Peripheral Vascular Disease In Lower Limb



Case 1

  • Navin Shah 68/M
  • Came with complaints of blackening over left little toe since 2 months
  • He has been to 4 other hospitals where he could not get the satisfactory treatment and was advised lower limb amputation
  • We have taken up the case and after discussions and meticulous planning with the help of available diagnostics and set off for the management
  • H/o DM (Diabetes) / HTN (Hypertension) for the past 25 years
  • H/o CAD-TVD (Coronary artery disease) on medical management
  • H/o chronic smoking +
  • Peripheral angiogram was done which showed ATA/PERONEAL ARTERY total occlusion, Distal Percutaneous Transluminal Angioplasty (PTA) 90% stenosis.
  • He was first treated with POBA and angioplasty (Plain Old Balloon Angioplasty) to ATA / PTA and PERONEAL artery.
  • Subsequently with limited amputation of just the little toe we are able to achieve our goal of limb salvage surgery.

Case 2

  • T Rama Rao 61/m
  • Came with complaints of ulcer over left foot for over 2 months. He is known case of heart disease undergoing treatment
  • History of Diabetes since 25 years
  • Evaluated – complete block of main artery supplying lower limb
  • Treatment – PTA (Percutaneous Transluminal Angioplasty) with 3 stents
  • Debridement and regular dressings has heeled the wound completely

Case 3

  • Prathap Reddy 71/M
  • k/c/o CAD (Coronary Artery Disease)
  • History of HTN + (Hypertension) / DM + (Diabetes)
  • C/o Blackish discoloration of left little toe
  • Peripheral angiogram shows left ATA and PTA – 99% stenosis
  • Treatment – Amputation of left 4th,5th toes followed by


  • In peripheral arterial disease there is a decreased or total loss of blood supply to the peripheries (most commonly affects lower limbs)
  • Due to
    • Embolism
    • Atherosclerosis, thrombosis
    • Trauma
    • Complications of peripheral aneurysm


  • Age
  • Gender – Male common
  • Obesity
  • Family history
  • Diabetes
  • Smoking
  • Hypertension
  • Dyslipidemia
  • Hyperhomocysteinemia
  • Race (Asian / Hispanic / black vs white)


  • Approximately 12% of the adult population has PAD, almost 20% of adults older than 70 years have PAD
  • A new analysis published by THE SAGE GROUP concludes that atherosclerotic peripheral arterial disease (PAD) afflicts over 20 million in India
  • Once PAD has progressed to CLI (Chronic Limb Ischemia), the risks of limb loss and mortality increase. At six months approximately 20% of those with CLI will die; another 40% will experience amputation.
  • Diabetics represent 60% to 80% of CLI patients, we believe that India may unfortunately be on the path to becoming the Critical Limb Ischemia Capital


  • Under diagnosed, undertreated, and poorly understood even by the physicians and much more common than thought considering the lifestyle and the rise of share of the non communicable diseases like hypertension and diabetes.
  • The diagnosis of PAD should not be overlooked for 2 important reasons. First, patients with PAD may experience many problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. These lead to a poor quality of life and a high rate of depression
  • Cardiovascular death and have a higher rate of all-cause mortality compared with patients without PAD.


  • Amputation if wound does not heal and necrosis due to compromised blood supply revised amputation resulting in high morbidity and mortality rates
  • Due to new modalities for diagnosis such as colour doppler, CT angio, DSA, MRA and new interventions like peripheral stenting with advanced stents
  • Level of obstructed supply can be made and appropriate intervention can be done


  • Depending on the stage of presentation
  • Non healing ulcer – debridement if needed after endovascular technique
  • Gangrene – Infected – Amputate to reduce sepsis – endovascular technique
  • Non infected – endovascular technique – amputate
  • Vasodilators to increase blood supply and anticoagulants and anti platelets for stent patency and anti diabetics, anti hyper lipidemics and anti hypertensives depending on the risk factors and regular dressings and wound care.
  • The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death)
  • Accomplished by establishing a
    • Supervised exercise program and
    • Administering cilostazol or performing a revascularization procedure if medical therapy is ineffective.
    • A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter


  • Stent placement is typically used when residual stenosis after PTA is 30% or greater
  • Primary stent placement has become a viable alternative for treating ulcerative lesions that may potentially be the source for embolization
  • Several clinical studies have demonstrated the significant improvements of the new generation of nitinol stents for the SFA lesions: the German Multicenter Experience, the Mewissen trial, the BLASTER Trial, and the SIROCCO trial


Watch out for

  • Tingling sensation in the legs
  • Pain after walking a certain amount distance
  • Sudden rest pain
  • Ulcerations
  • Blackening
  • Especially on the background of the above said risk factors
  • Better to get evaluated about the limb and the doctor will decide if your heart status also needs to get evaluated 


  • Salvaging your precious limb
  • Adding miles to your walk

Pain in the surgical/trauma

1. What is pain?

Pain is an unpleasant physical and emotional response to actual or potential tissue damage or described in terms of such damage.

It is a protective response which ensures that an injured part of the body is carefully handled and further damage is prevented.

2. Why do we feel pain?

There are nerve endings distributed all over our body- from the skin to the intestines. These get activated in response to injuries from varied mechanisms like cuts and bruises, deep pressure, burns, extreme cold etc. Upon activation, signals are sent by the nerve endings to the brain and pain is perceived.


3. Why is it important to reduce pain?

Control of pain leads to a better life -Pain is unpleasant. It leads to emotional responses like depression and anger. It imposes a financial burden on the individual as well as society not only because of the expenses of treatment but also because there is loss of productive work-hours in the affected population. Long-lasting pain affects day-to-day functioning. People with pain tend to handle that body part carefully leading to stiffening of the joints and loss of muscle mass due to disuse. The stress leads to lack of control of blood pressure and blood sugar, sleeplessness, increase in acidity and body weight.

In patients undergoing surgery, pain relief leads to early recovery which means the patient walks sooner (Decreasing the chances of blood clots forming in the legs and travelling to the heart). He has better control of blood pressure and blood sugars due to decrease in stress levels and is less prone to stress-related complications like heart failure. All this leads to earlier discharge from the hospital.


4. How is pain classified?

There are various ways to classify pain:

There can be more than one type of pain in a patient due to more than one cause. This is important to know because the treatment changes with the cause/type/duration.

  • Based on the duration it can be acute ie immediate or sudden, usually lasting from 3 to 6 months or chronic ie long-lasting-more than 6 months or acute-on-chronic ie sudden pain superimposed upon a pre-existing pain.
  • Based on the site of origin it can be Somatic ie arising from the skin/Bones/muscles or Visceral ie from the internal organs like the intestine or Uterus.
  • Based on the cause of pain it can be Neuropathic ie arising from nerves which are injured or Inflammatory ie due to chemicals released after injury.


4. What are the common means of reducing pain?

Pain can be mitigated by non invasive or invasive means. Non invasive methods include oral medicines (Aspirin, Paracetamol, morphine etc.) Hot fomentation, cold compresses, physiotherapy, yoga and so on.

Invasive methods include pain killer injections either into the muscles or veins and more recently blocking nerves causing pain with anaesthetic drugs. Each method has its advantages and disadvantages.

Medicines which are called NSAIDS ( Nonsteroidal anti-inflammatory drugs) include Ibuprofen and Diclofenac. They act by decreasing the inflammation at the site of the pain. But when taken for a prolonged duration they might cause damage to the kidneys. They should also not be taken by those suffering from asthma or heart/bleeding problems.

Opiod drugs like Morphine, while very very effective, are the leading cause of addiction in the US and active research is ongoing to find alternate means of pain relief especially in the acute setting of trauma or surgery.



5. My friend recently had an accident and fractured his thigh bone and has to undergo surgery. What modes of pain relief can she be given?

After an accident there are various factors to take into consideration before pain relief methods can be planned. The treatment differs for young people with no other health issues vis-a-vis older persons with say high blood pressure or diabetes or kidney failure. It will also change with the extent and region of injury, ensuing blood loss, ability of the patient to breathe adequately, neurological status (Drowsy/conscious) and the expertise of the medical personnel.

