Physiotherapy & Surgery

Physiotherapy & Rheumatoid Arthritis

by Dr. Suniti Shrotriya

Rheumatoid Arthritis is a systemic disease characterized by remissions and exacerbations which vary in severity and time among people. The chronic nature and often degenerative course causes those treating patients with R.A to follow these guidelines :

maintain the patient's physical, psychological and functional abilities for as long as possible through an ongoing carefully planned treatment programme and patient education.

Roles of Physiotherapist and Occupational therapist vary with different stages of the disease. In acute stage, when joints are inflammed, painful, swollen, red and hot, the goals are:

Relief of pain by various methods.

Don't - use heat in already inflammed joint.
Do - Apply ice pack.

Interferrential currents are also beneficial as they have strong analgesic effects. Prevention of deformity.

Do's - Gentle mobilizing exercises in the limit of pain directed towards recovery of function. Do isometric exercises. Position and support painful joints with the help of pillows, sandbags and splints.
Don't - Avoid excessive and forceful movements and also movements in typical pattern of deformity, eg. shoulder adduction and internal rotation.
Do's - Active assisted exercises.
Don't - Passive streching of joints.

In subacute or chronic stage aim is to improve mobility and strength.

Do's - Apply heat in the form of infrared, shortwave diathermy, waxbath or hot packs to reduce pain before starting any exercises. Gentle passive stretching of the contractures is done after the pain subsides. As joint loosens up, mildly resistive exercises are given to improve strength.
Don't - No abrupt application of stretch which may rupture the tissue. Excessive resistance is avoided while doing exercises.

Patient education about joint protection and energy conservation:

Do's - Maintenance of muscle strength and joint range of motion by regular exercise regime provided by therapist.
Don't - Avoid positions of deformity and pressures on the joint, e.g. twisting the knees when standing up first and then turning. Avoid strong grasp or pinch, movement of the wrist in ulnar deviation e.g. opening and closing lids, press the cloth than wring it.
Do's - Use of proximal body parts in lieu of the more distal ones, e.g. slip a pocket book or shopping bag over a forearm instead of holding in hand.

Energy Saving Techniques.

Do's - Use light weight energy saving equipments. Plan ahead to balance rest with exertion, gather all necessary equipment ahead of time, make convenient and sit to mark when possible.
Don't - Avoid unplanned events or work. Do not push beyond your capacity. Also avoid complete bedrest as inactivity can result in weakness, stiffening and loss of mobility. It can also start a cycle of discouragement, depression and further inactivity.

Group therapy to deal with issues of disturbance of self image, body image, job status, family relationships coping mechanism. would be useful. An "Arthritis Club" run by and for person's with R.A and their families would improve the persons chances of coping successfully with the disease on a long term day to day basis.

Back Pain

by Dr. Jayashree Patil & Dr. Nidhi Jain

"No precautions back pain, know precautions no back pain."

Back pain is the most common reason for seeking a doctor. It is one of the most frequent causes of absenteeism in work places. It affects the productivity. Muscles of the neck and trunk primarily act as stabilizers of the spinal column in upright posture. They are the dynamic control against the force of gravity as the weight of the various segments shifts away from the base of support.

Continual exaggeration of the curves to faulty posture and muscle strength and flexibility imbalances as well as other soft tissue tightness or hyper mobility. Imbalances in the flexibility and strength of hip, shoulder and neck musculature will cause asymmetric forces on the spine.

Causes of back pain :- stress, poor posture, improper lifting of heavy objects, depression, arthritis, osteoporosis, spinal stenosis, spinal injury, sprain in back muscles and ligaments. Back pain often goes away with minimum treatment. In some cases it gets better within two weeks, but in some it may recur. Some causes of back pain can be serious and cause permanent nerve damage, if not treated properly.

Back pain is difficult to treat; it is best to prevent it. Here are some ways to prevent back pain.

Exercise : Health cycling, walking, swimming atleast 3 to 4 times a week keeps your back in good condition. Exercise also helps to prevent osteoporosis.

1) Lie on your back with your knees bent, arms at your side, and feet flat on the floor.

