Saturday, 19 March 2011

What an iro-knee !

One of the major advances in the medical science over last 50 years has been the evolution of the artificial knee and hip joint replacement surgery. Extensive past and ongoing research has led to a tremendous improvement in the long term results of the joint replacement procedures benefiting millions of patients over the years, especially in western countries. The knee and hip replacement surgery is now well accepted as the standard treatment for arthritis of these joints by the general population in these countries. The procedure allows increased mobility and functional activity, relieves pain and improves quality of life tremendously. The procedure is so sought after that in certain countries like UK, there is a waiting period for 1-2 years before surgery is performed. This is one of the reasons why medical tourism has grown in leaps and bounds in last few years in India. 
 Patients from Europe, the US and other affluent nations visit for routine procedures like knee replacement surgery either due to high cost of the procedure in their own countries, lack of complete insurance cover or long waiting times for surgical procedures.  Patients from countries with poor health infrastructure like Afganistan, Iraq, Nigeria and other African nations visit India for better healthcare facilities.  Advantages for medical tourists include reduced costs, availability of latest medical technologies and a growing compliance on international quality standards. Total knee replacement surgery in USA will cost in excess of 20,000 USD on an average, however majority of healthcare providers in India are charging 6000-8000 USD. India’s medical tourism sector is expected to experience an annual growth rate of 30%, making it a Rs. 9,500-crore industry by 2015. Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012. The major healthcare providers in the India are doing all they can to get a share of the pie and they are focusing extensively on the international patients.

Number of knee replacement surgery in India has also grown up in leaps and bounds due to medical tourism. The acceptance of joint replacement surgery as a standard treatment of severe arthritis has increased amongst the general population, especially in the metropolitan cities. Indian patients with medical insurance cover and health cover from employers are increasingly opting to undergo the surgery improving their quality of life significantly.  However, irony remains that while our healthcare providers are increasingly treating international patients with joint problems, majority of the elderly population of our country who do not have an insurance cover cannot benefit from advances in the medical science and improved health care infrastructure in India as they cannot afford the joint replacement surgery.
 On an average the cost of a knee replacement surgery in Delhi NCR area is anywhere between 2 lacs to 3 lacs rupees. Cost of the implants is a major contributor and usually accounts for approximately 30 % of the total expenditure. Almost all artificial implants, that have a proven track record, are manufactured in Europe/USA and are imported. At present, there is not even a single Indian manufacturer that is producing artificial joint implants of the desired quality and standards. There is an immense opportunity waiting for the health care providers as well for the implant manufacturers if they could reduce the cost of these procedures and implants while maintaining the quality standards. It is likely that in near future the cost of joint replacement surgery will come down substantially as Indian manufacturers will acquire the technical knowhow to produce good quality implants locally or international implant manufacturers will reduce their implant costs. If and when it happens, a large proportion of local population as well as people from other developing countries will benefit and joint replacement surgery in India will become as common as in western countries.

Friday, 11 March 2011

Ankle arthritis following avascular necrosis of talus.


Dear Michael
 
Your Xrays show AVN of Talus with arthritic changes in Tibiotlar(ankle ) joint as well as some arthritis in the Talo-navicular joint(midfootJoint). 
Unfortunately there are not many surgical options that would provide you with long term  pain relief. One of the options would be to fuse the ankle joint. This procedure will give you pain relief, but will stiffen up your ankle completely. There is not much mobility at the ankle joint currently so main benifit of the ankle fusion will be the long term pain relief. However after ankle fusion you are likely to develop pain ,discomfort and arthritis of the remaining midfoot joints few years down the line(10-15 years). If and when it happens, these joints can also be fused but they will produce further stiffness of the ankle and foot.
 
Second option will involve ankle joint replacement. This procedure is certainly feasible, should provide you with pain relief and mobility at the ankle however artificial ankle joints do not last long(5-7 years) in young individuals.  Also, poor skin condition ove the ankle joint secondary to previous injuries may complicate joint replacement surgery by increasing the chances of wound breakdown and infection. Artificial ankle implant will eventually lossen and ankle will again become painful. When it happens the usual course is to remove the artificial joint and do an ankle fusion -- which willl be significantly difficult to achieve compared to if you go for it now and will also result in significant shortening of leg as replacement involves removal of the bone from the ankle.
 
There are no satisfactory answers to your problem, however in my opinion better longterm results and minimal complications of ankle fusion makes it a better surgical alternative compared to ankle replacement surgery especially in young individuals leading an active lifestyle. Surgery should be delayed as long as possible and surgical intervention should only be considered if you have significant pain that is limiting your function and conservative treatment (injections in the joint, braces, physiotherapy and analgesia) have failed.
 
Please feel free to contract me if  you have any further queries.
Good Luck!
 
