BONE AND JOINT
What is Arthroscopic Surgery?
Arthroscopy is a surgical procedure performed by Orthopedic Surgeons to view, diagnose and treat joint problems. The term Arthroscopy comes from two Greek words, ‘arthro’ (joint) and ‘skopein’ (to look). The term simply means ‘to look inside the joint.’ Arthroscopic surgery has revolutionized the diagnosis and management of joint problems. Initially used only as a diagnostic tool prior to open surgery, the availability of better instruments and techniques has encouraged the use of arthroscopy for treating a variety of joint problems, avoiding complicated surgeries and longer recovery. In fact, except joint replacement and major intra-articular fractures, all other problems involving the hip, knee, ankle, shoulder, elbow and wrist joint can be treated with arthroscopic surgery.
What are the advantages of Arthroscopic Surgery?
The procedure is carried out under General or Regional Anesthesia. The Arthroscope (telescope) is introduced into the joint through a small puncture wound. Images are sent from the arthroscope to a television screen so that the surgeon is able to see the joint. Firstly, a detailed examination of the joint is performed, the problem identified and thereafter appropriate surgical treatment is carried out. Cartilage damage, ligament tear, etc., are treated with small instruments introduced into the joint through a second puncture wound.
Some of the advantages of an arthroscopy compared with traditional open surgery include:
Why AIMS Hospital?
Our Arthroscopic Surgeons are
What is Knee Replacement?
In simple terms, Knee replacement is a surgical procedure most often performed to relieve the pain and disability and restricted mobility arising out of degenerative arthritis. Major causes of debilitating pain include meniscus tears, osteoarthritis, rheumatoid arthritis, post trauma, ligament tears, and cartilage defects. Yes, primarily there are two kinds of Knee replacement surgeries TKR (Total Knee replacement) and UKR (Unicondylar / Partial Knee Replacement). Knee Replacement surgery can be performed as a partial or a total knee replacement. In general, the surgery consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee joint. This is termed as Implant or Prosthesis.
Partial Knee Replacement (PKR)
Partial knee replacement, also called ‘unicompartmental knee arthroplasty or unicondylar knee arthroplasty’ is a surgery that may be considered for treatment of osteoarthritis of the knee joint where the complete knee joint does not require replacement. Traditionally, patients have undergone total knee replacement for severe arthritis of the knee joint. In a total knee replacement, all cartilage is removed from the knee joint, and a single metal and plastic implant (prosthesis) is substituted.
Conditions for Partial Knee Replacement
The partial knee surgery may be possible if the arthritis in the knee is confined to a limited area. If the arthritis is widespread, then the partial knee replacement is not the solution.
Total Knee Replacement (TKR)
In a Total Knee Replacement procedure, the surgeon removes damaged cartilage and bone from the surface of knee joint and replaces them with metal and plastic. In Total Knee Replacement, the surgeon replaces three parts of the knee joint.
The two parts of the prosthesis are placed onto the ends of the femur, tibia, and undersurface of the patella using a special bone cement. Usually, metal is used on the end of the femur, and plastic is used on the tibia and patella for the new knee surface. However, surgeons are now using newer surfaces, including metal on metal or ceramic on ceramic.
Situations when TKR is helpful
Hip Replacement is a treatment modality when other pain management therapies fail to provide relief from the arthritis of the Hip. Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Such joint replacement surgeries are generally conducted to relieve pain due to arthritis or severe physical joint damage as part of the hip fracture. After the Hip Replacement surgery one gets back all motions that one may need to carry out daily tasks. Also referred to as Total Hip arthroplasty or Total hip replacement.
Osteoarthritis of the hip joint is the most common reason for people opting in favor of Hip Replacement surgery. Hip Replacement is an option worth considering if there is severe pain, loss of motion or deformity of hip joint. Hip replacement is also used in people with hip injuries, rheumatoid arthritis and other medical conditions, such as a bone tumor or bone loss due to insufficient blood supply (Avascular necrosis).
Symptoms requiring hip replacement:
Earlier Hip replacement was an option primarily for adults aged 60 and above. But rapid improvements in medical technology has made strong and longer lasting artificial joints easily available that are suitable for even active and younger people. However, active people face the possibility of another surgery to replace worn out artificial hip joints after 15 or 20 years.