Tighten your abdominal muscles, and press the lower back down to flatten your back against the floor. Hold your back down for a count of five. This exercise strenghtens your abdominal muscles (Fig. 1, 2, 3).

2) Lie on your back, knees bent, feet on the floor. Feet and knees should be parallel about a foot apart. Keep hands behind your head with your elbows out on the sides. Lift your head and upper back off the floor as high as you can use your abdominal muscles, not your arms. Keep your elbows back. Hold for a count of 10 (Fig. 4, 5).

3) Lie on the back with your knees bent, arms at your side, and feet flat on the floor. Grasp your knee with both arms and pull it gently towards your chest. Return to the starting position and repeat with the other knee (Fig. 6, 7).

4) Lie on your back, knees bent, feet flat on the floor. Turn out your feet slightly, opening the space between your knees. Extend your arms back over your head. Reach your arms forward through your knees lifting your head and shoulder off the floor. Hold the position for a count of 10 (Fig. 8, 9).

5) Lie on your back with your knees bent. Hold the knees together, roll your hips to the right, pushing the outside of the right leg towards the floor, do this very comfortably, do not force yourself to touch the floor if you are not able to do it. Return to the starting position and roll your hips on the left and repeat the same exercise on the left. This exercise strengthens the lumbar portion of the spine.

6) Sit sideways on a chair with your back straight. The back of the chair should be on your left. Turning your shoulders and body to the left, grasp the back of the chair and slowly twist yourself to the left. When you feel a gentle stretching in the middle of your back, hold the position and don't go further. Hold this position for a minute or so, and then slowly return to your starting position. Then turn around so that the back of the chair is to your right and repeat the same exercise, turning to your right. This exercise strengthens the thoracic (chest) portion of the spine.

7) Lie on your stomach for 3 minutes, relaxing your back muscle.

8) Lie on the stomach. Then prop yourself up on the elbows, allowing the pelvis to sag (Fig. 10).

9) Lie on stomach with hands placed under the shoulders, then extend the elbows and lift the thorax up off the mat but keep the pelvis down on the mat. This is a prone press up (Fig. 11).

But be careful before doing these exercises, because some exercises may worsen your back pain if not done properly. So do not start any exercise programme until you see a doctor or until you are no longer in pain.

Weight management :- Extra weight puts extra stress on the back muscles and makes them work harder. Extra weight can be managed by exercise and a wellbalanced and nutritious diet.

Controlling weight helps the whole body,not just the back, to be healthy.
Sitting, Standing And Lifting Objects :-

1) When standing for long periods, use a small stool to keep one foot up with the knee bent.
2) While sitting on a chair sit straight,keep a cushion to support your back (Fig.12).

3) Do not sit in one position for long periods. If you have to sit for long periods,get up and walk around for a minute or two after every hour.
4) When sitting on a chair for long periods, your knees should be higher than your hips. To do this rest your feet on a low stool. This prevent your knees from dropping below the hips or dangle in the air (Fig. 13).

5) Avoid sustained bending forward while sitting (Fig. 14).

6) Don't stand in the same position for prolonged periods, shift from one foot to the other. Best way to stand is by propping one foot on a footstool or a rail.
7) When turning to walk from a standing position move the feet first and then the body, as in the left and right face in the military, pivot the feet rather than twist the spine (Fig. 15).

8) Stand up tall pulling up out of your torso. Pull your head up but don't stick your chin out.
9) Avoid high heels. Wear non-slip shoes, which keep toes out for extra stability (Fig. 16).

10) Do not lift heavy objects by bending in you waist, but squat, hold the object close to your body and then lift. By doing this your lower back will not be stressed (Fig.17).

11) It is better to lift two small suitcases rather than one heavy suitcase (Fig. 18).
12) Avoid lifting above the level of your elbows or at indirect angles. It is better to reach a high shelf with the use of a footrest. Similarly to reach a lower shelf squatting is better than bending (Fig. 19).

13) Lift with your legs muscles. Your leg muscles are much stronger than your back or abdominal muscles. Keep your back relatively motionless, and let your legs bear the load. Sleep properly :- The bed should be comfortable. It should not be very soft, not very hard. Sleep on your side with knees bent and hips tilted forwards. Don't sleep on your stomach. This will increase the pain (Fig. 20).

