EDITORIAL BOARD INDEX -...

1

INDEX

President, IMA MS DR . BAKULESH S. MEHTA (022) 26832359 / 9820131926 [email protected]. Past President, IMA MS DR. ARUN B. PAWADE (07157) 223750 / 9373240703 [email protected]. State Secretary, IMA MS Dr. HOZIE D. KAPADIA (022) 23711051 / 9833793005 [email protected]. Treasurer, IMA MS DR. SHIVKUMAR S. UTTURE (022) 24305373 / 9820089321 [email protected]. Vice President, IMA MS DR. M. S. PATWARDHAN (0233) 2232104 / 9423036173Vice President, IMA MS DR. T. C. RATHOD (07232) 245186 / 9422168300 [email protected] President, IMA MS DR. RAVINDRA D. JAGTAP (02166) 222998 / 9921992168 [email protected] President, IMA MS DR. ANIL SUCHAK (022) 2889148 / 9820080151 [email protected]. Jt. Secretary, IMA MS DR. ANIL LADDHAD (0712) 2765287 / 9822565225Hon. Jt. Secretary, IMA MS Dr. SANJEEV SHARANGPANI 9422429224 [email protected]

[email protected]. Jt. Secretary, IMA MS DR. JAYESH M. LELE (022) 28823408 / 9819812996 [email protected], IMA MS SSS DR. ANIL J. TALATHI (02143) 252261 / 9422594236 [email protected]. Secretary, IMA MS SSS DR. SHRIKANT H. KOTHARI (022) 25171198 / 25001269 / [email protected]

9821012970Hon. Treasurer, IMA MS SSS DR. SHAILENDRA C. MEHTALIA (022) 25132114 / 9820377174 [email protected] of Studies DR. AKIL CONTRACTOR (022) 26127481 / 9892084360 [email protected] MS CGP FacultyHon. Secretary, DR. DILIP G. DEODHAR (020) 24334136 / 9371005036IMA MS CGP FacultyHon. Jt. Secretary, DR. VIVEK BILLAMPELLY (020) 26832658 / 9822894963 [email protected] MS CGP FacultyChairman, IMA AMS Chapter DR. RAVI S. WANKHEDKAR (02562) 246695 /94222 96495 [email protected]. Secretary, DR. MAYA TULPULE (020) 25440530 / 9923709210IMA AMS Chapter

IMA MAHARASHTRA STATE OFFICE BEARERS 2009-10

EDITORIAL ....................................................................... 3PRESIDENT’S MESSAGE .................................................... 5HON STATE SECRETARY’S MESSAGE ................................... 7DR. ABDUL KALAM’S SPEECH ........................................... 9HAEMATOLOGY TODAY .................................................. 11ELECTIONS REPORT ....................................................... 13MASTACON - 2010 ......................................................... 14EVE C0N - 2010 - DHULE ................................................ 15AUTOMATION IN HAEMATOLOGY ................................... 17BLOOD COMPONENT THERAPY ...................................... 21AUTOLOGOUS BLOOD TRANSFUSION ............................. 23TREATMENT OF VENOUS THROMBOEMBOLISM .............. 25COMMONLY ASKED QUESTIONS IN ANAEMIA ................. 29NATIONAL THALASSEMIA CONTROL PROGRAM .............. 33INVESTIGATION & MANAGEMENT OF LEUCOCYTOSIS ..... 36HAEMATOPOIETIC STEM CELL TRANSPLANTATION .......... 39MARROW DONOR REGISTRY INDIA (MDRI) .................... 4550 YEARS IN HEMATOLOGY ............................................ 47INDUSTRIAL DISASTER MANAGEMENT ........................... 52SUPER SESSION OF MCI - THE PATH AHEAD ..................... 53IMA - ACTIVITIES REPORTS ............................................. 56IMA MS SOCIAL SECURITY SCHEME ................................ 60

DISCLAIMER : Opinions expressed in the various articles are those of the authors and do not reflect the views ofIndian Medical Association Maharashtra State Branch. The appearance of advertisement in MAHIMA is not aguarantee or endorsement of the product or the claims made for the product by the manufacturer.

EDITORIAL BOARDChairman : Dr. DEEPAK K. JUMANIEx.- Editor : Dr. ANIL SUCHAKEx.- Editor : Dr. P.N. RAOEx.- Editor : Dr. AJOY K. SAHA

MembersDr. RAJESH SUBHEDAR Dr. JAYESH LELEDr. BALKRISHNA INAMDAR Dr. Y. S. DESHPANDEDr. SUBRAMANIUM JAYARAM Dr. GOPINATHAN INDUMATIDr. NIRANJAN VAIDYA Dr. AVINASH BHONDWEDr. VYANKATESH METAN Dr. RAJENDRA GANDHIDr. SANJAY DESHPANDE Dr. KRISHNESHKARDr. RAVI PATEL Dr. GURUDATT BHATDr. AJAY TILWE Dr. GOVIND DHAWALE

Published by : IMA MAHARASHTRA STATEContact for write-ups, articles, interviews andadvertisements : Editor : Dr. Deepak Jumani

E-mail : [email protected]

IMA Bldg, 2nd Floor, J.R.Mhatre Marg, J.V.P.D. Scheme,Juhu, Mumbai - 400 049. Office : 2623 2965 / 6521 5756

E-mail : [email protected] : www.imamaharashtrastate.org

Advertisement Cheques must be drawnin favour of IMA MAHARASHTRA STATE

2

1 Action Committee & Dr. Pt. RelationshipChairman Dr. DEVENDRA K. SHIROLEConvener Dr. VIJAY GHATE

MembersDr. KISHORE GANGURDE Dr. SALIM SACCHANIDr. ARSHAD G. MOHAMAD Dr. PRATAP JADHAV

2 Press PublicityChairman Dr. BAKUL S. MEHTAConvener Dr. HOZIE DARA KAPAIDAMembers Dr. ANIL LADDHAD

3 Professional Protection SchemeChairman Dr. ANAND KATEConvener Dr. KRISHNA PARATE

4 Medico Legal CommitteeChairman Dr. MILIND M. NAIKConvener Dr. NISAR SHAIKH GULABMembers Dr. DILIP PATILDr. RAJENDRA ABHYANKAR Dr. SUBHASH TIWARI

5 Mahima Editorial BoardChairman Dr. DEEPAK K. JUMANIEx.- Editor Dr. ANIL SUCHAKEx.- Editor Dr. P.N. RAOEx.- Editor Dr. AJOY K. SAHA

MemberDr. RAJESH SUBHEDAR Dr. JAYESH LELEDr. BALKRISHNA INAMDAR Dr. Y. S. DESHPANDEDr. SUBRAMANIUM JAYARAM Dr. GOPINATHAN INDUMATIDr. NIRANJAN VAIDYA Dr. AVINASH BHONDWEDr. VYANKATESH METAN Dr. RAJENDRA GANDHIDr. SANJAY DESHPANDE Dr. KRISHNESHKARDr. RAVI PATEL Dr. GURUDATT BHATDr. AJAY TILWE Dr. GOVIND DHAWALE

6 Resource & Finance CommitteeChairman Dr. ANIL PANCHNEKARConvener Dr. ANIL SUCHAKMembers Dr. SANJAY S. JOSHI

Dr. AKIL CONTRACTOR7 Membership Promotion committee

Chairman Dr. SUHAS PINGLEConvener Dr. JAYANT MAKARANDE

MemberDr. DEEPAK KHALANI Dr. ANIL D. KABRADr. SHRIDHAR G. SHANBAUG Dr. KIRAN V. NABARDr. BALIGA PRADEEP Dr. CHANDAK UMAKANTDR. GANGADHAR V. MAHESHWARIDr. YUVRAJ GEHLOT (Not Member) Dr. PATEL RAMESH

8 Rural Health CommitteeChairman Dr RAVI WANKHEDKARConvener Dr SAVITA S. NAIK

MembersDr. NARAYAN K. PURANIK Dr. BHARAT VALVIDr. SEHEJWAL Dr. YASH LOKHANDWALADr. NAPHADE NINAD EKNATH Dr. RAJKUMAR SACHDEV

9 Medical Education Committee & Medical Ethics CommitteeChairman Dr. TATYARAO. P. LAHANEConvener Dr. KISHOR TAORIMembers Dr. GIRISH THAKREDr. YASH LOKHANDWALAL Dr. SUDHAKAR TAMBE

10 Occupational Health / Service DoctorsCommitteeESIS/ LIC Sub Committee

Chairman Dr. YOGESH SHAHConvener Dr. MANGALA GOMARE

Dr. SANTOSH KADAMMembers Dr. RAJESH VASAVEDr. SAJAY SHINDE Dr. SUBHASH SHAH

11 Group Health & Insurance SchemeChairman Dr. DILIP DEODHARConvener Dr. DEVENDRA K. SHIROLE

12 Women Doctors WingChairman Dr. MAYA TULPULEConvener Dr. VIJAYA MALIMembers Dr. SUNITA KSHIRSAGARDr. VIDYUT SHAH Dr. SHRADDHA WALVEKAR

13 Constitution committeeChairman Dr. SHAILENDRA C. MEHTALIAConvener Dr. JAYESH LELEMembers Dr. NIRANJAN R. VAIDYADr. BHALCHANDRA WAGH Dr. DILIP SARDADr. PARTHIV SANGHVI Dr. PRASHANT NIKHADE

14 New Premises / Building CommitteeChairman Dr. ANIL PANCHNEKARConvener Dr. AJAY KATEMembers Dr. KAILASH GINDODIA

16 DASS CommitteeChairman Dr. Y. S. DESHPANDEConvener Dr. BAL INAMDARMember Dr. VANDANA GANDHI Dr. VILAS

BHOLE18 Award Committee

Chairman Dr BAKULESH MEHTAConvener Dr ARUN PAWADEMembers Dr R. D. JAGTAP

19 Projects committeeChairman Dr. PRAKASH DEOMember Dr. AKIL CONTRACTORDr. SUHAS PINGLE Dr. RAVI WANKHEDKAR

20 Co-ord. State H.Q. CommitteeChairman Dr. NIRANJAN VAIDYAConvener Dr. ANAND KATE

21 Anti Quackery cellChairman Dr. GHANSHAYAM UMREConvener Dr. BALDWA MAHESH

MembersDr. SANJAY DEORE Dr. SHRADDHA WALVEKARDr. SANDIP PHADKE Dr. PANKAJ GUPTADr. NITIN TURASKAR Dr. RAM SHIVEKDr. PRASAD MAGAR Dr. POLKAT

22 Information & CommunicationChairman Dr. JAYESH LELEConvener Dr. SATHAYE CHANDRASHEKHAR B,.Members Dr. JAYA DIGHE

23 Geriatric Cell CommitteeChairman Dr. DILIP DEODHARConvener Dr. PRAKASH J. KHALAPMembers Dr. RAMESH SHAH

25 Sports CommitteeChairman Dr. MANGESH GULWADEConvener Dr. SURESH GOKHALEMembers Dr. SACHIN PAWDE

Dr. CHARUHAS S. JAGTAP Dr. KISHOR GANDECHADr. ASHUTOSH KELKAR Dr. AMIT DEWAIKARDr. SANJAY DEOTALE Dr. UDAY PHUTEDr. RAJESH PATIL Dr. DILIP SHIRSHIKAR

26 BMW & Nursing HomeChairman Dr. SANJEEV SHARANGPANIConvener Dr. BAL INAMDAR

MembersDr. SANJAY DAMKE Dr. RAJENDRA JADHAVDr. VIPIN CHECKER Dr. AJAY TILWE

27 Advisory CommitteeDr. VIJAY PANJABI Dr. VASANT PAWARDr. R. G. JIMULIA Dr. RAM ARANKARDr. ASHOK ADHAO

28 Legal Advisory CommitteeChariman Dr. JAYANT NAVRANGEConvenor Dr. SUBHASH TIWARIMember Dr. ANIL LADDHAD

Dr. BHUJANG PANDURANG Dr. NIKHIL DATAR

SUB COMMITTEES

3

Pranaam to all my Respected teachers andall the members of medical fraternity.

