Steroid injections, physio and fish oils: what really works for painful knees?--- Dr Jayant Arora answers some of the common questions his patients ask about knee pain.

It’s not until your knees start hurting that you realise how much work they do. So, which problems should you worry about, and which treatments work and which won't.....

Our knees are a marvel of engineering. They take quite a battering over the course of a lifetime, especially an active one; knees bear our full weight when we’re standing, with extra force when we run, jump, twist, go up and down stairs, kick a ball or run around a tennis court. Little wonder knees are susceptible to short-term (acute) injuries and long-term (chronic) problems such as osteoarthritis (“wear and tear”). Most acute knee problems get better without specific treatment, and the best initial treatment for chronic knee pain is exercise and weight loss.Other options include simple painkillers, physiotherapy, steroid injections, cartilage and ligament repair, and total knee replacement. Claims are made for dietary supplements and spices such as fish oils, turmeric and glucosamine. Newer therapies being investigated include injecting the knee with hyaluronic acid, stem cells or platelet-rich plasma.

Does it matter if my knees pop or crack when I squat?

A popping or cracking noise does not matter if there’s no pain, swelling or difficulty moving your knee. The alarming sound can be caused by air bubbles popping in the joint fluid or ligaments and tendons snapping back into place after moving or catching on bits of bone or cartilage. If you also get pain, swelling or find the knee catches in certain positions, you may have a small cartilage tear. Most minor tears get better without specific treatment within six weeks; if not, see your Doctor.

I have heard people talk about ACL and meniscal tears. What’s the difference?

It helps to visualise the whole knee. The joint between the femur (thigh bone) and tibia (shin bone) is helped by the patella (kneecap) and stabilised by four powerful ligaments, which are fibrous bands between the bones (anterior and posterior cruciate – ACL and PCL – which cross the joint space, and lateral and medial collateral – LCL and MCL – which run down either side of the joint). The strong quadriceps (thigh muscles) are attached to the patella via a tendon and are key to the smooth movement and stability of the joint; strong quadriceps make for strong knees. Cartilage lines the surfaces of femur and tibia to prevent bone grinding on bone, and two cushions of cartilage (menisci) sit in the joint as shock absorbers. Most cartilage and ligament tears get better on their own within a few weeks, but surgical repair is sometimes needed. An ACL tear is a common sports injury that makes the knee painful and unstable. It particularly affects footballers, badminton and tennis players who stop or change direction suddenly or get a direct blow to the knee during a tackle.

I’ve got patellofemoral pain syndrome; should I give up my gym membership?

Patellofemoral pain syndrome often affects young, sporty women and is a fancy name for the dull ache and crunching sound you get at the front of both knees around the kneecap. It can be worse after sitting for a long time, pounding up and down stairs, kneeling or doing squats. Ice packs and anti-inflammatory gel or tablets help in the short-term, and exercises to strengthen the muscles around the knee may solve the problem. You may have to change your exercise regime; walking and cycling in place of running and jumping. Giving up the gym is your call but you would be advised to stay active for your physical and mental wellbeing.

My knees are weak; should I avoid running?

Not necessarily. Professional athletes, runners and footballers certainly get knee injuries as an occupational hazard. But for the rest of us, the evidence suggests that even long-distance running doesn’t increase the chances of developing osteoarthritis. Older runners with mild osteoarthritis don’t seem to make it worse if they keep on running.

I’ve been told that my knee pain is osteoarthritis and there’s nothing I can do. Is that really true?

No, there’s lots you can do, but it’s not about heroics or headline-grabbing new therapies. It’s essential to keep exercising and lose weight. “If people lose weight, their knee pain improves, and if they need surgery, they do better.” People can take a low dose of mild painkillers if they need something to keep active, but  use of regular use of opiates and NSAIDS(Brufen, Voveran etc) taken regularly can cause  huge problem in the form of dependence or Kidney damage. Steroid injections help some people in the short-term, but injections of platelet-rich plasma, stem cells or hyaluronic acid haven’t been shown to have any long term benefit in arthritis. These may provide short term pain relief and may delay need for surgery by a few months

I get occasional knee pain and my X-ray shows severe osteoarthritis; should I have a knee replacement? 

