A Clinico-Radiological Outcome of Total Hip Replacement – A Combined Retrospective and Prospective Study

Vol 34 | Issue 1 | Jan – April 2019 | page: 26-29 | Pratyush Parag, Najmul Huda, Ajay Pant, Pulkit Jain


Authors: Pratyush Parag [1], Najmul Huda [1], Ajay Pant [1], Pulkit Jain [1]

Address of Correspondence

Dr. Pulkit Jain,
Department of Orthopaedics,
Teerthanker Mahaveer Medical College and Research Centre,
Teerthanker Mahaveer University,
Moradabad, Uttar Pradesh India – 244 001.
E-mail: pjain1060@gmail.com


Abstract

Introduction: Total hip arthroplasty (THA) is one of the most common and effective forms of surgery, resulting in a generally excellent outcome. Conventional joint replacement implants are better suited for western lifestyles and needs. In the Indian scenario, patients expect a higher range of motion post-THA considering their routine cultural practices which involve floor seated positions (cross-legged sitting, squatting, and kneeling). Although there have been many studies on short- and medium-term outcome, studies pertaining to India are insufficient. The present study was undertaken to evaluate the clinical and radiological outcome of THA.
Materials and Methods: This was a combined prospective and retrospective study. The study commenced in January 2017. Operative records of all patients who underwent the procedure from 2010 until December 2017 was screened from the operating room registers and case files. Clinical assessment was done using Harris Hip Score (HHS). Radiological assessment was done using radiographs in anteroposterior and frog lateral view and the following parameters were assessed: Limb length, horizontal center of rotation, vertical center of rotation, inclination of acetabulum, positioning of femoral stem, anteversion of acetabulum, and cement mantle thickness.
Results: A total of 25 patients fulfilled the inclusion and exclusion criteria and were included in the study, of which 19 patients were male. The mean age of patients was 51.04 ± 14.79 years (range 27–40 years). Avascular necrosis of hip was the most common indication for THA, as seen in 80% of the patients (n = 21). Excellent outcome was seen in 11 patients based on HHS. On radiological evaluation, limb length discrepancy was seen in two patients, and osteolysis was seen in only one patient. None of the cases was infected. The mean duration of follow-up was 3.2 years (range 2–7 years).
Conclusion: Our study shows that of the patients who underwent THA, only two patients had poor outcome, excellent outcome was seen in 11 patients, good and fair results were seen in six patients each at a mean duration of follow-up of 3.2 years (range 2–7 years).
Keywords: Total hip arthroplasty (THA), Total Hip Replacement (THR), Harris Hip Score (HHS)


References

1.Mulholland SJ, Wyss UP. Activities of daily living in non-western cultures: Range of motion requirements for hip and knee joint implants. Int J Rehabil Res 2001;24:191-8.
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3.Springer BD, Connelly SE, Odum SM, Fehring TK, Griffin WL, Mason JB, et al. Cementless femoral components in young patients: Review and meta-analysis of total hip arthroplasty and hip resurfacing. J Arthroplasty 2009;24:2-8.
4.Torchia ME, Klassen RA, Bianco AJ. Total hip arthroplasty with cement in patients less than twenty years old. Long-term results. J Bone Joint Surg Am 1996;78:995-1003.
5.Finkbone PR, Severson EP, Cabanela ME, Trousdale RT. Ceramic-on-ceramic total hip arthroplasty in patients younger than 20 years. J Arthroplasty 2012;27:213-9.
6.Wangen H, Lereim P, Holm I, Gunderson R, Reikerås O. Hip arthroplasty in patients younger than 30 years: Excellent ten to 16-year follow-up results with an HA-coated stem. Int Orthop 2008;32:2038.
7.Busch V, Klarenbeek R, Slooff T, Schreurs BW, Gardeniers J. Cemented hip designs are a reasonable option in young patients. Clin Orthop Relat Res 2010;468:3214-20.
8.Engesæter LB, Engesæter IØ, Fenstad AM, Havelin LI, Kärrholm J, Garellick G, et al. Low revision rate after total hip arthroplasty in patients with pediatric hip diseases. Acta Orthop 2012;83:436-41.
9.Chmell MJ, Scott RD, Thomas WH, Sledge CB. Total hip arthroplasty with cement for juvenile rheumatoid arthritis. Results at a minimum of ten years in patients less than thirty years old. J Bone Joint Surg Am 1997;79:44-52.
10.Haber D, Goodman SB. Total hip arthroplasty in juvenile chronic arthritis: A consecutive series. J Arthroplasty 1998;13:259-65.
11. Flóris I, Bodzay T, Vendégh Z, Gloviczki B, Balázs P. Short-term results of total hip replacement due to acetabular fractures. Eklem Hastalik Cerrahisi 2013;24:64-71.
12.Hulleberg G, Aamodt A, Espehaug B, Benum P. A clinical and radiographic 13-year follow-up study of 138 Charnley hip arthroplasties in patients 50-70 years old: Comparison of university hospital data and registry data. Acta Orthop 2008;79:609-17.
13.Pitera T, Guzik G, Biega P. Assessment of post-operative physical performance in patients after resection arthroplasty of the proximal femur. Ortop Traumatol Rehabil 2017;19:333-40.
14.Lee DW, Hwang SK. Primary total hip arthroplasty using third generation ceramic-ceramic articulation: Results after a minimum of three-years of follow-up. Hip Pelvis 2014;26:84-91.
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16. Paleochorlidis IS, Badras LS, Skretas EF, Georgaklis VA, Karachalios TS, Malizos KN, et al. Clinical outcome study and radiological findings of zweymuller metal on metal total hip arthroplasty. A follow-up of 6 to 15 years. Hip Int 2009;19:301-8.
17.Singh SKK, Kumar B, Suman SK and Meena AK. Treatment of avascular necrosis of femoral head with cemented total hip replacement a prospective study. Int J Orthop Sci 2017;3:484-8.
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19.Reuven A, Manoudis GN, Aoude A, Huk OL, Zukor D, Antoniou J. Clinical and radiological outcome of the newest generation of ceramic-on-ceramic hip arthroplasty in young patients. Adv Orthop Surg 2014;2014:6.
20.Mulholland SJ, Wyss UP. Activities of daily living in non-Western cultures: Range of motion requirements for hip and knee joint implants. Int J Rehabil Res 2001;24:191-8.