 
 

Dr Jayant Arora
MS(Ortho), DNB(Ortho), MRCS(Edinburgh)
Fellowship in Joint Replacement and Arthroscopic Surgery, Newcastle, UK

Senior Consultant Orthopedics and Joint Replacement Surgeon
Columbia Asia Hospital
Gurgaon

 

 

 

Web: http//www.arthrocure.com





Ankle Arthritis following Avascular necrosis of Talus



Patient name:
Michael Morrissey  
Age: 24 years
Nationality: Irish
Briefs: The patient had a 
road traffic accident in April of 2007 and suffered a compound fracture to the left talus. The body of the talus has become avascular. He has loss of ankle joint space. And he cannot move my ankle and he can do very little standing or walking because he suffer a lot of pain in his ankle. He is looking to avoid fusion so he is asking if there is anything we can do to help him.

 


Wednesday, 2 March 2011

Left Knee Meniscus injury and MCL sprain

 
Hi Mohit
 
I suggest that you should stop taking nucoxia  on a regular basis now and only take it if it is painful.
I suspect that the stiffness is due to MCL strain and should settle with time(it usually takes a minimum of 6 weeks for mild MCL sprains to settle). If you feel that stiffness if improving with time then wait for 2-3 weeks, it might settle as the sprained ligament heals. I would like to examine you again, you can fix up an appointment to see me at Columbia Asia over next few days.
 
Kind regards
 

Dr Jayant Arora
MS(Ortho), DNB(Ortho), MRCS(Edinburgh)
Fellowship in Joint Replacement and Arthroscopic Surgery, Newcastle, UK

Senior Consultant Orthopedics and Joint Replacement Surgeon
Columbia Asia Hospital
Gurgaon

 

 

 

Web: http//www.arthrocure.com




From: MOHIT KHEMANI <mohit85@yahoo.com>
To: Jayant Arora <arorajayant@yahoo.com>
Sent: Wed, March 2, 2011 8:24:07 PM
Subject: Left Knee Meniscus:Mohit Khemani

Doctor Jayant
Hello
Just to give you a catch up on me. I had this left knee meniscus surgery done 3 weeks back. now all dressing and the pins are out and i have been doing those two exercises half an hour a day.
Doctor the stiffness still persists. If I am sitting for a long time and get up its more. At times i also feel a slight pain in case it moves sideways..otherwise walking and driving has been really normal.
Have been taking Nucoxia 90 for 18 days now.
Is this normal or i should do something more?
Thanks a lot for your time.
Best Regards
Mohit Khemani
Ps: More info on me I am Rashmi Hingorani's Brother.




Left Knee Meniscus injury and MCL sprain



Doctor Jayant
Hello
Just to give you a catch up on me. I had this left knee meniscus surgery done 3 weeks back. now all dressing and the pins are out and i have been doing those two exercises half an hour a day.
Doctor the stiffness still persists. If I am sitting for a long time and get up its more. At times i also feel a slight pain in case it moves sideways..otherwise walking and driving has been really normal.
Have been taking Nucoxia 90 for 18 days now.
Is this normal or i should do something more?
Thanks a lot for your time.
Best Regards
Mohit Khemani
Ps: More info on me I am Rashmi Hingorani's Brother.



Friday, 18 February 2011

Tennis Elbow

One of the common causes of pain around the elbow, seen not only in fit , active, sporty individuals but also in patients with diabetes. Treatment depends on the severity of the functional deficit and varies from simple stretching exercises, ice packs, counterforce braces, NTG patches,  injection of cortisone or autologus blood and infrequently a surgical intervention.

Very rarely it can present as "Snapping Elbow".Seen one chap today in the evening clinic with snapping of the elbow most likely due to a partial tear in ERCB, awaiting  the MR results. Also came across a worm manisfestation (cystecercosis-- MRI pic above)) of the common extensor orign, presenting as tennis elbow a few months ago.

Thursday, 17 February 2011

Knee pain and arthritis in active, young individuals

Newer techniques for treatment of knee arthritis in young patients

Knee pain, stiffness and loss of function are extremely common symptoms seen in general population resulting in patients seeking treatment and advice from orthopaedic surgeons. Treatment primarily depends on the cause of pain, severity of symptoms and age of the patient. Arthritis (damage to the joint lining cartilage) is the commonest cause of pain and in majority of patients this damage occurs as a result of natural wear and tear with ageing (Osteoarthritis). In younger patients damage to the cartilage is usually localised to a small part of knee joint and often result from injury, mal-alignment (bowing) of legs. Knee replacement surgery is now a well established successful treatment for patients with severe arthritis. Total knee replacement is not indicated in patients with localised (small area) of cartilage damage due to injury and in patients with mild arthritis and mild functional deficit. Knee replacement should be avoided in younger patients where ever possible as it tends last considerably less as compared to older patients where it is expected to last 12-18 years. Artificial knees provide excellent pain relief but they lag in term of providing full functional recovery (bending, twisting movements and sensations) and hence many younger and active patients are not satisfied after knee replacement surgery.