We are living in a world of rapid change.Everything is right here, right now—everybodywants everything faster and better than everbefore. Seems everyone is looking for the next,new, best thing. Orthopedic Surgeons of today’sgeneration have a different vision, they are cleverbut aggressive, and they must know that Scienceis organized knowledge. Wisdom is organizedlife. Knowledge comes, but wisdom lingers.Nothing can hold you back from making profitablecareer advancement. Nothing can stop you frombeing, doing, or having everything you want inlife. You can apply your new found knowledge tosolve problems and create new ideas at rapidspeed. But Remember, knowledge is only powerif you use it. Use it wisely and you will prospersays our dynamic, dearest, lover of ethics and ahighly skilled Orthopaedic Surgeon Dr. RamPrabhoo, rightly so Indian Medical Association,Maharashtra State is honoured to have him asour Guest Editor.

“You have not lived a perfect day, unless youhave done something for someone, who will neverbe able to repay you.” Dr. Ram in his practice at VN Desai Municipal Hospital and also in his ownclinic spends hours and hours operating andsharing his expertise in training buddingorthopaeds in various unique techniques andalso at various workshops in several nationaland international venues. Rightly so he ishonoured to be the First Indian to be the VicePresident of Asia Pacific Association ofOrthopaedic Surgeons... indeed a rare honour tolead this huge chariot. He is a man who haskindness, empathy and action as his innatepowers.

Promise only what you can deliver. Thendeliver more than you promise. This has been Dr.Ram’s USP, which is tested as Gospel truth. Dr.

EDITORIAL

Ram has been associatedwith all the prestigiousorganizations fororthopaedic surgeons asIOA, WOC, ARSI, JRDS, andBombay Orthopaedic Society which headed twice.It is not enough to find a person that unifiesone’s goal, one must also carry through and meetits challenges. The purpose must result instrivings, intent has to be translated into action .Dr. Ram Prabhoo has always been a true man ofaction, whom one loves to emulate.

Any man who thinks he is more intelligentthan his wife, is married to a clever woman. Thispersonifies Dr. Ram and Dr. Meena, whom he knewsince he was 6 yrs of age. They are one of thefinest and happy go lucky couples in our fraternityand blessed with two darling kids and hisambitious son Dr. Tanay is following his footstepsto be a Modern Orthopedic Surgeon. Dr. Ram hasa great philosophy of life which can be said intwo words- sustain and abstain.

No duty is more urgent than that of returningthanks. I thank you God for this most amazingday, for the leaping greenly spirits of trees, (mydearest and respected teachers,) and for the bluedream of sky, (my window of opportunities) andfor everything which is natural, (my rightchoices), which is infinite and which is yes (myattitude and mind set).

One can pay back the loan of gold, moneyand any material thing, but one dies forever indebt to those who are kind. The kindness of myteachers is unimaginable. What we do forourselves dies with us. What we do for othersand the world remains and is immortal. I amgrateful nay indebted to all my teachers for theirbeautiful art of teaching and with always aattitude of gratitude. I thank all my teachers toname few are Dr. O P Kapoor, , Dr. N H Banka, Dr.Abhay Bhave, Dr Shashank Joshi, Dr Y K Amdekar,

4

Dr Rakesh SInha, Dr Ram Prabhoo, Dr SanjayAgarwala, Dr Praful Desai, Dr Gustad Daver, DrKhushrav Bajan, Dr Sree Nair of Mayo Clinic, DrV R Joshi, Dr Camela Rodrigues, Dr Prateeksha,Dr Sanjiv Shah, Dr Jamshed Dalal, Dr AshwinMehta, Dr Sudhanshu Bhattachharya. RJ ArchanaPania and many many others. These are all whohave made our lives worth living and are truegardeners who have blossomed our soul.

Champions aren’t made in Gyms. Championsare made from something they have deep insidethem – a desire, a dream, a vision. They have tohave a skill and the will. But the will must bestronger than the skill. IMA has many such strongwilled heroes who have steered so many ideasinto reality and have brought a smile on the faceof IMA are Dr Jayesh Lele, Dr Akil Contractor, DrHozie Kapadia, Dr Anil Suchak, Dr RaviWankhedkar, Dr Suhas Pingle, Dr S S Utture, DrAnil Pachnekar, Dr Vijay Panjabi, Dr S K Joshi, DrSubodh Kedia, Dr Bal Inamdar and many manymore all across Maharashtra who shall alwaysbe hard core grass root trend setters of ourassociation.

We cannot control the negative atmosphereof the world around us, but we can control theatmosphere of our minds , we are a knot, a web, amesh into which relationship are tied. Only theserelationship matter, says our Dear President DrBakulesh Mehta. He has always been a constantand strongest source of inspiration andmotivation to all of us. He with his mighty courageand a balanced mind has endured finest changesat IMA MS, as he believes that the dogmas of thepast are inadequate to the stormy present. He isthe only son on this soil of our mother land whohas given more than he was asked for. He hasbrought to reality his dreams of giving all what aman can. The Five issues of Mahima, The FirstCGP conference, The Late Dr K RamamoorthyOration and many other issues which shallalways remain as the sweetest memory in ourfraternity to rejoice. He has done everything forIMA and IMAites with a wholesome heart,commitment and devotion. He has raised IMA MSat a higher pedestal and has brought a shining

glow to the image of IMA MS. In his game of lifeone sees him always saying once you pledge don’thedge. Truly one vouches for him as a man withgolden heart and symbol of kindness, giving andlove. Dear President Sir, We all love you.

I have always enjoyed writing besidesworking at IMA and these have been one of themost durable satisfactions in life. In case if I havehurt any one in doing my bit of work, I offer myunconditional apology and beseech you to forgiveme. When you work you are a flute through whoseheart the whispering of the hours turns to musicand your work is love made visible.

All I say is I stand before all my teachers,humbly head bowed and with joined hands:

Guru Brahma, Guru Vishnu, Guru DevoMaheshwaraha,

Guru Sakhsaat Param Brahma, Tasmai ShreeGuruveha Namah.

Thank you and Bless me.

With loads of love and light.

With lots of love and light,

DR. DEEPAK K. JUMANI

5

Dear Members,This is 5th & last Mahima published in this

year. We have started new trend & I am sure thenext team will continue the same

This Mahima is a special edition onorthopedic faculty & articles are written byeminent orthopedic surgeon of Mumbai. Ourguest editor is Dr. Ram Prabhoo a senior wellknown & popular orthopedic surgeon, has workhard & has help in publishing Mahima. I am Verymuch thankful to him.

Office bearers have work hard to carry outvarious activities during the year & I hadpleasure to work with team. Many programmecarried out & reported in Mahima.(previousedition)

Last few months we have observed assaulton doctors/Hospitals at the many places in thestate. In spite ordinance (Rules) such episodehave become a routine. With every such incidenceour moral goes down & Medical fraternity has towork in fear.

The assault on Doctors/ hospital premisesis not accepted & IMA strongly condemned it &expect the authority to take appropriate actionto prevent. But in spite of repeated appeal &unfortunately the authority is not given priorityor not take any action and not concerned. Thetime will come; IMA will have to give a call oftotal Bandh (stoppage of Work)

To Avoid such incidence (assault onDoctors), we should also introspect our self &take proper measure & improve our approach/attitude & knowledge.

I personally feel that we have to enhanceand strengthen the Doctor-Doctor relationship,Doctor-patient relationship, and doctor publicrelationship in the future years ahead.

We should regain our status of being“Spiritual Healers” rather than merely physicianhealers”. Just restore the traditional nobility ofour won profession. It is high time, to-day torebuild the confidence of the public by becoming

class examples of Karmayoga. Whose basicobjective is to provideselfless service (Karma)with no expectations orrewards.1) Selfish is immoral.

a) Un-selfish is moral. Do good and be good. Itis good to do good Promote highest ethicalstandards in their profession by performingit in and upright and honorable manner.

We should recognize the worthiness of theirprofession and should utilized as an opportunityto serve the society at larges. Our profession beingthe noblest of all the professions. It should havehighest possible ethical system to serve thesuffering humanity through our spiritual andhealing approach.

We should uphold the standers in medicalprofessionalism, belongs be honest in all ourprofessional interaction equations with thepatients, our colleagues and the public at large.

DUTIES OF PHYSICIANS TO OTHER PATIENTSOBLIGATIONS TO THE SICK :-

1 Should be punctual in consultation hours2 In case of emergency RMP should treat the

patient and then refer if proper competenceand facility are not their

3 It is not compulsory one to treat all patientsasking for their services.

4 Without solid reason a doctor can’t refusetreatment to a patient.

5 In case if the physician is not competent totreat the patient he should refer the patient toanother physician.

PATIENCE DELICACY AND SECRECY:-

1. Patience and Delicacy should be he characterof the physician

2. Secrecy should be maintained with high order.3. Secrecy may be disclosed if the law demands so.

President’s Message

6

4. Secrecy should be disclosed to the officials ifthreatens others life. (e.g. Infectious diseases)

PROGNOSIS:-

1. Should not exaggerate or minimize the gravityof a patients condition.

2. Should state only the facts as they are.

PATIENTS MUST NOT BE NEGLECTED:-

1. A Physician is free to choose whom he willserve.

2. Should respond to any request in anemergency and life saving situations.

3. Should not neglect the patient causingdeprivation of medical care.

4. Should not withdraw from the case withoutadequate notice.

CONCLUDING REMARKS:-

Learning is a lifetime continuous processfor all professionals In general and MedicalProfession in particular, Attending the CME &workshops organized by IMA and otherprofessional bodies will enrich us with the latestdevelopments in the field of medicine.

Growing awareness about the patientsrights, patients safety, professionalaccountability of doctors have recently Increasedin the Litigations against medical profession.There is a wider gap in the Doctor-patientrelationship also.

Hence legal and ethical regulations areneeded for sensitizing our colleagues.

The latest development in the Medico-legaland ethical systems should also be known to allmedical practitioners through CMLE (ContinuingMedical Legal Education) to have a litigation freeand peaceful medical practice.

Once Doctors were considered next to God.Now patients view us with suspicion. Doctorsshould spend some more time with the patients.We have to change a lot of restore the nobility ofour profession. We should not practice ourprofession like business people. We are karmayogis. We should exhibit reasonable degree ofcare to our patients.

We should strengthen Doctor-PatientsRelationship., Doctor-Public Relationship andalso Doctor-Doctor Relationship.

How to achieve this?. The leaders of IMAshould initiate this move to make all the membersto do Ethical Practice and action should be takenagainst the erring doctors. Unless the wholeprofessionalists change our attitude we as wellas our successors will have tough time in future.

Also the Medical Council of India and StateMedical Councils should revamp and modify theEthical codes to suit our needs as per thedevelopments.

Wish you a successful, purposeful, fruitfuland ethical practice ahead!

Let us adhere to the essence of Hippocratic Oath& strive for a peaceful and litigation free practice!Let us enhance the traditional Nobility of our Profession!!Let us strengthen our relationship with our colleagues, our patients and our general public at large !!!

