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.

Rheumatoid Arthritis

Joints are complex moving parts of the body made up of bones and ligaments and moved by muscles. Inside the joint, the bones are lined by a smooth cartilage that allows friction free movement between the bones. The joint is covered by a capsule that has an inner lining (synovium) which secretes lubricating fluid. Arthritis means inflammation of a joint (from Greek: arthro - joint + itis - inflammation). In arthritis there is damage to cartilage. Arthritis causes the joint to become painful, swollen and stiff.  There are different types of arthritis. The commonest type is called osteoarthritis. Osteoarthritis (OA) is caused by wear and tear that occurs with age (mechanical disorder). It usually affects large weight bearing joints like the hip and knee. It is a slow process that worsens over many years and it affects the older individual. The second type of arthritis is inflammatory arthritis. In this type there is severe inflammation of the lining of the joint (synovium). There are many types of inflammatory arthritis. Rheumatoid arthritis is the most common type of inflammatory arthritis. In addition to osteoarthritis and rheumatoid arthritis, arthritis can also be caused by infection (septic arthritis) and trauma.

Rheumatoid arthritis (RA) is a type of inflammatory arthritis. It typically affects the younger individual and is more common in women. Why rheumatoid arthritis occurs, is still not clear. It is hereditary, which means that if a mother has it, her daughter is more likely to get it. It is also an auto-immune disorder. Normally the immune system of the body has mechanisms to detect foreign bodies (invading bacteria in infection) and attack them. In auto-immune disorders, these mechanisms are disturbed and the immune system starts attacking the body’s own structures (self). RA affects multiple joints. The commonest joints to be affected are the small joints of both hands and feet. In addition to the hands and feet, it can affect almost all other joints like ankle, knee, hip, wrist, elbow and shoulder. In the spine it affects the cervical spine (neck). In addition to pain, RA causes swelling of the joints and stiffness. The swelling is severe and obviously visible. The stiffness also is severe and typically occurs in the morning. It usually takes more than an hour for the stiffness to settle. RA factor is a blood test that is positive in RA. But RA is a clinical diagnosis and around 30% of RA patients will show RA factor negative. So a negative RA factor may not mean that a patient does not have RA and vice versa. RA is an aggressive disorder causing severe pain, deformity and disability. It is also a very destructive disease and disfigures the joints in a short time if untreated. Unfortunately many patients have become permanently handicapped by this disorder.

The good news is that RA can now be treated effectively. Modern medicine has made progress in the treatment of RA. There is no need for patients to suffer from this disease anymore. The usual pain killers reduce pain but are unable to control the disease and stop the destruction. Treatment of RA is with a special group of drugs called DMARD’s (Disease Modifying Anti-Rheumatoid Drugs). These drugs not only control pain but also stop the disease process. So patients have a reduction in swelling and stiffness. These medicines prevent the destruction and deformity of joints. Permanent handicap can be prevented. These are strong medicines and patients need to be monitored for side effects. In spite of this, I recommend patients to take these medications as the benefit outweighs the risk from side effects. These medications typically take 1-2 months to take effect. Also your doctor may change the combinations to find the medicines that best suit your body. Most patients tolerate these medications well for many years. We need to understand that there is no cure for RA. The disease can only be controlled like blood pressure or diabetes. So it is important for patients to continue these medications for a long period of time. Most failures in treatment are because patients stop taking the medication.

Patients who have severe pain in multiple joints accompanied my swelling and morning stiffness should visit a doctor to check if they are suffering from RA. Patients suffering from RA should take treatment with DMARD’s and continue treatment for many years if necessary. They should regularly visit their doctors to manage dosage and monitor side effects. For advanced stages of arthritis, especially of the hip and knee, joint replacement (hip replacement / knee replacement) is a boon.

To conclude, patients of RA don’t need to suffer anymore. With modern medicine, deformities and handicap can be prevented and patients can remain pain free.    

JOINT REPLACEMENT SURGERY – GETTING IT RIGHT

I’ve had knee pain since quite some time. Initially the pain was mild. It used to disappear for months after taking a few pills and doing some exercises. Slowly the pain increased and I had to take a pill every day. However I was still able to do everything I enjoyed like a long walk or a vacation or a family wedding. Now things have become much worse. My legs have become crooked. The pain killers work for a couple of hours at best. The docs say if I continue popping pain killers at this rate my kidney will break down. I cannot walk and have started to gain weight. Just the other day I visited my ortho and he said I need joint replacement surgery. O God, I’m scared. I don’t want surgery. What If something goes wrong? Neetu didi had got one done a few years back and she isn’t even walking anymore. I’d rather bear the pain and forget about surgery.