In all cases no one method is considered superior or enough by itself. A multi-prong approach to pain relief ranging from oral/i.v medicines to blocking the nerves carrying pain from the injured area (Nerve block) helps in lessening the side effects, complications and costs involved.


6. What is a nerve block?

A nerve block involves deposition of local anaesthetic drugs near a nerve or a bundle of nerves to temporarily stop them from working. This cuts off pain transmission at the very first step.

For example this patient with a fracture of the thigh bone will have severe pain upon any sort of movement and may be taken up for surgery only after a few days especially if he has other problems like being on blood-thinning medicines or uncontrolled diabetes. In the meantime she will need a Femoral nerve block along with other pain medication. The femoral nerve is present on the front of the thigh near the groin.



7. How is the nerve block given?

Before giving the nerve block we ensure that the nerve itself is not injured from the accident by testing sensation and muscle movement. If there is any doubt we do not proceed with the block and give alternate means of pain relief.

Nerve blocks are given by qualified Anaesthesia doctors. All nerves in the body have more or less a constant location in humans. They can be identified by means of landmarks eg the Femoral nerve is close to the major artery in the groin whose pulsations are easily felt.

Sometimes the Anaesthetist might use a needle through which very small current pulses are given in order to locate the nerve. These pulses do not cause pain and are felt more like vibrations. When the needle is close to the nerve, the muscles supplied by the nerve show contraction. With the femoral nerve the muscles on the front of the thigh will move. At this point all the drug is given.

Another precise way of identifying the nerve is by using ultrasound where the pulsating artery and the nerve next to it are visible on the screen.

After the drug is injected the patient will get pain relief in 5-10 minutes. If prolonged pain relief needs to be given we leave small tubes called catheters next to the nerves and give a constant supply of the numbing medicine through syringe pumps for as long as needed (Commonly 3-4 days).


8. Will I have pain when the nerve block is given?

No, the doctor will first give a small numbing injection on the skin before using the other needle.


9. How soon will I get pain relief and how much of relief can I expect? Is there a way to measure pain?

Pain relief usually starts within 10 minutes and depends on the concentration of the drug given. It might take upto an hour for maximum relief.

The extent of relief varies from tolerable pain to sometimes complete relief.

The level of pain perceived is very individual-specific. Some people can bear the pain after Hip replacements and some may cry holy murder while an i.v cannula is being placed.
Most commonly the health care provider uses a visual analogue scale (VAS) to note down the pain level being experienced. This is a scale where the facial expression of the patient is assigned a number ranging from 0 to 10 . Here 0 means a happy face and 10 denotes extreme crying. Similarly, the health care provider or nurse might ask the patient to give a number to the pain being experienced (Numerical scale). Again 0 means no pain and 10 is the worst pain imaginable. The aim for us is usually to bring the pain down to less than 3 denoting mild/tolerable pain.


10. Will there be any side effects/complications of the nerve block?

Like any procedure done on the human body there are always chances of complications during nerve blocks. When done by expert hands minor complications are infrequent and major complications rare.
These range from failed blocks with no pain relief, injury to blood vessels/lungs/nerves/other organs, temporary weakness of the muscles supplied by the nerve and very rarely injection of the drug into blood vessels leading to Local Anaesthetic Systemic Toxicity.

The doctors giving the nerve blocks are trained to prevent and recognise such complications. They will use full monitoring like Blood pressure, ECG and oxygen saturation in the blood before, during and for 3 to 4 hours after the procedure. You will need to be admitted in the hospital for that duration.


11. Why should I undergo a nerve block when there are other means of pain relief?

Different degrees of pain need different methods of treatment.
A simple headache after a sleepless night might subside after an oral painkiller. Pain due to falling on the ground while running might need an injection into your arm/buttock. A fracture pain or one after a surgery will need oral medicines, injectable pain killers like i.v Morphine and yet not lead to adequate relief. It is such pain which benefits from nerve blocks.
In the surgical setting physiotherapy and active movements become easier and less painful if continuous pain relief is given with nerve block catheters. Our patients undergoing total knee replacement generally walk within 4 hours of surgery.