Miscellaneous:-

1) Beware of overweight, obesity. Pulling the entire of gravity forwards can cause the spine to hyperextend (Fig.21).

2) While driving, push the front seat of your car forwards so that your knees will be higher than your hips (Fig. 22).

3) Avoid awkward reaching. Position objects carefully (Fig. 23, 24).

4) While making beds, it is helpful to get onto your hands and knees (Fig. 25).

5) To get out of bed, bend your knees so that your feet are flat on the bed. "Log roll" to your side. As you bring your legs over the edge, start to sit up.

6) While working arrange the working bench at a correct height, e. g. at the washbasin or while ironing (Fig. 26, 27).

7) When moving a large object, push it, don't pull it (Fig. 28).
8) Household equipments with long handles are ideal as they eliminate stooping (Fig. 29).

Some back pains are serious and require immediate medical attention.

They are :

1) Pain that shoots down the leg or arm with or without any back pain.
2) Numbness in leg, foot, arm or hand.
3) Back pain that has lasted longer than 2 weeks.
4) Loss of control over the bladder or bowels.
5) Sudden back pain which is getting worse with fever and chills.
6) Back pain after falling on the back and immediately experience severe pain.

Do not try to move unless your are in danger. You may have a spinal dislocation or a fracture, which can crush or severe the spinal cord causing partial or total paralysis. Your neck and back must be immobilized before you are moved.

When you suffer from any of the abovementioned condition seek medical help without wasting any time.

Orthopaedic support for bones & joints

by Dr. Kalindi Phadke

The joints and muscles in the body function most efficiently when they are in physical balance. The body is like a chain where abnormal movements of one link or joint can interfere with proper movements of other joints. For example, when one has imbalance in the foot, there is negative effect on the knees, hips, pelvis and spine. These abnormal forces need to be removed before one can achieve improved spinal functions.

Orthotics is an applied science of biomechanical discipline that deals with neuromuscular and skeletal problems. The main aim of this branch is to use devices to enhance or maintain the patient's quality of life, particularly the individual's locomotor function. They compensate for paralysed muscles, provide relief from pain or prevent orthopaedic deformities from progressing.

Orthopaedic supports are useful for patients of all ages. Congenital bone deformities in infants can be corrected by using supports,particularly when the muscles and bones are in the formative stages. In young children or young adults, deformities such as flat feet can be corrected by fitting special shoes, scoliosis with back supports, patients of poliomyelitis with proper braces, so that they can function normally, while the correction takes its own course. Sports injuries involving muscles, tendons, ligaments, bones and cartilage are very common among young adults, where orthotic supports can be of great help. The aged population suffering from osteoporosis or arthritis is in need of different supports for balance, dealing with pain, bone deformities, neuromuscular problems, post surgical rehabilitation, etc.

In the last issue of MAI magazine, some information was given regarding the orthotic supports. In this article, an effort is made to give a complete overview of available orthotic devices.

Determination of appropriate device or treatment for a patient involves considering a range of factors, including diagnosis, range of motion, strength, tone, cognition, dexterity, compliance, gait pattern, edema and pain. No device should be used without proper guidance from the physician and / or surgeon and the physiotherapist. Use of unfit devices may create more harm than releif.

Use of orthoses is required when there is injury to the tendons, ligaments, muscles, cartilage or bones, and also at times to treat inflammation and pain.

The injuries of bones and joints can be treated in different ways - medication for pain and discomfort, immobilisation or proper physiotherapy, surgical repair or in extreme cases, joint replacement. The art of orthotics is to achieve balance between stability and mobility. The orthotic devices are sometimes used instead of plaster casts, when the cast is removed and partial immobilization is necessary, or during rehabilitation after the surgery. Various types of ready to use orthoses are available in the market or can be made according to the patient's needs. They are mostly made of polymers and velcro belts and therefore are light weight, durable and user friendly.Metal rods and strips are used only where rigid supports are required.

Hands, Wrists and Arms Supports :- In the cases of injuries to fingers, the splints offer protection and immobbilisation (Figs. 1A, 1B and 1C).

Heat moldable polymer orthoses can be fitted as necessary and offer a fast, effective and low cost treatment.

Wrist binders are commonly used by the sports persons (Fig. 2A).

Those with double lock (Fig. 2B)

can be used for sprains, tendonitis, bursitis, post fracture recuperation or other orthopaedic conditions involving wrist. To offer support and partial immobilization of wrists and forearms, different types of orthoses are available (Figs.3A, 3B, 3C, & 3D).

New elbow supports and protectors, made from paded fabric and velcro, are used for tennis elbow pains (Fig. 4A & 4B).

More managable splints with adjustable fastening impart variable degrees of support (Fig. 5A , 5B).

For upper arm, regular corset (Fig. 6A),

one with shoulder immobilzation strap (Fig. 6B),

combination corsets for upper arm and forearm Figs. 6C and 6D)

, or an aeroplane splint (Fig. 6E)

are available.

Supports for the Back :- The structure of backbones is the engineering masterpiece of Mother Nature. There are several vertebrae forming a link,encasing and protecting the spinal cord. Between every two vertebrae is a rubbery white cartilage disc which serves as a cushion. The central portion of the disc is filled with a jellylike shock absorbing material. Dozens of spinal nerves thread out from the cord between the bones. There are muscle bands and ligaments which support the vertebral column (Fig. 7).

Various injuries can occur in this complicated and intricate network, causing back or neck pain. Such pain affects almost everyone at some point in his life. Sudden traumatic injuries or certain repetitive movements may stretch and tear muscles and ligaments, inducing inflammation and painful spasms. With the weakening of joints or intervertebral discs, one vertebra may slip over another, pinching or pushing against the nerves, thus causing pain. The discs may degenerate with age,lose their cushioning power and collapse under the weight from above. The jelly-like substance in the center of the disc may buldge outward and pressurize a nerve, the condition known as herniated disc. If the pressure is on the sciatic nerve, one experiences shooting pain in the lower back and leg. If the degenerated vertebra or disc is in the upper portion of vertebral column, the pain is in the neck and arms. With such unbearable pain, rest is advised, but longer periods of inactivity may weaken the muscles and any undue movement can lead to severe pain. Using a proper brace for some time provides relief in many cases. At times,corrective surgery has to be performed, but one has to often wear a brace during the recovery period. A variety of braces for neck, upper and lower back and lumber area is available. Everyone is familiar with cervical collars to stabilize cervical vertebrae and restrict the neck movements (Figs. 8A, 8B).

A firm, soft and contoured cervical pillow gives relief to the patients suffering from cervical spondylosis (Fig. 9).

A clavicular brace is useful when there is injury to the collar bone (Fig. 10).

Light weight and firm back supports, which can be adjusted according to the contour of the back give relief from back pain (Fig. 11A and 11B).

Then there are different orthoses for lumbosacral area (Fig. 12A, 12B & 12C).

or combination supports for thoracolumbosacral portion of the back (Fig. 12D). A good versatile lumbosacral back rest provides correct posture and comfort during prolonged sitting or driving periods (Fig. 13).

Supports and braces for legs, ankles and feet :-

Most common sports related injuries involve knees, tibiae and ankles. Knee injuries may occur due to injured or torn muscle, tendon, ligaments, patella or meniscus, besides a fracture. Wearing a brace gives the tissues proper immobilization and rest necessary for early recovery. In older and arthritic patients, using a proper brace can help reduce pain. The braces are also used by patients with valgus or varus knee deformity where the knee is turned inward or outward. Fig. 14

shows a nonweight bearing femoral corset. A tibial brace with or without the foot plate is shown in Figs. 15A & 15B.

An ankle stabilizer is shown in Fig. 15C.

Braces for valgus and varus deformities are seen in Figs. 15D & 15E respectively.

Problems with relatively common in people of all ages. Use of wrong footwear, such as high heels, pointed toes, too loose or too tight fit over a long time period eventually leads to deformities, such as crooked toes, bunion at the base of large toes, loss of arch etc. Some of these deformities are often noticed in the aged and arthritic persons. Footache eventually gives rise to knee and back pain. