Psychological Medicine

PRESIDENTIAL ADDRESS
	Spirituality in psychiatry practice	p. 103
	Padma Sudhakar Thatikonda DOI:10.4103/IJPSYM.IJPSYM_532_18
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GUEST EDITORIALS
	Legal and ethical aspects of mental health care	p. 108
	Rajshekhar Bipeta DOI:10.4103/IJPSYM.IJPSYM_59_19
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	Mental Healthcare Act 2017 – The way ahead: Opportunities and Challenges	p. 113
	A Jagadish, Furkhan Ali, Mahesh R Gowda DOI:10.4103/IJPSYM.IJPSYM_38_19
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REVIEW ARTICLES
	The rights of persons with disabilities Act 2016: Mental health implications	p. 119
	Abhilash Balakrishnan, Karishma Kulkarni, Sydney Moirangthem, Channaveerachari Naveen Kumar, Suresh Bada Math, Pratima Murthy DOI:10.4103/IJPSYM.IJPSYM_364_18   India's ratification of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) necessitated the need for a rights-based, biopsychosocial model of disability, which was endorsed in the Rights of Persons with Disabilities (RPwD) Act, 2016. This article examines the Act, its rules, and guidelines provided by the Government of India, from a mental health perspective, and compares it to its predecessor, the Persons with Disabilities (PwD) Act, 1995. The RPwD Act provides clearer definitions of various constructs, a greater focus on rights of PwD, and guidelines for assessment and certification of disabilities. There is, however, an underemphasis on mental illnesses in the reservation and legal decision making, and a move toward centralizing the process of disability certification. Also, there is a lack of clarity about screening instruments to be used, resource allocation to implement the provisions, and the guidelines for inclusive education. This article suggests recommendations that could strengthen some of these provisions.
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	Psychiatrist in court: Indian scenario	p. 126
	Vinay Basavaraju, Arun Enara, Guru S Gowda, Shashidhara Nagabhushana Harihara, Narayana Manjunatha, Channaveerachari Naveen Kumar, Suresh Bada Math DOI:10.4103/IJPSYM.IJPSYM_53_19   The impetus for practical exposure to legalities that arise in the context of psychiatry and law is minimal in postgraduate training in psychiatry and curriculum. Those who choose to get trained often do not get first-hand exposure to court proceedings. Law and psychiatry often come into each other's interface, and psychiatry is regulated by the legal system more often than the other specialties in medicine. This article is an attempt to equip the psychiatrist in dealing with instances where they will present themselves in court.
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	Suicide risk in comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review	p. 133
	Andrea Amerio DOI:10.4103/IJPSYM.IJPSYM_367_18   Introduction: The co-occurrence of bipolar disorder (BD) and obsessive-compulsive disorder (OCD) seemed to be a poor prognostic factor associated with greater disability, lower social and occupational functioning, poorer treatment response, and higher suicidal ideas and attempts compared to BD patients. Materials and Methods: A systematic review was conducted on the risk of suicide in BD-OCD patients compared to BD patients. Relevant papers published through August 2018 were identified searching the electronic databases MEDLINE, EMBASE, PsycINFO, and the Cochrane Library. Results: In all cases, diagnoses were according to the standard Diagnostic and Statistical Manual criteria and were established using validated assessment scales. More than 80% of the selected studies presented higher rates of history of suicide attempts and lifetime depressive episodes in BD-OCD patients compared to non-comorbid patients. Conclusions: Osler's view that medicine should be a treatment of diseases, not of symptoms, is consistent with the approach of mood stabilization as the first objective in apparent BD-OCD patients, as opposed to immediate treatment with antidepressants. In line with that, especially in comorbid patients, lithium may be preferred because of its proven anti-suicidal effect.
