Joint replacement and Arthritis

Arthritis means inflammation of the joint, which means there is pain, swelling, tenderness around joint. This simple looking disease arthritis is of many types. It’s important to know which kind of “Arthritis” one is suffering from. This will make you able to nip it in the bud and control this deadly disease easily.

In India osteoarthritis, i.e. degenerative arthritis, which affects the knee, is more prevalent with every third person above the age of 70 years affected. The incidence of rheumatoid arthritis is little less than in the West.

More than 20 crore Indians are suffering from arthritis. Let us talk how to manage osteoarthritis. Since this is degenerative in nature so we should all understand how to prevent it. 

Knee  joint replacement is adviced for:

Advanced knee osteoarthritis or arthritis, where conservative therapy (NSAID medication, knee injections for 6months or more) has failed.

Inability to work because of knee pain.

Inability to sleep through the night because of knee pain.

inability to walk more than 50-100 meters because of knee pain.

Loose knee prosthesis.

Some knee fractures.

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We can prevent it by followings:

1.         Reducing weight  

2.         Regular physiotherapy – strengthening muscles around knee like quadriceps and hamstrings.

 3.         Maintaining strong bones by keeping normal Bone Mineral Density (Normal value is T score – 1 and above). Regular walking.

 4.         Maintaining normal vitamin D 3 levels. A recent survey showed that health personnel are vitamin D 3 deficient to the tune of 65%. This is an eye opener report as we think that medical illness is not meant for us.


In spite of all the preventive measures osteoarthritis affects people and the affected person feels the following features:

1.         Pain while climbing stairs more on coming down. The person looks for railing to catch hold   

2.         Seeking for some support to get up from sitting on ground.

3.         Experiences some cracking sound while bending knees.

4.         Avoid going to Indian toilet and prefers western commode.                                               

5.         Usually feels pain on inner side of knee joints.

6.         Stiffness around knee joint.

And when you see their knees you will find there is disturbed knee alignment.

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You might have observed that if knee is aligned normally then there is about 7 degrees of valgus between femur and tibia that is leg goes outward from thigh by 7 degrees. In osteoarthritis this valgus alignment is reversed to knee varus i.e. leg comes inside from thigh. Look the following pictures, which are self-explanatory.

You can observe that the weight bearing line is passing from the centre and the whole knee joint cartilage (circular surface) is taking part in weight bearing.

Observe that in osteoarthritis inner joint space is reduced. There is extra pressure on medial side of joint. Cartilage is denuded; underlying pain nerve endings are exposed and give pain. The weight bearing line is shifted to medial or inner side of knee. Therefore, whatever cartilage is left is not taking part in weight bearing. Weight is borne by the inner small point focused area where the cartilage is denuded so nerve endings are exposed to give you pain, the moment the person puts weight on it.

To bring

1.         Healthy remaining cartilage to take part in weight bearing

2.         So that weight is borne by the healthy cartilage and pain is avoided

3.         And to offload medial or inner angle of knee joint from excess pressure

We need to change present alignment of the knee and bring it back to the normal, which is 7 degrees of valgus. High Tibial Osteotomy (HTO) does this safely and simply. One of the ways to do HTO is shown here. A triangular piece of bone has been removed to realign the knee joint.


  



When you close the wedge normal alignment is achieved. By its virtue following things happen.

1.         Normal healthy cartilage starts taking part in weight bearing so pain of the person goes away.

2.         Excess pressure from medial (inner) cartilage goes away.

3.         Since the inner angle is offloaded the cartilage gets a pressure free environment to grow freely.

See the real X-ray pictures showing how they look in affected knee and what happens when HTO is performed.


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Similar problem can also be tackled by Total Knee Replacement (TKR) surgery, especially when all three compartments of knee cartilage are damaged. In this we shave of ends of femur and tibia and replace by an artificial metal joint, which has certain life.

Advantages of HTO surgery:

1.         Since it is not performed at joint level so the knee joint movements are not restricted.

2.         Your God given natural cartilage is not excised.

3.         Cartilage is provided suitable pressure free atmosphere to grow.

4.         It’s cheaper.

5.         Can be performed in all operation theatres.

6.         Complications are negligible and are never dreadful.

Let us see how we Indians are different from the West.

The need in today’s scenario is to provide best and customized treatment, which is most suited to that particular person. Still there is a huge common cohort of osteoarthritic people who can be offered either TKR or HTO. Responsibilities lie upon we doctors to see what procedure suits most to that particular person, rather than driven by many other things.