It’s best to treat the person, not the X-ray. X-ray and MRI findings don’t correlate well with symptoms; you can have an awful-looking X-ray but not suffer much pain or stiffness, and vice versa.  You should not consider undergoing  a knee replacement until your symptoms are severe and you have tried other options such as exercise regimes, weight-loss and painkillers. Rapid developments in technology like robotics, patient specific knee implants etc. mean that partial and full knee replacements are likely to become even safer, more effective and long lasting in the coming years.

Ever since I Googled “knee osteoarthritis” I have been bombarded by things to buy and try. How do I know what works and what doesn’t?

Look at evidence and price. Does it work? Does it cause any harm? Is it worth the money? The trial evidence to date is that acupuncture doesn’t work, but it’s safe and may help some individuals. There’s a lack of evidence for the effectiveness of a Tens machine, but is cheap and safe. Lateral wedge insoles can be bought online and put in shoes to take pressure off the knee; evidence is weak, but they’re cheap, safe and sometimes effective. Glucosamine and chondroitin supplements are popular, but there’s no evidence that they have any benefit in delaying arthritis. The yellow pigment in the spice turmeric (Curcumin) contains chemicals that are said to be beneficial in osteoarthritis, but it’s likely you would have to eat 4-8 capsules a day for any significant effect

What about a steroid injection or Lubricating Gel injection?

Steroid injections alone or with combination with Gels into the knee joint can provide rapid relief from pain, swelling and stiffness. The effect lasts up to three months or more. But the evidence is inconclusive; 44% of people given a steroid injection reported an improvement in pain compared with 31% given a saline injection. The effect is bettter in patients who are sedentary, not obese and with moderate xrays changes of OA. Late stages of arthritis show no improvement in pain with any injection and thesde are a wate of time and money.

Knee replacement surgery in Gurgaon by Dr Jayant Arora

Mr AD, a 67 -year-old gentleman seen two months after his bilateral knee replacement surgery done by Dr Jayant Arora , at Columbia Asia Hospital, Gurgaon. Patient has recovered well and has regained  complete movement. This was possible due to advanced surgical techniques and high flex knee implants.

For further information please feel free to contact Dr Jayant Arora at

Dr Jayant Arora
1. Gurgaon  Knee and Shoulder Clinic.
Mon-Sat : 5.30- 8.00 pm
 570,  Sector 56, Behind Jalvayu towers.
For appointments  contact 01244214431 or 9999847468 or visit www.gurgaonkneeandshoulderclinic.com

2.Columbia Asia Hospital
Mon - Sat 8.00- 4.00 pm
For appointments 01243989886

Partial Knee resurfacing-- an excellent alternative to Total Knee replacement surgery.

What Is Partial Knee Replacement?

Dr Jayant Arora explains the benefits of Partial knee replacement. Gurgaon Knee and shoulder Clinic offers Partial Knee replacement to patient suffering from Knee arthritis as an alternative to Total knee replacement.

A partial knee replacement is an alternative to total knee replacement for some patients with osteoarthritis of the knee when the damage is confined to a particular compartment of the knee. In the past, partial knee replacement was reserved for older patients who were involved in few activities. Now, with better implants and improved surgical techniques, more patients are being considered for partial knee replacement compared with a few years ago. About 15% to 20% of patients with arthritic knees are estimated to be eligible for partial knee replacement.

What is a partial knee replacement?

In a partial knee replacement, only the damaged part of the knee cartilage is replaced with a prosthesis.

What are the advantages of partial knee replacement over total knee replacement?

Compared to total knee replacement, partial knee replacement better preserves range of motion and knee function because it preserves healthy tissue and bone in the knee. For these reasons, patients tend to be more satisfied with partial knee replacement compared with total knee replacement, and they are still candidates for total knee replacement should they ever need it in the future. There is also less blood loss during surgery, and knee motion recovers faster with partial knee replacement.

Small Incision 

What is recovery like?

Because a partial knee replacement is done through a smaller, less invasive incision, hospitalization is shorter, and rehabilitation and return to normal activities is faster.