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ORIGINAL ARTICLES
	Sociodemographic, legal, and clinical profiles of female forensic inpatients in Karnataka: A retrospective study	p. 138
	Guru S Gowda, Sai Komal, Tarasingh N Sanjay, Saumya Mishra, Channaveerachari N Kumar, Suresh B Math DOI:10.4103/IJPSYM.IJPSYM_152_18   Background: Forensic patients are often admitted to psychiatric hospitals without any details of illness or treatment. They pose a unique challenge for clinical services in the context of diagnosis, management, and particularly legal issues. Materials and Methods: We conducted a retrospective chart review using a structured data-extraction tool. A total of 23 female forensic inpatients were admitted under the Department of Psychiatry from January 2006 to June 2016. Data were analyzed by descriptive statistics. Results: The mean age of the patients was 31.3 ± 7.9 years. In total, 82.6% of them were married, 87% were from a nuclear family, and 78.3% were from an urban background. Totally, 73.9% were referred from prison and 26.1% from the court. However, 73.9% were referred for the purpose of diagnosis and treatment and 21.7% for assessment of fitness to stand trial. Moreover, 47.8% had an alleged charge of murder (of killing close family members). A total of 30.4% had schizophrenia and other psychotic disorders, and 47.8% had a mood disorder. The mean duration of inpatient care was 6.2 ± 7.4 weeks, and 87% had shown considerable clinical improvement at the time of discharge. Conclusions: The majority of female forensic patients were young adults from nuclear families. They had mood disorders, schizophrenia, and other psychotic disorders. They were referred primarily for treatment purposes. Prospective studies are required for a better characterization of the relationship between crime and psychiatric disorders.
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	Prevalence and clinical and coercion characteristics of patients who abscond during inpatient care from psychiatric hospital	p. 144
	Guru S Gowda, Abel Thamby, Vinay Basavaraju, R Nataraja, Channaveerachari Naveen Kumar, Suresh Bada Math DOI:10.4103/IJPSYM.IJPSYM_188_18   Background: Patients absconding from psychiatric hospitals pose a serious concern for the safety of patients and public alike. Absconding is associated with an increased risk of suicide, self-harm, homicide, and becoming "missing" from society. There are only scarce data on profile and outcome of the absconding patients in India. Aims: To study the prevalence and describe the clinical and coercion characteristics of patients who abscond during inpatient care from an open ward. Methodology: "Absconding" was defined as patients being absent from the hospital for a period of more than 24 h. This is an analysis of absconding patients out of the 200 admitted patients at a tertiary psychiatric hospital. Descriptive statistic was used to analyze the demographic, clinical, and perceived coercion profile and outcome. Results: The absconding rate was 4.5 incidents per 100 admissions. Most of these patients were males, from a nuclear family, admitted involuntarily, belonging to lower socio-economic status, diagnosed with schizophrenia or mood disorder with comorbid substance use disorder and had absent insight. The MacArthur Perceived Coercion Scale score was 4.58 (±1.44), and 80% of the absconded patients felt subjective coercive experiences in most domains at admission. Out of the 9 absconded patients, 2 patients had completed suicides and one continued to remain untraceable. Conclusion: The absconded patients were males; admitted involuntarily; diagnosed with schizophrenia, mood disorder, and comorbid substance use disorder; and had absent insight and high perceived coercion. Absconding patients had the tendency to harm themselves and wander away from home.
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	How does india decide insanity pleas? A review of high court judgments in the past decade	p. 150
	Parthasarathy Ramamurthy, Vijay Chathoth, Pradeep Thilakan DOI:10.4103/IJPSYM.IJPSYM_373_18   Background: The Section 84 of the Indian Penal Code (IPC) describes how Indian courts have to deal with 'the act of an unsound person'. This study was undertaken with the objectives of estimating the success rate of insanity pleas in Indian High Courts and determining the factors associated with the outcome of such insanity pleas. Materials and Methods: The data was collected from the websites of 23 High Courts of India using the keywords 'insanity' and 'mental illness', and the judgments delivered between 1.1.2007 and 31.08.17 were retrieved. Information regarding the nature of the crime, diagnosis provided by the psychiatrist as an expert witness, documents used to prove mental illness, and the judgment pronounced by the High Court were retrieved. Results: A total of 102 cases were retrieved from 13 High Courts for which data was available. Out of the 102 cases examined, the High Court convicted the accused in 76 cases (74.50%), thereby rejecting the insanity defense. The High Court acquitted the accused under section 84 IPC in 18 cases (17.65%), thereby accepting the insanity plea raised by the accused. Chi-square tests of independence revealed that the verdict of the lower court, documentary evidence of mental illness prior to the crime, and the psychiatrist's opinion were associated with the success of insanity pleas. Conclusion: Insanity pleas had a success rate of about 17% in Indian High Courts in the past decade. The factors associated with success of insanity pleas provide valuable guidance to several stakeholders who are dealing with mentally ill offenders.
