Knee Arthroscopy

Arthroscopy is a procedure in which the inside of a joint is visualised using advance camera and lighting equipment. Technology has allowed both the camera and the light source to be incorporated in a thin tube. This tube can be introduced inside the joint through a very small incision or cut. The name key-hole surgery has been coined for arthroscopy as it is minimally invasive. Knee arthroscopy has many advantages. The interior of the joint can be completely visualised by this procedure. As it doesn't require a lot of skin and tissue cutting, it can be used as a diagnostic tool. Because the arthroscope tube is thin, we can visualise areas at the back of the knee which are difficult to see in open surgery.  As the surgery is done through small holes, postoperative pain is minimal and recovery is very quick.

Knee arthroscopy has revolutionised treatment of certain problems. A classic example is synovitis or thickening of the lining of the knee. Synovitis can happen due to various reasons. Sometimes it is necessary to remove a part of the synovium (or lining) as a biopsy. In other cases it is required to remove the entire lining as treatment. Formal open synovectomy (or removal of lining) was a major surgery that led to postoperative pain and knee stiffness. Besides some synovium would remain behind at the back of the knee due to difficult access. With arthroscopy, total synovectomy can be achieved with minimal pain and stiffness.
 
Another area where arthroscopy has made tremendous progress is in the field of ligament and meniscal injury. The commonest ligament which gets injured during a sport or road traffic accident is called the anterior cruciate ligament (ACL). Once this ligament is injured, it leads to instability. The patients knee buckles every now and then and he/she loses balance and may fall. The patients describe the problem as a 'wobbly knee' and get a typical 'giving way' sensation in the knee. These repeated instability episodes eventually wear out the knee and patients end up with knee arthritis in a few years. In earlier times there was no good solution for this problem. Open ligament reconstruction procedures were fought with failure. All this changed with the advent of arthroscopy. Nowadays arthroscopic ligament reconstruction has become an extremely successful procedure. The patients own hamstring muscle tendon is harvested and a new ligament is made by folding the tendon on itself. This new ligament is then fixed into pre-drilled tunnels in the patients thigh and leg bone to become the new ACL ligament. This eliminates instability so efficiently that patients can start playing contact sports like football after the procedure. The patients knee is restored to its original state and any further wear and tear is arrested. It has now been proved beyond doubt, in multiple studies done internationally that results of ACL reconstruction are much better than non surgical treatment.

The meniscus is a thick structure found inside the knee joint which acts like a shock absorber. Just like the ligaments, the meniscus can also tear due to injury. A meniscal tear classically causes pain and locking of the knee. The locking occurs because the torn meniscal fragment gets stuck between the two bones. Repeated locking episodes lead to pain and swelling. Before the advent of arthroscopy, it was very difficult to treat meniscal tears. Surgeons ended up removing the entire meniscus which was not only unnecessary but also harmful as it lead to early degeneration of the knee. With arthroscopy it is now possible to tackle only the torn fragment. Either the torn part is removed and the rest of the meniscus is left behind or the torn fragment is repaired. Again arthroscopy allows the knee to be restored to its original state.

Arthroscopy is a major advance in orthopaedics and it is now being successfully utilised in solving problems of other joints as well like the shoulder. Patients should be aware of the benefits of arthroscopy and must take advantage of this science when required.

...ANYTHING BUT SURGERY!! (PART 2)

In the last article, I discussed treatments for knee arthritis that have poor results but are aggressively marketed to make quick profits! These treatments are experimental or commercial, many are non scientific and most result in a huge waste of money for the patient.

So if these treatments do not work, which ones do? What does authentic scientific research say? Why is this scientific research so important? If a particular medicine works for one person without side effects, can it be recommended for all? You may think why not? We do it all the time! Most of us have seen some medicine or treatment work very well in our friends or relatives. Then we start recommending that treatment to everybody! What’s wrong with that?

The problem is that a treatment that works for one person may not work for another. A treatment that is safe for one person may not be safe for another. That’s where scientific trials and statistics come in! If there are hundred patients, scientific evidence tells us if a treatment works for all 100 or it works for 75 out of 100, or 50 out of 100 or for only 10 out of 100.

Now let’s consider the treatment that worked for our friend. What if that treatment worked only in 10 out of 100 and caused side effects in 80 out of 100? Our friend was lucky, wasn’t he? With this information, will you start recommending this treatment to everybody? I’m guessing – NO!

There are multiple scientific review committees all over the world who have formed recommendations for knee arthritis by looking at research, evidence and statistics. The effectiveness and safety of these recommendations has been solidly proven. So what are these recommendations? These recommendations are for osteoarthritis of the knee. They are not for arthritis affecting other joints or for rheumatoid arthritis which is different type of arthritis.