Rheumatology is a specialty of medicine which involves non surgical care of musculoskeletal and autoimmune diseases. Musculoskeletal diseases involve the joints, muscles, bone and tendons. They are a major cause of disability and one of the most common ailments for which a person consults a doctor. Autoimmune diseases are conditions in which the immune system of the body treats its own tissues as foreign and tries to destroy them. Rheumatic diseases consist of more than 100 conditions that can have a profound effect on the ability to perform daily activities and damage internal organs. In the past, treatment of rheumatic diseases included just pain relieving medications and exercises, but in the last two decades, scientific knowledge has revolutionized the entire approach to management of these conditions.
Who is a Rheumatologist?
A rheumatologist is a physician who is qualified, by additional training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. After four years of medical school and three years of training in internal medicine, rheumatologists devote additional two to three years in specialised rheumatology training.
What are these diseases?
Rheumatic diseases can be classified in to the following groups:
- Arthritis which affects the joints and spine: Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic arthritis, Osteoarthritis and Gout
- Autoimmune Multisystem Diseases which affect the joints, skin, various internal organs of the body: SLE, Vasculitis, Myositis and Sarcoidosis
- Metabolic Bone Diseases: Osteoporosis, Osteomalacia and Vitamin D deficiency
- Soft Tissue Rheumatism: Myofascial Pain, Fibromyalgia, Tendinitis and Bursitis
Why one needs to be aware?
Arthritis, if untreated, damages the joints leading to deformities and disability thereby restricting movements and functionality. Autoimmune diseases can irreversibly damage internal organs like kidney, lungs, brain and can be life threatening. Osteoporosis results in fractures with minimal injury and affects quality of life. The good part is that if treated timely, these diseases can be controlled effectively and damage can be prevented.
Are you in the high risk group?
Though the exact cause of many arthritis and autoimmune diseases are unknown, there are specific risk factors.
- Age: Contrary to the popular belief that arthritis affects only elderly, it can affect any age group, including children. Young females in particular are at high risk for arthritis and autoimmune diseases. Post menopausal women are at increased risk of osteoporosis. Osteoarthritis is age related (> 50 yrs) degeneration of joints. Some arthritis affecting the spine is more common in young males.
- Family history of arthritis also increases the chances of developing arthritis.
- Calcium deficient diet, lack of exposure to sunlight, lack of exercises leads to Metabolic Bone Diseases.
- Certain infections, smoking, stress contribute to the risk of arthritis.
What are the common signs and symptoms?
What is the importance of screening?
- It is a well established fact that treatment for arthritis is most effective when started early. It is, therefore, essential to diagnose it in its initial stages. Consulting a rheumatologist at the earliest signs and symptoms helps in early diagnosis. Careful clinical examination, certain blood tests and x-rays are used to confirm the disease.
- Osteoporosis is a silent disease and needs evaluation of bone health with DEXA scan in the high risk group to prevent fractures.
What are the various methods of management?
- Modern science has effective treatment for arthritis and related conditions.
- Disease modifying drugs like Methotrexate control the arthritis very well and prevent deformities and damage. Drugs like Steroids, Azathiopurine prevent abnormal attack of immune system and can be organ and life saving.
- Biologics are highly effective drugs which are used in severe arthritis.
- Osteoporosis is best treated with Calcium, Vitamin D supplement and bone preserving and bone forming medications.
- Joint injections given in certain cases are effective in controlling arthritis
- Apart from medications, physiotherapy plays important role in maintaining joint mobility and strengthening the muscles. Lifestyle modification, weight loss and activity modification are useful in degenerative joint diseases.
What is the possible prognosis?
In the past, rheumatological diseases were ignored and patients suffered from deformities and disability with many of them being wheel chair bound or bed-ridden. Also, the autoimmune diseases were often not diagnosed correctly with resultant damage to internal organs and also mortality. However, with appropriate expertise and care while utilising the best of currently available treatment modalities, we can effectively prevent the damage and improve patient’s quality of life and also prevent mortality.
In today’s times, increased traffic, better roads and faster life are leading to increased incidents of accidents and increased severity of injuries. Such accidents occur mostly in young adults between 20 – 35 years and may lead to disability and death. In fact accidents are the leading cause of death in age group between 20 to 35 in developed and developing countries.