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	Does sociodemographic background determine the responses to ethical dilemma vignettes among patients?	p. 155
	Snehil Gupta, Siddharth Sarkar, Vaibhav Patil, Bichitrananda Patra DOI:10.4103/IJPSYM.IJPSYM_110_18   Background and Aims: Patients are important stakeholders in the care process and may have different viewpoints on clinical disclosure, which may be influenced by their sociodemographic and cultural background. Hence, the aim of this study was to assess whether age, gender, employment status, educational status, and other sociodemographic variables of persons with mental illness influence their views about ethical issues in clinical care. Materials and Methods: The study was conducted at the Outpatient Department of a tertiary care mental health/de-addiction center in North India. Patients aged ≥18 years and currently in remission of their primary psychiatric illness were included. Using case vignettes, their responses to ethical issues related to clinical situations were assessed. Results: The study included a total of 160 participants. The younger age group less frequently agreed on disclosure of a man's Human Immunodeficiency Virus-positive status to other family members against his wishes. Women less frequently agreed on disclosure of marital strife to husbands' parents. Higher educational status was associated with a less frequent agreement to disclosure of a man's suicidal ideas to other family members, and those currently employed less frequently agreed to disclosure of marital strife of a female patient to her parents. Conclusion: Age, gender, education, and employment status might influence some of the responses to ethical dilemmas in the clinical setting. These factors may be considered while clinical decision-making faces ethical challenges.
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	Geographical and temporal variation of suicide in India, 2006–2015: An investigation of factors associated with suicide risk difference across states/union territories	p. 160
	Parthasarathy Ramamurthy, Pradeep Thilakan DOI:10.4103/IJPSYM.IJPSYM_569_17   Background: In India, about 130,000 people died by suicide in the year 2015. It is important to understand the variation of suicide across different parts of India and the trend of suicide rates over the years. The objectives of this study were to determine whether suicide rates in India showed temporal variation in the last decade and to determine whether suicide rates in India showed geographical variation across different states and union territories (UTs). Methods: Data on suicide rates for the years 2006–2015 were collected from the official publication of the National Crime Records Bureau. This study looked for time trend in suicide rates over the years. Further, the variation in suicide rates across different states/UTs in India and the factors associated with the variation were also analyzed. Results: The average suicide rate in India for the years 2006–2015 was 10.9/100,000 population. Overall, there was no significant variation in the suicide rate over time in the years studied. The average suicide rate varied widely across the states and UTs, between 0.91 and 43.92 per 100,000 population. The analysis revealed a positive association between suicide rates and accident rates for the above years. In addition, for the year 2011, a positive association between suicide rate and per capita state domestic product was noted. Conclusion: There was no variation in the suicide rate in India over time. However, there were significant regional differences. Reporting differences and economic factors could partially explain the differences.