Patients usually experience less postoperative pain, less swelling, and have easier rehabilitation than patients undergoing total knee replacement. In most cases, patients go home 1 to 3 days after the operation.

You will begin putting weight on your knee immediately after surgery. You may need a walker, cane, or crutches for the first several days or weeks until you become comfortable enough to walk without assistance.

A physical therapist will give you exercises to help maintain your range of motion and restore your strength. You will continue to see your orthopaedic surgeon for follow-up visits in his or her clinic at regular intervals.

You will most likely resume your regular activities of daily living by 6 weeks after surgery.

People undergoing partial knee replacement surgery, in which only the parts of the knee affected by osteoarthritis are removed, have fewer complications, are less likely to be readmitted to hospital and less likely to have serious complications, the researchers found.The main benefit of the partial knee is that it provides better function.

We are one of the first centers in Gurgaon to offer knee replacement using Patient Specific instrumentation (PSI) or Custom made instruments.


PSI uses advanced imaging to generate one-time-use instruments specific to each patient. A computed tomography (CT) or magnetic resonance imaging (MRI) scan is taken of the patient’s leg. A three dimensional bone model of the patient's knee is created based on the CT/MRI images. Dr Arora will then plan your surgery on this 3D image regarding overall alignment, femoral and tibial bone cuts and size of the implant needed. The detailed plan is then sent to the implant manufacturing unit based in USA and an engineer uses the data to fabricates a corresponding set of disposable cutting blocks or pin guides designed to help the surgeon position and align the implant during surgery. These jigs are then shipped to us for use during surgery.


These patient-specific surgical instruments are custom made for the precise alignment of patient’s knee.There are several distinct advantages of this technology. It removes multiple steps from the traditional surgical technique and shortens surgical time as most of the planning about size and placement of implants takes place preoperatively using computer software programme. This may lead to less blood loss and a lower risk of infection.


Patients are counseled about this technique at the clinic and once they have decided to proceed with custom made implants, an MRI/CT scan of the knee(s) is arranged at a designated center in Gurgaon.
The images are sent to USA/ Belgium for fabrication of patient matched bone cutting instruments. They are received after 2-3 weeks, following which the surgery can be done.


Video below explains the process of PSI in detail.

Oxynium Knee Replacement in Gurgaon by Dr Jayant Arora

Rheumatoid arthritis can lead to crippling deformities in joints and unlike osteoarthritis which is seen in elderly population, it can affect us at any age. Rheumatoid arthritis is the second commonest type of arthritis due to which patients require a knee replacement surgery world wide.

Despite many advances in the medical treatment if this disease, severe joint damage can happen in-spite of medications and often such patients have to undergo  replacement surgery of multiple joints for pain relief and to regain normal functional life.

We would like to share a story of thirty seven year old courageous school teacher suffering from crippling rheumatoid arthritis, that affected her at the age of seventeen.

The disease was aggressive and inspite of regular medications, she developed painful and stiff joints. She braved her condition with steely determination and a smile on her face. The disease progressed relentlessly, affecting both the knees. Gradually, the knees developed deformities, became very stiff and remained painful even at rest. Both the knees lost all the movement and were fixed in a bent position. She had started walking laboriously with a marked limp. This was affecting her physically as well as emotionally and she had started losing the mental battle against the crippling disease. In her quest to remain mobile, she tried rigorous physiotherapy and even took injections in the knee joints,  all without any improvement in her condition. She visited us at Gurgaon Knee and Shoulder Clinic to consult Dr Jayant Arora, where the option of knee replacement surgery was discussed with her as a last resort to restore movements, relieve pain and improve walking. She was explained, that unlike most knee replacements, her surgery was not going to be straightforward and there were several issues that needed to be addressed. Since, she was nearly half the age as compared to a typical patient under going knee replacement, knee replacement made from a special material (Oxynium) was used instead of a standard metal implant. Oxynium implants are preferred in young patients undergoing knee replacement as that are stronger than metal implants and are expected to last longer. Our vastly experienced Surgeon performed the replacement of both knees  at Columbia Asia Hospital using a modified surgical technique to account for stiff and  tight muscles,deformed and weak bones. The rehabilitation was carefully planned and done under regular supervision, leading to a very quick recovery. Her colleagues were left amazed when she resumed working three months after surgery, able to walk normally, climb stairs and drive, as if there was never anything wrong in her knees. The only thing that didn't change was her infectious smile!

