip and knee replacements: a prospective study. Qual Life Res. 1996; 5(1):56–64.
23. Järvenpää J, Kettunen J, Soininvaara T, Miettinen H, Kröger H. Obesity has a negative impact on clinical outcome after total knee arthroplasty. Scand J Surg. 2012; 101(3):198–203.
24. Bagarić I, Šarac H, Borovac JA, Vlak T, Bekavac J, Hebrang A. Primary total hip arthroplasty: health related quality of life outcomes. Int Orthop. 2014; 38(3):495–501.
25. Martinez-Cano JP, Herrera-Escobar JP, Gutierrez ASA, Vergel AS, Martinez-Rondanelli A. Prospective quality of life assessment after hip and knee arthroplasty: short- and mid-term follow-up results. Arthroplasty Today. 2017; 3(6):125–30.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Belsare P, Joshi R, Sanghavi S, Dugad M, Sonawane D, Shyam A, Sancheti P. Integrating Patient-Specific Lifestyle Demands into Post-Arthroplasty Care: Hypothesis - Enhancement of HRQoL in Indian Patients. Journal of Medical Thesis. July-December 2023; 9(2):9-12. |
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Hypothesis on the Surgical Management and Outcomes of Terrible Triad Injuries around the Elbow
Vol 9 | Issue 1 | January-June 2023 | page: 21-24 | Haroon Ansari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.202
Author: Haroon Ansari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Haroon Ansari,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: ansariharoon045@gmail.com
Abstract
Background: The terrible triad of the elbow—radial-head fracture, coronoid fracture and posterolateral dislocation—creates a mechanically unstable joint that commonly leads to pain, stiffness and impaired daily activities when not reconstructed properly. Modern surgical care aims to restore the anterior bony buttress by fixing the coronoid, to preserve or replace the radial head to maintain radiocapitellar contact, and to repair the lateral collateral ligament to regain stability and permit early controlled motion.
Hypothesis: We hypothesize that a disciplined, anatomy-focused operative sequence—fixation or repair of the coronoid, reconstruction or arthroplasty of the radial head as determined by fracture morphology, repair of the lateral collateral ligament, and selective medial-sided repair only if residual instability persists—combined with early supervised mobilisation will restore joint stability, reduce pain and result in meaningful functional gains in adult patients with terrible-triad injuries. Functional success will be measured by improvements in the Mayo Elbow Performance Score, restoration of a functional flexion-extension arc commonly greater than 100 degrees, recovery of near-normal forearm rotation, and acceptable pain scores, while monitoring complications and reoperation rates.
Clinical importance: For surgeons, applying this reproducible protocol improves the likelihood of a stable, functional elbow. Repairing even small coronoid fragments, selecting radial-head replacement when reconstruction is impractical, and reserving medial repair for persistent instability reduce recurrent instability and need for salvage operations. Close follow-up, clear patient counselling about expected recovery and complications, and a structured physiotherapy programme are essential to manage stiffness and restore strength.
Future research: Large multicentre prospective cohorts and randomized trials comparing radial-head fixation versus arthroplasty for defined fracture types, head-to-head comparisons of coronoid fixation techniques, and standardised rehabilitation protocols with long-term follow-up are needed to refine indications and reduce complications. Biomechanical work linking fragment morphology to fixation choice would further reduce practice variability. Studies should include validated patient-reported outcome measures, cost-effectiveness analyses, and subgroup analyses by age and bone quality, and implant survivorship.
Keywords: Terrible triad, Elbow, Coronoid, Radial head, Lateral collateral ligament, Arthroplasty, Fixation, Rehabilitation.
Background
The “terrible triad” of the elbow — a combination of radial-head fracture, coronoid fracture and posterolateral elbow dislocation — was named because, left untreated or treated poorly, it frequently led to pain, recurrent instability and poor function. Early descriptions emphasized that the triad disrupts both the bony constraints (radial head and coronoid) and the soft-tissue stabilizers (lateral collateral ligament complex), producing a mechanically unstable elbow that is difficult to manage without surgery. Hotchkiss popularized the term and highlighted the poor natural history without adequate reconstruction; Regan and Morrey provided the familiar coronoid classification that helps guide fixation decisions; Mason’s classification of radial-head fractures remains central to choosing fixation versus replacement. [1–3]
Biomechanical and clinical work shows that the coronoid is the primary anterior buttress against posterior translation, while the radial head contributes to valgus and radiocapitellar stability. Cadaveric and finite-element studies indicate that even relatively small coronoid tip fragments can be functionally important because they carry capsular and ligamentous attachments that affect stability; conversely, large coronoid defects (type III) reliably require fixation to avoid late instability. The radial head, particularly when comminuted, cannot always be reconstructed — in those cases arthroplasty is used as a spacer to re-establish height and radiocapitellar contact. [4–6]
Contemporary operative practice has therefore adopted a principle-based, stepwise approach: restore the anterior bony buttress (coronoid), restore the radial head (fixation when feasible; arthroplasty when not), repair the lateral collateral ligament (LUCL/LCL) and reassess stability — repairing the medial collateral ligament only when residual instability persists; a hinged external fixator is a salvage option for persistent instability. Studies reporting this sequence show better maintenance of concentric reduction, permit early controlled motion and achieve satisfactory functional scores in most patients, though complication rates remain meaningful. [7–12]
Surgical technique is adapted to fragment size and location: small coronoid tip fractures are commonly stabilized with suture lasso or anchors while larger fragments require screws or buttress plating; anteromedial facet fractures often need medial exposure and buttress fixation because they act as a varus/medial buttress. For radial-head fractures, attempts at reconstruction are reasonable in younger patients when fragments can be anatomically restored; for severely comminuted heads, modular metallic arthroplasty more reliably restores length and radiocapitellar mechanics and avoids proximal migration. Approaches vary (lateral-only versus combined medial and lateral exposures) and each has tradeoffs related to soft-tissue dissection and neurovascular risk. [13–16]
Despite improvements in technique, the literature documents a substantial complication burden — heterotopic ossification, stiffness, nerve palsies and a nontrivial reoperation rate for stiffness, instability or implant problems. Outcomes are better when reconstruction is performed early, when the reconstruction restores radiocapitellar contact and coronoid buttress, and when early supervised rehabilitation is begun once a stable construct is confirmed. Published series show a majority achieving good to excellent results on validated scores (for example MEPS), but with
Complication and reoperation rates that demand careful patient counselling and meticulous surgical technique. [17–20]
Hypothesis
Primary hypothesis:
When surgeons apply a systematic, anatomy-focused operative sequence — restore coronoid (repair/fixation) → restore radial head (fix or replace) → repair lateral collateral ligament → reassess and address the medial side only if needed — and begin early controlled rehabilitation, patients with terrible-triad injuries will gain significant functional improvement (as measured by MEPS, range of motion and pain scores) with acceptable complication rates. [21]
Secondary hypotheses:
1. Radial-head arthroplasty is more reliable than attempted fixation in severely comminuted radial-head fractures within the terrible-triad pattern, producing more consistent restoration of radiocapitellar contact and reducing late instability or need for secondary procedures. [22]
2. Repair of even small coronoid tip fragments (with a suture lasso or anchor) materially improves early stability compared with leaving them untreated, because capsular and ligamentous insertions on small fragments contribute disproportionately to joint restraint. [23]
3. Routine medial collateral ligament (MCL) repair is unnecessary; selective MCL repair only for persistent instability after anterior and lateral reconstruction minimizes surgical morbidity while addressing instability when indicated. [24]
4. A stepwise algorithm (coronoid → radial head → LCL → reassess → MCL/hinge if needed) results in a majority of patients achieving a functional arc of motion and good/excellent MEPS scores at medium-term follow-up, while keeping reoperation rates within published expectations. [25]
Rationale and plan for measurement:
These hypotheses rest on the mechanical role of the coronoid and radial head and the central role of the lateral collateral complex in resisting posterolateral rotatory and varus-posteromedial failure. Practically, the study measures pre- and post-operative MEPS, active flexion/extension and forearm rotation (goniometer), VAS pain, radiographic maintenance of reduction and evidence of heterotopic ossification. Success is operationalized as a clinically meaningful rise in MEPS category and restoration of a functional arc of motion (commonly >100° flexion-extension and near-normal pronation/supination) with no recurrent dislocation. Complications including HO, nerve palsy, implant failure and need for reoperation are recorded and compared with historical series. [21–25]
Discussion
This series and the thesis literature support the central idea that a disciplined, anatomy-first operative approach converts a once “terrible” injury into one that frequently yields useful function. Restoring the coronoid — even when the fragment appears small — is important because it re-establishes the anterior buttress and the capsular attachments that restrain posterior translation; repair by suture lasso/anchors for tip fragments or screws/plates for larger or anteromedial facet fractures prevents varus collapse and later arthrosis. [1–5]
When the radial head is reconstructable, fixation preserves native anatomy and is reasonable in younger patients. However, when the head is severely comminuted, arthroplasty more predictably restores length and radiocapitellar contact and avoids problems such as proximal migration and late valgus deformity that were seen historically with simple excision. Several comparative series in the thesis point toward lower instability and improved short-term function with arthroplasty in the appropriate setting. [6–9]
Repair of the lateral collateral ligament complex is essential to control posterolateral rotatory instability; the MCL need only be repaired if the elbow remains unstable after reconstituting bony anatomy and repairing the lateral side. Selective MCL repair avoids unnecessary additional medial dissection and its attendant risks. If residual instability persists despite soft-tissue repair, a hinged external fixator offers a temporary stabilizing strategy that allows early motion while soft tissues heal. [10–14]
Outcomes reflect this logic: most patients reach a functional arc of motion and report reduced pain and improved MEPS, but the complication rate remains substantial — heterotopic ossification, nerve symptoms (radial or ulnar neuropraxia), stiffness requiring adhesiolysis, and occasional implant problems are reported across multiple series. Timely surgery, careful reconstruction of coronoid and radial head, judicious use of arthroplasty, meticulous ligament repair and early supervised rehabilitation together reduce but do not eliminate these risks. [15–20]
Clinical importance
For surgeons, this work clarifies a reproducible pathway: restore the coronoid buttress, preserve or replace the radial head depending on reconstructability, repair the lateral collateral ligament, and only address the medial side if residual instability remains. Applying this sequence allows early controlled motion and yields useful elbow function in most patients while recognizing and mitigating common complications through careful technique and dedicated rehabilitation. The practical benefit is fewer recurrent instabilities and better early function compared with historical non-operative care.
Future direction
Future research should aim for larger, multicentre prospective cohorts or randomized comparisons of radial-head fixation versus arthroplasty in defined fracture patterns, and head-to-head trials of coronoid fixation techniques (suture lasso/anchor vs screws vs medial buttress plating for anteromedial facets). Standardized, protocolized rehabilitation regimens and longer-term follow-up will help define drivers of late arthritis and hardware-related problems. Biomechanical studies that link fragment morphology to a specific fixation strategy would also reduce practice variability.
References
1. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green‘s fractures in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 980–981.
2. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989; 71:1348–1354.
3. Mason ML. Some observations on fractures of the head of radius with a review of one hundred cases. Br J Surg. 1954; 42:123–132.
4. Miyazaki AN, Checchia CS, Fagotti L, Fregoneze M, Santos PD, Andrade L, et al. Evaluation of the results from surgical treatment of the terrible triad of the elbow. (May/June 2014) Vol 49 No.3.
5. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987; 216:109–119.
6. Hong-wei Chen, Guo-dong Liu, Shan Ou, Jun Fei. Operative treatment of terrible triad of the elbow via posterolateral and anteromedial approaches. Apr 2015.
7. Guanyi Liu, Weihu Ma, Ming Li, Jianxiang Feng, Rongming Xu, Zhijun Pan. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol.
8. Armstrong AD. The terrible triad injury of the elbow. Curr Opin Orthop. 2005; 16:267–270.
9. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am. 1999; 30:63–79.
10. Armstrong AD, Dunning CE, Faber KJ, et al. Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Surg. 2000; 25:1051–1057.
11. Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability: a biomechanical analysis of axial loading. J Bone Joint Surg Am. 2000; 82A:1749–1753.
12. Wake H, Hashizume H, Nishida K. Biomechanical analysis of the mechanism of elbow fracture–dislocations by compression force. J Orthop Sci. 2004; 9:44–50.
13. Pugh DMW, McKee MD. The terrible triad of the elbow. (2002) 6(1):21–29.
14. Ring D, Jupiter J, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. (2002) 84(4):547–551.
15. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason type 3 radial head fractures with a titanium prosthesis, ligament repair and early mobilisation. (2004) Vol. 86-A: 274–280.
16. Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible triad injuries. J Hand Surg. 2006; 31A:794–797.
17. Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process: surgical technique. J Bone Joint Surg Am. 2007; 89:267–283.
18. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: results of operative treatment without repair of the medial collateral ligament. 2007.
19. Ring D. Displaced, unstable fractures of the radial head: fixation vs replacement — what is the evidence? 2008.
20. Clarke SE, Lee SY, Raphael JR. Coronoid fixation using suture anchors. 2008.
21. Lindenhovius ALC, Jupiter JB, Ring D, McKee MD. Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg. 2008; 33A:920–926.
22. Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. 2008.
23. Seijas R, Ares-Rodriguez O, Orellana A, Albareda D, Collado D, Llusa M. Terrible triad of the elbow. J Orthop Surg. 2009; 17(3):335–339.
24. Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. 2009.
25. Micic I, Kim S-Y, Park Me-H, Kim P-T, Jeon I-H. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop (SICOT). 2009; 33:1141–1147.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
| How to Cite this Article: Ansari H, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. Hypothesis on the Surgical Management and Outcomes of Terrible Triad Injuries around the Elbow. Journal of Medical Thesis. January-June 2023; 9(1):21-24. |
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A Biomechanical Hypothesis for Inferomedial Calcar Screw Augmentation to Prevent Secondary Varus Collapse in Osteoporotic PHILOS‐Plated Proximal Humerus Fractures”
Vol 7 | Issue 1 | January-June 2021 | page: 17-20 | Dhruv Varma, Chetan Pradahan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i01.158
Author: Dhruv Varma [1], Chetan Pradahan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Proximal humerus fractures range from simple, minimally displaced breaks to complex multi-part injuries that can compromise the blood supply and functional integrity of the humeral head. Treatment choices must balance preserving the native joint against the risk of fixation failure, a balance that becomes more delicate with advancing patient age, comorbidities and poor bone quality. Locking plates such as the PHILOS design offer fixed-angle support and improved purchase in osteoporotic metaphyseal bone, but predictable success depends on achieving anatomic reduction, restoring or substituting medial column support, correct implant positioning and a disciplined rehabilitation program.
Hypothesis: We propose that accurate anatomic reduction combined with PHILOS fixation and deliberate reconstruction or substitution of medial column support, together with a standardized, progressive rehabilitation protocol, will produce satisfactory functional outcomes for the majority of two- and three-part proximal humerus fractures. By contrast, four-part, head-splitting, or severely comminuted fractures in elderly patients with markedly poor bone stock are at higher risk of fixation failure and may achieve more reliable functional recovery when managed with targeted augmentation techniques or primary arthroplasty in selected cases.
Clinical importance: This synthesis highlights a short, practical checklist surgeons can apply: recreate or buttress medial support (calcar engagement when indicated), place the plate to avoid subacromial impingement, measure and limit screw length conservatively under fluoroscopic control, and secure tuberosities robustly. Applying these modifiable steps reduces predictable complications such as varus collapse, intra-articular screw penetration and postoperative stiffness, shortens the interval to safe mobilization, and lowers reoperation rates. Honest, shared decision-making is essential for elderly or frail patients.
Future research: Prospective, comparative trials that incorporate objective bone-density measures and standardized rehabilitation protocols are needed. Randomized evaluations of calcar-screw strategies, cement or graft augmentation techniques, and defined rehab timelines, with longer follow-up, will clarify late avascular necrosis rates and long-term durability and help build evidence-based treatment pathways.
Keywords: Proximal humerus fracture, PHILOS, Locking plate, Medial support, Calcar screw, Arthroplasty, Rehabilitation.
Background
Proximal humerus fractures are a common clinical problem that spans the age spectrum. Younger patients typically sustain these injuries in higher-energy events such as road-traffic accidents, while older adults usually fracture after a low-energy fall on osteoporotic bone. The anatomic complexity of the proximal humerus — a compact area where the head, greater and lesser tuberosities and the surgical neck sit close to vital rotator-cuff insertions and a delicate vascular supply — explains why some patterns are straightforward to manage and others are prone to poor outcomes and complications. [1]
Over many decades treatment options have ranged from nonoperative care to percutaneous pinning, intramedullary nailing, open reduction and internal fixation, and joint replacement for selected severe patterns. [2, 3] the advent of angular-stable locking plates represented an important technical advance because the fixed-angle construct transfers load through the screw-plate interface rather than relying solely on bone screw purchase — an advantage in osteoporotic metaphyseal bone. [4,5] The PHILOS system, with its precontoured plate geometry and multiple options for locking screw placement and suture fixation, became widely used to control fragments and permit earlier rehabilitation when reduction is achieved.[ 6,7]
Despite these benefits, locked plating is not without predictable pitfalls. Reported complications include intra-articular screw penetration, progressive varus collapse of the head, sub acromial impingement from plates placed too proximally, wound problems, and in certain complex fracture patterns avascular necrosis of the humeral head. [8, 9] Many of these complications are related to modifiable technical factors: inadequate restoration of the medial column (the calcar), imprecise plate positioning, selection of screws of inappropriate length, and incomplete fixation of the tuberosities. [10, 11]
Biomechanical studies and clinical series repeatedly emphasize the importance of medial support. When medial cortical contact is preserved or reconstructed, the construct better resists varus moments; when the medial cortex is deficient, targeted inferomedial or “calcar” screws act as a buttress and substantially lower the risk of secondary collapse and screw cut-out. [12,13] In conjunction with medial support, plate height and anterior–posterior positioning matter because a high plate invites impingement and a malpositioned plate increases lever arms that can overload the fixation. [14]
Patient factors also influence the decision between head-preserving fixation and arthroplasty. Advanced physiological age, poor bone quality and limited functional demands may make arthroplasty a more predictable option for some complex, comminuted four-part or head-splitting fractures, while younger, fitter patients with reconstructible anatomy generally benefit from fixation and early mobilization. [15]
Contemporary best practice therefore combines three pillars: sound preoperative planning (fracture classification and assessment of bone quality), meticulous intraoperative technique (anatomic reduction, restoration of medial support, correct plate and screw choices), and a structured rehabilitation program that balances early motion with protection of the fixation. [16,17] When these principles are followed, two-part and many three-part fractures reliably regain useful function; four-part patterns remain the most challenging and require individualized judgment. [18]
Hypothesis and Aims
Primary hypothesis
In skeletally mature patients with displaced proximal humerus fractures, anatomical reduction combined with angular-stable fixation using a PHILOS locking plate will provide satisfactory functional outcomes and an acceptable complication profile for most two- and three-part fractures; however, outcomes will be less favorable for four-part fractures and in patients with poor bone quality. [19]
Secondary hypotheses
1. Restoration or substitution of the medial column (through anatomical reduction or targeted inferomedial calcar screws) significantly reduces the incidence of secondary varus collapse and screw cut-out. [20]
2. Precise plate placement (positioned to avoid sub acromial impingement) and conservative screw length selection under fluoroscopic control will reduce intra-articular screw penetration and symptomatic impingement. [21]
3. Early, graduated, supervised rehabilitation started after a stable fixation improves range of motion and patient-reported outcomes without increasing fixation failures when the construct is mechanically sound. [22]
4. Advanced age and objectively poor bone stock are independent predictors of worse functional outcomes and higher reoperation rates; for selected elderly patients with severe comminution, augmentation strategies or primary arthroplasty may produce more reliable functional restoration.[ 23]
Rationale and measurable aims
locking plates function by creating a fixed-angle relationship between screw and plate so that load is transferred through the hardware rather than being borne only by cancellous bone, a helpful feature in osteoporotic metaphyses. 19 Nonetheless, the mechanical environment still requires a medial buttress to resist varus deforming forces. Clinical outcomes and biomechanical models both show that calcar engagement and restoration of medial cortical continuity markedly improve the mechanical resilience of the construct and lower complication rates. [20, 24]
The hypotheses are therefore practical and testable. A prospective protocol to evaluate them should include: primary outcome of validated shoulder function at 12 months (for example, Constant–Murley score) and secondary outcomes such as DASH score, range of motion, radiographic maintenance of neck-shaft angle, time to union, complication categories (varus collapse, screw penetration, infection, avascular necrosis) and reoperation rate. Key predictor variables would be Neer classification, age group, documented bone quality (or standardized radiographic surrogate), presence or absence of reconstructed medial support, plate height and screw configuration. Statistical analysis would seek associations between these predictors and functional/radiographic outcomes to quantify which technique and patient factors most strongly influence success. [25]
Discussion
When study data and the wider evidence are considered together, a few practical, immediately actionable lessons emerge.
First, PHILOS and similar locking plates are effective head-preserving tools for many displaced proximal humerus fractures when anatomical reduction is achievable. Two-part and many three-part fractures usually recover satisfactory motion and strength if fixation is stable and rehabilitation proceeds in a timely, graduated fashion. The surgeon’s judgment is key — if the fracture anatomy cannot be reconstructed to a satisfactory mechanical state, fixation may be futile.
Second, medial support is the primary mechanical determinant of durability. Achieving anatomic medial cortical contact or deliberately engaging the inferomedial calcar with screws transforms the construct’s resistance to varus collapse. Including calcar engagement as an explicit intraoperative goal reduces secondary collapse and the need for reoperation.
Third, avoidable technical errors produce a large share of complications. Overlong screws that breach the joint, plates seated too proximally that lead to impingement, and incomplete tuberosity fixation are common, preventable causes of poor outcome. Simple intraoperative habits — careful multi-plane fluoroscopic checks, conservative screw length selection and placing the plate a few millimetres distal to the greater tuberosity tip — prevent many of these problems.
Fourth, biology and patient expectations must guide decision making. Older adults with poor bone stock and diminished soft-tissue quality have less capacity to recover after fixation; augmentation (bone graft or cement around screws) may help, but in some patients primary arthroplasty, especially reverse shoulder arthroplasty when the rotator cuff is deficient, gives more predictable pain relief and earlier return to activity.
Fifth, rehabilitation is not optional — it is part of the fixation strategy. A stable construct allows early pendulum and passive motion that limits stiffness; timely progression to active-assisted and strengthening exercises is important to regain function. Protocolized rehabilitation tied to clinical and radiographic milestones gives the best balance of protection and motion.
Finally, limitations in many series (including incomplete objective bone-density assessment and relatively short follow-up) constrain the ability to predict late avascular necrosis or long-term implant behavior. Future prospective efforts should standardize bone-quality metrics, capture rehabilitation adherence, and follow patients longer to better understand late failures. Even so, the current best practice — meticulous reduction, medial support restoration, cautious plate/screw technique and structured rehab — gives the highest probability of consistent, reproducible results in everyday practice.
Clinical importance
PHILOS locking-plate fixation remains a practical, head-preserving option for many displaced proximal humerus fractures. To minimize complications and optimize function: restore or recreate medial support; position the plate correctly to avoid impingement; measure and limit screw length under fluoroscopy; secure tuberosities robustly when involved; and pair fixation with early, supervised rehabilitation. For elderly patients with severe comminution or radiographic signs predicting poor humeral-head viability, discuss the option of arthroplasty honestly, emphasizing predictable pain relief and faster functional recovery in appropriately selected cases.
Future direction
Future priorities are randomized or well-matched comparative trials for complex four-part fractures in older patients, routine inclusion of objective bone-density measures to guide augmentation or implant choice, and trials that standardize calcar-screw strategies and rehabilitation protocols. Longer follow-up (≥2–5 years) is needed to quantify late avascular necrosis and implant durability and to refine treatment pathways for specific patient subgroups.
References
1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006; 37(8):691–7.
2. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006; 442:87–92.
3. Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein J. Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Joint Surg. [as given in thesis].
4. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. [as given in thesis].
5. Williams GR Jr, Wong KL. Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning. Orthop Clin North Am. 2000; 31:1–21.
6. Codman EA. Rupture of the supraspinatus tendon. Clin Orthop Relat Res. 1990:3–26.
7. Carofino BC, Leopold SS. Classifications in Brief: The Neer Classification for Proximal Humerus Fractures. Clin Orthop Relat Res. 2013; 471:39–43.
8. Handoll HH, Gibson JN, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2003 ;( 4).
9. Lind T, Kroner K, Jensen J. The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg. 1989; 108:285–87.
10. Rohra N, et al. Management options and outcomes in proximal humerus fractures. Int J Res Orthop. 2016 Mar; 2(1):25–28.
11. Kiran Kumar GN, et al. Surgical treatment of proximal humerus fractures using PHILOS plate. Chin J Traumatol. 2014; 17(5):279–84.
12. Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003; 34(2):B63–76.
13. Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res. 2006; 442:100–8.
14. Sudkamp N, et al. Prospective multicentre study of open reduction and internal fixation of proximal humerus fractures. 2009.
15. Fazal MA, Haddad FS. PHILOS plate fixation for displaced proximal humeral fractures. J Orthop Surg. 2009; 17(1):15–18.
16. Geiger EV, et al. Clinical outcomes of PHILOS fixation in elderly patients. 2010.
17. Hettrich CM, et al. Quantitative assessment of the vascularity of the proximal humerus. J Bone Joint Surg Am. 2010; 92:943–8.
18. Olerud P, Ahrengart L, Soderqvist A, Saving J. Functional outcome after a 2-part proximal humeral fracture treated with a locking plate. J Shoulder Elbow Surg. 2010.
19. Roderer G, Erhardt J, Graf M, Kinzl L. Minimally invasive locked plating of proximal humerus fractures: clinical results. J Orthop Trauma. 2010; 24(7):400–6.
20. Ricchetti ET, Warrender WJ, Abboud JA. Outcomes after proximal humerus locking plate osteosynthesis. J Shoulder Elbow Surg. 2010.
21. Duralde XA, Leddy LR. Prospective study on displaced proximal humerus fractures. J Shoulder Elbow Surg. 2010.
22. Isiklar Z, Gogus A, Korkmaz M, Kara A. Operative treatment of proximal humerus fractures utilizing locking plate fixation: comparison between elderly and younger patients. 2010.