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	Utilization of emergency psychiatry service in a tertiary care centre in north eastern India: A retrospective study	p. 167
	Subrata Naskar, Kamal Nath, Robin Victor, Kaveri Saxena DOI:10.4103/IJPSYM.IJPSYM_55_18   Background: In a developing country like India, with a lot of psychosocial stressors and ample stigma toward psychiatry, we studied the sociodemographic pattern of the patients coming to a tertiary care center for emergency psychiatry services and also evaluated the types and pattern of emergency services provided to them. We also assessed the predominant presenting complaints with which patients presented at the emergency department, "reasons for referral" in an emergency by other departments, and types of psychiatric diagnoses in the patients. Subjects and Methods: Data were extracted retrospectively from the general emergency and psychiatry emergency register of Silchar Medical College and Hospital for 1 year and analyzed. Results: Out of 41,040 patients attending the hospital seeking emergency care, referral rate to the psychiatric emergency was only 2.8%. The commonest presenting complaint of subjects who were referred was "medically unexplained somatic complaints" (47.70%). The main reason for a referral from other departments was "no physical illness was detected" in the patient (38.59%). About 78.8% of the subjects were diagnosed as having a proper psychiatric illness, with the majority presenting with stress-related and somatoform disorders (F40–49) (43.45%). Conclusion: This study highlights various important parameters regarding emergency services being provided and their utilization by the patients attending a psychiatric emergency, which could be helpful for future policies and resource allocation for providing superior quality and cost-effective mental health care to the patients.
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	Perceived stigma regarding mental illnesses among rural adults in Vellore, Tamil Nadu, South India	p. 173
	Apoorva Guttikonda, Aleena M Shajan, Adeline Hephzibah, Akhila S Jones, Jerlyn Susanna, Sunil Neethu, Sharon Poornima, Sarah M Jala, D Arputharaj, David John, Nehemiah Natta, Dolorosa Fernandes, Shalini Jeyapaul, Dimple Jamkhandi, H Ramamurthy Prashanth, Anu M Oommen DOI:10.4103/IJPSYM.IJPSYM_297_18   Background: Stigma is an important factor that determines whether individuals seek treatment for mental illnesses. Studies assessing public perceptions regarding mental illnesses are scarce in India. This study documents the stigma perceived by a rural population toward patients with mental illness and their families. Materials and Methods: A cross-sectional pilot study was done in five villages, selected by simple random sampling, from a rural block in Vellore, Tamil Nadu. Households in each village were selected by systematic random sampling. From the selected households, 150 subjects aged 18–65 years, without known mental disorders, were chosen by convenience sampling, based on availability. Stigma was assessed using the Devaluation of Consumers Scale (DCS) and Devaluation of Consumer's Families Scale (DCFS). Results: The proportion with high perceptions of stigma associated with mentally ill persons was 63.8%, among the 150 interviewed rural respondents (women: 112, median age: 37 years). The proportion which perceived that there was public stigma toward families of those with mental illnesses was 43.4%. Older respondents (>37 years) had higher perceptions of stigma (odds ratio: 2.07; 95% confidence interval: 1.02–4.20) than others. Conclusion: The high perception of stigma associated with persons who are mentally ill as well as their families needs to be kept in mind while planning interventions to decrease the treatment gap for psychiatric morbidity, especially in rural areas.
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BRIEF RESEARCH COMMUNICATION
	Hypochondriasis: Clinical profile in a tertiary care psychiatry and neurosciences hospital in Southern India – A retrospective chart review	p. 178
	N Pavithra, Ajit Bhalchandra Dahale, Geetha Desai, Santosh Kumar Chaturvedi DOI:10.4103/IJPSYM.IJPSYM_177_18   Background: Hypochondriasis is a complex disorder in the realm of psychosomatic medicine, yet understudied in India. The aim of this study was to assess the clinical profile of patients diagnosed with hypochondriasis. Materials and Methods: Retrospective chart review was done in a tertiary care psychiatry and neurosciences hospital in southern India. Medical records of adults diagnosed with hypochondriasis between 2000 and 2010 were analyzed. These patients were also rediagnosed retrospectively using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for illness anxiety disorder (IAD) and Diagnostic Criteria for Psychosomatic Research (DCPR) criteria for health anxiety and illness phobia. Data were organized and analyzed using PSPP for descriptive statistics of different variables. Results: There were 114 patients with hypochondriasis, with the most common belief being about dysmorphic appearance. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed medications. The median follow-up duration was only 2 months. Five percent of the cases fulfilled the criteria for DCPR health anxiety and 20.4% for DCPR illness phobia. DSM-5 criteria for IAD were fulfilled by 45.6% of the cases. Conclusion: Dysmorphic appearance was the most common concern in patients with hypochondriasis and SSRIs the most common medications. The follow-up rate and the diagnostic concurrence with DSM-5 IAD and DCPR were low. Studies assessing the influence of psychopathology and culture on the presentation, course, and prognosis of hypochondriasis would be beneficial.