Further most analgesics (Pain-killers) come with their own respective set of side effects. Many of them cannot be used if you have a history of poor kidney function/ Asthma/ Heart attacks/Bleeding tendencies. They can lead to nausea, dizziness, retention of Urine, constipation, breathing difficulty, drowsiness etc.

In the trauma/surgical setting we need to use all methods in order to attack every step of the pain pathway in the body and minimise the overall dose of individual drugs. So you will be getting oral medicines, i.v injections as well as nerve blocks. These have an additive effect and individual doses of each medicine reduce drastically.


12. How long does pain last after surgery?

After any surgery maximum pain is felt during the first 3 to 4 days and this gradually decreases over a period of the next 7 days.


13. My father has fractured his ribs and finds it difficult to breathe without pain. He cannot afford to take long leave from work. Can nerve blocks help?

Yes. Rib injuries prevent patients from taking deep breathes due to pain. This causes gradual collapse of the small airways in the lungs. The ensuing inadequacy of oxygen in the body and chances of developing Pneumonia will require hospitalisation.

Such patients can be helped by the placement of Erector Spinae or Serratus Anterior plane blocks. A small catheter will be placed in between the muscles of the chest wall or back and a continuous infusion of local anaesthetic medicine will be given from a portable infusion pump which can be taken home. Deep breathing exercises are thus possible and prevent deterioration of the lung and loss of work-hours.

The infusion pumps will contain medicine for upto 48 hours and you will need to get it refilled at the hospital. A week of such treatment will give enough time for the body to heal.

Pulmonologist in Hyderabad


The common belief is that the person who smokes is the one only affected by smoking. However, that’s not true. Over time we have understood that children and non-smoking adults around a smoker might also have an adverse effect of smoking. Risks due to third-hand smoke can vary from recurrent asthma attacks to cancer.

Smokers are of 3 types depending on type of exposure

  • FIRST HAND SMOKERS: Smokers himself
  • SECOND HAND SMOKERS: Those who inhale a mixture of exhaled smoke and other substances left by the smoldering end of the cigarette
  • THIRD HAND SMOKERS: Those exposed to toxins residues that cling to different indoor surfaces.


Third Hand Smoke

Third-hand smoke is residual nicotine, tar, and other carcinogenic (cancer-causing) toxins left on indoor surfaces by tobacco smoke.

It clings on to clothes, furniture, drapes, walls, bedding, carpets and lingers on surfaces long after smoking has stopped which accumulates on the surfaces over a period of time. Non-smokers are exposed to these chemical toxins when they inhale, swallow or touch these surfaces.


Health Hazard due to third hand smoke

It may cause illnesses such as heart disease, cancer, chronic obstructive pulmonary diseases (COPD), ear infections in a third-hand smoker is equal to that in a smoker.

Infants and children are at the highest risk of health hazards. Children have poor brain dependent and frequent “Asthama Attacks”.

Research at Lawrence Berkeley National Laboratory found that baby mouse exposed to clothes and third-hand smoke were underweight and had negative effects on red cell production.


  1. The only way to protect non-smokers from Third-hand smoke is to create a smoke-free environment away from children, pets and those at risk.
  2. To remove residues from hard surfaces, fabrics, and upholstery must be regularly cleaned professionally.
  3. Simply airing rooms via air conditioners and fans do not eliminate third-hand smoke. The only way to completely protect is to quit.


Early detection & treatment for Diabetes

Diabetes is a complex, chronic illness which requires continuous medical care with multifactorial risk-reduction strategies beyond glycemic control. Ongoing patient education on self- management and support are critical to preventing acute complications and reducing the risk of long-term complications.

Criteria for the diagnosis of Diabetes:

  • Fasting Plasma Glucose ≥126 mg/dL. Fasting is defined as no caloric intake for at least 8 hours.* OR
  • 2-h Plasma Glucose ≥200 mg/dL during Oral Glucose Tolerance Test. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*OR
  • Glycosylated hemoglobin HbA1C ≥6.5%.* OR
  • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL

In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.