How to Cite this Article: Parag P, Huda N, Pant A, Jain P. A Clinico Radiological Outcome of Total Hip Replacement – A Combined Retrospective & Prospective Study. Journal of Bone and Joint Diseases Jan-April 2019;34(1):25-28.


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A Comparative Analysis of Posteromedial Soft-Tissue Release and Differential Distraction with Joshi’s External Stabilizing System Fixator in Neglected Resistant Congenital Talipes Equinovarus

Vol 34 | Issue 1 | Jan – April 2019 | page: 21-25 | Ashwani Sadana, Karuna Shankar Dinkar, Chandra Prakash Pal, Rajat Kapoor, Yajuvendra Kumar


Authors: Ashwani Sadana [1], Karuna Shankar Dinkar [1], Chandra Prakash Pal [1], Rajat Kapoor [1], Yajuvendra Kumar [1]

Address of Correspondence

Dr. Karuna Shankar Dinkar,
Department of Orthopaedics,
Sarojini Naidu Medical College,
Agra – 282 002, Uttar Pradesh, India.
E-mail: drksdinkar27@yahoo.in


Abstract

Club foot is among the most common of congenital deformities. Congenital talipes equinovarus is a complex three-dimensional deformity having four components – equinus, varus, adduction, and cavus. The present study was conducted to compare the results of posteromedial soft-tissue release (PMSTR) and Joshi’s external stabilizing system ( JESS)  fixator in neglected, resistant, and relapsed
or recurrent club foot. This a prospective study comprising of 36 children was conducted in the department of orthopedics, S.N. Medical College, Agra. Pre-operative none of the feet in either group had a clinical satisfactory rating, but after surgery, a significant improvement was seen. Of the 25 feet subjected to PMSTR procedure, it was observed that 16 feet (64%) were in the category of the satisfactory rating where all the 9 clinical criteria were in satisfactory range (36%) had an unsatisfactory result. Of the 22 feet subjected to differential distraction method using JESS fixator, it was observed that 19 feet (77.3%) were in the category of satisfactory rating, where all the 9 criteria were in satisfactory range, and the unsatisfactory result was seen in 5 feet (22.7%).
Keywords: Cavus, compare, Pre-operative, Joshi’s external stabilizing system, Feet


References

1.Kelly EC. Hippocrates (400B.C.): The Genuine Work of Hippocrates Translated from Greek by Francis Adams with an Introduction. Philadelphia, PA: Williams and Wilkins; 1939.
2.Ikeda K. Conservative treatment of idiopathic clubfoot. J Pediatr Orthop 1992;12:217-23.
3.Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop 1990;250:8-26.
4.Joshi BB, Laud NS, Warrier SS, Kanaji BG, Joshi AP, Dabake H. Treatment of CTEV by Joshi External Stabilization System (JESS) In Kulkarni GS, editor. Textbook of Orthopedics and Trauma. Ist ed. New Delhi: Jaypee Brothers Medical Publishers Ltd.; 1999.
5.Turco VJ. Resistant congenital club foot one-stage posteromedial release with internal fixation. A follow-up report of a fifteen-year experience. J Bone Joint Surg Am 1979;61:805-14.
6.McKay DW. New concept of and approach to clubfoot treatment: Section II correction of the clubfoot. J Pediatr Orthop 1983;3:10-21.
7.Yamamoto H, Furuya K. One-stage posteromedial release of congenital clubfoot. J Pediatr Orthop 1988;8:590-5. Simons GW. Complete subtalar release in clubfeet. J Bone Joint Surg 1985;67:105665.
8.Grill F, Franke J. The ilizarov distractor for the correction of relapsed or neglected clubfoot. J Bone Joint Surg Br 1987;69:593-7.
9.Suresh S, Ahmed A, Sharma VK. Role of Joshi’s external stabilization system fixator in the management of idiopathic clubfoot. J Orthop Surg (Hong Kong) 2003;11:194-201.
10. Sudmann E, Hald JK Jr., Skandfer B. Features resisting primary treatment of congenital club foot. Acta Orthop Scand 1983;54:850-7.
11.Cohen-Sobel E, Caselli M, Giorgini R, Giorgini T, Stummer S. Long-term follow-up of clubfoot surgery: Analysis of 44 patients. J Foot Ankle Surg 1993;32:411-23.
12.Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am 1992;74:448-54.


How to Cite this Article: Sadana A, Dinkar K S, Pal C P, Kapoor R, Kumar Y. A Comparative Analysis of Posteromedial So-Tissue Release and Differential Distraction with Joshi’s External Stabilizing System Fixator in Neglected Resistant Congenital Talipes Equinovarus. Journal of Bone and Joint Diseases Jan – Apr 2019;34(1):20-24.


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Evaluate the Efficacy Of Autologous Blood Injection Versus Local Corticosteroid (triamcinolone) Injection In Treatment Of Plantar Fasciitis: A Randomised Controlled Study

Vol 34 | Issue 1 | Jan – April 2019 | page: 16-20 | Surya Prakash, Mahesh Babu Shankhwar, Imran Sajid


Authors: Surya Prakash [1], Mahesh Babu Shankhwar [1], Imran Sajid [2]

Address of Correspondence

Dr. Imran Sajid,
F.H. Medical College, Etmadpur, Agra
Email: imransajid60@gmail.com


Abstract

Background: Plantar fasciitis is the most common cause of heel pain for which professional care is sought. Fortunately, most patients with this condition eventually have satisfactory outcomes with non-surgical treatment. Recently, an injection of autologous blood has been reported beneficial for a both intermediate and long-term outcome for the treatment of plantar fasciitis and there was a significant decrease in pain. Hence, the present study was undertaken to evaluate the efficacy and role of autologous blood injection in plantar fasciitis by comparing with the local corticosteroid injection.
Materials and Methods: The present study was based on analysis of 60 patients with the diagnosis of plantar fasciitis treated with conservative methods. 60 patients are randomized in two groups. 30 patients were given ABI and 30 were given local corticosteroid and comparative analysis was made.
Result: Participants were clinically evaluated. A baseline visual analog scale (VAS) score and the modified Roles and Maudsley (RM) score staging of the pain at the heel region were recorded prospectively. Cases were treated with autologous blood injection and controls with local corticosteroid injection follow-up at 1 week, 4 weeks, and 12 weeks interval after the intervention. The present study showed that autologous blood injection significantly reduced the pain without complications with no recurrence. It also provided complete relief of pain for a period of 3 months.
Conclusion: Autologous blood injection reduced the pain based on VAS and functional outcome based on the modified RM score without Complications, thereby lowering the recurrence rate up to 3 months in patients with plantar fasciitis. Autologous blood provides intermediate and long-term results in terms of pain relief in compared to corticosteroid injection which gives short-term relief.
Keywords: Planter fasciitis, Autologous blood injection, corticosteroid


References

1.Dirckx JH, editor. Stedman’s Concise Medical Dictionary for the Health Professions: Illustrated. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2001.
2.Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review. Plantar fasciitis. BMJ 1997;315:172-5.
3.Lemont H, Ammirati KM, Usen N. Plantar fasciitis: A degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93:234-7.
4.Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003;3:CD000416.
5.Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: A national study of medical doctors. Foot Ankle Int 2004;25:303-10.
6.Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: Long-term follow-up. Foot Ankle Int 1994;15:97-102.
7.Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med 2004;350:2159-66.
8.Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003;4:CD000416.
9.Lennard TA. Fundamentals of procedural care. In: Lennard TA, editor. Physiatric Procedures in Clinical Practic. Philadelphia, PA: Hanley and Belfus; 1995. p. 1-13.
10.Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998;19:91-7.
11.Schippert DW, DiGiovanni BF, Baumhauer JF, Flemister AS. Recent updates in the management of plantar fasciitis. Foot Ankle 2009;20:2-5.
12.Campbell WC, Christian CA, Terry CS. Campbell’s Operative Orthopaedics. 9th ed. Philadelphia, PA: Churchill Livingstone; 1998. p. 1321-4.
13.Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet 2002;359:657-62.
14.Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int 2007;28:984-90.


How to Cite this Article:  Prakash S, Shankhwar M B, Sajid I. Evaluate the Efficacy Of Autologous Blood Injection Versus Local Corticosteroid (triamcinolone) Injection In Treatment Of Plantar Fasciitis: A Randomised Controlled Study. Journal of Bone and Joint Diseases Jan-April 2019;34(1):15-19.


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Electronic Vacuum Assisted Closure – An Advanced Wound Healing Technique

Vol 34 | Issue 1 | Jan – April 2019 | page: 8-9 | Tarun Khare, Anup Khare


Authors: Tarun Khare  [1], Anup Khare [2]

Address of Correspondence

Dr. Tarun Khare,
SRM medical college Hospital, Chennai
E-mail: tarun1589@gmail.com


Abstract

Background: It is a new way of advanced wound healing technology. High-velocity trauma causes grievous soft tissue injuries, which requires good soft tissue and bone management. EVAC is a method of soft tissue care. Fracture management is done by some suitable method.
Material And Method: This study was conducted at Rainbow Hospital Agra. 30 cases of roadside high-velocity trauma patients with gross soft tissue injuries and long bone fracture were included in this study. EVAC was applied to all these patients after stabilization of fracture by EX. FIX/Intramedullary fixation after surgical toilet and debrima. 110 mmHg intermittent negative pressure was observed to give best results. VAC unit was changed after 4 days or earlier if the container gets full. Final stabilization of fracture was done after healing of the wound. Skin grafting /secondary closure of the wound is done when required
Results: Its an excellent tool for wound healing. Patients felt very comfortable with no wound wetting and smell. Good, soft tissue healing support good fracture healing also. Out of 30 cases, 27 cases had excellent results. 2 patients lost follow-up, 1 developed infection. There was no mortality during the study period.
Conclusion: EVAC is the modern way of tissue healing. It can be applied in the hospital as well as at home. Most of the cases, require 3 to 4 VAC dressing at a minimal 4 days interval with a healthy wound. Further management of fracture and wound can be done as a primary wound.
Keywords: Vacuum-assisted closure, wound healing technique, high-velocity trauma


References

1-Fleischmann W et al: Vaccum sealing as treatment of soft tissue damage in open fractures
2-Morry Kwas et all 1990
3-Philbeck et al: Intermittent cycling results in Rhythmic perfusion of tissue
4-Muller: 45 pts study on Sacral ulcers.
5-Vacuum sealing: unfallchirurg 1993;96:488-492
6-Patterson et al: Mycosis 1990; 33:297-302
7-Ford CN et al: Interim analysis of prospective Randomized trial of vacuum-assisted closure vs. The health point system in the management of pressure ulcers point system in the management of pressure ulcers


How to Cite this Article:  Khare T, Khare A.  Electronic Vacuum Assisted Closure – An Advanced Wound Healing Technique. Journal of Bone and Joint Diseases Jan – Apr 2019;34(1):7-8.


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Osteosynthesis of Distal Tibial Fractures using Anterolateral Distal Tibia Locking Compression Plate

Vol 34 | Issue 1 | Jan – April 2019 | page: 10-15 | Dinesh Kumar, Jasveer Singh, Rajeev Kumar, Harish Kumar, Manish Raj, Ankit Mittal


Authors: Dinesh Kumar [1], Jasveer Singh [1], Rajeev Kumar [1], Harish Kumar [1], Manish Raj [1], Ankit Mittal [1]

Address of Correspondence

Dr. Jasveer Singh,
Department of Orthopaedics,
Uttar Pradesh University Of Medical Sciences,
Saifai, Etawah, Uttar Pradesh, India
E-mail: singhkgmc@gmail.com