Friends the time has come to take propermeasure and meet together a small group (areawise ) all discuss our day to day problem anddecide line of action & deference in the worksituation. Stand by your colleague & extent youhelp whenever required

Long Live IMA!Yours sincerely

DR. BAKULESH S. MEHTAPresident, IMA MS

7

Dear Friends,With moral standards falling all round in all

walks of life and ethical values crumbling, it istime for us to rededicate ourselves to the society,as friend, philosopher and guide to our patientsand their families. Life is short but there is alwaystime enough for courtesy. Be upright, gentle andpure hearted and be aware of your potential. Inthis world of ours there is a lot of misery. One ofthe major reasons for human misery and sufferingis ill health and disease. If a doctor can reducepeople’s misery even to a small extend, he shallhave the satisfaction of repaying in a smallmeasure the debt he owes to the society.1. The Assault On Doctors’ Bill was passed by

Maharashtra State Assembly. This was due to unityin IMA and the profession and Late Dr. Vasant Pawarwas very enthusiastic and instrumental in gettingthe Bill passed on April 24, 2010.

2. 2483 bottles of blood were collected by 48IMA branches in the State on Doctors’ Day.The bottles were distributed to civil andgovernment hospitals in the nearby areas.

3. 1855 new members were added by the yearending March 31, 2010. IMA branches arerequested to make new life members only andconvert the existing annual members to lifemembers. Bigger branches are galloping innumber of members. Branches having lessthan 10 members will be discontinued as perIMA, HQ directive at the ensuing CWC meetingat Vizakhapatnam. The existing members willbecome direct members of the IMAMaharashtra State Branch in cases ofbranches having less than 10 members. Theyare advised to make at least 10 members assoon as possible if they wish to remain as aseparate IMA Branch.

4. Workshop on code of Medical Ethics.5. EVECON - It was an excellent cultural get-

together of ladies wing of IMA.6. First IMA, CGP State Conference was dedicated

to late Dr. K. Ramamoorthy.7. Five issues of MAHIMA.8. President Dr. J. Kaddu and Vice Presidents Dr.

S. Sharangpani, Dr. S. Kshirsagar and Dr. A.Ladad were elected unopposed. This was dueto magnanimity of the members who withdrewin their favour. We congratulate all of them.

9. The long standing HFC problems of IMA, Dapoli

& Gondia have beenresolved amicably & thoseof other branches arebeing actively pursued.

IMA MS Social SecurityScheme, IMA ProfessionalProtection Scheme andMedical Insurance Schemeare doing very well.

Medico legal problems of members of differentIMA branches were helped by IMA, Maharashtra Stateand its Action and Legal Advisory Committees. Theelected members of the Maharashtra Medical Councilare still not installed. IMA, Mumbai branch has filedan enquiry under RTI in the office of MedicalEducation, Government of Maharashtra. IMA, Nagpurbranch has filed a petition in the High Court.

It was a very satisfying year with fullcooperation from all of you. During the year Itraveled extensively and had an excellentinteraction with Presidents / Secretaries andother members of various IMA branches, inregional meetings, during installation,conferences and other cultural programs.

We congratulate all the IMA, MaharashtraState Award winners. We also congratulate theaward winners of IMA, HQ elections, Dr. VinayAgarwal, Dr. Dharam Prakash, Dr. D. R. Rai, Dr. D.K. Shirole and all others for winning the electionswith thumping majority.

I sincerely thank all those who have helped meduring last year while working as an Hon. StateSecretary especially Dr. Dharam Prakash, Dr. D. R.Rai, Dr. Ashok Adhao, Dr. Vijay Panjabi for theirguidance. I also thank President Dr. Bakulesh Mehta,for all the help and cooperation, Dr. S. Utture, Dr.Jayesh Lele, Dr. Akil Contractor, Dr. S. Pingle, Dr.Niranjan Vaidya, Dr. S. Kothari, Dr. S. Mehtalia, Dr.Anil Pachnekar, Dr. Deepak Jumani and all otherswho have helped me in day to day activities.

I wish all the best to the new team under theleadership of Dr. Jayagosh Kaddu. The Presidentelect for the year 2010-11

The office staff Mr. P. S. Purandare (Office incharge), Mr. Ashish Bhatkhande, Miss PrachiMatvankar, Miss Vijaya Shedge & Mr. Maheshhave worked hard throughout the year.

DR. HOZIE KAPADIAHon. State Secretary, IMA, MS

Hon. State Secretary’s Message

8

CHIRALLY PURE NON-STEROIDAL ANTI-INFLAMMATORY DRUGS

Author : Dr. Ram Prabhoo / Dr. Tanay PrabhooMukund Hospital, Mukundnagar CHS, Marol Pipeline, Andheri-Kurla Road,Andheri East, Mumbai - 400059. E-mail: [email protected]

Chirally Pure Non-Steroidal Anti-Inflammatory Drugs

Chirally Pure Non-Steroidal Anti-Inflammatory DrugsAbstract : Racemates compounds containingmore than one enantiomer. Out of theseenantiomers only one enantiomer may betherapeutically active. Other enantiomer may beinert, less active or some times responsible foradverse effects. Many NSAIDs used in clinicalpractice are racemic drugs containing ‘R’ and ‘S’enantiomers. Various preclinical andpharmacokinetic studies reported that the ‘S’enantiomer of NSAIDs is an active componentwhile ‘R’ enantiomer do not possess anyanalgesic- anti-inflammatory properties. Theactive ‘S’ enantiomer of many NSAIDs are isolatedand available for clinical use. Dexketoprofen (S(+)Ketoprofen), S(+) Etodolac and Dexibuprofen (S(+)Ibuprofen) are recent introduction of chirally pureNSAIDs in India. Various clinical trials involvingIndian patients supported the safety and efficacyof these drugs in painful inflammatory conditionsat half the dose of racemic NSAIDs.

Key Words: Dexketoprofen, S(+) Etodolac,DexibuprofenIntroduction: Stereoisomers are made of sameatom, same sequence of bonds but differentdimensional structures. Racemates are fixed-dosecombinations of stereoisomers. Each stereoisomermay have different pharmacokinetic andpharmacodynamic properties which may haveclinical significance.1

Since many years racemates are used inclinical practice. This may be due to ignoranceabout of pharmacological aspects ofstereoisomers and technology required toseparate stereoisomers on large scales. Withdevelopment of newer technologies andencouragement of regulatory authorities fordevelopment of chirally pure (single isomer)drugs, many newer drugs are developed in

chirally pure form or achiral. Many drugs whichwere originally introduced as racemates have nowmade available as chirally pure compounds.

Apart from decrease in dosage and increasein potency; many chirally pure compound hasunique advantages. As example S(-) Amlodipinecauses negligible edema and R-Ondansetron donot cause QTc prolongation.2,3

Many Non-steroidal anti-inflammatorydrugs (NSAIDs) are racemic compounds. Naproxenis a chirally pure compound, already availablefor clinical use. In this article we have revivedthe chirality, chirally pure NSAIDs used inorthopedic practice and their advantages.

Chirality and its clinical implications:An object is “chiral” if and only if it is not

super imposable on its mirror image.4 “Chiral”refers to the spatial orientation of objectsincluding molecules. This chiral compound hasan asymmetrical carbon or nitrogen or sulfuratom in their structures. There are four differentgroups are attached to asymmetrical atom. Thisleads to generation of enantiomers, which hassame chemical formula but different structuralorientation (Fig 1).

9

Figure 1: Enantiomers of Ibuprofen.Ibuprofen is a chiral compound, having

asymmetrical carbon atom which leads toformation of R(-) Ibuprofen and S(+) Ibuprofen.These two enantiomers are mirror image of eachother.

The enantiomers are denoted as ‘S’ or ‘R’according to their structural orientation. Theenantiomers are also denoted as dextrorotatory(+) or laevorotatory (-) depending on clockwiseor anticlockwise rotation of plane polarized lightby them resepectively.5

The enantiomers differ in pharmacokineticsand pharmacodynamics. A. M. Evans (1992)reviewed enantioselective pharmacodynamicsand pharmacokinetics of chiral non-steroidalanti-inflammatory drugs. According to author ‘Senantiomer’ is the active enantiomer of racemicarylalkanoic acid NSAID. The author enumeratedthe advantages of chirally pure NSAIDs as follows:6

1) Reduced metabolic and renal load.2) Avoidance of adverse effects due to

administration of ‘R enantiomer’.3) Reliable dosage recommendation and simple

assessment of the metabolic fate.4) Less risk for pharmacokinetic and

pharmacodynamic interaction with other drugs.5) Easy assessment of plasma concentration

relationship with synovial fluid concentrationand therapeutic response.

CHIRALLY PURE NSAIDs:Many NSAIDs are racemic compound

containing more than one enantiomer. Naproxen,moderately potent analgesic is already availableas single enantiomeric drug. In following sectionchirally pure important NSAIDs available in Indiaare discussed.

1) Dexketoprofen Trometamol:Ketoprofen is a nonsteroidal anti-

inflammatory drug (NSAID) of the propionic acidchemical class. This molecule has been availablesince long time. Dexketoprofen is the S (+)enantiomer of ketoprofen that has the typicalactions of NSAID while R (-) enantiomer do notpossess analgesic and anti-inflammatoryactions. Dexketoprofen is available astromethamine salt of (S)-(+)-2-(3benzylphenyl)propionic acid. Dexketoprofen is

highly lipophilic drug while tromethamine salt ishighly water soluble. Due to this dexketoprofentrometamol is 100 times more water soluble thanthe free acid form. There is rapid and completeabsorption of dexketoprofen trometamol ingastrointestinal tract. The rapid absorption ofdexketoprofen gives rise to less exposure ofgastrointestinal lumen to the drug.7

Dexketoprofen trometamol is available inEuropean countries as oral, topical and injectableform since long time. Recently, dexketoprofentrometamol is also available in India as oral,topical and injectable form as will as in a fixeddose combination (FDC) with paracetamol.

Gastrointestinal Safety of Dexketoprofen:Francesc Cabré et al, had examined the

intestinal ulcerogenic effects of single oral dosesof S(+)-ketoprofen in comparison to racemicketoprofen in the small intestine and cecumthrough an experimental study in rats. This studyrevealed that oral administration ofdexketoprofen was significantly less ulcerogenicin the small intestine than racemic ketoprofen.8

Ana I Nieto et al, reported that conventionalketoprofen and R-Ketoprofen treated animalshowed significantly higher lesions in mid-jejunum than dexketoprofen treated animals. Theauthor concluded that dexketoprofen had betterintestinal toxicity profile than the racemate.9

These studies demonstrated that gastrointestinalsafety of dexketoprofen was superior toconventional ketoprofen.Role of dexketoprofen in chronic pain:

In a multicenteric, randomized, double-blindclinical trial; efficacy and safety of dexketoprofentrometamol was assessed with ketoprofen in 183patients with pain due to osteoarthritis of theknee. At the end of 3 weeks treatment, the mainefficacy outcome measures (pain intensity on VASand Lequesne index scores) were significantlysuperior in the dexketoprofen trometamol groupthan in the ketoprofen group. As per thephysicians’ overall assessment for efficacy, 75%patients in the dexketoprofen group had improvedcompared to 50% patients in ketoprofen group.The study revealed that in symptomatic treatmentof knee osteoarthritis, dexketoprofen trometamol25 mg tid was more effective than ketoprofen 50mg tid and the tolerability of dexketoprofentrometamol was more favorable than ketoprofen.10

10

The efficacy and tolerability ofdexketoprofen trometamol was compared withdiclofenac, in 117 patients with chronic pain dueto knee osteoarthritis through a multicentric,randomized, double-blind, comparative study of2 weeks duration. The study revealed that orallyadministered Dexketoprofen trometamol 25 mgthree times daily was at least as effective asdiclofenac 50 mg three times daily for thetreatment of pain in patients with osteoarthritisof the knee.11

Roetta G. et al assessed the effect of earlymorning administration of dexketoprofentrometamol (50 mg) in morning stiffness inducedby nodal osteoarthritis (OA) of hands. Thirty fivepatients were compared with 19 controls. Thedegree of morning stiffness evaluated by meansof WOMAC scale for OA stiffness wassignificantly diminished 40 minutes after the drugadministration in treated patients but not incontrols. This demonstrated that dexketoprofenwas rapidly acting and effective in reducingmorning stiffness in OA of hands.12

Role of dexketoprofen in acute pain:The time of onset and difference in analgesic

efficacy of oral dexketoprofen was comparedwith oral diclofenac in patients with acute lowerlimb injury through a prospective, double blind,randomized controlled trial. Total 122 patientswere studied (diclofenac = 57 and dexketoprofen= 65) and were given either 25 mg oraldexketoprofen trometamol or 50 mg sodiumdiclofenac immediately after triage; baseline and15 minute pain scores were then recorded forone hour. The results revealed that the differencesin group mean pain scores between diclofenacand dexketoprofen at 15, 30, 45, and 60 minuteswere; 0.53 (95% confidence intervals 20.03 to1.09), 0.70 (0.16 to 1.24), 0.89 (0.32 to 1.47), and0.83 (0.21 to 1.45). Odds ratios for a decrease inpain score of at least 1 from baseline (on the 11point scale) when given dexketoprofen rather thandiclofenac at 15, 30, 45, and 60 minutes were;2.66 (1.19 to 5.98), 3.52 (1.60 to 7.73), 4.48 (1.72to 11.65), and 5.54 (1.90 to 16.15). Correspondingodds ratios for a decrease in pain score of >2were; 6.88 (1.48 to 32.0), 3.79 (1.59 to 9.01), 5.19(2.29 to 11.78), and 5.87 (2.68 to 12.88). Studyconcluded that dexketoprofen trometamol was

an effective and rapidly acting analgesic for thetreatment of acute musculoskeletal injuries.13

One study evaluated the analgesic efficacyof dexketoprofen trometamol 25 mg. vs. Ibuprofen600 mg. after their administration in patientssubjected to oral surgery. The results of studyshowed that during the first hour after taking theanalgesic, those patients treated withdexketoprofen trometamol presented with lesspain compared to those who were treated withibuprofen. The study concluded that,dexketoprofen trometamol demonstrated thegreater analgesic efficacy in the first hour afterthe oral surgical intervention and it had a greateranti-inflammatory effect.14

A multicenteric, randomized, double-blind,parallel group study evaluated the analgesicefficacy and safety of dexketoprofen trometamol(25 mg q.i.d.) vs. ketorolac (10 mg q.i.d.) in 115patients with bone cancer pain. The resultsdemonstrated that, dexketoprofen therapy wascomparable to ketorolac. Treatment-relatedadverse events were reported in lesser percentageof patients in dexketoprofen group (16%)compared to ketorolac group (24%).15

Clinical Studies with Dexketoprofen Injection:A multicentric, randomized, double-blind,

parallel-group study evaluated the analgesicefficacy and tolerability of dexketoprofentrometamol compared to ketoprofen in 252patients with moderate to severe postoperativepain. The results of this study showed that boththe drugs were equivalent in terms of analgesicactivity in the management of postoperative painafter orthopaedic surgery. Compared toketoprofen dexketoprofen trometamoldemonstrated superior tolerability profile.16

Another randomized, double-blind, parallel,active controlled, multicentric study comparedthe analgesic efficacy of dexketoprofen 50 mgtwice daily versus diclofenac 75 mg twice dailyin 370 outpatients with acute low back painshowed similar results. Study concluded thatdexketoprofen 50 mg administered twice dailyintramuscularly provided a clinically significantanalgesic effect with good tolerability.17

Safety and efficacy of Dexketoprofen in IndianPatients:

11

Dexketoprofen Trometamol Injection:

Efficacy and safety of dexketoprofentrometamol injection in Indian patients wasassessed through a multicentric, randomized,comparative, clinical trial. A total 202 patientswith postoperative pain were enrolled to receivesingle intramuscular (IM) injection ofDexketoprofen or Diclofenac sodium, at time ofpain onset. Total 55.56% patient in dexketoprofengroup showed pain relief of >50% at 8 hours afterinjection while 35.92% patient in diclofenacgroup showed pain relief of >50% at 8 hours afterinjection(p = 0.007). Sum analogue of painintensity difference (SAPID) value was higher indexketoprofen group than diclofenac group(p<0.0001). Tolerability in both the group wassimilar. This study confirmed the safety andefficacy of Dexketoprofen trometamol injectionin Indian patients (Data on File).

Dexketoprofen Trometamol Tablet:RAPIDD Study evaluated the efficacy and

safety of dexketoprofen in treatment of dentalpain. This was an observational, prescriptionevent monitoring study analyzing data of 3318patients. After administration of dexketoprofen,statistically significant decrease in pain intensityon VAS was noted in 10 minutes. Most of adverseevents noted during the study were mild in nature.According to the investigators’ globalassessment for efficacy and safety; efficacy ofdexketoprofen was good to excellent in 96.5%patients and tolerability of dexketoprofen wasgood to excellent in 97.8% of patients.18

Efficacy and safety of dexketoprofen 25 mgwas compared with ketoprofen 50 mg in Indianpatients through multicentric, comparative,randomized, parallel group studies involvingpatients undergoing dental surgery and inpatients with dysmenorrhoea. In patients withdental pain, dexketoprofen showed early onsetof statistically significant analgesia as comparedto ketoprofen. Dexketoprofen was equallyeffective to ketoprofen in relieving painassociated with dysmenorrhoea.19

Dexketoprofen Trometamol Gel:A multicentric, randomized, comparative

clinical trial assessed the efficacy and safety ofDexketoprofen trometamol gel in comparison

with diclofenac diethylamine gel in 208 Indianpatients of knee osteoarthritis. The study reportedthat both the drugs decreased pain intensity andWOMAC score at the dose of 2 g/4 g. TID. Higherresponder rate was noted in dexketoprofen 4 ggroup compared to the diclofenac 4 g group. Mildlocal irritation was reported in higher proportionof patients in the diclofenac group than thedexketoprofen group. Thus this study confirmedthe safety and efficacy of dexketoprofentrometamol gel for topical application inosteoarthritis (Data on File).

Fixed dose combination (FDC) of dexketoprofenand paracetamol:

Efficacy and tolerability of fixed dosecombination (FDC) of dexketoprofen andparacetamol was compared with FDC ofdiclofenac and paracetamol in 110 Indianpatients of acute musculoskeletal pain. This studyreported that the FDC of dexketoprofen trometamoland paracetamol was as effective as diclofenacand paracetamol (Data on File).

Dexketoprofen – Salient Features:o Dexketoprofen trometamol is an effective and

safe analgesic for acute pain.o Dexketoprofen trometamol has a rapid onset

of action and lower incidences ofgastrointestinal adverse effects

o Dexketoprofen trometamol in oral, injectable,topical and FDC with paracetamol; hencesuitable for wide variety of clinical conditions.

o There is clinical evidence of role ofDexketoprofen trometamol in wide variety ofclinical conditions involving acute andchronic pain.

Safe and effective in Indian patients.

2) S(+) Etodolac:Etodolac is a potent anti-inflammatory drug

with analgesic and anti-pyretic activity. Evidencesupport that Etodolac induces lessgastrointestinal bleeding than other NSAIDs,including aspirin, naproxen, indomethacin, andibuprofen.20 Etodolac is more selective for inducedCOX-2 than COX-1.21 Etodolac is a racemic mixtureof (+)S and (-)R-enantiomers. All NSAID propertyof etodolac is due to S(+) Etodolac.

Christopher A. Demerson et al evaluatedanti-inflammatory effects of the etodolac and its

12

enantiomers in the rats with establishedadjuvant induced polyarthritis. This studyrevealed that S-Etodolac was 2.6 times (95%confidence limits 1.5 to 5.3) more potent thanracemate (Etodolac). R-Etodolac was inactive asanti-inflammatory analgesic. Authors alsostudied the effects of Etodolac and itsenantiomers on prostaglandin biosynthesis. Theresults of study demonstrated that theconcentration of S-Etodolac required forproducing 50% inhibition of arachidonic acidutilization was half of the concentration ofEtodolac. 21 This points out that the S-Etodolac isat least twice potent that of Etodolac.

Dion R. Brocks et al studied the uptake ofEtodolac and its enantiomers in synovial fluid.The study revealed that pharmacokinetics ofEtodolac was highly stereoselective.Concentration of S-Etodolac was greater insynovial fluid than in plasma (SF: plasma ratio =1.98 ± 0.8): No such difference was seen for R-Etodolac (SF: Plasma = 0.91 ± 0.3).22

Dion R. Brocks et al studied thepharmacokinetics of Etodolac and it ’senantiomers in young and elderly subjects. Theresults of study demonstrated that, in humansthe pharmacokinetics of the Etodolacenantiomers were highly stereoselective.Pharmacologically inactive R-Etodolac achievedhigh concentration in plasma thanpharmacologically active S-Etodolac. They alsoreported that R and S enantiomers of etodolachave different pharmacologic andpharmacokinetic properties. As per the resultsof the study no dosage adjustment was requiredin elderly subjects with normal renal and hepaticfunction.23

I. Mignot et al studied the albumin binding sitesfoe etodolac enantiomers. Results of this studyshowed that S-etodolac was more strongly boundto human serum albumin than R-Etodolac.Authors concluded that S- Etodolac interactedmainly to site II of human serum albumin whileR-Etodolac interacted to site I and site II of humanserum albumin.24

Above preclinical and pharmacokineticstudies proved that S-Etodolac is the active NSAIDcompound of conventional Etodolac. S-Etodolachas potency at least twice that of Etodolac.

Therapeutically active S-Etodolac achievedgreater concentrations in synovial fluid thanplasma. S-Etodolac avoids isomeric interactionsin binding to albumin. S-Etodolac can beadministration at the half the dose of etodolac, ithas less metabolic load.

Safety and efficacy of S-Etodolac in Indian Patients:P. Sancheti et al reported the efficacy and

safety of S-Etodolac with Etodolac in the treatmentof osteoarthritis in Indian patients. This was adouble-blind, multicentric, comparative clinicaltrial conducted in 108 Indian patients withosteoarthritis. All patients received either S-Etodolac ER 300 mg or Etodolac ER 600 mg tabletsonce daily. Assessment was done on the basis ofWOMAC score and VAS pain score, patient’s andphysician’s global assessment of the arthriticcondition. All patients were evaluated after everytwo weeks for four weeks for efficacy and safetyvariables. Total 49 patients in the Test group and52 patients in the reference group completed thestudy. There was significant improvement(P<0.0001) in all WOMAC subscales (pain,stiffness and physical function), WOMAC totalscore and VAS pain score in both the groups.Patient’s and physician’s global assessment ofthe arthritic condition also improvedsignificantly (P<0.0001). All patients in bothgroups showed improvement in WOMAC and VASpain score by e+ 20%. There was no significantdifference between the groups for the efficacyparameters. The adverse events reported in testand reference groups were few and no seriousadverse events were reported. Total five patientsin S-Etodolac group and two patients in Etodolacgroup dropped out of the study. Only one patientdropped out because of the side effects of burningsensation, palpitations and anxiety in the testgroup.

This study proved the efficacy, tolerabilityand safety of S-Etodolac extended release tabletsin the treatment of osteoarthritis in Indianpatients.25

In another multi-centric, randomized, clinicaltrial assessed and compared the efficacy andsafety of the FDC of S-etodolac and Paracetamol(test group) versus the FDC of Diclofenac andParacetamol (comparator group) in 111 patientswith acute musculoskeletal pain randomized in

13

two groups: 57 patients in test group and 54patients in comparator group. The demographicand baseline data did not show any statisticallysignificant difference between the two groups.The responder (defined as patient with>50% improvement in VAS score) rate for testgroup was 85.96% versus 75.92% for thecomparator group (difference not significant onFisher’s Exact test). The sum of analog painintensity difference (SAPID), sum of pain intensitydifference (SPID), and total pain relief (TOTPAR)score were not significantly different between thetwo groups. The patient’s global assessment ofthe efficacy of each treatment was similar in eachgroup. The patient’s global assessment of thetolerability of each medication was significantly(p=0.02) in favor of the test product. Thephysician’s global assessment of the efficacy ofthe drug was also similar between the two groups.Analysis of adverse events (AE) showed that intest group 8.77% suffered AE while in comparatorgroup 26.31% suffered AE (p=0.0128). This studyconfirmed the safety and efficacy of FDC of S-etodolac and Paracetamol in Indian patients(Data on file).

S-Etodolac – Salient Features:o S-Etodolac is the active NSAID component of

Etodolaco S-Etodolac has potency at least twice that of

racemate (Etodolac)o Therapeutically active S-Etodolac achieves

greater concentrations in synovial fluid thanplasma

o S-Etodolac administration avoids isomericinteractions in binding to albumin

o S-Etodolac can be administered at half thedose of Etodolac

o S-Etodolac administration avoids metabolicload

o S-Etodolac administration avoids 50%impurity in form of R-Etodolac

o Safe and effective in Indian patients

3) DexibuprofenDexibuprofen (S(+) ibuprofen) is the

pharmacologically active enantiomer of racemicibuprofen. Racemic ibuprofen is a non-steroidalsubstance with anti-inflammatory and analgesiceffect. Dexibuprofen’s mechanism of action is

thought to be due to inhibition of prostaglandinsynthesis and formation of thromboxanes viablockade of cyclooxygenase (COX) enzymes.Dexibuprofen inhibits both COX-1 and COX-2.

A. Bonabello et al (2003), determined theanalgesic and anti-inflammatory actions and therelated acute mucosal gastric damage from theactive S(-) isomer ibuprofen (dexibuprofen), incomparison with those of the standard racemicformulation of ibuprofen in rodents. Their resultsrevealed that S(-)-ibuprofen isomer was found tobe more potent than the racemic formulation inanalgesic and anti-inflammatory tests andpresented fewer gastric toxic effects. On the basisof the results of the authors recommended thatthe administration of chemical entities, such asR(-)-ibuprofen, should be avoided if they were notessential for the anticipated therapeutic activity.26

A randomized, parallel-group, double-blind,active controlled clinical trial, was conducted toassess the relative therapeutic efficacy ofdexibuprofen (S(+)-ibuprofen) and the selectiveCOX-2 inhibitor celecoxib in adults with OA ofthe hip. Total 148 in patients were randomlyassigned to dexibuprofen 800 mg or celecoxib200 mg daily. Evaluation of the WOMAC OA indexdemonstrated that dexibuprofen 400 mg b.i.d. wasnot inferior to celecoxib 100 mg b.i.d. with theMann-Whitney estimator equal to 0.5129 and thecorresponding lower boundary of the 95%confidence interval equal to 0.4409. The overallincidence of adverse drug reactions was 12.16%in the dexibuprofen group and 13.51% in thecelecoxib group. 8.1% of patients on dexibuprofenand 9.5% on celecoxib suffered fromgastrointestinal disorders.27

A short-term efficacy study in patients withosteoarthritis of the hip and a 1-year tolerabilitystudy in patients with rheumatic disordersreported that the dexibuprofen demonstrated tobe an effective NSAID with a significant dose-response relationship. Compared to the doubledose of racemic ibuprofen, dexibuprofen was atleast equally efficient, with borderline superiorityover dexibuprofen (P = 0.055). The tolerabilitystudy of dexibuprofen showed an incidence ofclinical adverse events of 15.2% after 12 months.The results of these studies suggested that

14

dexibuprofen was an effective NSAID with goodtolerability.28

One double-blind randomized trialcompared the dexibuprofen (S(+)-ibuprofen) withthe double dose of racemic ibuprofen in 178patients with painful osteoarthritis of the hip.The results revealed that the WOMAC OA indexshowed statistically significant equivalence ofdexibuprofen 400 mg t.i.d. compared withracemic ibuprofen 800 mg t.i.d. by a Mann-Whitney statistic of 0.578 and the correspondinglower bound of the 95% confidence interval of0.498. The test for superiority of dexibuprofenwas borderline significant with p = 0.055.Dexibuprofen 400 mg t.i.d. and dexibuprofen 200mg t.i.d. showed a statistically significant dose-response relationship in improving the WOMACOA index (p = 0.023). Authors concluded that thedexibuprofen (S(+)-ibuprofen) proved to be aneffective non-steroidal anti-inflammatory drugwith a significant dose-response relationship inpatients with painful osteoarthritis of the hip.Compared with racemic ibuprofen half of thedaily dose of dexibuprofen showed at leastequivalent efficacy. 29

Raymond A. Dionneet al (1998) evaluatedthe suppression of acute pain and plasma â-endorphin levels after administration ofpharmacologically active S(+)-isomer ofibuprofen in the oral surgery model of acute pain.This was a single-dose, double-blind, parallel-group study. Patients received either 200 mg S(+)-ibuprofen, 400 mg S( +)-ibuprofen, 400 mg racemicibuprofen, or placebo. Both doses of S(+)-ibuprofen resulted in significantly greateranalgesia over the first 60 minutes in comparisonto racemic ibuprofen and placebo; the 400 mgdose of S(+)-ibuprofen also produced greateranalgesia at 2 and 3 hours. Plasma levels ofimmunoreactive â -endorphin decreased overtime coincident with the onset of analgesia in allgroups but were significantly less than placeboafter both doses of S(+)-ibuprofen from 30 to 120minutes. These findings demonstrated that,compared with racemic ibuprofen,administration of the S(+)-isomer of ibuprofenresulted in faster analgesic onset, greater peak

analgesia, similar duration of action, and a lowincidence of adverse effects, while suppressingnociceptive activation of the pituitary-adrenalaxis.30

From above discussion it is clear thatadvantages of dexibuprofen over ibuprofen arelesser toxicity, greater clinical efficacy, lessvariability in therapeutic effects achieved, andeasier dose optimization, all at half the dose ofibuprofen.

Summary :Many NSAIDs are racemic compounds

containing more than one enantiomer. Manypharmacokinetic and preclinical studies revealedthat all anti-inflammatory and analgesic activityof racemic NSAID resides in S(+) enantiomer andR(-) enantiomer do not possess any anti-inflammatory and analgesic activity attherapeutic dose. This fact is also supported byvarious well controlled clinical trials.

Many chirally pure (single enantiomeric)NSAIDs drugs are available in India. The generaladvantages these drugs are: 1) these drugs canbe administered at half of the racemic drugs 2)there is less metabolic load and 3) avoidance ofimpurity in the form of R-enantiomer. Apart fromthis there are specific advantages like:Dexketoprofen trometamol has rapid onset ofaction and favorable gastrointestinal tolerability.S-Etodolac is 2.6 times more potent thanconventional etodolac with two times moreconcentration in synovial fluid than plasma.Dexibuprofen has lesser toxicity, greater clinicalefficacy, less variability in therapeutic effectsachieved, and easier dose optimization. Thesafety and efficacy of these drugs in Indianpatients has been established by well controlledrandomized control clinical trials.

The potential benefits of using racemicNSAIDs are limited and replacing existing racemicNSAIDs with chirally pure compound is an idealapproach. So development and usage of chirallypure compounds is rationale approach in clinicaltherapeutics and must be encouraged.

15

INTRODUCTION:The optimal treatment of mobile, independent patients who have sustained a displaced

intracapsular fracture of the femoral neck remains controversial1 some authors have advocatedopen reduction and internal fixation and others, prosthetic replacement of the femoral head2,3,4,5,6.Randomized, controlled trials that have compared internal fixation with either total hiparthroplasty(THA) or hemiarthroplasty have demonstrated inferior results for internal fixation,with reoperation rates ranging from 18% to 47%7-10 When prosthetic replacement of the femoralhead is chosen, hemiarthroplasty (unipolar or bipolar) and conventional small head THA are thecommon choice. The major long-term problem associated with hemiarthroplasty is painfulacetabular erosion with reported rates of ranging from 0%11 to 26%12 for bipolar designs andfrom 2.2%11 to 36%13 for unipolar designs. In contrast, the major early complication of conventionalTHA is dislocation with reported rates of dislocation after conventional THA for a displacedintracapsular fracture of the femoral neck being 2% to 20%14-19The other major concern is rangeof motion. The Charnley prosthesis (22mm head) allowed only 80 degrees of flexion comparedwith 96 degrees with the Muller prosthesis (32 millimeters head)20 The direct relationshipbetween head-neck ratio, hip stability, and range of motion after THA is well recognized in thebiomechanical literature20-22. These large head metal on metal(Large MOM) lead to increasedhead-neck ratios and jumping distances that allow for near normal range of motion anddecreased dislocation rates.

To date we know of no reported English literature on the large head metal on metal forfracture neck femur.

We analyzed outcome in a displaced intracapsular fracture of the femoral neck in Gardentype II, III, IV fractures using large MOM THA in a relatively healthy, active and elderly patientwith hip function as the primary end-point along with activity of patient, range of movementsand dislocation and survival rates of prosthesis.

Between July 2004 and November 2009, 50 patients underwent 50 Large MOM THA with useof a resurfacing socket, an anatomic diameter femoral head, and a femoral stem.

There were 34 men and 16 women with a ratio of 2.12:1 who had a mean age of 77.89years(range 60 to 85years). 31 patients had a total hip arthroplasty on right side and 19 on the leftside. The average weight was 65 kilograms (54 to 98 kilograms) taken post operatively and theaverage body mass index was 25.94 (range 19 to 36). There were Garden type II, type ,III, typeIVfemoral neck

Big MOMs best ROMs: Maintaining Indian Life style – Aversatile option for acute fracture neck of femur

Dr. Sanjay AgarwalaChief Of Surgery and Head,Department of Orthopaedics ,P.D.Hinduja National Hospital and MRC, Mumbai.Email: [email protected]

Dr.Ganesh MohrirClinical Associate ,Department of Orthopaedics ,P.D.Hinduja National Hospital and MRC, Mumbai.

16

TABLE 1: POPULATION DEMOGRAPHICS

No. of patients 50

No of hips 50

Median age (range) (yr) 77.89 years (60 to 85 years)

Male: Female 34:16 (2.12:1)

Side: Right: Left 31:19

WeightHeight(in meters) 65kgs1.55 meters

Implant : Acetabular Cup 54 (44 to 58) Femoral Head 46 (41 to 51)

Median duration of follow-up (range) (yr) 34 months (24 to 54 months)

THE IMPLANTThe implant used was a resurfacing socket (Depuy ASR) which is porous coated, heat treated

high carbon cobalt-chromium and the corresponding modular metal femoral head which is highcarbon cobalt-chromium. The average acetabular socket size was 54 mm (range, 44 to 58 mm),and the corresponding modular heads size was 46mm (range, 41 to 51 mm). The femoral stemsused were based on the anatomy of the femoral shaft noted on pre-op templating.

Surgical Technique and Hospital CourseA modified Hardinge approach was used in all 50 hips. A press-fit acetabular cup insertion

was done on achieving under reaming by 1mm in normal bone and 2mm in osteoporotichips. Full weight-bearing walking was encouraged from the first postoperative daywith walking aids. Patients were instructed to avoid flexion of >90° or adduction beyondthe midline for six weeks. All routine activities of daily living were allowed at 6 weeks.Patients were advised against high-impact activities, including jogging, contact sports,and high-impact aerobics till 3 months.

Outcome EvaluationThe average duration of follow-up was 34 months (range, 24 to 54 months). The range of

motion (flexion, abduction, adduction, internal rotation, and external rotation) for each replacedhip was measured passively using goniometer at 3 months, 6 months, 12 months, 24 months,and at last follow up.

Standard radiographs, including anteroposterior and cross-table lateral radiographs ofthe operated hip were made at each scheduled visit.

Results :At last follow up, the average postoperative range of movement gained was 280.20 (2640 to

2900). The average post operative flexion at last follow up was of 135.880, abduction was 36.760,adduction was 36.080, internal rotation was 34.840 and external rotation was 36.680. There wassignificant increase in range of movements up to 6 months. The adduction and internal rotationmovements where last to be regained. The average range of movements at each followup is shown in table 2.

17

TABLE 2. RANGE OF MOTION

Time of visit Flexion Abduction Adduction Internal External TotalRotation Rotation

3mths 123.58 31.08 26.88 26.52 32.52 240.58

6mths 135.56 36.36 34.64 32.76 36.24 275.56

1year post op 135.68 36.8 35.66 34.54 36.42 278.92

2 year post op. 135.68 36.88 36.12 34.96 36.36 279.93

Final follow up 135.88 36.76 36.08 34.84 36.68 280.56

DISCUSSION:The treatment of displaced fractures of the femoral neck in elderly patients has evolved, but it

remains controversial1,2,3,4,5,6. Displaced intracapsular fracture of the femoral neck have been treatedconventionally with internal fixation, unipolar or bipolar hemiarthroplasty, or conventional THA . In ameta-analysis, Bhandari et al.23 concluded that arthroplasty was associated with lower revision rates buta higher prevalence of infection, greater blood loss, and longer operative time when compared withinternal fixation. Other comparative studies have demonstrated that total hip arthroplasty andhemiarthroplasty are superior to internal fixation for achieving pain relief and restoring function 2-5,7-10

In a prospective randomized study of 83 displaced femoral neck fractures, Dorr et al.18, foundthat function improved with time after total hip replacement but not after hemiarthroplasty. In aretrospective study of 166 displaced femoral neck fractures, Gebhard et al.24found that total hiparthroplasty demonstrated superior longevity when compared with hemiarthroplasty with and withoutcement.

The success of total hip arthroplasty has been measured by the criteria of implant survival, painrelief, improvement in function, increase in range of motion and the dislocation rate. Historically,concerns about fixation failure, bearing surface wear, material failure or dislocation have led surgeonsto restrict from activities involving extreme range of motion.25

The low rates of wear and excellent survivorship reported for some historical metal-on-metaltotal hip prostheses, such as the Ring and the McKee-Farrar prosthesis 26, stimulated thereintroduction of metal-on-metal bearings in the early 1990s for hip resurfacing and large-diametermodular-head devices. Many authors have advocated increasing femoral head size as a theoreticalmethod of increasing the range of motion because of enhanced head neck ratio21. However, becausethis technology has been developed only recently with better understanding of the tribology , thereare few clinical confirmatory studies.

In our series no patient was asked to restrict from any physical activity in the long term and100% were able to return to their activity by a activity year after operation which would have beenneither advisable nor possible with a total hip replacement using small head diameter. None of thepatients changed their occupation following surgery including those who were involved in heavyactivities at work. Many patients indicated that they had forgotten about their hips and were able tofunction as normal. The survival rate was 100% even with all our patients were involved in extremerange of motion and heavy activities.

The results of our study demonstrate achievement of near normal range of movement at lastfollow up. Our patients achieved, a total range of movements at last follow up was 280.56 0, flexionto 135.88 0 which is near normal comparing with Paul E.Beaule series using 44mm head in which 14patients achieved total range of 2750 and flexion of 1150. There was significant improvement in all

18

individual range of movements comparing to other series where there was limitation of adductionand internal rotation. Johnston and Smidt considered a flexion of 1200, abduction of 200, and externalrotation of 200 as functional range of movements in normal individual. All our patients achievednear normal movements and beyond this functional range. All the patients were able to sit crosslegged and squat at final follow up. This is very important from the cultural prospective of Asiansliving anywhere in the globe.

Table 3. Comparison of range of movements

Author No of hips Flexion Abduction – Rotational TotalAdduction arc arc ROM

Normal NA 140 80 80 300

Our results 50 135.88 73.02 71.67 280.56

Amstutz, MD 122 69.8 73.7 265.5( Resurfacing arthroplasty)

Paul E. Beaulé (44mm head) 115 75 85 275

Amstutz et al (32 mm head) 103 54 28 185

Charnley et al. (22 mm head) 95 50 31 176

CONCLUSION : The large, anatomic diameter femoral heads described in this study allows nearnormal range of movements and activities that require greater range of motion. The use of theseanatomic metal-on-metal implants offers anatomic hip reconstruction, increased range of movements,more stability, long durability, decreased dislocation rate and long-term pain relief. It also allowsour patients to squat and sit cross legged and hence socio-culturally more acceptable. Our resultswith the large femoral heads have confirmed our initial enthusiasm for this technique. Furtherclinical confirmation with larger series and longer-term reports is necessary.

21

The Children’sfracturesare different!

What is different about children’s fractures?

- Patterns of fracture

- Diagnosis and imaging

- Healing time

- Remodelling

- Efect on growth

- Methods of treatment

I am different!

DR TARAL NAGDAPediatric Orthopedic Surgeon

Director IPOD MumbaiConsultant Hinduja Saifee Jupiter

Office 09320141234 Personel [email protected]

www.ipodindia.orgThe children are not small adults. Just as thepediatric dose of medicine is not half the adultdose, the children’s bones are different from adultbones. This is because the anatomy,biomechanics, and physiology of a child’sskeleton are very different from those of an adult.. Children’s injuries not only differ from those ofadults but they also vary depending on the age ofthe child. Infants, children, and adolescents aredifferent. Appreciating these differences isessential to optimal management.

This article aims to highlight some one thepoints differentiating the pediatric fractures fromthe adult fractures and discusses gthe modernmanagement of the fractures in children.

The children’s fractures are not uncommon• About half of boys and one-fourth of girls can

expect to experience a fracture duringchildhood.

• Fractures are becoming more common as

Sports Activities increase.• Boys are injured more often than girls.• Injuries increase in frequency with advancing

age during childhood• The percentage of fractures that occur through

the physis increases with age• The wrist is the most frequent site of injury

Sometimes Children’s fractures are difficultto diagnose

8 year child with fall from bicycle

Xrays of knee were normal, MRI shows that

this is type 2 physeal fracture

22

Children especially younger may not be ableto communicate or localize the tenderness. Manytimes physeal injuries cause very little pain ascartilage is an avascular structure. An importantpart of the child’s skeleton is radiolucentcartilage which is invisible on plane x-rays. As aresult many of the pediatric fractures can bemissed and obviously one needs a high index ofsuspicion to detect these fractures. Stress xrays,ultrasound, arthrograms, and MRI are some ofadditional tools to diagnose the fractures inchildren. Some of the fractures can haveassociated nerve or vascular injury and it isimportant to evaluate for the same in every childwith a fracture.

Why and How are the children’s fracturesdifferent

The anatomical, physiological andbiomechanical differences between adult andpediatric bone explains why children’s fracturesare different .These differences graduallydiminish with age, so that fractures in theadolescent are similar to those of the adult.

Anatomical Differences- The most important part of a child’s skeleton

is composed of radiolucent growth cartilage.Injury can only be inferred from widening ofthe growth plate or from displacement ofadjacent bones on plain or stress radiographs.

- The periosteum is thicker and stronger andproduces callus more quickly and in greateramount than in adults.

Anatomical features of children’s bones and theeffect it has on the fracturesin children

Biomechanical differencesBiomechanics of Bone

Child’s bone ismore flexible andporous than adult ’sbone and can toleratea greater degree ofdeformation. Thisaccounts for thevarious fracture typessuch as bucklefracture, greenstickfractures and plastic deformation which are notseen in adults. Some of the force of impact isdissipated in bending the bone in children,whereas in adults the kinetic energy of impact isentirely used to disrupt the intermolecular bondsin the bone. Hence complete fractures are rarelycomminuted in children.Biomechanics of the Growth cartilage

The children’s bones have growth plateswhich have the consistency of hard rubber. Whenthe plate is thick, the epiphysis can be rockedslightly on the metaphysis because of theelasticity of the plate. This property not onlyprotects the bone from injury but also appears toprotect the joint surface from the type of crushinginjury that is common in adults. Because of thisis the weakest link in pediatric skeleton thephyseal separation is more common than jointdislocation in children. Similarly epiphysealfractures of lower femur are more common aresults of trauma in children than a ligamentinjury around the knee.Physiological DifferencesGrowth Remodeling

Types of children’s fractures

Upper humerus fracture in 8 year old childshowing remodeling of fractureGrowth provides the basis for a greater degree ofremodeling than is possible in an adult . As a boneincreases in length and girth, the deformityproduced by a fracture is corrected by asymmetricgrowth of the physis and the periosteum.

23

I am special!

Gowth arrest as resulyof physeal injury tolower femur

MRI clearly shows thepresence of bony bar

Speed of HealingChildren heal quickly; reduction should be

secured early. The orthopaedic surgeon does nothave as long to deliberate over a fracture in achild as he does in an adult.

Children’s fractures can have uniquecomplications

The physeal injuries can give rise to growtharrest resulting in shortening, deformity or both.The physeal injuries there fore need immediateattention and precise & gentle reduction.

The fracrures around elbow if massaged ormanipulated with force can give rise to myositisossificans and stiffness of elbow.

Children’s fractures have unique operativetreatments

The newer modalities oftreatment for the children’sfractures are as follows

1. Elastic stable nailsElastic nails in thetreatment of bilateralcomminuted shaft femurfracture in 7 year old child

The elastic nails have revolutionized thetreatment of long bone fractures in children Thetreatment is minimally invasive, child friendlyand aloows early return to function.2. Percutaneous screw fixation:

Type 4 physeal fracture treated with a closed reduction and percutaneous

trans epiphyseal screw fixation

The long incisions with plate and screw fixa-tions are out in children the fixations in childrenshould be minimal, stable and should not violatethe growth plate.

3. Percutaneous reduction techniques

The percutaneous reduction techniques avoid longincisions & maintains vascularity of fracture fragments

Children’s fractures need a specialistA paediatric orthopedic surgeon is specially

trained to treat the fracturesin children in the precise way. He has studied

the natural history of the fractures in children and isaware of the latest knowledge and techniques.Pediatric orthopaedic surgeons know how to examineand treat children in a way to help them be relaxedand cooperative. He appreciates the worry that goeswith having a child with a musculoskeletal problemand they have experience in communicating withanxious family members. Most pediatric orthopaedicsurgeons’ offices are arranged and decorated withchildren in mind. Specially designed equipment,available toys, videos, and reading materials allhelp to create a comfortable and nonthreateningenvironment for the child.