Diabetes can be classified into the following general categories:

  1. Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency)
  2. Type 2 diabetes (due to a progressive loss of β-cell insulin secretion frequently on the background of insulin resistance)
  3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation)
  4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with steroid use)


If untreated or inadequately treated, it may lead to complications like cardiovascular diseases (heart attack), stroke (cerebrovascular accident), diabetic retinopathy and visual loss, foot ulcers, diabetic neuropathy, diabetic nephropathy with protein loss and chronic kidney disease.

Comprehensive care for a diabetic patient involves control of blood glucose, cholesterol levels, blood pressure, maintenance of ideal body weight and risk assessment for cardiovascular and peripheral vascular diseases. Regular eye check-up, foot care, self-monitoring of blood glucose, and ability to recognize hypoglycemic symptoms and take remedial measures is of paramount importance. Every person with diabetes need to know the correct technique to self- administer insulin, basics regarding anti-diabetic oral medications, and should be provided with an individualized diabetic diet plan.


With this comprehensive approach, a good control of diabetes can be achieved and the person can lead a productive life like any other individual.

The Hip in Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is a condition most commonly affects young males. It is known to cause stiffness in spine and hip joints. Importance of hip involvement in AS has been recognised as a commonly disabling problem, whereas involvement of other joints like shoulder is less frequent and less severe. In contrast to the classical changes of AS in the spine the changes in hip does not lead to formation of new bones, but it results in an erosive disease, which destroys the joint. These changes start occurring fairly early on in life, and total hip replacement is often the therapy of choice in this difficult clinical situation.


In the early stages, ankylosing spondylitis is  likely to cause:

  • pain in the lower back in the early morning which eases through the day or with exercise
  • pain in the sacroiliac joints (the joints where the base of your spine meets your pelvis), in the buttocks or the backs of your thighs.
  • Hip involvement usually comes on gradually, and although the pain often is felt in the groin area, it can sometimes be felt in other areas of the body, such as the knees or the front of the thigh


In advanced stages

  • Lower back and neck stiffness resulting in bending and twisting of torso and neck
  • Fusion of hips(Hip Ankylosis)


In the past, surgical fusion of the hip was performed to reduce the pain but at the cost of losing movement at the hip joint. Numerous studies now have however proven that total hip replacement in hip ankylosis is the most favourable line of treatment. It provides patient with pain relief , near normal movement of the hip joint and perfectly normal walking pattern.


At Udai Omni, total hip replacement for a fused or ankylosed hip has a long history of over ten years. To date, we have had a 100% success rate with no failures. This is a technically demanding procedure but if done well, the results are extremely gratifying as one can see in the example seen below:


Case Review:

A 33 year old software engineer came to us in 2009 with a fused right hip that resulted in a very awkward gait. He was obviously very conscious of his disability that affected his social life as well as his work. He had been to see many orthopaedic surgeons but could never get the confidence that he would walk normally again. During my annual visit to Udai Omni hospital from the UK, this young man consulted me and agreed to get his surgery done by me. Within six weeks, he could walk independently without a limp and eventually got back to his passion of swimming.

Video of patient swimming!


Joint Replacement Summary

Update on Joint Replacement Surgery


Joint replacement surgery has come a long way over the last six decades. The most common joints that are being replaced across the world are the knee, hip, shoulder, elbow and ankle in that order.  In the USA over 700,000 knee and around 400,000 hip replacements are done annually.  These numbers are expected to rise exponentially to over 4 million procedures by 2030.  The data in India is not very robust but estimates vary between 100,000 – 200,000 knee replacement procedures. Hip replacement numbers are substantially less. Indians seem genetically more predisposed to knee arthritis compared to their counterparts in the West. The most common indication for knee replacement is osteoarthritis. In contrast, Indians seem well protected against osteoarthritis of the hip which is very common in the West.  The most common indication for a hip replacement in India is Avascular Necrosis because of injudicious and rampant use of steroids by medical practitioners.


Knee Replacement:

Indications for a knee replacement include :

  • Osteoarthrtitis
  • Rheumatoid arthrits
  • Post traumatic arthritis


When is a knee replacement advisable? I generally advise surgery in patients who have advanced arthritis when conservative measures have failed to control the pain and disability. Age should not be a criterion for advising a knee replacement.


There are two types of knee replacements : Total Knee Replacement and Partial Knee Replacement. Partial Knee replacements are done by surgeons who are trained in the procedure. Most surgeons perform a total knee as a standard procedure for osteoarthritis whether it involves a single compartment or not. At Udai Omni, we perform partial or unicompartmental knee replacement if the arthritis is limited to one compartment. About 40% of our knee replacement procedures are partial. The benefits of partial knee replacement include:

  • early recovery
  • fewer complications like MI and DVT
  • ability to sit on the floor and climb stairs
  • natural feel of the joint rather than a feeling of a lump of metal in the knee
  • ability to take part in leisure sports and activities

The success rate or survivorship of knee replacements in general are very good. Overall we are seeing a 90% survivorship at 20 years.


Many different types of implants are available. A standard implant made of cobalt chrome alloy and a polyethylene spacer is sufficient for over 90% of the patients. A ceramic coated implant like the “bionic gold” or “oxinium” prosthesis is advisable for those with allergy to artificial jewellery. There is no evidence that these implants perform better than a standard implant.


Hip Replacement:


The most common indication for a total hip replacement in India is Avascular necrosis of the femoral head. Other indications include rheumatoid arthritis, post traumatic arthritis, sequelae of childhood conditions like dysplasia, infections, Perthes’, SCFE etc.

Age is not a concern these days with advent of better materials and designs. Many patients in India tend to be young – in their 20s and 30s.


Floor activities: Traditionally, patients with hip replacements were told not to perform any activities on the floor. With better designs now available in India, a good competent surgeon should allow their patients to sit on the floor for various washroom activities and other activities like eating, praying etc. Many patients with a hip replacement get back to a normal lifestyle which can also include gentle sporting activities like badminton, table tennis, golf, trekking etc.


There are essentially two types of hip replacements – cemented and uncemented. Both perform equally well although the tendency is to do uncemented hips in the younger people. The bearing – ie the ball and the socket lining are the key for long term success. Ceramic heads and liners are generally recommended in the young and a metal head with polyethylene line may be suitable for the middle aged to elderly.


Survivorship and success of most standard hip replacements has improved significantly over the last few decades. Now, over 90% of our patients can expect their hip to survive 20 years. I would imagine this figure will get better as we follow our patients up in the future.


Enhanced Recovery after joint replacement:


Success of joint replacement, whether it is the hip or the knee depends on many factors. A well trained experienced surgeon is the key. However, other factors like patient engagement, physiotherapy and pain management are also extremely important.


At our hospital, we provide multi modal analgesia with the help of our expert anaesthetists to mobilise the patient within a day of surgery and discharge them home within 3 days on average. With advent of ambulatory selective nerve blocks and judicious use of oral and injectable analgesics, our patients mobile early and their VAS (visual analog score) for pain out of 10 is usually between 2-4. Knee and hip replacement need not be a painful experience any more.


The Future:

Surgery and joint replacement for advanced arthritis is going be around for a long time to come. There is no procedure or medicine to reverse advanced arthritic changes and deformity, whether it is the hip or the knee. No stem cell procedure or cartilage regenerative procedure will help in this regard. Media and pharmaceutical industry have a long track record of influencing the patient who would obviously prefer conservative procedures over surgery.


Industry is working on improving the performance of the implant by improving the coating and bearing materials.


Preventing arthritis by keeping oneself active and lean may be the best solution to prevent future arthritis and this avoid surgery.


Biological replacement from either ones own tissue or animal tissue is still a distant dream but a lot of work is being done across the world.

3 out of 10 People are Affected by Hypertension

What is blood pressure?