23. Neslihan A., et al. Complications after locking plate fixation of proximal humerus fractures. 2010.
24. Agarwal S, et al. Functional outcome and predictors of complications for locking plate fixation. 2010.
25. Osterhoff G, et al. Importance of calcar screw in angular stable plate fixation. 2011.
| How to Cite this Article: Varma D, Pradahan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P| A Biomechanical Hypothesis for Inferomedial Calcar Screw Augmentation to Prevent Secondary Varus Collapse in Osteoporotic PHILOS‐Plated Proximal Humerus Fractures | Journal of Medical Thesis | 2021 January-June; 7(1): 17-20. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
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Home Modifications in Chronic Stroke Patients
Vol 4 | Issue 1 | Jan - Apr 2016 | page: 7-9 | Bhavika Chawhan[1], Dinesh Chavhan[1], Rachana Dabadghav[1], Savita Rairikar[1], Ashok Shyam[2], Parag Sancheti[2].
Author: Bhavika Chawhan[1], Dinesh Chavhan[1], Rachana Dabadghav[1], Savita Rairikar[1], Ashok Shyam[2], Parag Sancheti[2].
[1] Sancheti Institute College of Physiotherapy.
[2] Sancheti Institute of Orthopedics and Rehabilitation.
Institute Where Research Was Conducted: Sancheti Institute Of Orthopedics and Rehabilitation Shivajinagar, Pune.
University Affiliation: Maharashtra University of Health Sciences (MUHS) Nashik.
Year Of Acceptance Of Thesis: 2015.
Address of Correspondence
Dr. Dinesh Chavhan
Sancheti Institute College of Physiotherapy, Thube Park, Shivajinagar, Pune 411005.
Email:drdineshchavhan@gmail.com
Abstract
Background: Stroke is a condition characterized by motor deficits like hemiplegia and hemiparesis. Stroke survivors face a heightened fall rate and an increased risk of getting injured post attack. The various sections of the house limit the stroke patients to different degrees. The aim of this study was to find out the modifications done in the stroke survivors' houses as a part of rehabilitation in various sections of a chronic stroke patient's house. It was concluded after this study that a high level (79%) of stroke patients made home modifications in the bathroom (71%) then in living room (65%), bedroom (51%) and the kitchen (47%).
Hypothesis: It is hypothesized that modifications in the house as a part of rehabilitation reduces the fall risk and aids in independence of the patient.
Clinical importance: Modification of sections reduces the limitation in the house and risk of falls.
Future direction: Various sections of the house can be studied individually to scan the most limiting parameter of the house.
Key words: Home modifications, chronic stroke, rehabilitation, fall risk.
Thesis Question: Is flexible elastic nailing an effective treatment modality in skeletally immature children?
Thesis Answer: Based on our results, we conclude that flexible intramedullary nailing is an effective way of fixation with excellent functional results and minimal complications in diaphyseal fractures in skeletally immature patients.
| THESIS SUMMARY |
Introduction
A stroke[1] is a medical emergency. The two kinds of stroke, ischemic stroke and hemorrhagic stroke produce clinical deficits like changes in the level of consciousness and impairments of sensory, motor, cognitive, perceptual and language functions. Motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis), typically on the side of the body opposite to the side of the lesion. Balance is affected and there is an increase in risk of getting injury from the surroundings if not taken proper measures to reduce fall rate and risk2. Transient ischemic attack3 survivors recover from the attack almost completely without major impairments.
Modifications4 to the Home should be done with this in mind:
Renovating the structure
Renovating the environment
Safety
Assistive devices
There has been a study on the gender affected by stroke5 which shows that males are more affected than females. The modifications are done keeping this in mind.
Incidences of falls increase post stroke attacks. The literature concerning home modifications post stroke is limited and restricted to certain sections6 of the house.
A better understanding of home modifications helps design a framework within which modifications7 that can be used to improve the patient's recovery and give them a better lifestyle8.
NEED FOR STUDY: The reason was to find out the sections modified post stroke in a house of an Indian setup.
Materials and Methodology
A demographic questionnaire was sent to caretakers of 100 stroke patients all over Maharashtra who were living in their houses post hospitalization by email. The Demographic questionnaire included Name, Age, Gender and Years post stroke. The demographic questionnaire contained components whether changes were made in the house, which sections of the house were modified and how it helped reduce injury with 22 questions in all. All the of stroke survivors' houses post stroke were included in the study and the questionnaire was filled by the caretakers of stroke patients. All the patients with Transient Ischemic Attack4 and patients not living in a house post hospitalization post stroke were excluded from the study. A written consent was taken from the participants and the study was approved by the Institutional Ethical Committee. The data was analyzed using Microsoft Excel.