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LETTERS TO EDITOR
	Binge-watching: A matter of concern?	p. 182
	S Umesh, Swarnali Bose DOI:10.4103/IJPSYM.IJPSYM_279_18
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	Creutzfeldt–Jacob disease with psychiatric presentation: Hen's teeth in Indian subcontinent: A case report	p. 184
	Gurmukh Singh, Shivangi Mehta, Mitesh Kumar, Alisha Salhotra DOI:10.4103/IJPSYM.IJPSYM_102_18
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	Atypical limbic encephalitis and its complex psychiatric presentations: Implications for diagnosis and management	p. 187
	Ashvini Vengadavaradan, Karthick Subramanian, Ravi Philip Rajkumar DOI:10.4103/IJPSYM.IJPSYM_233_18
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	Mirtazapine induced tremors: A case report	p. 190
	NA Uvais, VS Sreeraj, P Shihabudheen, TP Mohammed DOI:10.4103/IJPSYM.IJPSYM_436_18
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	Lurasidone-induced parkinsonism and hyperprolactinemia	p. 192
	Navratan Suthar, Jitender Aneja DOI:10.4103/IJPSYM.IJPSYM_274_18
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	Use of stimulants in patients with psychosis having past history of or co-occurring attention deficit hyperactivity disorder: Is it safe?	p. 195
	Sumedha Purkayastha, Vaibhav Patil, Anamika Sahu DOI:10.4103/IJPSYM.IJPSYM_262_18
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COMMENTS ON PUBLISHED ARTICLES
	Multiple testing and protection against Type I error using P value correction: Application in cross-sectional study designs	p. 197
	Vikas Menon DOI:10.4103/IJPSYM.IJPSYM_12_19
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	Author's response to 'Multiple Testing and Protection against Type I Error Using P Value Correction: Application in Cross-Sectional Study Designs'	p. 198
	Chittaranjan Andrade DOI:10.4103/IJPSYM.IJPSYM_61_19
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	Comments on "Stressful Life Events and Relapse in Bipolar Affective Disorder"	p. 199
	Satish Suhas, Gurvinder Pal Singh, Naga V. S. S. Gorthi, Chittaranjan Andrade DOI:10.4103/IJPSYM.IJPSYM_42_19
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LEARNING CURVE
	Describing research design	p. 201
	Chittaranjan Andrade DOI:10.4103/IJPSYM.IJPSYM_66_19   This article explains how the research design of a study can simultaneously be described in many different ways as nonempirical or empirical, case-based or sample-based, observational or interventional, retrospective or prospective, cross-sectional or longitudinal, uncontrolled or controlled, single arm or multiple arm, nonrandomized or randomized, crossover or parallel group, nonblind, single-blind, or double-blind, superiority or noninferiority, exploratory (hypothesis generating) or confirmatory (hypothesis driven), and many others. Some of these categories can be associated with special types of research design as well, such as cohort studies, case-control studies, nested case-control studies, wedge design studies, and so on. Readers should understand which descriptors are mutually exclusive and which are not.
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Limb Lengthening & Reconstruction

EDITORIALS
	Limb reconstruction in the 21st century: An amputation is a reconstructive procedure	p. 63
	Selvadurai Nayagam DOI:10.4103/2455-3719.253396
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	Limb reconstruction in the early 21st century: The indications are broader and wider	p. 65
	Dror Paley DOI:10.4103/2455-3719.253397
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ORIGINAL ARTICLES
	A magnetically controlled lengthening nail: A prospective study of 31 individuals (The PRECICE™ intramedullary nail study)	p. 67
	Stuart A Green, Austin T Fragomen, John E Herzenberg, Christopher Iobst, James J McCarthy, Scott C Nelson, Dror Paley, S Robert Rozbruch, Shawn C Standard DOI:10.4103/jllr.jllr_20_18   Purpose: We studied 31 individuals whose femur or tibia was elongated with the PRECICE™ intramedullary lengthening nail in a protocol-controlled, multicentric, prospective series. Only skeletally mature individuals were included in the study. Materials and Methods: The protocol entailed 2-year follow-up after consolidation of the regenerate new bone in the distraction gap. Since the external remote controller (that powers the nail's internal rotating magnet) must be within a predetermined distance from the implant, body weight limitations applied to the individuals. Similarly, a history of active or prior bone infection in the involved limb segment, an offset medullary canal that could not be successfully reamed for the implant, an angular deformity that precluded insertion of a straight device, and any potential limitation on regenerate new bone formation (such as metabolic bone disease or vascular compromise) were causes for exclusion. The mean age ± standard deviation was 24.3 ± 15.0, and the median age was 18 years. There were 20 males and 11 females in the series, with 21 Caucasians, 5 Hispanics, and 5 African-American individuals. The mean body mass index was 24.2 ± 4.7. Twentythree (74.2%) cases involved the femur and 8 (25.8%) involved the tibia. Results: One participant died of medical causes during the study period, and one participant was lost to follow-up, but 29 of 29 participants followed at least to consolidation achieved union (100%) although one of these participants was treated with a supplementary cancellous bone graft and another participant was converted to trauma nail before consolidation, to permit full weight-bearing as a stimulus to regenerate consolidation. On an average, participants achieved 96.3% ± 23.2% of the preoperative target lengthening (3.5 cm; range 1.8–6.0 cm) over an average of 48.5 ± 15.6 days. The average time to full weightbearing (permitted when the regenerate was consolidated on three sides) was 141.1 ± 80.7 days. The knee joint, at consolidation, lost an average of 6.5° of flexion and 0.3° of extension. The ankle lost an average of 1.4° of dorsiflexion and 5.4° of plantar flexion. The hip joint lost, on average, 2° of flexion, and gained 1.6° of extension. There was one deep infection involving the implant, successfully treated with intravenous antibiotics and superficial debridement. Nearly 25.8% of the participants had pain issues during lengthening, often over prominent hardware. In one participant, the nail failed to elongate during lengthening at home and had to be exchanged. One interlock screw broke. The internal components separated during implant extraction in the one subject had his nail exchanged by a trauma nail. Only 17 participants exited the protocol by presenting to clinic for evaluation 2 years after consolidation. None experienced significant deterioration of outcome. Conclusion: The PRECICE™ IM nail is a well-tolerated, reliable, fully implantable limb lengthening device that will accurately elongate the femur or tibia in a variety of causes of limb length inequality, with a low implant failure rate, and few complications.
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	Severe infantile blount's disease: Hemiplateau elevation and metaphyseal correction with use of the taylor spatial frame	p. 76
	Jonathan Wright, Peter Calder DOI:10.4103/jllr.jllr_2_18   Aims: Severe infantile Blount's disease can result in a challenging multiplanar deformity of the proximal tibia with intra-articular and metaphyseal components. We describe our results using the Taylor's spatial frame (TSF) for acute tibial hemiplateau elevation combined with gradual metaphyseal correction in patients with severe infantile Blount's disease with an associated physeal bony bar. Patients and Methods: Eight patients (ten knees) underwent tibial hemiplateau elevation and metaphyseal correction from 2012 to 2016. We undertook a retrospective case note and radiographic review of clinical and radiographic outcomes. The mean age at the time of surgery of was 11.7 years and the mean length of follow-up was 18.2 months. Results: Improvement in radiographic parameters was seen in all patients. The mean tibiofemoral angle improved from −28.3° to −5.9° postoperatively. The angle between femoral condyles and the tibial shaft improved from the mean of 56.3° to 90.3°. The joint depression angle was also seen to improve from the mean 47.4° to 9.8°. No significant complications were seen. Conclusion:This technique is effective in correcting the complex deformity encountered in severe infantile Blount's disease. Use of the TSF may provide certain advantages in comparison to previously described approaches.