Internet resources forfractures in childrenwww.fracturesinchildren.orgwww.ipodindia.org

25

IntroductionThere might be only few Medical problems

existing which must have created morecontroversies than ‘Low back pain’. In fact rightfrom inception (Definition) till extinction (Outcome/Prevention), this topic is marred with controversies!To add to our misery, there is no consistent orstandardized method of data collection. Thussummarizing and presenting a correct perspectiveof Low back pain is a Herculean task.

Low back pain is very common in GeneralPopulation. In fact it is second most common causeof pain (next to Headache). It is estimated thatroughly 80% of adults experience an episode oflow back pain atleast once during their lifetime.(Thus making it important for us all to know howto manage this huge burden of problem correctly)

When it comes to defining low back pain,there are a myriad of words and phrases fromwhich to choose. Few examples to site –

“the area below the 12th rib and abovethe gluteal folds” (Hoy et al 2003) or

“pain, muscle tension, or stiffnesslocalized below the costal margin and abovethe inferior gluteal folds with or without legpain” (Manek and MacGregor 2005) or

“pain within the lumbosacral region,buttocks and thighs that is ‘mechanical’ in nature:it varies with physical activity and varies withtime” (Waddell 1998 in Campbell et al 2005).

However the definition we recommend usingis – Pain and discomfort, localized below thecostal margin and above the inferior gluteal foldswith or without Leg pain.

Low back can be classified into -1. Acute pain- Lasting less than six weeks2. Sub acute pain – Lasting between six weeks to

3 months.

LOW BACK PAIN

3. Chronic low back pain – Lasting longer than 3months

Low back pain can be furthered classified as• specific or • nonspecific,

This classification is based on the ability toidentify causative agents responsible for the pain.In the instance of specific low back pain, “redflags” can be identified to alert a clinician to thepossibility of an infection, tumor, or spinaldisease. Here too if we go through variousguidelines(NZ guidelines, AHCPR guidelines,ACOEM guidelines, Europeon guidelines, Chouguidelines), we find that there is no uniformity inthis list of red flags. However, most cases of lowback pain (85%) are of the nonspecific categoryin which there is no identifiable cause of the pain,(henceforth addressed/ referred as MLBP –Mechanical low back pain).

Epidemiology –The prevalence rates of Low back pain in the

population vary widely. Most of theepidemiological studies in developed countriesestimated that one year prevalence of Low backpain in the population was 36-39%. Life timeprevalence of this problem varied largely (50-80%).

Figures in developing region too suggestsimilar figures. (Rural Tibet – one year prevalence– 41.9%, Turkey – One year prevalence was 35.9%).So this problem is definitely not limited to west.

Furthermore, episodes of low back pain costthe health services of many countries millions ofdollars. In fact, in the UK the annual health servicecosts associated with low back pain were 480million pounds and the costs incurred by socialsecurity were estimated to be 1400 million pounds(Campbell et al). in addition to the economicburden placed on some health systems, low backpain also leads to individual disability interferingwith work and quality of life (Ehrlich 2003).

26

Data is also available from rural India,demonstrating that nearly 50% of males hadexperienced generalized back pain (occurringaround the waist area) continuously for the threedays prior to being interviewed (SEARCHGadchiroli data- not published).

Natural history (Course) of Low back Pain:Now this is something to cheer for!!! Most of

these episodes of Low back pain are self limitingand chronicity is reported to be only 2-7% ofpopulation. Majority of Low back pain episodesresolve spontaneously within one to two weeks.

Thus, while the natural history of low backpain has usually been considered favorable, it ispossible that some cases may last for many yearsor possibly a lifetime thereby making it essentialthat people have the ability to live with the painwith as few restrictions as possible (Ehrlich 2003).

Anatomy of Low back:Before proceeding to specifics of this

problem, a brief anatomy of back is discussed.Lumbar spine (Commonly referred as the

back) is the mobile segment between fixed sacrumand less mobile Thoracic spine. Lumbar spineconsists of 5 Lumbar vertebrae. Each vertebraconsists of cylindrical vertebral body, twopedicles, two transverse processes, twooverarching laminae and a spinous process.These structures surrounds neural canal(consisting of dura and nerve roots). Anintervertebral disc interposes between eachvertebral body, providing elasticity and stabiliyto the vertebral column.Various ligaments arepresent to strengthen this structure – namely theAnterior longitudinal ligament, PosteriorLongitudinal ligament, Ligamentum Flavum,Interspinous Ligaments.

As already stated – more than 85% of peoplewith Low back pain is non specific in origin. Hencewe cant really attribute pathology in any of the abovementioned stuctures to cause Low back pain.

Clinical Presentations of Non specific backpain :-

Usually the pain is characterized as an ‘ache’or ‘spasm’. It is localized asymmetrically in thelumbar paraspinous muscle with radiation to thebuttock or posterior thigh proximal to the knee.

Movement usually exacerbates the pain andrest relieves it

There is no associated deficit in sensation,strength, bowel/bladder control

There might be some non specific tendernessand some stiffness (decreased ROM of the back).

It should be noted that the diagnosis of MLBPis usually made by excluding any seriouspathology. It can be done with help of Red Flags(Certain Signs and symptoms – which if presentdenotes possibility of spine pathology). If thesered flags are absent then we can safely classifythe back pain as Non specific one and can treatthem conservatively.

Red flags:-Fractures – It is suspected if –

• There is history of significant trauma• There is history of minor trauma in an

elderly individual• Patients on long term corticosteorids• Tenderness over the affected spine, Spasm

and Loss of mobility (Decreased ROM –Range of Motion)

Cauda equina syndrome – It is an Emergency.Suspect it if –

• Difficuly with bladder and bowel function.(Urinary retention and Loss of Anal tone)

• Saddle Anaesthethia• Varying bilateral neurological deficit.

Malignancy –

• Pain worse at night/ Not relieved by rest• Weight loss• Previous history of Malignancy• Pain persisting for more than 4-6 weeks

Infection –

• Fever• Immunocompromised patients (HIV)• IV drug abuse,• Past history of Kochs

Also beware of Abdominal pathologies(especially Kidneys, Pancreas, Appendix, Aorticaneurysms), since they might presentpredominantly as Low back pain.

Yellow flags

27

Psychosocial ‘Yellow flags’ are the factorsthat increase the risk of developing or perpetuatingchronic pain and long term disability.These are

• Inappropriate attitudes and beliefs aboutback pain

• Inappropriate pain behavior• Work related problems or compensation issues• Emotional problems (depression, anxiety,

stress, tendency to low mood, andwithdrawal for social interaction).

If these yellow flags are identified, stress shouldbe given on behavioral/ cognitive management.

InvestigationsFor patients with Non specific back pain (If

red flags are ruled out by thorough history takingand clinical examination), Lab investigations orImaging is not indicated.

However if Red flags are positive, thenappropriate lab inv and Imaging should becarried out.

X Rays – Plain film radiography is rarely usefulin the initial evaluation of patients with Low backpain. There are numerous clinical studies to showthe futility of radiographs in a patient with Nonspecific back pain. However if one or more redflags are positive, then plain AP and Lateralradiographs should be considered.

MRI – It is the gold standard. However it isindicated only if one or more red flags arepositive. As with plain radiographs – MRI too inpatients with only MLBP is a futile exercise. Infact MRI is oversensitive and many abnormalfindings are found in asymptomatic patients too.Thus it should be stressed that positive findingsin MRI in patients with MLBP are frequently ofquestionable clinical significance.

CT scan – Indicated only in cases in which bonyanatomy is to be studied – example fractures,certain tumors etc. Advent of MRI has drasticallyreduced need of CT scans in most of the cases.

Management – Since cause of back pain is notknown in majority of the patients – there aremultiple management options available. And the

fact that multiple management options areavailable stamps the fact that we are yet to findthe perfect solution to this mystic problem!!Non pharmacological TherapyPatient Education : This is critical for success ofany management program advocated. Successfultreatment depends on the patient’sunderstandings and not having unrealisticexpectations. In fact taking care of apprehensionsof the patients is the key to manage MLBP

Bed Rest – It is commonly practiced and shouldbe strongly condemned. There are many Class 1evidence that bed rest do not help the patient andshould not be advocated.

Traction – Another therapy which is widelypracticed and found to be ineffective in multiplestudies. (strong evidence). Do not apply tractionin patients with MLBP.

Emotional and behavioral therapy – Sincepsycosocial factors play an important role in LBP,especially if yellow flags are positive, they shouldbe addressed if found during counseling the patient.

Physiotherapy – Do not prescribe Activephysiotherapy in patients with Acute Low back pain.However once pain is taken care of, do not forget toprescribe them!

Physiotherapy (Exercise therapy) has provento be effective in patient with MLBP and is thefirst line of management for these patients.However it is important to emphasize the patientsto adhere to their exercise regimen.

Manipulation – This may be suggested ifpatients are resistant to treatment and ifchiropractors/ trained Physiotherapists areavailable in vicinity. Morever adding Exercisetherapy to Manipulation therapy is beneficial.

Massage – Though most studies have found thatit does not help, it may be tried if patient is notresponding to first line of management.

Acupuncture – This therapy, though quiteancient, is becoming popular lately. Whether it ismore effective than other therapies is not known.Two types of acupuncture techniques exists:French energetic method (more common), andtraditional Chinese method. However superiority

28

of one technique over other is yet to be evaluated.

Lumbar supports – They are not found to beeffective in management of Low back pain. Neitherthey are found to be effective to prevent Low backpain. They are hence not recommended.

Pharmacotherapy -Paracetamol : Should be the first choice ofAnalgesia for Patients with MLBP. However manypatients are not relieved of their exacerbations withparacetamol alone. Should be weighed accordingto previous experiences before prescribing it.

NSAIDs – They are also recommended fortreatment of MLBP. However caution should be takenthat patients don’t take them for long, since theyhave risks of renal failures, Acid peptic disease etc.

Opiods – They should be considered as secondline of therapy– and should be given for shorterperiods.

Muscle relaxants - They can be added to NSAIDsif additional improvement is sought. Drowsinessand dizziness are common side effects which maylimit their usefulness.

Corticosteriods – They are mentioned just tobe condemned for use in MLBP.

SURGERY - Surgery is best – If avoided in patientswith MLBP. However it is recommended in selectconditions if patients have positive red flags and

Imaging shows some pathology (Lumbar canalstenosis/ fracture/ Tumor etc)

The Future – (Newer Treatment Strategies)

IDET (Intradiscal Electro Therapy)–It is becoming popular recently. This is a

minimally invasive technique which uses anavigable catheter to provide thermal energywithin the disc. However there is dearth of goodquality Randomised controlled trials torecommend their use.

Facet Injections – Here the degenerated facetsare injected with local steroids and anaesthetics.Can be judiciously used as a last resort forpatients with resistant chronic Low back pain.

Epidural steroid injections – It should not beadvocated in patients with MLBP. However theyhave got specific role, if pain is radiating to legsand imaging is inconclusive

Selective nerve root blocks – Can be used bothfor diagnostic purpose and for pain relief.Especially useful in patients with radiating painwhich is not getting better with medications.

X stop (Interspinous spacer devices) –Indicated by few for patients with Lumbar

canal stenosis. However good studies needs tobe published before recommending their use.