The initial first hour after an accident is called the ‘Golden Hour.’ If an accident victim is treated properly in a well equipped Trauma centre during this period, it may save the life and give a better quality of life after recovery.
AIMS Trauma Centre has state of the art tertiary care treatment facilities.
A dedicated Trauma Care area.
What is the ACL?
ACL stands for Anterior Cruciate Ligament of the knee. The knee is the largest and most complex joint in your body. It depends on four primary ligaments as well as multiple muscles, tendons and secondary ligaments to function properly.
There are two ligaments on the sides of the knee: the Medial Collateral Ligament (MCL) and the Lateral Collateral Ligament (LCL), and two crossed ligaments in the centre of the knee, the Anterior Cruciate Ligament (ACL) and the Posterior Cruciate Ligament (PCL). The ACL connects the front top part of the shin bone to the back bottom part of the thigh bone and keeps the shin bone from sliding forward.
How is the ACL injured?
One of the common ways for the ACL to be injured is by a direct blow to the knee, which commonly happens in football. In this case, the knee is forced into an abnormal position that results in the tearing of one or more knee ligaments. However, most ACL tears actually happen without contact between the knee and another object. Such non-contact injuries happen when the running athlete changes direction or hyperextend their knee when landing from a jump. These movements are common to all agility sports.
What are the signs of an ACL tear?
In many cases, when the ACL is torn, you will feel the knee give way with an audible ‘pop.’ The injury is usually associated with a moderate amount of pain and continued activity is usually not possible. Over the next several hours, the knee becomes very swollen and walking becomes difficult. The swelling and pain usually increase over the first two days and then begin to gradually subside.
How is an ACL tear diagnosed?
Discomfort after an ACL tear is usually severe enough that the injured person will seek medical attention. The physician will examine the knee, and, in most cases, be able to identify which ligaments are injured. However, there may also be injuries to the joint surface that are more difficult to diagnose. At times, swelling may make it difficult to diagnose a tear. This will necessitate the use of an MRI scan to ensure that an accurate diagnosis is made.
Will I need surgery?
The most frequent question after an ACL injury is ‘Will I need surgery?’ The answer varies from person to person. Many factors must be considered by the patient and the physician when determining the appropriate treatment. These factors include the activity level and expectations of the patient, the presence of associated injuries (cartilage tears, etc.) and the amount of abnormal knee laxity.
A young patient with an ACL tear and knee laxity who wants to return to sports or an active lifestyle is more likely to require surgery for a satisfactory outcome. The older patient who can return to limited activity is less likely to require surgical stabilisation. In either scenario, rehabilitation of the knee begins with exercises to help restore full range of motion. This is followed by strengthening exercises for the muscles around the knee. Return to sports with or without a brace is allowed only after leg strength, balance, and coordination have returned to near normal.
Long term research studies have shown that a non-functioning ACL due to complete tear results in future damage to the joint (meniscus tears, arthritis) and hence, early surgery to reconstruct a new ACL is the preferred treatment.
How are ACL tears treated surgically?
Many different surgical approaches have been developed for the ACL injured knee. Years of experience have shown that simply stitching the ligament together is rarely successful. Therefore, current techniques involve reconstructing the ACL by building a new ligament out of tissue harvested from one of the other tendons around the knee. This tissue is passed through drill holes in the thigh bone and shin bone and then anchored in place using implants to create a new ACL. Over time this graft matures and becomes a living ligament in your knee.
What happens after surgery?
Rehabilitation of the knee after ACL reconstruction requires time and hard work. Time off from work varies depending on job type. Desk job employees can return in one or two weeks, whereas construction workers usually are not able to return for approximately one month. Athletes are allowed sports after 4 to 6 months. The rate of rehabilitation may take even longer, depending on the specific requirements of the individual’s sport/activity and rate of recovery.
The overall success rate for ACL surgery is very good. Many studies have shown that over 98% of patients are able to return to sports and workplace activities without symptoms of knee instability. Although some patients do complain of stiffness and pain after surgery, these problems have been minimised by current surgical techniques.
What is the Meniscus?