Lot of research is being undertaken in developing treatments to preserve and to restore (repair) natural cartilage and to delay/prevent the need of knee replacement surgery. These treatments are particularly useful in younger patients and in patients with localised cartilage damage. Also some of these treatments can be performed through arthroscopic techniques (keyhole surgery) allowing quick recovery, minimal pain and early return to full function. The aim of these treatments is to repair the damaged structures, slow the progression of the damage and delay or prevent the need of  an artificial joint.

Some of the cartilage restoration techniques used in current medical practise are mentioned briefly below.
 Articular cartilage restoration techniques
Arthroscopic debridement      (knee arthroscopy)
Aided by a small camera (arthroscope) and using specialized surgical instruments like radiofrequency probes surgeons can locate damaged tissue and trim away areas of torn cartilage and remove the damaged tissue to reduce knee pain and improve knee function.
Arthroscopic microfractureAided by the arthroscope, surgeons create small holes in the area of bone with complete loss of cartilage cover – called microfractures . Stem cells are released from the holes in the bone, which then assist in healing of the cartilage defect by forming a type of cartilage covering that resembles normal articular cartilage.  These stem cells are stimulated by passive knee movement using a CPM machine following surgery to produce the cartilage.
Autologous cartilage cell implantation (ACI)Also called autologous chondrocyte implantation, or ACI, this is one of the most advanced techniques for cartilage regeneration. This technique allows surgeons to harvest cells from a patient’s own cartilage.  The cells are then manipulated using tissue engineering in a laboratory and grown in a culture. In a second procedure, the cells are re-implanted in the knee to repair and resurface areas where there’s been cartilage loss.
Osteochondral autograftThis technique allows surgeons to remove a small section of the patient’s own bone and cartilage in an area that does not bear weight to serve as donor cartilage. The donor bone and cartilage is then transferred to the damaged part of the knee being repaired.
Allograft reconstructionFor larger areas of bone and cartilage loss, surgeons can implant a piece of freshly donated cartilage and bone that eventually functions as if it were the patient’s own tissue.
Meniscus Restoration techniques
In addition to the white glistening articular cartilage that coats the ends of our bones in our joints, the meniscus is another important cartilage structure that prevents then onset or progression of arthritis (cartilage breakdown). These two pads of cartilage provide a cushion in the knee joint connection between the thighbone (femur) and the shinbone (tibia). They are crescent-shaped discs that act as shock absorbers, provide protection to the knee joint from the weight of the body and enhance stability and mobility. The meniscal cartilage allows the knee joint to withstand the day-to-day pressures placed on it by walking, running, sitting and standing.
Preserving the meniscus
Surgeons repair the meniscus whenever possible, removing only the portions that are considered beyond repair. In the past, the first line of treatment for such injuries was complete removal of the meniscus. This could lead to problems later in life, including early development of arthritis. Today, we recognize the protective value of the meniscus and do everything we can to repair or replace it.
Replacing the meniscusFor patients who have had the meniscus completely removed in a previous surgery, the missing meniscus can be replaced with a human meniscus transplant. Unlike other forms of tissue transplantation, this procedure does not require patients to be on medications to prevent tissue rejection. To replace meniscus cartilage, surgeons can sew in a new meniscus that heals and functions much like it was the patient’s own. This leads to a more stable and less painful knee that might otherwise have developed progressive arthritis.
 Lack of donor tissue remains a major limiting factor in meniscus and allograft cartilage transplant in our country.
Restoration of Limb alignment

Bowing of legs from younger age also contributes to development of early arthritis due to increased stress on inner compartment of the knee. Most of the above described cartilage and meniscus restoration procedures will fail if leg alignment (shape) is not correct. Abnormal shape (mal-alignment) of the legs can be surgically corrected by osteotomy(cutting the bone).  Patients who have Bow legs and early degenerative changes usually respond well to High Tibial Osteotomy (HTO). The aim of corrective osteotomy is to shift the stress of weight bearing from damaged part of the knee to the healthy part of the knee joint. This procedure is indicated in younger patients with arthritis affecting only one part of the knee joint.
Above procedures are indicated, either alone or in combination, in young patients with localised area of damage to the knee cartilage. However, in patients with severe arthritis or damage involving whole knee joint, irrespective of the age of the patient, knee replacement surgery is the gold standard treatment providing consistent pain relief for many years.
Dr Jayant Arora
MS(Ortho), DNB(Ortho), MRCS(Edinburgh)
Fellowship in Joint Replacement and Arthroscopic Surgery, Newcastle, UK
Senior Consultant Orthopedics and Joint Replacement Surgeon
Columbia Asia Hospital
Gurgaon
00-91-9873830947