Authors algorithm for management ofAcute LBP

Acute LowBack Pain

Any red flags Investigateand manage

Advise to stay activeControl symptoms

Note potential Yellow flagsBlood work (Vit D3, B12 levels)

Review

Symptoms Improving

Investigations X rays / ?MRI, Blood work

Reinforce TreatmentPhysiotherapy

Reassess Red flagsLook for Yellow flags

Treat accordingly

Pain Clinics

Yes

No

Yes

No

First 4-6 weeks

After 6 weeks

abN

Physiotherapy

Chronic LowBack Pain

Any red flags Investigateand manage

Yes

No

Physiotherapy Active exercisesNSAIDs short course

Capsicum patchesBlood work

Check Yellow flagsInformation and education

Reassess the patientRed flags/ Yellow flags

Counselling

Yellowflags +ve

MultidisciplinaryTreatment

Rehabilitation

Author’s recommendation formanagement of Chronic LBP –

PREVENTION – Since relapses of back pain are common and the burden to society due to back painis large, prevention strategies definitely have a big role. Many studies/ Guidelines recommend exer-cise to prevent occurrence or prolongation of back pain. Use of lumbar belts/ braces have found tobe ineffective in prevention of back pain. Back schools/ Patient education have been found to beeffective and should be tried.

29

Introduction :Diagnostic ultrasound (US) has been around

in India since the past 30 years and has beeninformally considered as an extension of clinicalexamination. It ’s usefulness in evaluatingmusculoskeletal (MSK) disorders has beenrealized only since the past two decade.

Rapid advances in US technologies havecontributed to tremendous improvement in imagequality from this diagnostic modality. Refinedtransducer technology, B-mode image quality, aswell as information gained from Doppler imaginghave made US a preferred imaging modality inthe assessment of MSK disorders.

Due to the excellence of spatial resolutionand definition of muscle and tendon structure,US keeps its leading edge when dealing withmusculoskeletal pathology, both in the initialphase for recognition of a lesion, but also forfollow-up of lesions and search for healingproblems such as fibrosis, muscle cysts, herniasor myositis ossificans.

Major advantages of US are its low cost,availability at short notice, ease of examinationdynamic capability, short examination times andlack of radiation exposure. The recent additionof color-power Doppler imaging to US hasallowed for the non-invasive study of blood flowand vascularity within anatomic structures andlesions. Furthermore, US provides image guidancefor interventional procedures such as drainageof fluid collections and cysts.

This article tends to provide a brief overviewof the wide range of current applications of US inMSK imaging for the physicians, sportsphysicians, physical therapists, orthopedicsurgeons and radiologists.

Overvierw of Instrumentation and theTechnique

High-frequency (5, 7.5 ,10 ,13.5 MHz) linear-array probes are used to performmusculoskeletal US examinations. Dynamic USstudy may be very helpful to the correct

Clinical Applications Of Ultrasound In Orthopaedic DisordersDR. BIPIN R. SHAH, MDDR. ANKIT B. SHAH, MBBS

diagnosise.g., to look for shoulder impingement(during tenon contraction) or to evaluatedevelopmental dysplasia of the hip (during hipflexion and lateral rotation). To avoid artefactsor pitfalls, comparison with the contra-lateralside is extremely helpful.

Applications

I] TraumaMuscular trauma

Muscular lesions include hematoma andpartial or total muscle tears. US will determinethe presence, location and severity of anatomicdamage. The US appearance of traumaticmuscular lesions depend on the extent of the tear.With complete muscle rupture, the two fragmentsare separated, and the gap is filled by ahematoma with heterogeneous contents.Hematoma consists of a hypoechoic or anechoiccollection dissecting between two muscles. Thetorn muscle may be swollen and increased in size

Tendon traumaTendons are the most frequently studied

structures in MSK US. Lesions include partial orcomplete tears, tendinitis, on tenosynovitis. Thecommonly evaluated tendons are the rotator cuff,Achilles tendon, and patellar tendon. Flexortendons of the fingers, long head of triceps tendon,attachment of flexor and extensor tendons atelbow epicondyles and peri-ankle tendons canalso be evaluated.

A special mention must be made about theusefulness of US in the evaluation of the rotatorcuff lesions. US abnormalities present ashypoechoic areas, due to excess synovial fluid,granulation tissue, or synovium. The bicipitaltendon is evaluated systematically during the USinvestigation of the rotator cuff. The presence offluid within the synovial sheath should stimulatethe search for rotator cuff tear. US may alsoidentify bicipital tenosynovitis, tendinitis, loosebodies in the tendon sheath, tendon subluxationand tendon rupture.

30

Arthritis and joint pathologiesUS has been shown to be valuable for a wide

spectrum of articular disorders especiallyinflammatory arthritis. The role of US has beendemonstrated in the early diagnosis and theevaluation of the response to therapy in patientswith rheumatoid arthritis. US can reliably identifyjoint space effusion and tendon involvement. Thisfeature permits an initial early work up of thesoft tissues in the extremities, before the onset ofbony erosions .

When large joints are involved, US easilydiscriminates between simple effusion and thepresence of proliferative synovitis, the lattershowing thick synovial villi floating within thearticular fluid. US is a sensitive modality fordetecting synovial effusions especially in deep-seated joints like the hip in which clinicalexamination is difficult.

US is ideal for guiding aspiration of smalleffusions, e.g. in the hip of children. In proliferativesynovitis, such as pigmented villonodularsynovitis or rheumatoid arthritis, high frequencysonography shows the hypoechoic thickenedsynovium. It has been postulated that US is moreaccurate than clinical examination of the kneeespecially when serial examination is neededduring the course of the disease. US readilydemonstrates tendon rupture presenting as acomplication of chronic inflammatory arthritis.

A Baker’s cyst is the most common distendedsynovial bursa. Dissection of a Baker’s cyst may berecognized with US, which shows a hypoechoic band-like structure spreading down the calf between twomuscular planes or the soft tissue spaces. Thesefindings may help in the distinction betweendissecting Baker’s cyst and deep venous thrombosis,which often present with identical clinicalsymptoms, but require a very different treatment.

Infection : Detection of MSK infections dependson their location, size and extension. DifferentUS patterns can be seen and include soft tissueabnormalities, joint or tendon sheath effusion,and bony abnormalities.

Osteomyelitis(a) Acute Osteomyelitis: It is well known thatconventional radiographs are normal in the early

stages of infection. US, however, may be a quickand efficient modality for the diagnosis of acuteosteomyelitis by showing subperiosteal abscessin the metaphyseal region. Subperiosteal fluid isan anechoic or hypoechoic collection separatingthe periosteum from the cortical bone in themetaphyseal region.

(b) Chronic Osteomyelitis: US can readilydemonstrate abscess or sinus tract formation insoft tissue, which are characteristic of activeosteomyelitis. Occasionally, sonography canvisualize a detached sequestrum .

Joint infection : This group includes acute pyogenicarthritis and chronic granulomatous arthritis.The common pattern in septic arthritis on US is ajoint effusion with a synovial membrane thatbecomes edematous and thickened. US typicallyshows an irregular echoic membrane surroundingthe fluid. Joint aspiration for microbiologicexamination is needed to confirm sepsis. Inadvanced stages, the infection may extendthrough the joint capsule with a draining sinusto the skin. As in pyogenic arthritis, US may showjoint effusion associated with a thick pannusexhibiting a villous or nodular hypoechoic massin the joint fluid.

Septic bursitis : The most commonly affected arethe olecranon and prepatellar bursa. US findingsinclude a fluid filled collection surrounded by athickened bursal wall. However, only needleaspiration of the distended bursa can confirmthe sepsis.

Tenosynovitis : US is useful in the evaluation ofhand infections. Tendon sheath effusions are readilydemonstrated by US and are easily differentiatedfrom cellulitis. On transverse US scan, tenosynovitishas a target appearance with the anechoic rimrepresenting fluid in the tendon sheath.

Soft tissue infection(a) Cellulitis: The diagnosis is made clinically butthe main problem is to rule out underlyinginfection such as soft tissue abscess,osteomyelitis or septic arthritis. In cellulitis, USshows a diffuse thickening of the subcutaneoustissue that becomes more hyperechoic than thatof the normal contralateral extremity.

31

(b) Abscess: US displays the characteristic ill-defined fluid collection in the subcutaneoustissue or in the muscle and helps to evaluate theunderlying bony structures.

Infectious complications of orthopedicprocedures

In the follow up of orthopedic procedures,US may help in the evaluation of clinicallysuspected infection by showing fluid collectionaround a joint prosthesis or fracture. US is criticalmethod for the determination of the type ofpathology involving prosthetic joints andsurrounding soft tissues, because the moresophisticated imaging methods such as CT andMR imaging are likely to generate artifacts fromthe metallic implant .

Congenital dislocation / dysplasia of the hip andperthe’s disease

In newborns and infants the entire proximalfemoral head and greater trochanter arecartilaginous and only some portions of theacetabulum may be ossified. US can directlyvisualize both the cartilaginous and bony partsof the hip for accurate assessment of size, shapeand symmetry. US is preferred over arthrographyfor evaluation of the infant hip due to its non-invasive nature. With real time US scanning,dynamic studies are also possible for detectingthe laxity of ligamentous structures in potentiallydislocable hips. Apart from establishing thediagnosis, this technique can also be used tomonitor the effect of treatment with repetitivestudies even when the patient is in a spica cast.

Tumors and pseudotumorsSoft tissue masses are better evaluated with

MR imaging, but US may play a role in the initialwork-up of a mass of uncertain etiology. In mostinstances, the liquid or solid state of the mass inextremity can be differentiated. The identificationof a cystic mass does not command the samework-up, as would a solid lesion with a highpotential of malignancy. Cystic masses aroundthe knee include synovial cysts, meniscal cystsor ganglion cysts. Other characteristics of a cysticlesion may be established by US, such as its exact

location, relationships with adjacent structures,nature of the cyst fluid, or septations within thecyst. US plays a pivotal role in vascular masses,such as aneurysms and pseudoaneurysms.

Miscellaneous[A] Foreign bodies: Post traumatic retained foreignbodies are common in the subcutaneous tissuesof the distal extremities. US has proved to be anaccurate imaging modality for visualizing foreignbodies in the subcutaneous tissues, includinglow-density, radio transparent materials such aswooden splinters. Foreign bodies appear asbrightly echogenic foci associated with acousticshadowing. When present, inflammatory changesin the surrounding tissues give rise to an ill-defined hypoechoic area. US is instrumental inthe preoperative or intra-operative localizationof foreign bodies.

[B] Carpal tunnel syndrome: US can showabnormalities from the carpal tunnel syndrome.In typical cases, US shows swelling and flatteningof the median nerve as well as an increasedbowing of the flexor retinaculum.

[C] Interventions: US guided corticosteroid andchemotherapy for arthritis, painful heel lesionsand malignant tumors is very useful. Aspirationand lavage of rotator cuff calcifications hasshown good results. Aspirations and biopsies ofvarious lesions are very easy to perform underUS guidance.

Conclusion : In the evaluation of MSK disorders,US has proved to be very accurate in confirmingthe presence or absence of a morphologicabnormality, with a very high negative predictivevalue, in determining the cystic or solid nature ofa mass, in guiding percutaneous needle biopsyor drainage, in localizing non-palpable lesion pre-or intra-operatively and in monitoring lesionstreated conservatively. However, provided theexamination is done by a well-trained operatorusing state-of-the-art equipment, the cost-effectiveness of US justifies its use as a first-lineexamination technique in many situationinvolving soft tissues, with MRI and CT being usedas problem-solving tools.

EDITORIAL BOARD INDEX -...

Documents

Transcript of EDITORIAL BOARD INDEX -...