RESULTS: A total of 100 subjects completed the questionnaire, providing an overall response of 100%. The mean age was 57.95 years. A total 56% were males and 44% were females. It was concluded after this study that a high level (79%) of stroke patients made home modifications in Maharashtra, India. The most significant changes were made in the bathroom (71%) followed by living room (65%), bedroom (51%) and the kitchen (47%). This may point towards the maximum number of falls and injuries taken place post stroke are in the bathroom2. The kitchen not being modified may be due to more number of male5 patients who don't participate in culinary activities in a house on a regular basis.
Discussion
In this study, 79% of subjects made significant changes in their houses with most significant changes being made in the bathroom (71%) followed by living room (65%), bedroom (51%) and the kitchen (47%).
This showed that the highest risk of falls was in the bathroom which required assistive devices and modifications in the bathroom [2-3] such as addition of railings and increasing the height of commode. This was statistically significant as it suggested that bathrooms require the most amount of modification post stroke.
Living room and bedroom had been modified according to the patient's individual impairments and the statistics suggested that modifications in these rooms made moving around the room easier for the patient and making closet and shelves accessible considering the impairments.
Kitchen had been modified the least. This suggested that the stroke patients were dependent on their caretakers for their diet and nutritional needs and due to more male5 stroke patients compared to females.
Since, 57% of the subjects did not use stairs post stroke and 76% of the subjects used the help of railings for stair climbing post stroke; it may be due to lower limb involvement caused by stroke and age related changes which restricted the subject from climbing stairs effectively. This was significant as it pointed out the need to add the railings for staircases7 in the vicinity of the stroke patients.
Houses of 69% of the subjects had been modified to make their shelves accessible to the patients. This suggested that people were more aware of the impairments in the stroke patients and conducive of their shortcomings.
Furniture at 68% of the subjects' houses had furniture which had sharp edges that were not made blunt post stroke. It was suggestive of increased risk of getting injured while moving around the house. This pointed out the need to make the furniture edges blunt if possible to reduce injuries.
A 72% of patients experienced a reduction in their fall rate and a reduced risk of injuries post modifications in their houses4. This was statistically significant as it pointed out the need to modify the house according to the stroke patient's needs and impairments.
Conclusion
As observed from this study:
1. Most people modify their houses post stroke.
2. Maximum modifications are done in the bathroom then living room, bedroom and the kitchen is minimally modified.
3. There is reduction in the rate of falls and injuries post home modifications.
Clinical Importance
Modification of sections reduces the limitation in the house and risk of falls.
References
1. What is a Stroke?
[http://www.nhlbi.nih.gov/medlineplus/stroke.html] March 26, 2014. Retrieved: 16 March 2015.
2. Tsur A, Segal Z. Falls in stroke patients: risk factors and risk management. ISR Med Assoc J. 2010 Apr;12(4):216-9
3.Transient ischemic attack
[http://www.nlm.nih.gov/medlineplus/ency/article/0007370.htm] August 28, 2014. Retrieved: March 16 2015.
4. Hope: The stroke recovery guide.
[http://rehab.ucla.edu/workfiles/NRRU-Unit%20stroke.pdf] Retrieved: March 16, 2015
5. Peter Appelros, Birgitta Stegmayr, Andreas Terent.
Stroke.2009;40:1082-1090 Published online before print February 10, 2009, doi:10.1161/STROKEAHA.108.540781
6. Schulz CH, Hersch GI, Foust JL, Alicia L Wyatt, Kylar M Godwin, Salimah Virani et al. Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment. Physical & occupational therapy in geriatrics. 2012;30(2):10.3109/02703181.2012.687441.
doi:10.3109/02703181.2012.687441.
7. Sørensen HV, Lendal S, Schultz-Larsen K, Uhrskov T. Stroke rehabilitation: assistive technology devices and environmental modifications following primary rehabilitation in hospital--a therapeutic perspective. Assist Technol. 2003 Summer; 15(1):39-48.
8. Huijgen BC, Vollenbroek-Hutten MM, Zampolini M, Opisso E, Bernabeu M, Van Nieuwenhoven et al. Feasibility of a home-based telerehabilitation system compared to usual care: arm/hand function in patients with stroke, traumatic brain injury and multiple sclerosis. J Telemed Telecare. 2008;14(5):249-56. doi: 10.1258/jtt.2008.080104.
| How to Cite this Article: Chawhan B, Chavhan D, R Dabadghav, Rairikar S, ShyamA, Sancheti P. Home Modifications in Chronic Stroke Patients. Journal Medical Thesis 2016 Jan-Apr ; 4(1): 7-9. |
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