Blood pressure is simply the physical pressure of blood in the blood vessels. It is similar to the concept of air pressure in a car tyre.

What do the numbers mean?

A common blood pressure might be 120/80 (said as ‘120 over 80’). These values are quoted in units known as millimetres of mercury (mmHg). There are 2 numbers because the blood pressure varies with the heartbeat. The higher pressure (120) represents the pressure in the arteries when the heart beats, pumping blood into the arteries. This pressure is called systolic pressure. The lower pressure (80) represents the pressure in the arteries when the heart is relaxed between beats. This pressure is called diastolic pressure.

Does blood pressure change?

Blood pressure can be quite variable, even in the same person. Blood pressure goes up and down with different normal daily activities. For example, exercise, changes in posture and even talking changes blood pressure. Blood pressure tends to be higher during the day than at night and higher in the winter than in the summer. Blood pressure also rises when we grow older, particularly systolic blood pressure. Before adulthood, blood pressure rises in parallel with height. In adult years, weight and blood pressure are closely related. When weight goes up, blood pressure tends to go up and we can lower blood pressure by losing weight. Blood pressures differ between individuals. Some people have low, some average and some high blood pressure levels.

What is high blood pressure?

There are various definitions of high blood pressure, which is also known as hypertension, but most doctors consider blood pressures of 140/90 and greater to be high. The precise values that doctors might interpret as high blood pressure depend to an extent on individual circumstances. For example, in patients with diabetes, the definition of hypertension is considered by some to be pressures greater than 130/80. The definition of hypertension is used by doctors to help decide which patients would benefit from medical (lifestyle and drug) treatment to lower pressure. The definitions depend on the balance of risk of not lowering blood pressure (heart attack and stroke, etc) versus the risks of treatment (drug side effects, etc). This explains why hypertension is defined at lower blood pressure levels in diabetic subjects. For the same blood pressure, cardiovascular complications (that is damage to the heart, blood vessels and brain) are more likely in diabetics and blood pressure reduction offers benefit even when a diabetic’s blood pressure is not as high as regular definitions of hypertension.

How common is high blood pressure?

Approximately 4 in 10 adults over age 25 have hypertension and in many countries another 1 in 5 have prehypertension. An estimated 9/10 adults living to 80 years of age will develop hypertension. One half of blood pressure related disease occurs in people with higher levels of blood pressure even within the normal range.

Why is blood pressure important?

Blood pressure is important because it is the driving force for blood to travel around the body to deliver fresh blood with oxygen and nutrients to the organs of the body. However, high blood pressure is important because it leads to increased risk of serious cardiovascular disease, with complications such as heart attack, heart failure, stroke, kidney failure and blindness.

Who gets high blood pressure?

High blood pressure is more common is older age groups and in people with a family history of hypertension. It is also more frequent in those who are overweight. However, high blood pressure can affect young thin people with no family history, so no one should consider himself or herself immune from high blood pressure.

Does high blood pressure need to be treated?

It is the goal of good clinical practice to reduce high levels of pressure wherever possible in order to reduce the risk of complications such as heart attack and stroke. Changes to lifestyle such as weight loss, reduced salt intake, reduced alcohol consumption or exercise are often the first line of treatment. If these approaches don’t return blood pressure to acceptable levels then drug treatment is usually required.

How do I know if I have got high blood pressure?

The truth is you cannot know your blood pressure unless you have it measured and every adult should know his or her blood pressure. Although headaches and nose bleeds can be the result of very high blood pressure, there are many more innocent causes for these common ailments.

Can high blood pressure be cured?

Although not ‘cured’ as such, modern therapeutic approaches to blood pressure are very effective and generally very safe. However, if treatment is stopped the high blood pressure usually returns reasonably quickly.

Ref: International Society of Hypertension


Case of The Month – May 2019

A 45-year-old lady came to our hospital with a fracture of her right thigh bone following a simple twisting injury and severe pain in her spine and was not able to sit or even turn in bed. She was in agonising pain. She was fully evaluated with blood tests, PET CT and MRI scans. There was a strong suspicion of cancer in her spine as well as the thigh bone.  She underwent surgery on her thigh bone and on her spine, which allowed us to take a tissue biopsy – as a sample from the site of cancer.  The patient was mobilised with a walker after surgery, and the cancer was diagnosed as Multiple Myeloma – cancer that forms in a type of white blood cell called a plasma cell. Plasma cells help you fight infections by making antibodies that recognise and attack germs.