Recommendation – patient education. Education by the doctor, physiotherapist or counsellor or patient self education from books or internet tremendously helps patients with arthritis. One may wonder how? Most fear and anxiety is out of ignorance!  Patients who learn about the problem, how and why it has happened to them, what will make it worse, what will make it better etc are less anxious. And as anxiety goes down, so does pain. Patients with knowledge look after themselves better, are more likely to follow advice and treatment recommendations and stay away from quack therapies.

Recommendation – weight loss. Weight loss is strongly proven by multiple studies in different countries to help decrease pain in patients with knee arthritis. I have written about weight loss in a previous article. It’s not easy to lose weight! But it’s not impossible like most of my patients think. It is a full time job. It requires huge efforts and 100% commitment. A conscious effort to adopt a healthy diet, reasonably restrict quantity of food consumed and daily exercises will result in weight loss in 9 out of 10 people. The problem is that we are lazy. We don’t want to put in any effort. We want some magic medicine or some belt or some therapy to melt the fat away. Unfortunately none of these work!

Recommendation – exercise. Exercise is a recommendation that I give all the time. I have written extensively on exercise in the past. I have dedicated multiple articles on the subject. This recommendation is backed by solid scientific research! Exercise is the magic pill you are looking for. It’s cheap and has no side effects! And it works. And it will work in all patients. But a lot of my patients tell me ‘exercise didn’t work for me!’  Exercise does not work in 2 situations. First is when arthritis is very advanced. And the second and most common reason is that patients don’t do exercise properly. Exercise is something which is taken very lightly. People will go to driving school for a month to learn to drive their car but will refuse to go to a physiotherapist for 10 days to learn the right way to do exercise. People will research the internet thoroughly to find a good doctor but will not research to find the different types of exercise that will benefit them. Exercise is a gold mine, my friends. The physiotherapist and the doctor will only show you the way... they will only show you the tip of the iceberg. It’s up to you to dig deeper after that. 10 minutes of doing a few repetitions when you wake up in the morning doesn’t help. You have to spend effort and time to achieve results.

Recommendation – braces and footwear modification. There is no strong evidence in scientific literature for or against braces (knee caps and belts) and footwear modifications. There is no harm in trying braces! Patients who find benefit in braces should continue to use them.

Recommendation – assistive devices for walking. Again... a very effective recommendation. Using a walking stick decreases pain and increases the distance that the patient can walk. It would also decrease the requirement for medication, buy time and postpone surgery. But most patients refuse to use a stick because of some misplaced sense of shame! As a patient, I would give little importance to what other people think especially because I am suffering and others are not!

Recommendation – medication. So which medications are recommended for arthritis? Is there a medicine that will cure the problem? The answer unfortunately is NO. No medication, whether it is allopathy, ayurveda, homeopathy or Chinese has been conclusively proven to cure knee arthritis. Lot of them ‘claim’ to cure arthritis but there is no concrete scientific evidence. That means that the chances that a particular medicine will work for you are as good as the chances that drinking a glass of water will work! Another common misconception is to take calcium supplements for arthritis pain. Osteoporosis or weak bones is a problem that accompanies arthritis or joint inflammation. Calcium supplements are used to treat osteoporosis. They have no role in the management of arthritis.

Medications are however recommended to control the pain of knee arthritis. The main medication is Acetaminophen (Crocin). Acetaminophen is a mild analgesic with a very good safety profile. It does not cause acidity in majority of people and does not affect the kidney even with long term use. It has been scientifically proven to be safe even if used for a long period of time. Other analgesics (pain killers) can be used as short term treatment to control attacks of severe pain. Topical analgesics (pain killer ointments) are also strongly recommended and useful. They are also safe for long term use. What about Glucosamine? There have been extensive studies carried out on the effects of glucosamine. The results say that all it does is give relief of pain in some patients. It does not cure the problem or cause cartilage to grow back. It is safe. The recommendation is to use it (if you can afford it) only if it gives relief from pain.  

 To conclude, I recommend my readers to develop a scientific outlook while assessing treatments especially new miraculous cures promoted by aggressive marketing. Here Science, Statistics and Evidence all become your friends as they protect you from being cheated of your time, energy and hard earned money!

Recommendations from

•        AAOS 2008 (American Association of Orthopaedic Surgeons)

•       OARSI 2007 (Osteoarthritis Research Society International)

•       NICE 2009 (NHS, UK)

•       RACGP 2009 (Royal Australian college of General Practitioners)

•       NGC 2007 (Singapore)

•       EULAR 2003 (European League Against Rheumatism)