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	Spring technique for correction of multilevel deformity using hexapod external fixator	p. 83
	Leonid N Solomin, Munetomo Takata, Elena A Shchepkina, Fanil Sabirov, Konstantin L Korchagin, Hiroyuki Tsuchiya DOI:10.4103/jllr.jllr_7_18   Context: Osteotomies in several parts of one long bone are recommended for correction of a long, curved, and wide-angled deformity. Hexapod external fixators (HEFs) allow for the single-stage correction of multiplanar deformity, but they are heavy, expensive, and requires continuous management of 12 struts, if at more than one level. Aims: We proposed the use of springs with HEF to support the intermediate ring. Deformity between the proximal and distal rings is corrected using one HEF, and the intermediate fragment is automatically corrected by the tension of the springs. Settings and Design:This was a retrospective descriptive study. Subjects and Methods: We treated seven males and eight females with 17 affected limbs. Four patients with familial hypophosphatemic rickets, five posttraumatic deformities, two osteogenesis imperfectas, three fibrous dysplasias, and one neurofibromatosis were included. The mean preoperative angle between the most proximal and distal fragments was 62.5°. First, small distraction at each level was initiated with one HEF fixed to the most proximal and distal rings, and Ilizarov hinges applied between the proximal and intermediate rings. Then, a set of three springs was applied for each interval between the rings. Gradual correction using HEF was performed, considering only the axes of the proximal and distal bone fragments. Results: Good alignment was achieved in all patients without severe complications. The mean correction period was 5.5 weeks and mean fixation period was 33.8 weeks. Conclusion: Combination of HEF and springs is capable of correcting severe deformity.
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	Anesthesia for removal of external fixation with hydroxyapatite-coated half pins	p. 90
	Austin T Fragomen, Anton M Kurtz, Philip J Wagner, Joseph Nguyen, Spencer S Liu, S Robert Rozbruch DOI:10.4103/jllr.jllr_29_17   Background: External fixation utilizing hydroxyapatite (HA)-coated half pins has produced excellent clinical results revolutionizing the field of limb lengthening and deformity correction surgery. Removal of these pins is a painful patient experience that may be best conducted under anesthesia. Purpose: The current study documents how a deformity practice removes these external fixators (frames) under anesthesia. We asked: (1) How much anesthesia is needed for frame removal? (2) How effective was this protocol in controlling patient pain? (3) How did patients taking narcotic medications at the time of frame removal differ from those not taking narcotics during frame removal surgery? Patients and Methods: We prospectively recorded data during the removal of 53 consecutive external fixators that used HA-coated half pins including the use of pre operative narcotics at the time of frame removal, location and complexity of frames, type and dosages of medications administered, and adequacy of anesthesia. Results: All patients were managed with a combination of midazolam, propofol, fentanyl, and ketamine. Anesthesia was graded as good to excellent in 91% and unsatisfactory to poor in 9% of cases. The preoperatively medicated group was administered significantly less fentanyl (P = 0.020) and had significantly more frames located about the ankle and foot (P = 0.049) than the preoperatively non-medicated cohort. Conclusions: IV sedation administered by an anesthesiologist in the operating room provided adequate pain control to perform fixator removal and pin site debridement in most cases. External fixation used for foot and ankle reconstruction may provide a more painful experience for patients.
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	Rotational-guided growth	p. 97
	Gonzalo A Martel, Larry Holmes, Gabriela Sobrado, Eduardo Santini Araujo, Dror Paley, Francisco Praglia, Gabriel Arguello, Elena Arellano, Gustavo Rodriguez Flores DOI:10.4103/jllr.jllr_6_18   Background: Rotational deformities of the femur and tibia are some of the most common orthopedic alignment problems in the lower extremity. In-toeing and out-toeing are common complaints seen by pediatric orthopedic surgeons as well. The idea of guided growth to correct axial rotation deformities in children is appealing. The purpose of this study was to investigate this concept and to test it in a large animal model taking advantage of the human like dimensions and biomechanics. Method: To generate axial-rotational growth we tether the growth plate on both sides at a fixed inclined angle on each side a cable with two screws. This construct was called the Percutaneous Progressive Derotator (PPD). Eight calves, two-month old, four male (50%) and the other four female, were used as models. The PPD device was implanted at the distal physis of the right metacarpal in an external rotation configuration, leaving the left side as control. The PPD device was left in for 3 months and was then removed. The total followed up was 2 years and 3 months. Results: The hypothesis that guided growth was possible in large animals has been confirmed. Rotation of 24° average were achieved in the right metacarpus of the growing cattle (P < 0.001), using the torque generated in the growth plate by the PPD.
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CASE REPORTS
	Concomitant bone regeneration to restore bone stock during revision distal femur replacement after large tumor resection	p. 106
	Eugenia Schwarzkopf, Ridhi Sachdev, Venkat Boddapati, Daniel Eduardo Prince DOI:10.4103/jllr.jllr_17_18   Loss of bone stock is a common problem in revision arthroplasty, specifically in large distal femur replacements (DFRs) after tumor resection. It can lead to worse functional outcomes and increased risk of revision procedures. Restoration of bone using distraction osteogenesis (DO) with an intramedullary nail may be an appropriate solution for this problem, especially in younger adults who may require future surgical interventions. In this series of three patients, we describe the successful use of DO through an internal device to address bone loss after a large osseous resection and revision endoprosthetic reconstruction. Bone stock was restored with a combination of lengthening and bone transport using a multistage revision strategy: removal of existing hardware, treatment of infection if present, lengthening of proximal femur with a temporary antibiotic spacer in the distal femur, and reimplantation of a definitive DFR after bone stock restoration. A magnetically actuated internal lengthening intramedullary rod was utilized to perform the proximal femur osteoplasty. Conversion to a definitive weight-bearing DFR was achieved in two patients; one patient required an above-the-knee amputation for chronic osteomyelitis which could not be controlled after numerous debridements and courses of IV antibiotics. In this patient, the infection could be eradicated from the lengthened bone, the regenerate bone served to provide length to the amputation stump and fully remodeled to provide full weight-bearing and prosthetic use. DO was successfully used in three patients for revision DFR and bone stock restoration. In one of the two patients who required revision surgery for infection, amputation was ultimately required. All three patients achieved successful bone regeneration.
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	Staged humerus lengthening with monolateral fixation followed by a circular frame: Technique of fixator change	p. 111
	Muayad Kadhim, John E Herzenberg DOI:10.4103/jllr.jllr_12_18   Monolateral external fixator (MEF) has been commonly used for limb lengthening in both upper and lower extremities. Since MEF can only lengthen or shorten the bone, sagittal, coronal, and torsional deformities need to be corrected acutely at the time of MEF application. Acute correction, particularly torsional correction, may endanger the radial or peroneal nerves. Gradual correction of torsion may be safely achieved using a circular external fixator (CEF) frame. We present a case study of humeral lengthening with derotation to describe a technique, whereby it is possible to first lengthen with MEF and then derotate with CEF. This is a case report of a 14-year-old boy with a history of neonatal sepsis and growth arrest of the proximal humerus that led to a short right humerus and loss of external rotation. Humerus lengthening was achieved (6.6 cm) using MEF. Conversion to CEF was done after the distraction phase and prior to regenerate bone consolidation. Two 2/3 rings were connected to the proximal and distal fixation half-pins, and then the six connecting struts were added. The rotation deformity correction was then performed gradually to achieve 60° of external rotation. The described technique to convert the MEF into CEF is versatile and can be employed in the clinic safely and without sedation.
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SPECIAL FEATURE
	The ilizarov technology revolution: History of the discovery, dissemination, and technology transfer of the ilizarov method	p. 115
	Dror Paley DOI:10.4103/2455-3719.253395
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