Advanced Knee replacement surgery in Gurgaon by Dr Jayant Arora

Advanced Knee Replacement Surgery in Gurgaon by Dr Jayant Arora

 

Advanced Hip Replacement surgery at Gurgaon Knee and Shoulder Clinic.

Bilateral simultaneous Ceramic Hip replacement in Gurgaon performed by Dr Jayant Arora, using minimally invasive surgery (MIS) surgery.

Gurgaon Knee and Shoulder Clinic-- Facebook page

Follow us on our Facebook page at https://www.facebook.com/gurgaonkneeandshoulderclinic

Fw: Re-Hip Replacement Surgery: Feedback

 

 

   From: Lawal Abubakar <lawalabubakari@yahoo.com>
To: Arora Jayant <arorajayant@yahoo.com>
Sent: Friday, August 23, 2013 6:17 AM
Subject: Re-Hip Replacement Surgery: Feedback
 

Dear Sir,

My name is Mr. Lawal Abubakar from Nigeria. You may recall that about 2 years ago, I had a hip replacement surgery, which you led. Am happy to inform you that I am ok now. I don't feen any pain. Thanks a lot.

Best regards.

Lawal

Deformity Correction by Knee replacement Surgery at Gurgaon Knee and Shoulder Clinic

Hospitals are not Hotels... by Theresa Brown published in NYT

Interesting and a different view coming from a prolific writer on patient's care in USA. Raises interesting points on what should considered as benchmarks of care in Indian healthcare senario especially in the corporate hospitals where "patients" are now usually reffered to as Customers or Clients.-- read the article below

By THERESA BROWN

Pittsburgh

YOU should never do this procedure without pain medicine,” the senior surgeon told a resident. “This is one of the most painful things we do.”

She wasn’t scolding, just firm, and she was telling the truth. The patient needed pleurodesis, a treatment that involves abrading the lining of the lungs in an attempt to stop fluid from collecting there. A tube inserted between the two layers of protective lung tissue drains the liquid, and then an irritant is slowly injected back into the tube. The tissue becomes inflamed and sticks together, the idea being that fluid cannot accumulate where there’s no space.

I have watched patients go through pleurodesis, and even with pain medication, they suffer. We injure them in this controlled, short-term way to prevent long-term recurrence of a much more serious problem: fluid around the lungs makes it very hard to breathe.

A lot of what we do in medicine, and especially in modern hospital care, adheres to this same formulation. We hurt people because it’s the only way we know to make them better. This is the nature of our work, which is why the growing focus on measuring “patient satisfaction” as a way to judge the quality of a hospital’s care is worrisomely off the mark.

For several years now, hospitals around the country have been independently collecting data in different categories of patient satisfaction. More recently, the Centers for Medicare and Medicaid Services developed the Hospital Consumer Assessment of Healthcare Providers and Systems survey and announced that by October 2012, Medicare reimbursements and bonuses were going to be linked in part to scores on the survey.

The survey evaluates behaviors that are integral to quality care: How good was the communication in the hospital? Were patients educated about all new medications? On discharge, were the instructions the patient received clear?

These are important questions. But implied in the proposal is a troubling misapprehension of how unpleasant a lot of actual health care is. The survey measures the “patient experience of care” to generate information important to “consumers.” Put colloquially, it evaluates hospital patients’ level of satisfaction.

The problem with this metric is that a lot of hospital care is, like pleurodesis, invasive, painful and even dehumanizing. Surgery leaves incisional pain as well as internal hurts from the removal of a gallbladder or tumor, or the repair of a broken bone. Chemotherapy weakens the immune system. We might like to say it shouldn’t be, but physical pain, and its concomitant emotional suffering, tend to be inseparable from standard care.

What’s more, recent research suggests that judging care in terms of desirable customer experiences could be expensive and may even be dangerous. A new paper by Joshua Fenton, an assistant professor at the University of California, Davis, and colleagues found that higher satisfaction scores correlated with greater use of hospital services (driving up costs), but also with increased mortality.