The human meniscus is a wedge shaped structure in the knee that consists of fibrocartilage, a very tough but pliable material. The medial meniscus is located on the inside of the knee (towards the middle of the body) and the lateral meniscus is located on the outside of the knee. Together, they act primarily as shock absorbers and stabilisers in the knee joint. They also help nourish the articular cartilage through their rich blood supply. This blood enhances the ability of the cartilage to repair itself.
How is the Meniscus torn or injured?
In young athletes, most injuries to the meniscus are the result of trauma. The menisci are especially vulnerable to injuries in which there is both compression and twisting applied across the knee. It is also common for the meniscus to be damaged in association with injuries to the anterior cruciate ligament. In older athletes, many meniscal tears are the result of trivial trauma, like twisting the knee, squatting or through repetitive activities like running, which stress the knee joint. These tears happen because the meniscus has a tendency to degenerate as part of the aging process. This degeneration often takes place in conjunction with early arthritic changes in the knee joint.
How is a Meniscal tear diagnosed?
When a meniscus is torn, it will often produce pain, swelling and mechanical symptoms like catching, or locking, in the knee joint. An injury to the meniscus can be diagnosed based upon the history that the patient provides and a physical examination of the knee. The orthopaedic surgeon may also require further diagnostic studies like an MRI (Magnetic Resonance Imaging) which provides a three-dimensional image of the interior of the knee joint.
How is a Meniscal tear treated?
Certain patterns of injury, especially in younger patients, may call for repair of the meniscus. The decision to repair is based on many factors, including:
Other patterns of tears, especially in older patients, are not suitable for repair.
If the patient is symptomatic, and conservative treatment options like physical therapy are not working, surgery to remove the torn section is recommended. This surgery is called arthroscopic partial meniscectomy and is usually performed on an outpatient basis, typically in one hour or less.
Most patients ask, “What is the benefit of removing the meniscus? Isn’t it an important structure in my knee?” Clearly, the meniscus does play an important role in the human knee, but once torn and unable to be repaired, many of the beneficial effects of that structure are lost. If a tear is causing pain and impaired function, removal of that tear is the treatment of choice.
Osteoporosis – A Growing Problem
Osteoporosis, a common yet neglected condition, affects one in three women and one in five men over the age of fifty. However, this bone disorder can strike a person at any age.
Osteoporosis, which literally means ‘porous bone’, is a disease in which the bone mass and bone strength are reduced. As we get older, we are no longer able to replace bone tissue as quickly as we lose it. Osteoporosis occurs when new bone formation does not match the bone loss. If not prevented or left untreated, the loss of bone occurs ‘silently’ and progressively. This reduces the density of bone, making them weak and easy to break, resulting in fractures.
What causes Osteoporosis?
Bone is a living tissue. Old bone is constantly replaced by new bone. Bone mass increases from birth, reaching a maximum strength and size (peak bone mass) in early adulthood. A person’s peak bone mass is determined largely by genetic factors, but other factors such as nutrition, physical activity and disease also influence bone development. As we get older, we are no longer able to replace bone tissue as quickly as we lose it. Osteoporosis occurs when new bone formation does not match the bone loss.
What are the risk factors for Osteoporosis?
Can Osteoporosis be prevented?
As the loss is gradual and painless, often there are no symptoms until the first fracture occurs. The most common fractures associated with osteoporosis occur at the hip, spine and wrist. Spinal fractures can result in serious consequences, including loss of height, intense back pain and deformity. A hip fracture often requires surgery and may result in loss of independent living. But in some cases, a stooped back and loss in height may be the only visible signs that a person has osteoporosis.
However, osteoporosis is a preventable and treatable condition. A combination of lifestyle changes and appropriate medical treatment can prevent fractures. Recent advances in treatment of osteoporosis not only prevent further bone loss but can also lead to the formation of new bone.
Therefore, if you are more than 50 years or have any of the risk factors, or have had a fracture at wrist, spine or hip, then it is highly recommended that you seek advice from an expert to assess your bone health status and take the necessary treatment to prevent further complications.
Do’s and Don’ts
Did You Know?
Why does a child need an Orthopaedic Specialist?