Now world is changing, more and more importance is being given to the conservation of natural, God given things. HTO is one of these natural cartilage-preserving techniques. This should be used in abundance in suitable persons to provide relief to the arthritic population of our country (rather the whole Indian subcontinent) who has different social customs then the West.




Why ‘new’ knee isn’t the final answer

http://health.economictimes.indiatimes.com/news/diagnostics/why-new-knee-isnt-the-final-answer/58993555

“Nearly 30-35% of knee replacements conducted in the country are unnecessary. At AIIMS, we have been holding awareness programmes to educate patients about the need to focus more on lifestyle modification than surgeries,” said Dr C S Yadav, professor of orthopaedics, AIIMS.



Total Hip Joint Replacement - THR / THA

Conditions that may contribute to the need for a hip replacement include bone cancer, osteoarthritis, rheumatoid arthritis, and bone deformity. The most common indication for a total hip replacement is osteoarthritis which may be primary or secondary.

The hip joint may be replaced with a variety of material, including metal, polyethylene, and ceramic. A joint prosthesis is identified as a total hip replacement if both the articular surfaces of the acetabulum and femur are replaced.

In USA m ore than 120,000 total hip replacement are performed annually. A 3% prevalence of prosthetic loosening and a 1% prevalence of prosthetic infection. 

Why is this procedure performed?

Usually, treatment for hip problems begins with pain medication and physical therapy to control discomfort. If this fails, doctors may suggest a hip replacement. Because hip problems cause pain, decrease a person's mobility and range of motion, and affect social or daily activities, hip replacement presents an appealing option for people in reasonably good health.


COMPONENTS OF HIP ARTHOPLASTY: 

1) Acetabulum: Polyethylene plastic (with or without metal backing) or lucent polyethylene plastic acetabular component may contain metal wire. Prosthesis fixation to bone may use cement, spikes, screws or may be cementless (bone ingrowth or press fit).

2)Femoral stem composed of metal, femoral head composed of metal or ceramic.

Fixation may use cement or may be cementless (bone ingrowth or press fit).


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COMPLICATIONS:

Early complications include dislocation, improper placement, and cement extrusion, DVT, fractures. 

Late complications include implant failure, osseous fracture, heterotopic ossification, loosening, infection, and aggressive granulomatosis (or particle disease), implant failure, heterotopic ossification, loosening of a prosthesis.

Absolute contraindications to total hip replacement include sepsis, a remote source of ongoing infection, muscular dysfunction and severe vascular disease. Relative contraindications include medical conditions that preclude safe anesthesia and the demands of surgery and rehabilitation.

How should I prepare for this procedure?

Your complete medical history will be documented and an examination of the hip will take place before the procedure. The doctor performing the procedure may also request other tests to understand your joint's performance.
  1. routine blood tests as in any major surgery
  2. Bone density tests
  3. magnetic resonance imaging (MRI)
  4. specific checkups for chronic diseases
  5. urinalysis
  6. X-ray
Patients with ischemic heart disease, congestive heart failure, and chronic obstructive airway disease should be seen by a medical specialist or anesthetist.
 

The aim of total hip replacement is to resurface the deficient and damaged joint surfaces with a low-friction articulation.

Selection of regional or general anesthesia is made following preoperative discussion between the anesthetist, the patient and input from the surgical team. The operation should be performed in a laminar flow operating theatre with meticulous attention to detail to prevent contamination of the operation site.

The patient is recovered and usually observed for a 24-hour period in a high-dependency ward. Adequate hydration and analgesia are essential in this time of high physical stress.

Drains are usually removed within 24 hours, and the patient is encouraged to walk on the second postoperative day. At this early stage, the patient begins hip exercises. These are continued under the supervision of a physiotherapist until discharge. Continual improvement is generally observed, and discharge occurs in 5-7 days. Discharge is only recommended once wound healing is satisfactory patient able to walk with crutch support and no complications are present. 

PHYSIOTHERAPY often continued at home for a period of time. The first outpatient review generally is in 2 weeks then 6 weeks and after 3 months.

Follow-up care: Follow-up depends on the surgeon, the patient, and the health care system. A typical example would be a surgical follow-up appointment at 6 weeks, 3 months, 6 months and then every year. This is modified for each patient according to age, degree of activity, and presence of complications.

We strive to provide exceptional & cost-effective medical care that improves the quality of life for patients who suffer from joint diseases and disorders. Here's what you can expect from us.

  • Personalized services
  • Comprehensive diagnosis
  • Effective treatment and surgery
  • Diligent Post-operative attention
  • Pain Management
  • Physiotherapy and Rehabilitation program
  • All these at very affordable prices


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