The paper examined patient satisfaction only with physicians, rather than hospitals, and the link between satisfaction and death is obviously uncertain. Still, the results suggest that focusing on what patients want — a certain test, a specific drug — may mean they get less of what they actually need.

In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.

To evaluate the patient experience in a way that can be meaningfully translated to the public, we need to ask deeper questions, about whether our procedures accomplished what they were supposed to and whether patients did get better despite the suffering imposed by our care.

We also need to honestly assess our treatment of patients for whom curative care is no longer an option.

I had such a patient. He was an octogenarian, but spry, and he looked astoundingly healthy. He’d been sent to us with a newly diagnosed blood cancer, along with a promise from the referring hospital that we could make him well.

But we couldn’t. He was too old to tolerate the standard chemotherapy, the medical fellow on duty told him. When I came into his room a little later he said to me, with a stunned and yearning look, “Well, he made it sound like I don’t have a lot of options.” The depth of alienation, hopelessness and terror that he was feeling must have been unbearable.

The final questions on the survey ask patients to rate the hospital on a scale from worst to best, and whether they would recommend the hospital to family and friends. How would my octogenarian patient have answered? A physician in our hospital had just told him that he would die sooner than expected. Did that make us the best hospital he’d ever been in, or the worst?

Hospitals are not hotels, and although hospital patients may in some ways be informed consumers, they’re predominantly sick, needy people, depending on us, the nurses and doctors, to get them through a very tough physical time. They do not come to us for vacation, but because they need the specialized, often painful help that only we can provide. Sadly, sometimes we cannot give them the kind of help they need.

If the Centers for Medicare and Medicaid is to evaluate the patient experience and link the results to reimbursement, it needs to incorporate questions that address the complete and expected hospital experience. It’s fair and even valuable to compare hospitals on the basis of how well they maintain standards of patient engagement. But a survey focused on “satisfaction” elides the true nature of the work that hospitals do. In order to heal, we must first hurt.

Recent advances in knee replacement surgery-- Techniques and Technology

RECENT ADVANCES IN KNEE SURGERY-TECHNIQUES AND TECHNOLOGY

Total knee replacement surgery has been a safe and effective surgery for treatment of advanced stages of knee arthritis. It has been in use for many decades and over the years many advances in technology, surgical techniques and material have enabled this surgery to become even more precise with better and longer lasting  results and allow quick recovery. I have attempted to explain some of these advances in simple words

Advancement in Technology--Computer Navigated Knee Surgery

Computer navigation in total knee replacement has been in clinical use for last 10 years in US and UK and it attempts to correct some of the problems faced in traditional total knee replacement. Accurate placement of a knee replacement is one of the most important predictors of longevity of knee replacement. Minor misalignment can lead to early loosening, early polyethylene wear and poor function. Computer navigation allows the surgeon to accurately check and adjust, if necessary, each step along the way, whilst performing the knee replacement, which still allows the surgeon to exercise his skill and judgement for optimal positioning of the implant.

The computer navigation system works by combining computers, infrared cameras and instruments that reflect infrared light back to the camera. This permits the surgeon to finely adjust the position of the new knee with certainty, so that he or she can orientate the replacement joint to function optimally. The surgeon is always in control of the operation and only uses the computer to provide information on where to place the new knee.

When using the computer navigation system, pins are required, to be temporarily inserted into the bone; they are then removed once the new knee is inserted. This requires two very small (half a cm long) additional incisions to be made on the skin over the shin bone in addition to the standard scar used to insert the new knee, which is over the front of the knee.

Numerous studies have shown that the information from the computer navigation provides patients with a more precise operation to those performed with the standard instruments. It was thought to be a breakthrough technological advance, however one of the main reasons why this technology is not more widespread is that it can take longer to perform the surgery using the computer navigation system, additional costly equipments are needed and it needs two small additional incisions. Some of the drawbacks of this technology are now addressed by Patient matched instruments which is described below.