Following surgery, on her spine, she is almost pain-free and is now walking. She will undergo chemotherapy, which we hope will cure her cancer.

45-year-old non-diabetic female presented with complaints of:

  • Rt. thigh pain and upper back pain since 4-5 months
  • An acute increase in Rt. thigh pain after mild twisting injury 1 day back

  • Neurology: intact
x rays of the spine and fractured thigh bone


The circled area of spine shows cancer of spine

Fixed femur and sent for biopsy

Cancerous bone removed Spine stabilized with rods and screws







Swellings in the neck region are a common problem. Although a majority of them are due to benign conditions there is a rise in the incidence of malignant neck swellings in the new age world. With better understanding of the disease and with the advancement of technology, newer diagnostics and treatment modalities are now available There is scope for better survival and quality of life when the lesions are caught early.

Neck swellings can be nodal (lymph nodes)/ non nodal; benign/ malignant.




1 .Infectious mononucleosis (viral infection)

2. Diptheria, actinomycosis (bacterial)

3. Toxoplasmosis, leishmaniasis (parasitic)

4. Histoplasmosis(fungal)

5. Tuberculosis,sarcoidosis,HIV (chronic)


1. Primaries like Hodgkin’s and non hodgkins lymphoma, Leukemia

2. Metastatic from upper aerodigestive tract, Infraclavicular malignancy

3. Other draining sites like parotid, eye, scalp, skin, thyroid

Some autoimmune diseases are rheumatoid arthritis, SLE, Kikuchi, Kimura, Rosai-Dorfman, Castleman’s.

Non nodal swellings include Lymphangioma, Cystic Hygroma, Branchial Cyst, Lipoma, Sebaceous Cyst, Dermoid Cyst, Paraganglioma (Carotid body tumor), Schwannomas, Diverticulae, Laryngocele, Aneurysms, Ranula. Swellings from salivary and thyroid gland pathologies

It is nearly impossible for the common eye to differentiate whether  a benign from a malignant lesion. It is highly recommended to see a specialist without delay.


orthopedic hospital in Hyderabad

Do you need to consult VASCULAR SURGEON?

Medical world has always been evolving. Each and every medical or surgical broad speciality is branching out in to super speciality. For example earlier patients for joint related problems were treated by Orthopaedic surgeons, however, nowadays; there are Joint replacement and Revision surgeons who are Orthopaedicians specially trained to excel out in this speciality.

Vascular Surgery, better known as Peripheral Vascular Surgery is a super speciality that deals with the blood vessels of human body except those within the heart and brain.

A Vascular Surgeon is a highly trained specialist who deals with the blood vessels of our body. There are two types of blood vessels in our body: Artery-carrying oxygen rich blood to supply body organs and vein- carrying blood back to heart for purification. Smooth and uninterrupted flow of blood is essential for healthy body and “Road block” in any of these blood vessels is managed by Vascular Surgeon.

A Vascular Surgeon is trained to perform open surgery, minimally invasive Endovascular Surgery and all sorts of hybrid, complicated procedures. However, which patient to offer any surgical intervention or to treat by medicines or exercises is the key deciding factor for better patient outcomes.

The arteries of our body can become hardened (Atherosclerosis) or blocked giving rise to symptoms like Leg aches,  Leg Stroke, ulcers, gangrene which if not treated in time will end in limb loss.

The veins of our body become bigger in size and do not pump blood back to heart properly or blood clots starts forming in veins . These patients present with skin discoloration around ankle and foot, leg swelling and leg ulcers.

If you have any of the above symptoms or you have risk factors like- Tobacco intake in any form (Chewing/smoking), Diabetes , Hypertension then it’s time to consult a Vascular Surgeon!

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