Abstract

Introduction: The management of distal tibia fractures has been a great challenge to orthopedic surgeons due to soft tissue damage, extensive comminution, intra-articular extension, and lack of vascularity. Conservative treatment of these fractures quite often results in a number of complications including malunion, non-union, and ankle stiffness. These fractures are generally not suitable for intramedullary nailing despite certain studies indicating satisfactory results in some of these fractures. External fixation can be used either as a temporary or definitive method of treatment, especially in fractures with severe soft tissue injury, but malunion and delayed union continues to be the main problems with this method of fixation. Some studies show significant good results in distal tibial fracture mixed with anterolateral distal tibial locking compression plate (LCP) using the anterolateral approach.
Materials and Methods: In this study, 36 patients were treated using the anterolateral distal tibia LCP plate between January 2017 and August 2018. The functional outcome was measured by Teeny and Wiss clinical assessment criteria.
Results: Of the 36 patients in the study, 29 were male and seven were female. The mean age was 37.86 years with standard deviation ± 9.54. The majority of cases were AO Type B (50%). In the majority of cases (77.13%), the complete union was achieved by 16–20 weeks. Three patients had an immediate complication in the form of infection and one patient had wound dehiscence. Early complication includes deep infection in four patients, of which two progressed to wound dehiscence. One patient develops non-union and two develop malunion, one patient had an infection, one united in valgus, and one had non-union. The mean functional score was 78.16 ± 10.02 with one excellent outcome, six good, 24 fair, and have poor outcomes.
Conclusion: Anterolateral plating in the distal end tibial fractures using the anterolateral approach is safe, easy, and effective and has fair the functional outcome with less complication.
Keyword: Osteosynthesis, Anterolateral Approach, Distal Tibia


References

1.Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 11th ed., Vol. 3. Ch. 51. St. Louis: Elsevier Health Sciences; 2007. p. 3117-8.
2.Court-Brown CM, Robert WB, James DH, Charles M, Paul T. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005. p. 2079-146.
3.Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995;77:417-21.
4.Joshi D, Ahmed A, Krishna L, Lal Y. Unreamed interlocking nailing in open fractures of tibia. J Orthop Surg 2004;12:216-21.
5.Abd-Almageed E, Marwan Y, Esmaeel A, Mallur A, El-Alfy B. Hybrid external fixation for Arbeitsgemeinschaft für osteosynthesefragen (AO) 43-C tibial plafond fractures. J Foot Ankle Surg 2015;54:1031-6.
6.Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am 1986;68:543-51.
7.Digby JM, Holloway GM, Webb JK. A study of function after tibial cast bracing. Injury 1983;14:432-9.
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9.Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the treatment of severe tibial pilon fractures: A study of three techniques. J Orthop Trauma 2001;15:153-60.
10.Janssen KW, Biert J, van Kampen A. Treatment of distal tibial fractures: Plate versus nail: A retrospective outcome analysis of matched pairs of patients. Int Orthop 2007;31:709-14.
11.Mosheiff R, Safran O, Segal D, Liebergall M. The unreamed tibial nail in the treatment of distal metaphyseal fractures. Injury 1999;30:83-90.
12.Streicher G, Reilmann H. Distal tibial fractures. Unfallchirurg 2008;111:905-18.
13.Dickson KF, Montgomery S, Field J. High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface-preliminary report. Injury 2001;32 Suppl 4:SD92-8.
14.Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients. Injury 2006;37:877-87.
15.Krackhardt T, Dilger J, Flesch I, Höntzsch D, Eingartner C, Weise K, et al. Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg 2005;125:87-94.
16.Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD. Tibial pilon fractures: A comparison of treatment methods. J Trauma 1999;47:937-41.
17.Ristiniemi J, Flinkkilä T, Hyvönen P, Lakovaara M, Pakarinen H, Biancari F, et al. Two-ring hybrid external fixation of distal tibial fractures: A review of 47 cases. J Trauma 2007;62:174-83.
18.Borrelli J Jr., Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: A human cadaveric study. J Orthop Trauma 2002;16:691-5.
19.Fisher WD, Hamblen DL. Problems and pitfalls of compression fixation of long bone fractures: A review of results and complications. Injury 1978;10:99-107.
20.Strauss EJ, Schwarzkopf R, Kummer F, Egol KA. The current status of locked plating: The good, the bad, and the ugly. J Orthop Trauma 2008;22:479-86.
21.Synthes LC. Anterolateral Distal Tibial Plate and LCP Low Bend Medial Distal Tibial Plate. Technique Guide. Available from: http://www.synthes.com/lit.
22.Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res 1993;292:108-17.
23.Vallier HA, Cureton BA, Patterson BM. Factors influencing functional outcomes after distal tibia shaft fractures. J Orthop Trauma 2012;26:178-83.
24.Shabbir G, Hussain S, Nasir ZA, Shafi K, Khan JA. Minimal invasive plate osteosynthesis of close fractures of distal tibia. J Ayub Med Coll Abbottabad 2011;23:121-4.
25.Aksekili MA, Celik I, Arslan AK, Kalkan T, Uğurlu M. The results of minimally invasive percutaneous plate osteosynthesis (MIPPO) in distal and diaphyseal tibial fractures. Acta Orthop Traumatol Turc 2012;46:161-7.
26.Gupta RK, Rohilla RK, Sangwan K, Singh V, Walia S. Locking plate fixation in distal metaphyseal tibial fractures: Series of 79 patients. Int Orthop 2010;34:1285-90.
27.Lee YS, Chen SW, Chen SH, Chen WC, Lau MJ, Hsu TL, et al. Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: A retrospective comparison of fibular fixation methods. Int Orthop 2009;33:695-9.
28.Garg S, Khanna V, Goyal MP, Joshi N, Borade A, Ghuse I, et al. Comparative prospective study between medial and lateral distal tibial locking compression plates for distal third tibial fractures. Chin J Traumatol 2017;20:151-4.
29.Cheng W, Li Y, Manyi W. Comparison study of two surgical options for distal tibia fracture-minimally invasive plate osteosynthesis vs. Open reduction and internal fixation. Int Orthop 2011;35:737-42.
30.Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatut L, Simon P, et al. Distal tibia fractures: Management and complications of 101 cases. Int Orthop 2010;34:583-8.


How to Cite this Article: Kumar D, Singh J, Kumar R, Kumar H, Raj M, Mittal A. Osteosynthesis of Distal Tibial Fractures using Anterolateral Distal Tibia Locking Compression Plate. Journal of Bone and Joint Diseases Jan-April 2019;34(1):9-14.


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Austin Moore’s Prosthesis: Still the Flagship?

Vol 34 | Issue 1 | Jan – April 2019 | page: 3-7 | Pulkit Jain, Najmul Huda, Ajay Pant, Pratyush Parag


Authors: Pulkit Jain [1], Najmul Huda [1], Ajay Pant [1], Pratyush Parag [1]

[1] Department of Orthopedics Surgery, King George Medical University, Lucknow.

Address of Correspondence
Dr. Pulkit Jain,
Department of Orthopaedics, Teerthanker Mahaveer Medical
College And Research Centre, Teerthanker Mahaveer
University, Moradabad, India P.O – 244001.
E-mail: pjain1060@gmail.com


Abstract

Introduction: Fractures of neck femur in elderly have always been a challenge for Orthopaedic surgeons as it is associated with various medical comorbidities. By 2050 this number is suspected to be between 4.5 million – 6.3 million. A unipolar prosthesis is still extensively used in developing countries in low demanding patients. This study was undertaken to evaluate the functional and radiological outcome of geriatric patients treated with Austin Moore’s prosthesis.
Methods: Geriatric patients with femoral neck fractures, managed with hemiarthroplasty using Austin Moore’s prosthesis between January 2010 to March 2015 were included in this study. The data was extracted from the record room of our hospital. The patients were called up once and were analyzed clinically using the Harris hip score. Radiological the assessment was done on the Antero- Posterior & Lateral radiographs of the hip to look for seating of the collar of the prosthesis on the calcar, enlargement of the medullary anal, any degenerative changes over the acetabulum, varus pivoting, subsidence, osteolysis along the stem of prosthesis & lack of ossification in the fenestration hole of prosthesis.
Results: 112 patients fulfilled the inclusion and exclusion criteria and were included in the study, out of which 13 expired & 4 patients didn’t turn up for the follow-up. Remaining 95 patients were included in the study. Mean duration of follow up in our study was 5 .7 years (Range – 8.4 years to 3.6 years). 64.21% showed well while 3.16% showed poor Harris hip score. Radiologically 65 patients showed prosthesis collar seating over calcar while 11 patients showed acetabulum changes, 15 had enlarged medullary canal, 13 showed varus pivoting, 17 hips showed osteolysis along the stem of a prosthesis, subsidence was seen in 14 patients and 53 patients showed lack of ossification in the prosthesis fenestration hole.
Conclusion: Though the unipolar Austin Moore’s prosthesis faces criticism for causing degenerative arthritis of the hip, a year or two after surgery. Majority of patients showed excellent to good results. We concluded that the use of Austin Moore’s prosthesis is a good treatment of choice in the fractured neck of the femur for geriatric patients.
Keywords: Fracture neck of femur, Austin Moore’s prosthesis, Harris hip score


References

1.Kiebzak GM, Beinart GA, Perser K, Et Al. Under treatment Of Osteoporosis in men with Hip Fracture. Arch Intern Med. 2002;162:221-7.
2.Cooper C, Campion G, Melton LJ, 3rd Hip Fractures In The Elderly: A World-Wide Projection. Osteoporosint 1992;2:285.
3.Dhanwal D.K, Siwach R, Dixit V, Mithal A,Jameson K, And Cooper C Arch Osteoporos.2013;8:135.
4.Singh GK, Deshmukh RG. Uncemented Austin-Moore And Cemented Thompson Unipolar Hemiarthroplasty For Displaced Fracture Neck Of Femur Comparison Of Complications And Patient Satisfaction. Injury 2006; 37(2):169-74.
5.Thompson FR. Vitallium Intramedullary Hip Prosthesis, Preliminary Report. N Y State J Med. 1952;52(24):3011-20.
6.Moore AT.The Self-Locking Metal Hip Prosthesis.J Bone Joint Surg Am.1957;39(4):811-27.
7.Victor CR.Unipolar Versus Bipolar Arthroplasty”Techniques In Orthopaedics september 2004;Vol.19:3:138–42.
8.Crossman PT, Khan RJ, Macdowell A, Gardner AC, Reddy NS, Keene GS. A Survey Of The Treatment Of Displaced Intracapsular Femoral Neck Fractures In The UK. Injury. 2002;33(5):383-6.
9.Calder SJ, Anderson GH, Jagger C, Harper WM, Gregg PJ.Unipolar Or Bipolar Prosthesis In Displaced Intracapsular Hip Fractures In Octogenarians:A Randomised Prospective Study. J Bone Joint Surgery Br.1996;78:391–4.
10.Harris WH. Traumatic Arthritis Of The Hip After Dislocation And Acetabular Fractures: Treatment By Mold Arthroplasty. An End-Result Study Using A New Method Of Result Evaluation. J Bone Joint Surg Am. 1969;51(4):737-55.
11.Yau W.P, Chiu K.Y-Critical radiological analysis after Austin Moore hemiarthroplasty- Injury, Int.J.Care Injured (2004) 35, 1020—1024.
12.Vishwanath C and Mummigatti SB. Comparative Study Between Austin Moore Prosthesis And Bipolar Prosthesis In Fracture Neck Of Femur. National Journal Of Clinical Orthopaedics. 2017;1(2):53-61.
13.Mulay S, Singh A, Kumar P and Saji M. Study of treatment of fracture neck of femur with Bipolar/Austine Moore’s Prosthesis. International Journal of Orthopaedics Sciences 2017;3(3):377-82.
14.Agarwal VK, Singh A, Narula R, Tiwari G. A study of surgical management of fracture neck of femur in elderly with bipolar hemiarthroplasty. International Journal of Contemporary Medical Research 2016;3(6):1790-93.
15.Krishnan J and Kumarvk.Austin Moore Hemiarthroplasty Visa Vis Bipolar Arthroplasty In The Management Of Neck Of Femur Fractures. IJPTM Jan-Mar, 2014;Vol.2(1):5-9.
16.Mahendra B, Naresh Kumar V.Comparison Of Unipolar (Moore’s Prosthesis) And Bipolar Hemiarthroplasty In Fracture Neck Of Femur In The Elderly-A Short-Term Prospective Study. J. Evid. Based Med. Healthc. 2016; 3(92):5011-22.
17.Kalantri A, Barod S, Kothari D, Kothari A, Nagla A, Bhambani P. Hemiarthroplasty For Intra-Capsular Fracture Neck Of Femur In Elderly Patients: A Prospective Observational Study. Int J Res Orthop. 2017;3(5):991-7.
18.Balan B, Shetty SK, Shetty A, Chandran R, Mathias LJ. Displaced Intra-Capsular Neck Femur Fractures In Elderly: Austin Moore’s Prosthesis Or Cemented Modular Bipolar Prosthesis. IAIM, 2016;3(7):287-96.
19.Gandhi T, Kosada D, Thakor P, Patel J, Desai S and Patwa J. Comparative Study In Surgical Management Of Fracture Neck Femur Treated With Austin Moore Prosthesis And Bipolar Prosthesis. International Journal Of Orthopaedics Sciences. 2017;3(4):571-7.
20.Bhat RS, Mohan Kumar CR, Harsharaj K, Ramprasad Rai, Jacob IPE, Jabez Gnany And Reddy VAK. A Clinical Study On Intracapsular Fracture Neck Of Femur In Elderly Treated By Hemiarthroplasty. IJOS 2017;3(3): 1000-002.
21.Shekhar A , Gururajmurgod, Korlhalli S- Two Years Outcome Of Cemented Austin Moore Hemiarthroplasty For Fracture Neck Femur- Iosr Journal Of Dental And Medical Sciences (Iosr-Jdms) 2013;Vol.11:6:10-15.
22.Shah SA, Memon A, Pirwani M. Outcome Of Femural Neck Fracture Treated By Austin– Moor Hemiarthoplasty In Elderly Patients. Med Forum 2015;26(1):45-9.


How to Cite this Article:  Jain P, Huda N, Pant A, Parag P. Austin Moore’s Prosthesis: Still the Flagship?. Journal of Bone and Joint Diseases Jan-April 2019; 34 (1): 2-6.


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Midterm results with monobloc ceramic acetabular component and ceramic heads in THA

Vol 34 | Issue 1 | Jan – April 2019 | page: 33-38 | Chandeep Singh, Shitij Kacker, Gur Aziz Singh Sidhu, Rajesh K Bawari, SKS Marya


Authors: Chandeep Singh, Shitij Kacker, Gur Aziz Singh Sidhu, Rajesh K Bawari, SKS Marya

Address of Correspondence

Dr. SKS Marya,
# 115 Vista Villas Sector 46, Gurgaon.
Email: sksmarya@yahoo.co.in


Abstract

Introduction: Total hip arthroplasty [THA] has established itself as the surgery of the century and with the advent of improved prosthetic design and developments in the bearing surfaces and materials more are expected by surgeons and patients. The purpose of this study was to evaluate the clinical and radio¬graphic results of Delta Motion hip system in patients undergoing THA.
Conclusion: Delta Motion hip system shows excellent function, Harris Hip Score and a low rate of complications. As a monobloc system, it allows optimization of head diameter to acetabular cup ratio, head engagement, and stability of the hip.
Materials and Methods: This study comprised of 32 hips (31 patients) conducted at Max Hospital, Delhi. Patients with degenerative hip diseases were included whereas patients with an active infection, unable to give consent for surgery, neuromuscular diseases and revision total hip replacement were excluded. e mean age was 44.7 years (range, 35-66 years) and mean follow-up was 65.6 months (range, 48-74 months)
Results: The Harris Hip Score improved from a mean of 47.8 (30-60) preoperatively to 86.8(85-90) postoperatively. 97.5% of patients were able to participate regularly in leisure and daily routine activities. One patient had acetabular cup migration with an angular change of more than 10° and experienced squeaking. e mean abduction angle and anteversion of acetabular component were 38.6 degrees +/- 6.2 (range 27-54 degrees), 16.4 degrees +/- 4.6 (9-24 degrees).
Keywords: Total hip arthroplasty (THA), delta motion hip system, ceramic on ceramic, Harris Hip Score (HHS)


References

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12.Bal BS, Aleto TJ, Garino JP, et al. Ceramic-on-ceramic versus ceramic-on-polyethylene bearings in total hip arthroplasty: Results of a multicenter prospective randomized study and update of modern ceramic total hip trials in the United States. Hip Int, 2005, 15: 129– 135.
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Orthop Sci, 2005, 10: 378–384.
14.Pengde Cai, Yihe Hu, Jie Xie. Large-diameter Delta Ceramic-on-ceramic Versus Common-sized Ceramic-on-polyethylene Bearings in THA Orthopedics.2012 Sep;35(9):1307-13.
15.Cinotti G, Lucioli N, Malagoli A, Calderoli C, Cassese F. Do large femoral heads re¬duce the risks of impingement in total hip arthroplasty with optimal and non-optimal cup positioning? Int Orthop. 2011; 35(3):317-323.
16.Ha YC, Kim SY, Kim HJ, Yoo JJ, Koo KH. Ceramic liner fracture after cementless alumina-on-alumina total hip arthroplasty. Clin Orthop Relat Res. 2007;458:106–110.
17.Park YS, Hwang SK, Choy WS, Kim YS, Moon YW, Lim SJ. Ceramic failure after total hip arthroplasty with an alumina-onalumina bearing. J Bone Joint Surg Am. 2006;88:780–787.
18.William G. Hamilton, James P. Mcauley et al.THA with Delta Ceramic on Cearmic.Clin Orthop Relat res (2010)468:358-366
19.Miller AN, Su EP, Bostrom MPG, Nestor BJ, Padgett DE. Incidence of Ceramic Liner Malseating in Trident1 Acetabular Shell .Clin Orthop Relat Res (2009) 467:1552–1556
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22.Restrepo C, Parvizi J, Kurtz SM, Sharkey PF, Hozack WJ, Rothman RH. The noisy ceramic hip: is component malpositioning the cause? J Arthroplasty. 2008;23:643–649.
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26.Koo KH, Ha YC, Jung WH, Kim SR, Yoo JJ, Kim HJ. Isolated fracture of the ceramic head after third-generation alumina-on alumina total hip arthroplasty. J Bone Joint Surg Am. 2008;90: 329–336.
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31.Kress AM, Schmidt R, Vogel T, Nowak TE, Forts R, Mueller LA. Quantitative computed tomography-assisted osteodensitometry of the pelvis after press-fit cup fixation: a prospective ten-year follow-up. J Bone Joint Surg Am. 2011;93:1152–1157.
32.Zenz P, Stiehl JB, Knechtel H, Titzer-Hochmaier G, Schwagerl W. Ten-year follow-up of the non-porous Allofit cementless acetabular component. J Bone Joint Surg Br. 2009;91:1443–1447.


How to Cite this Article:  Singh C, Kacker S, Sidhu G A S, Bawari R K, Marya S K S.Midterm results with monobloc ceramic acetabular component and ceramic heads in THA. Journal of Bone and Joint Diseases Jan – Apr 2019; 34 (1):32-37.


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Simultaneous Separate Intrameniscal and Parameniscal Cyst of Lateral Meniscus: A Rare Case

Vol 34 | Issue 1 | Jan – April 2019 | page: 30-32 | Pulak Sharma, Abhey Wasdev, Iftekar Ahmed, Avneesh


Authors: Pulak Sharma, Abhey Wasdev, Iftekar Ahmed, Avneesh

Address of Correspondence

Dr.Abhey Wasdev,
Department of Orthopaedics, APEX Trauma Center, Sanjay
Gandhi Postgraduate Institute, Rae Bareilly Road, Lucknow –
226019, Uttar Pradesh, India.
E-mail: abheywasdev@gmail.com


Abstract

Meniscal cysts are rare and usually asymptomatic. ey may cause various symptoms depending on their size and site of origin. It may present as a palpable mass with or without pain and sometimes grows large enough to limit the patient’s activities of daily living. We report a rare case where both intrameniscal and parameniscal cyst was present in the same meniscus. The magnetic resonance imaging is the gold standard for diagnosis. We treated the intrameniscal cyst by arthroscopic decompression and debridement and the parameniscal cyst by a combination of an arthroscopic and open procedure. The outcome of the treatment was good. The patient had no recurrence and was able to return to his full functional status.

Keywords: Intrameniscal, parameniscal, cyst, arthroscopic


References

1.1.Burk DL Jr., Dalinka MK, Kanal E, Schiebler ML, Cohen EK, Prorok RJ, et al. Meniscal and ganglion cysts of the knee: MR evaluation. AJR Am J Roentgenol 1988;150:331-6.
2.Passler JM, Hofer HP, Peicha G, Wildburger R. Arthroscopic treatment of meniscal cysts. J Bone Joint Surg Br 1993;75:303-4.
3.Ryu RK, Ting AJ. Arthroscopic treatment of meniscal cysts. Arthroscopy 1993;9:591-5.
4.Clarke DC, Scott WN. Anatomic aberrations. In: Insall JN, Scott WN, editors. Surgery of the Knee. Philadelphia, PA: Churchill Livingstone; 2001.
5.De Maeseneer M, Shahabpour M, Vanderdood K, Machiels F, De Ridder F, Osteaux M, et al. MR imaging of meniscal cysts: Evaluation of location and extension using a three-layer approach. Eur J Radiol 2001;39:117-24.
6.Hulet C, Souquet D, Alexandre P, Locker B, Beguin J, Vielpeau C, et al. Arthroscopic treatment of 105 lateral meniscal cysts with 5-year average follow-up. Arthroscopy 2004;20:831-6.
7.Anderson JJ, Connor GF, Helms CA. New observations on meniscal cysts. Skeletal Radiol 2010;39:1187-91.
8.Campbell SE, Sanders TG, Morrison WB. MR imaging of meniscal cysts: Incidence, location, and clinical significance. AJR Am J Roentgenol 2001;177:409-13.
9.De Smet AA, Graf BK, del Rio AM. Association of parameniscal cysts with underlying meniscal tears as identified on MRI and arthroscopy. AJR Am J Roentgenol 2011;196:W180-6.
10.Imamura H, Kimura M, Kamimura T, Momohara S. An arthroscopic check valve release improves knee intrameniscal cyst symptoms in adolescent: A case report. Orthop Traumatol Surg Res 2014;100:239-41.
11.Antonios T, Huber CP. Lateral meniscal cyst presenting as medial compartment knee swelling: A case report and literature review. Int J Surg Case Rep 2013;4:342-4.
12.Reagan WD, McConkey JP, Loomer RL, Davidson RG. Cysts of the lateral meniscus: Arthroscopy versus arthroscopy plus open cystectomy. Arthroscopy 1989;5:274-81.
13.Campanacci M. Tumori Delle Ossa e Delle Parti Molli. Bologna: Aulo Gaggi Editore; 1981. p. 907-11.
14.Tigani D, Busacca M, Zappoli FA, Alfonso C, Pignatti G. Cyst of the medial meniscus: Observation of two cases. Chir Organi Mov 1995;80:449-52.
15.Mills CA, Henderson IJ. Cysts of the medial meniscus. Arthroscopic diagnosis and management. J Bone Joint Surg Br 1993;75:293-8.
16.Tasker AD, Ostlere SJ. Relative incidence and morphology of lateral and medial meniscal cysts detected by magnetic resonance imaging. Clin Radiol 1995;50:778-81.
17.Chen H. Diagnosis and treatment of a lateral meniscal cyst with musculoskeletal ultrasound. Case Rep Orthop 2015;2015:432187.
18.Bombaci H, Kuyumcu M, Coskun T, Kaya E. When should the external approach be resorted to in the arthroscopic treatment of perimeniscal cyst? SICOT J 2016;2:19.
19.Kumar NS, Jakoi AM, Swanson CE, Tom JA. Is formal decompression necessary for parameniscal cysts associated with meniscal tears? Knee 2014;21:501-3.
20.Glasgow MM, Allen PW, Blakeway C. Arthroscopic treatment of cysts of the lateral meniscus. J Bone Joint Surg Br 1993;75:299-302.


How to Cite this Article:  Sharma P, Wasdev A, Ahmed I, Avneesh. Simultaneous Separate Intrameniscal and Parameniscal Cyst of Lateral Meniscus: A Rare Case. Journal of Bone and Joint Diseases Jan – Apr 2019;34(1):29-31


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Violence against doctors: An occupational hazard

Vol 34 | Issue 1 | Jan – April 2019 | page: 1-2 | Najmul Huda


Author: Najmul Huda [1],[2]

[1] Editor JBJD
[2] Dept of Orthopedics,
Teerthanker Mahaveer Medical College,
Teerthanker Mahaveer University,
Moradabad, Uttar Pradesh, India. P.O 244001

Address of Correspondence
Dr. Najmul Huda,
Dept of Orthopedics,
Teerthanker Mahaveer Medical College,
Moradabad, Uttar Pradesh, India.
Email: hudanajamul@gmail.com


Violence against doctors: An occupational hazard

12th June 2019: Two interns of the NRS medical college assaulted by a mob of 200 people and suffered near-fatal injuries.
May 2018: Two doctors of the Sion hospital, Mumbai thrashed by angry relatives of a patient.
March 2017: An Orthopedic doctor of Dhule civil hospital was beaten and lost vision in one eye.
Headlines like these are though scary but on the rise these days. The problem of doctor bashing is a global one, but the Indian scenario is slightly unique as the problem is compounded by the presence of poor infrastructure, lack of manpower resources and a skewed doctor-patient ratio. The Indian policymakers have allocated only 1.5% of the GDP (1) as a budget for healthcare, which is amongst the lowest in the world as compared to even smaller neighbors like Maldives (13.7%), Nepal (5.8%) and Afghanistan (8.2%)(2). The WHO prescribes a doctor-patient ratio of 1:1000, in India this ratio is 0.62:1000 i.e there is one doctor for every 1613 patients!!(3) All these problems when combined together lead to long gruelling shifts, no time to catch sleep or be fed properly, less time given to each patient, long waiting hours for the patients and repeated visits to hospitals. About 80% of the healthcare in India is provided by the private sector, in the public sector the situation is dismal with one doctor on every 10,819 people!!(4) To top it all the media leaves no opportunity to demonize the doctors. Recently all of us saw the viral video of a mike wielding journalist inside the pediatric ICU of a medical college hospital who started asking absurd questions to the attending doctor. News features like these portray the doctors in a bad light, while on the contrary the doctors cannot be held responsible for this rot in the healthcare sector.
With the current scenario, the question arises how the hospitals and doctors should tackle this problem? Due to the enormous workload, the doctors are not able to give time to the patients, who have endless queries, though it is difficult to answer each and every question of the patient at the same time it is needless to say that effective communication with the patient/ attendants can bridge many gaps. Hospitals may keep counselors who can do the rest of the talking. Interacting with the relatives of a sick patient on a daily basis or maybe twice or thrice a day will not only help them accept the grim or serious state of the patient but will also go a long way in building faith and trust between the doctor and the patient. Do not hesitate to take proper consent from the patient, do not reduce it to a mere formality rather spend time on this important aspect of treatment. Do explain or read out the contents of the consent in whatever language the patient understands. Always refrain from making false promises or tall claims regarding the patients treatment, remember miracles occur only in storybooks, be realistic and have a practical approach to the patient’s condition. In the medical field complications do occur and occur even in the best of hands, never shy away from discussing a complication with the patient, assess the problem and manage it, if you can or else refer it to a person more competent than you. Often even the best of treatment may leave a patient dissatisfied in such cases proper documentation is obligatory, as this is the one and the only thing that can save you if the matter goes to the police or court. As every fatal illness throws some preceding signs similarly every major act of violence will show some warning signs, be alert and try to recognize them. The STAMP system(5) can help health professionals gauge a potentially violent situation. This lays down a few signs from the patient/attendant’s side which can help predict an act of violence, these include Staring, Tone, Anxiety, Mumbling, and Pacing. Most of the times the ruckus is created by a mob of people some of whom may be remotely linked to the patient but are instrumental in starting or escalating the violence, this can be prevented by ensuring a robust security system in the hospital and restricting the entry of unwanted people. Every hospital must chalk out a contingency plan or a standard operation protocol (SOP) for violence.
This malady will prove fatal, recently we have seen or heard hospitals refusing sick or troublesome patients. The general public needs to understand that a time may come when no nursing home or hospital will treat a critically ill patient.

References
1. Ministry of Health and Family Welfare, Government of India: National Health Policy Draft. Ministry of Health and Family Welfare; 2015. Available from:http://www.mohfw.nic.in/WriteReadData/l892s/35367973441419937754. pdf. [Last accessed on 2019 Jan 15].
2. Doctors Are Not to Blame for the Rot in Indian Healthcare. Available at https://www.biospectrumindia.com/news/70/14031/doctors-are-not-to-blame-for-the-rot-in-indian-healthcare.html. [Last Accessed on 2019 July 4].
3. Human Resources in the Health Sector. National Health Profile 2015. New Delhi: Central Bureau of Health Intelligence, Directorate General Health Services, Ministry of Health and Family Welfare, Government of India; 2015:252–6.
4. Healthcare indicators. Available at www.ita.doc.gov/td/health/india_indicators05.pdf (accessed on 15 May 2015).
5. STAMP system can help professionals to identify potentially violent individuals. Eurek Alert! The global source for science news. Washington, DC: Black Lack Publishing; 20 June 2007. Available at www.eurekalert.org/pub_releases/2007-06/ bpl-ssc062007.php (accessed on 2 Jun 2017).

Sincere regards
Dr. Najmul Huda


How to Cite this Article: Huda N. Violence against doctors: An occupational hazard Jan-April 2019; 34(1):1.


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