A child’s musculoskeletal problems are different from those of an adult. Because children are still growing, their body’s response to injuries, infections, and deformities may be quite different than what it would be seen in a full-grown person. Sometimes, what is thought to be a problem is just a variation of growth that will resolve with time. Many of the problems children have with their bones and joints do not even occur in adults. And, for the same problem that an adult might have, the evaluation and treatment is usually quite different for a child. Children with complex paediatric problems such as cerebral palsy and spina bifida are best managed by a combined medical-surgical team approach.
Children are not just small adults. They cannot always say what is bothering them, or answer medical questions, or be patient and cooperative during a medical examination. Paediatric orthopaedic surgeons know how to examine and treat children in a way to help them be relaxed and cooperative. They appreciate the worry that goes with having a child with a musculoskeletal problem and they have experience in communicating with anxious family members.
Who is a Paediatric Orthopaedist?
A Paediatric Orthopaedist is a highly trained and experienced Orthopaedic Surgeon who specialises in diagnosing and treating bone & joint problems in children who are still growing. A Paediatric Orthopaedist has chosen to make paediatric care the core of his medical practice. A Paediatric Orthopaedist has typically graduated from an approved medical school (five years), completed an approved Orthopaedic residency programme (three years) and then super-specialised in an accredited Paediatric Orthopaedic Fellowship programme abroad (one to two years). Thus, a Paediatric Orthopaedist has learned, from advanced training (more than ten years) and experience, the unique nature of medical and surgical care of children.
Orthopaedic Physiotherapy is the oldest branch of Physiotherapy and oriented towards the treatment of Musculoskeletal alignments.
Orthopaedic Physiotherapists are specialised in Impaired posture, Impaired Muscle functions, Impaired Joint Mobility. Motor Function, Muscle performance, Range of motion associated with Connective tissue dysfunctions and Localized inflammation as in.
We utilize a multi-disciplinary approach to access, advise and provide a full range of care using:
The shoulder has the greatest range of motion of any of the joints in the human body. It is also the most commonly dislocated joint in the body. The shoulder is comprised of the humeral head (ball) and the glenoid (socket). The shoulder, as opposed to the hip, has a very shallow socket similar to a plate or saucer. The joint capsule of the shoulder encases the entire ball and socket articulation, and is attached to the socket at the labrum (bumper of tissue surrounding the rim of the socket).
What happens when the Shoulder dislocates?
When the shoulder dislocates, the ball comes off the plate or socket. In many cases the person cannot get the ball back in by themselves, and medical attention is required. The shoulder typically dislocates when the elbow is away from the body and the arm is rotated in a way that the humeral head rolls over the front edge of the socket. Less commonly, the humeral head can be driven off the back of the socket with the arm in front of the body. In either case, the capsule and/or labrum typically tear away from the socket side of the joint when the ball dislocates. In some cases, the capsule and labrum may pull off a piece of bone from the edge of the socket as the ball dislocates.
In some cases the shoulder does not dislocate completely, and the ball spontaneously returns to its normal location after being perched on the rim of the socket. This is called shoulder subluxation and these cases, capsule and/or labral tears may still occur. Other tissues around the shoulder may be injured at the time of dislocation, including the rotator cuff tendons, the biceps tendon, the deltoid muscle and its accompanying nerve, and the cartilage surfaces of the ball and socket joint.
What is the treatment for acute Shoulder dislocation?
If the dislocation is recognised immediately, it is possible for the person to ‘pull the shoulder back in’ using their own muscles. After several seconds, however, the pain and muscle spasm from the dislocation typically prevents a person from getting their own ball back in their socket. In the majority of cases, the person seeks medical attention, X-rays are taken to identify the nature of the dislocation, and the shoulder is ‘reduced’ (put back in) by a medical professional. Pain medicine and sedation may be necessary to get the shoulder back into place. In some cases where the shoulder cannot be put back in, the patient may be taken to the operating room for surgical relocation of the joint. Immediately following successful reduction of the joint, X-rays are obtained to confirm the reduction and the patient is placed in an immobilising device to prevent re-dislocation.
What is the treatment after reduction of the dislocation?
Patients suffering shoulder dislocation are typically placed in an immobilizing device for a short period of days to weeks, and early range of motion exercises are initiated to prevent stiffness. In many cases a physical therapist will be consulted to assist with return of motion. Pain medicine and/or anti-inflammatory medicines can be used to decrease pain and swelling.