This is the situation many of us find ourselves in. Are we justified in our fear for surgery and are we better of accepting our handicap and living with it? The answer is NO. Today there is a very good chance that you can have a successful outcome from joint replacement surgery. With these few very logical tips you can maximize your chances of becoming independent and pain free.

Choosing your surgeon

This is the most important decision. For the right outcome the surgery needs to be done correctly. Joint replacement is a technically demanding surgery that requires a deep understanding, good surgical skill and lots of experience. There is a definite learning curve involved. So how do you choose the right guy? Your best chance is with a specialist. A surgeon doing 300 joint replacements a year is much more likely to get it right than one doing only 25. The other thing to look for is his reputation. A good reputation cannot be faked. One can earn it only by doing good work. Try to look for people operated by the surgeon and speak to them regarding their experience. Often you can get this list from the surgeon himself. This goes a long way in building your confidence.

You may come across an occasional patient that had a complication or bad experience. But you have to be statistically intelligent in judging that. It is stupid to drop a surgeon because one out of his 1000 cases went bad. You will never find a perfect surgeon. A good surgeon is enough.

Choosing the hospital

Generally one would leave that to the surgeon. But a patient should be aware that infection can ruin joint replacement surgeries. These surgeries should preferably be carried out in theatres with super aseptic conditions, laminar airflow and Hepa filters. Theatre condition and discipline is the most important determining factor for choosing the right hospital.

Choosing your joint

 Today information is at your fingertips. Newer prosthetic designs are flooding the market. Some promise better function, others better longevity and yet others both. Many of these designs are based on solid research and are really beneficial. However an equal number are marketing gimmicks to promote sales. One has to realize that joint replacement is a major industry and many a times new research is market based. The internet is an advertising platform. Like in any advertisement, information is blown up and full of half truths. Again your surgeon will come to your rescue. He is usually in the best position to help you make a decision. He knows the other side of the coin.

Your surgeon may have a preference for a particular joint. His preference will more often than not be in your best interest. Familiarity with a system is important to ensure the best result.  Forcing your surgeon to use a system he is not comfortable with may lead to a less than optimum result.

Having realistic expectations

This is probably the most important variable affecting the result of surgery. Don’t live in wonderland. You are not going to hop and skip and run around like a 14 year old after your joint replacement. The surgery will eliminate your pain and allow you to walk normally. But it is an artificial joint and will feel like one. Patients describe it in different ways but the underlying sentiment that the new joint doesn’t “feel normal” is constant. Having said that it is still worth getting it done because of the drastic improvement in function achieved after surgery. 

 

 With this better understanding, you can safely opt for joint replacement and become mobile and pain free again. Fear usually stems from ignorance. Once you learn about the surgery, hear from others experiences and understand the benefits and the risks involved, you will wonder why you didn’t opt for it earlier.    

A scary phase in total knee arthroplasty

Total knee arthroplasty(TKA) has revolutionized the care of patients with knee pain. This is one surgery that has given excellent results and has proved to be a boon for the arthritic knee.

Even so, TKA has its problems -

• By nature a prosthesis has a fixed life. One day it is going to fail. Just as a new car becomes old and starts breaking down, similarly a TKA prosthesis will give way in time. Much of the current research is concentrating on improving the life of the artificial joint.
  



• The second problem is that of reproducing the normal knee movements. The normal knee is a complicated joint with sliding, gliding and rotation occurring between the two surfaces as the knee bends. It is difficult for an artificial joint to mimic these movements. Hence an artificial joint is unable to flex (bend) as much. Knee bending is important especially in India for cultural and social reasons. Driven by this patient demand, there is much pressure to make designs which allow more bending (high flexion).

There are many new advances being made in this field. Many of these are truly beneficial, others still to be proved and a few of them are quite useless. Lets review some of these.

1. Unicondylar knee arthroplasty - Here only one compartment of the joint is replaced (usually the medial). The proposed advantages are that the minimal damage is done to the knee, the other 2 compartments are preserved, no ligaments are cut, surgery can be done in a minimally invasive way, revision to a total knee at a later date is easy. The good news is that the results of the unicondylar knee have come in and many centres are showing over 90% survival for 15 years. The bad news is that only a few patients qualify for this surgery (approx 7% of total patients needing surgery for knee arthritis). This surgery has disastrous results in improperly selected patients (beware of the over enthusiastic surgeon). Another thing the surgeon will not tell you is that a high tibial osteotomy, which is a simpler and cheaper procedure, works just as well. Further revision to a total knee has been cited by many authors to be difficult, disproving an earlier claim.
   



2. Minimally invasive surgery (MIS) - There is a lot of interest and media hype about minimally invasive surgery. Unicondylar knees are usually done the MIS way. TKA is also being done with MIS with or without the help of computer navigation. MIS basically means to do the same surgery through a smaller incision with lesser trauma to tissues. Well this concept sounds very appealing, doesn't it ? MIS surgery does allow faster rehabilitation, but the results are the same at the end of 3 - 4 months. Further, because access is not as good as the routine incision, some surgeons have reported errors in making the bone cuts and therefore in the position of the final implants. MIS is not as big an advance as it is being promoted. The advantage gained is not worth it if it is at the cost of implant alignment. I feel a properly aligned routine TKA would work just as well.
   



3. Computer assisted surgery (CAS) - Does computer navigation improve TKA results? The only thing that has been proved, is that it improves coronal alignment. Whether this translates into better longevity of the joint is still to be proved. CAS is as good as the operating surgeon. The surgeon needs to feed the computer information about the patients body parameters. He does this by placing probes at fixed points which transmit information to the computer via infra red rays (referencing). Using this information the computer creates a virtual model of the patient's knee. Over here lies the problem. There are a lot of errors in referencing. If wrong information is fed to the computer, wrong information is going to come out. Garbage in is garbage out. And yes, let me make it clear, the computer is not doing the surgery. To summarise, CAS is here to stay and will be indispensable in the future, but today it is of doubtful benefit in routine cases. However it is very useful in complicated cases, like those with deformities.
   



4. High Flex Knee - This is one of the new knees that have come into the market. As the name suggests it promises a greater degree of bending of the knee by virtue of its design. But post operative knee flexion depends on many things such as the preop range of motion, the type of arthritis, the weight of the patient etc. Some patients will get flexion and some will not, no matter what implant. So all that this implant does is give those patients who were anyways destined to get good flexion, some more flexion. Even this is doubtful as many reports have come in that the results are the same, high flex or no high flex. Besides there is a real concern that this design may actually accelerate prosthesis damage by increasing stresses.
   



5. The rotating platform Knee - This is another attempt to reproduce normal knee movements. By virtue of its design this knee allows some rotation that usually takes place in the normal knee. The proposed advantages are more knee bending and less prosthesis ware and a longer prosthesis life. Unfortunately most reports of long term follow up show no difference in either knee function or prosthesis life.

To conclude there are many attractive & new things happening in knee arthroplasty. A lot of people out there are trying to sell you something new claiming it to be better. But new is not always better. The routine TKA is still the gold standard and it has been proved time and over. This is a very scary phase in TKA surgery and I warn the patient/consumer to do their homework thoroughly before deciding to go ahead with a new and fashionable surgery.

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Suffering from Rheumatoid Arthritis ? .....are you getting a raw deal ?

The sad news is that rheumatologists are still treating RA sub optimally. If this is the scenario with rheumatologists (experts), imagine what orthopaedic surgeons and G.P.'s must be doing ?
Rheumatoid arthritis is a chronic debilitating condition that causes an inflammation of multiple joints. It is an autoimmune disorder, i.e. the body's immune system attacks the joints.

Today RA can be treated effectively and successfully. By current standards patients should have high expectation from treatments and most patients should be doing well. But, in India this is far from true. Literature reveals shocking information. The so called experts are just not delivering the goods.

So, is your rheumatologist doing the right things ? lets find out ...
I've listed ten things any decent rheumatologist should be implementing in his practice.

1. DAS28 - the disease activity score using 28 joint counts. This score is used to objectively monitor disease activity. It has been extensively validated. At each clinical assessment the doctor fills out a DAS28 form. A DAS28 less than 3.2 means low disease activity, and a score of less than 2.6 means that the patient is in remission. Remission is the goal of treatment. At each visit a scoring is done and if it is high, a positive measure is taken in the form of adding/changing a drug or increasing dosages. With objective assessments remission is achieved faster.

2. VAS - visual analogue scale. This is part of the DAS28 scoring system. It is used to more accurately measure pain. Attributing adjectives like mild, moderate or severe to a patients pain is not good enough. The patient marks a point on a 100mm line, depending on the severity of his pain. 0 - no pain, 100 - very severe pain. The measurement in millimetres from 0 is the VAS score.