Advancement in Technology--Custom made Instruments/Patient matched Instruments

One of the most recent recent advancement is the development is Patient Matched Instrumentation. These patient-specific surgical instruments are custom made for the precise alignment of patient’s knee, potentially increasing implant longevity.

This techniques requires MRI (Magnetic Resonance Images) and X-Ray images of patient’s affected leg into an advanced web-based software program, which will generate virtual images of the knee. Surgical instruments and guides are then designed and built, mapping out specific bone cuts to accurately align the implant to the knee. These knee instruments are specifically made as per the size and shape of the patient’s  knee bones and take 6 weeks to get ready.

There are several distinct advantages of this technology. It removes multiple steps from the traditional surgical technique and shortens surgical time as most of the planning about size and placement of implants takes place preoperatively using computer software programme.  This may lead to less blood loss and a lower risk of infection.

 Patient Matched instruments allow surgeon to achieve precise alignment of the knee implants, potentially reducing wear – a leading cause of early implant failure.Customized instruments enable a less invasive surgical procedure which can reduce soft tissue and muscle damage which may speed the recovery time.

A knee implant accurately aligned may not only feel more natural, but may also last longer than traditional knee replacements.

Advancement in technique-Minimally Invasive Knee (MIS) surgery

 I don’t think minimally invasive surgery is the kind of “disruptive technology” that is going to revolutionize total knee replacement, which is already a safe, effective, time tested operation. The gains, if any, are likely to be marginal, and I think these other approaches to postoperative care can probably match them. So my advice to the patients is to not to focus on the length of the incision because it will be irrelevant within 2-3 months of surgery! What would really matter in the long term would be the position of their implants !!!  Advances in technology like computer navigated  surgery  and patient matched instruments are helpful for the surgeon to achieve this goal.

Advancement in materials—Highly crosslinked Polyethylene and Ceramic implants

The plastic insert (polyethylene) that is used as a substitute of the cartilage in the artificial knee gradually wears out with time.  There has been a major advancement in the quality of these plastic inserts and by producing crosslinking in its structure, the durability if these inserts have increased manifolds in experimental studies. These Highly cross-linked plastic inserts and now available in both knee and hip replacement implants and should be offered to all patient and must always be used in young patients.  Similarly using ceramic implants instead of Metallic implants have shown to reduce the wear of this plastic insert further and should be offered to young patients who need knee replacement surgery. Ceramic implants have been used routinely in hipreplacement surgery for many years.

For Further Information regarding Knee and Hip replacement surgery visit my website www.gurgaonkneeandshoulderclinic.com.

 

Dr Jayant Arora

MS(Orth), FNB(Orth), MRCS(Ed)

Fellowship Joint replacement and Arthroscopy, Newcastle,UK

Senior Consultant and Joint replacement Surgeon

Columbia Asia hospital

For appointments at Hospital in Gurgaon contact: 01243989896

For appointments at Dwarka clinic Contact: 01132313201

Mobile 9873830947

www.gurgaonkneeadnshoulderclinic.com

I need a knee replacement and am trying to decide between a minimally invasive operation(MIS TKR) and a traditional one. Does the incision size really matter?? - Gurgaon Knee & Shoulder Clinic

I need a knee replacement and am trying to decide between a minimally invasive operation(MIS TKR) and a traditional one. Does the incision size really matter?? - Gurgaon Knee & Shoulder Clinic

Don't let your knee let you down!! - Gurgaon Knee & Shoulder Clinic

Don't let your knee let you down!! - Gurgaon Knee & Shoulder Clinic

ACL Injury—an undetected epidemic!

As a society we are gradually beginning to become obsessed with sports apart from cricket. This phenomenon is amply evident by emergence of star sports persons in various fields like tennis, boxing, hockey, golf, badminton, athletic, wrestling etc. They are adored and looked upon as role models by young and old alike. At recreational level, sports allows an escape from pressures of daily life and at elite level, sports is well established as a part of entertainment industry with enormous rewards for the professionals. At both these levels, sports related injuries especially knee ligament injuries remain a constant threat of a prolonged layoff or even a career ending event. These injuries are not only commonly seen in contact sports like football and rugby but also in noncontact sports like golf(Tiger Woods), Cricket (Yuvraj Singh), Badminton (Gopichand), all three sustained an ACL (Anterior Cruciate Ligament ) injury,  the commonest ligament to be injured (60% of all ligament injuries) in the knee. The number of women suffering ACL tears has dramatically increased. This is due in part to the rise in women's athletics. But studies have shown that female athletes are two to four times more likely to suffer ACL tears than male athletes in the same sports. Recent research has shown several factors that contribute to women's higher risk of ACL tears. Women athletes seem less able to tighten their thigh muscles to the same degree as men. This means women don't get their knees to hold as steady allowing them to twist easily. Also, shape of their thigh bone(Femur) puts them at a higher risk of the ACL rubbing on the bone in the event of a twisting injury.

  Data from the western world clearly show that knee injuries may require surgical treatment, prolonged rehabilitation and are the most common cause of permanent disability after a sporting injury. A study done in USA on the prevalence of ACL injuries in the general population has estimated the incidence as 1 case in 3,500 people, resulting in 95,000 new ACL ruptures per year. National Health Service UK (NHS) website reports a similar incidence of 30 cases of ACL injuries for every 100,000 people or a total of approximately 18000 ACL injuries across a population of 60 million every year.  At a similar rate we should see 3.6 lacs patients of ACL injuries per year. This may be a conservative estimate due to low average age of our population compared to the western world. So we may already be in the midst of an epidemic!!

These injuries are easily missed since X-rays are usually normal. A study from British Medical Journal showed an average delay of 22 months before these injuries were diagnosed despite the fact that the patients were seen in the emergency departments of the Hospitals at the time of injury. Infact, 30 % of these patients were assessed by an Orthopedic surgeon without the diagnosis having been recognised.  So we may be in the midst of an undetected epidemic!!!

The symptoms following a tear of the ACL can vary. Usually, the knee joint swells within a short time following the injury. This is due to bleeding into the knee joint from torn blood vessels in the damaged ligament. The instability caused by the torn ligament leads to a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip backwards.

The pain and swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what require treatment. Also important in the decision about treatment is the growing realization by orthopedic surgeons that long-term instability leads to early arthritis of the knee.

Diagnosis needs a careful clinical evaluation by an expert knee surgeon as ligaments and tendons do not show up on X-rays. Magnetic Resonance imaging (MRI) is probably the most accurate test for diagnosing a torn ACL without actually looking into the knee.

Treatment of ACL injury does not necessarily involve surgery in all patients. Physiotherapy and bracing may be attempted initially. If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.

Even when surgery is needed, most surgeons will have their patients attend physical therapy for several visits before the surgery. This practice also reduces the chances of scarring inside the joint and can speed recovery after surgery.

Arthroscopic reconstruction (Keyhole surgery) of ACL injury is the standard of care  and open surgery is not recommended.  Key-hole surgery is most often done with the aid of the arthroscope, although small incisions are usually still required around the knee, but the surgery doesn't require the surgeon to open the joint. The arthroscope is used to view the inside of the knee joint as the surgeon performs the work. The  torn ACL ligament is reconstructed with a piece of  Hamstring muscles tendon or with a part of patellar tendon. This tendon connects the kneecap (patella) to the tibia.

Most ACL reconstructions are now done on an outpatient basis, and many patients go home the same day as the surgery. Some patients stay one or two nights in the hospital if necessary.

View  an animation of the arthroscopic reconstruction of ACL here...

Recovery following surgery involves in a progressive rehabilitation program for four to six months to ensure the best results. During first few weeks following the surgery supervised physiotherapy may be needed followed by self administered exercises at home over the four to six month period.

For further information on ACL injury and its treatment visit www.gurgaonkneeandshoulderclinic.com

Total hip replacement for Avascular Nercrosis of the Hip

Avascular necrosis of the hip, also known as asceptic necrosis of the hip is a devestating condition usually affecting young individuals resulting from loss of blood supply to the ball of the hip joint. The condition tends to progress and results in early degenerative changes in the hip joint causing pain, stiffness, limp and loss of function. Treatment usually involves hip replacement surgery to restore function and treat pain. You can watch a video of one of my patients who suffered from this condition at : http://www.youtube.com/watch?v=XMz-T68D58E

Orthopedic boys like newer toys!!.

Having worked in the UK for a few years and believing in the old school of thought that newer technology/implants should only replace the time tested ones only after rigrous evidence of their advantage over older techniques is documented in the orthopedic literature, I have realised that in Delhi NCR area, a significant chunk of Orthopedic Surgeons are eager to jump on the the bandwagon of a newer, more advanced, fashionable  and of course, more expensive implants as soon as they are launched in the market. Many a times these so called newer more expensive  implants are used even if they are not clinically indicated. The whole idea behind this is to prove (to oneself and your colleagues) that one is producing the better results using the latest technology and in many instances coercing/impressing patients by demonstrating that his clinical acumen and skills are better than the doctor next door who recomended "old obsolete implants" or "1st Generation implants" . I have found that in majority of these patients either these newer implants are not indicated or there is not enough data in the literature to prover the superiority of these newer implants. I have observed this most common especially in the treatment of fractures where locking plates are used in simple transverse fractres even in perfectly healthy young individuals with goood quality bones. These plates were found to be better for fixation of fractures in patients with osteoporosis and sometimes in patients with comminuted(shattred fractures in multiple pieces) fractures near the joints. However these plates have also been used exensively to treat simpler forearm fractures in healthy individuals who were being treated perfectly well for many decades with DCPs and LCDCPs, which cost 50-75% less as compared to these locking plates.

Bigger the hospital, more expensive the implants that is likely to be used in the patients. Although I an saying this purely based on my experience of seeing patients in my OPD for last 3 years, but I am sure this can be substiantiated by the data from the insurance companies(if it has not already been done by them!!). 

It is the patient who ends up footing the bill for bragging rights and boosting the ego of the operating surgeon either at the time of discharge directly or at the time of paying the insurance premiums indirectly. 

Fw: Total Hip Replacement for Mahendra Kumar

 

----- Forwarded Message ----
From: Nilesh Kumar <nkumar@builtform.com.au>
To: rashmi.hingorani@columbiaasia.com
Cc: jayant.arora@gmail.com; arorajayant@yahoo.com
Sent: Fri, June 3, 2011 3:44:04 AM
Subject: Total Hip Replacement for Mahendra Kumar

Dear Dr. Jayant / Rashmi,

 

On behalf of the Kumar family we'd like to send warm thanks for an excellent outcome of your services.

 

We appreciate your originality, the fact the pre-care, surgery and post-surgery activities were unique in nature and showed an "excellent skills presentation" of consciences.

 

It's not always easy to get this organised with such a short notice but you managed to do a great job of it.

 

Again, thank you, and we'd be pleased to recommend your services to anyone that may require your services.

 

 

Thanks and regards,

Nilesh Kumar

Senior Contracts Administrator

 

Builtform Constructions Pty Ltd

West Ryde Village Construction Site

15 Chatham Road NSW 2114

Tel: 02 9858 2514| Fax: 02 9858 2572 | Mob: 0450 929 499

 

Fw: Mr. Rasheed Oyeniya, M39- Ortho case

 

Dear Rashmi

 

This patient has significant malunion of the femoral shaft fracture with an angulation of approximately 30 deg. I need to get orthognal views/CT of the femur to ascertain the plane and extent of deformity. He  will need removal of the bent implants, corrective osteotomy at the site of deformity and fixation with another plate/IM nail +/-bone grafting at the osteotomy site.

The shortening  will improve substiantially however he still may have some residual shortening of the leg needing a heel raise.

Other potential complications would be possibility of the nonunion at the osteotomy site and implant faliure.

 

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

---

Fw: Mr. R O, M39- Ortho case

 

Hi
Please get opinion from Dr Jayant Arora on this case Regards PT


i had road traffic accident 27 july 2009 where i sustaind fracture of the
left femur, had (ORIF),done on 28 july 2009 ,then ihad pulmunary embolism,
unconscius for four days.on the 5th day i fell in the hospital and the plate
bent, POP was used to stabilize the limb and the fracture healed,with
angulation on my femur and shortening of the limb(R).

Now i wont it repair. attarched is the x ray report.