Later, gradual strengthening exercises are added to return the shoulder to more normal function. Restoring strength to the shoulder also helps prevent re-dislocation. Avoidance of contact sports and other activities where the arm may undergo significant rotation is necessary in the early post-dislocation period to prevent re-injury.
Typically it takes several weeks to return to the routine activities of everyday life and several months to return to heavy lifting and contact sports. In some cases, a shoulder may dislocate more than once, or multiple times, despite adequate management. In these cases, surgery is the best choice.
What is the expected outcome from Shoulder dislocation?
The younger a person is when they dislocate for the first time the more likely they are to re-dislocate over the course of their life. For example, a 20 year-old who dislocates for the first time has an 80 percent chance of re-dislocation later on. If the shoulder continues to be unstable despite adequate management, it is reasonable to pursue surgical solutions.
In these cases, the capsule and/or labrum are repaired back to the bone from which they tore using sutures and anchors into the bone. In most cases, these repairs are carried out arthroscopically (minimally invasive), but in rare cases ‘open repair’ through a small incision remains the best option. In those cases in which instability occurs repeatedly, surgical solutions have been shown to be nearly 98 percent successful in returning patients to full activity with no limitations.
How can I prevent my shoulder from dislocating again?
By increasing the strength of the rotator cuff muscles and avoiding activities which place the shoulder at risk, the likelihood of re-dislocation diminishes. The rotator cuff muscles help squeeze the humeral head into the glenoid socket, thereby increasing the stability. Rehabilitation commonly focuses on the strengthening of these muscles using resistance weights, rubber bands and cables.
If surgical management is undertaken, post-operative rehabilitation begins in the first few days or weeks after surgery. The goal of this therapy is to restore the range of motion and subsequent muscle strength to the shoulder without jeopardising the stability of the recently repaired tissue.
Generally, early exercises are limited to range of motion only, followed several weeks later by strengthening of the rotator cuff after the repaired tissue has had a chance to complete the early healing process. Generally, three months are required for the shoulder to return to normal range of motion and strength, and a subsequent return to full activity.
Over the past few years, our lifestyle has changed tremendously. Skipping meals, increased intake of caffeine containing beverages, sedentary lifestyle, decreased exposure to sunlight – all these factors are not just responsible for the increasing incidence of obesity and diabetes in the population but also for many deficiency diseases. Vitamin D is one such common deficiency that could lead to a myriad of health problems.
What is Vitamin D Deficiency?
Vitamin D (Calciferol) belongs to a group of fat soluble seco-steroids. In humans, vitamin D is unique because of its functions as a pro-hormone as well as its synthesis to vitamin D3 in the body when exposed to adequate sunlight.
Vitamin D regulates the concentration of calcium and phosphate in the body and promotes healthy growth and remodeling of the bone. Vitamin D prevents rickets in children and osteomalacia in adults. Along with calcium, it protects elder adults from osteoporosis.
Vitamin D also affects neuromuscular functions, causes inflammation and influences the action of many genes that regulate proliferation and apoptosis of the cells. Vitamin D is also essential for the healthy growth of hair follicle as well as for a healthy immune system. Vitamin D deficiency is the main cause of rickets in young infants because breast milk is low in vitamin D and so is the cereal based diet.
What is the effect of Vitamin D on bones?
Vitamin D deficiency is known to cause several bone diseases like:
Who are at risk of developing Vitamin D Deficiency?
Human body makes vitamin D when the skin is directly exposed to the sunlight. That is why vitamin D is often called as the ‘sunshine’ vitamin. Ten to fifteen minutes of sunshine three times weekly is sufficient to meet your body’s vitamin D requirement. Most people meet at least some of their vitamin D needs this way.
Without sufficient vitamin D, which is crucial for calcium absorption in your intestines, your body cannot absorb calcium, thus rendering calcium supplements useless. Sunscreens, even the ones like SPF-8 block your body’s ability to generate vitamin D by 95%. Therefore, sunscreen products can create critical vitamin deficiency in the body.
Natural sunlight rays responsible for generating vitamin D in your skin cannot penetrate glass. Therefore, your body can not generate vitamin D from the sunlight you receive while sitting in your car or home.