3. HAQ - health assessment questionnaire. It is another useful way to assess disease activity.

4. TICORA - tight control of RA improves outcomes. Tight control means a visit to the rheumatologist every month. A DAS28 score is taken at every visit. All with scores greater than 2.4 should have an escalation of drug therapy.

5. DMARDS - disease modifying anti rheumatoid drugs. Anti inflammatory drugs alone are not effective in RA. DMARD's are drugs that have been found to revert the disease process and induce remissions. Problems include slow onset of action and significant side effects. Methotrexate is the commonest DMARD used. DMARD's are usually used in combinations.

6. Intra articular steroid shots - This is a very effective treatment modality. It is used as an adjunct to DMARD's to improve DAS28 scores.

7. Leflunamide - trade name ARAVA. It is a newer addition in the DMARD list. It is a promising new drug.

8. Biological agents - These drugs are the new happening thing in RA. RA is an auto immune disorder. The immune system causes an inflammation of the joint with the help of pro inflammatory molecules. The biological agents inhibit these pro inflammatory molecules, thus decreasing inflammation in RA. Eternacept and infliximab are the 2 agents available in India. The results of these drugs are very promising. On the downside they are very expensive. As they inhibit the immune system, some serious infections have occurred in patients taking these drugs. But with due care the risk is low.

9. Exercise - As an adjunct to medicines, the importance of exercise cannot be ignored. Exercises improve outcomes, restore function and add a feel good factor.

10. Surgery - Last but not the least is surgery. Timely surgery in RA, can help maintain function and relieve pain.
    

So if your suffering from RA, you can do something about it. If your rheumatologist has no clue about DAS 28, ditch him. But before you go, do the poor guy a favour and teach it to him.

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Chikungunya Fever

I was surfing the net for info on Chikungunya fever. I came across a review on Harshad's Site. I think he has written an excellent review and it is a must see for anyone wanting to know more about the disease.
Some excerpts from the review are

"The name has been derived from a Makonde word meaning that which bends up reference to some victims' inability to walk up right........
The history of Chikungunya outbreak in India dates back to 1824 whereas the virus was first isolated in 1963 from Kolkata. 4 The viral activity in humans have been observed till 1971......The present outbreak in India started during December 2005 where the country has so far experienced more than 11,00,000 (11 lakh) of Chikungunya infected cases which still continues. 6 The cases were first reported from Andhra Pradesh, one of the worst affected states. Subsequently reports were poured in from several districts of Karnataka, Kerala, Maharashtra , Orissa, Madhya Pradesh, and Tamil Nadu. Even Andaman experienced the first Chikungunya epidemic during June 2006. Presently the outbreak is underway in western parts of India specially Gujarat and Rajasthan. "

Essentialdrugs has a good article about the possible use of chloroquin in the treatment of arthralgia associated with Chikungunya.

Lastly a word about Chikungunya prevention. Its simple - 'avoid mosquito bites'. This is not something new for us Indians. Still I'd like to say again

• Eliminate stagnant water to avoid breeding of mosquitoes - avoid clogging of water pipes, cover all water tanks, get rid of outdoor containers retaining water like food cans and renew water in flower vases.

• Use insect repellants

• Use mosquito nets

• Wear long sleeve clothes of a light shade

• Apply 20 - 50 % DEET (N, N-diethyl-meta-toluamide)

• Apply 0.5% Permethrin spray on clothes

• If there are large collections of stagnant water in your neighborhood, inform the authorities (hopefully they will spray the area)

Intra articular steroid shots work for OA knee

Many patients suffer from painful knees. The common cause is osteoarthritis. Most patients can be managed by medicines and exercise. Some will need surgery.
However a significant number are in between. What I mean is that medicines don't help and their knees are still not bad enough for surgery.

Should these patients be considered for intra articular steroids? Traditional teaching says that they do not work for OA. Further they are likely to accelerate the joint deterioration.

Marshall Godwin ET AL., have done a study of literature to answer this question. Does traditional teaching hold any water?

They found that steroid shots have been proved to be useful, giving a statistically significant reduction in pain one week after injection. The beneficial effects could last for up to 4 weeks, but is unlikely to continue beyond that. Furthermore, there were no reported adverse consequences. Evidence for accelerated joint deterioration is weak. Radio graphic examination did not show worsening.

The conclusion - A steroid shot is an important tool in the treatment of osteoarthritis, and patients with painful knees should not be denied their benefits.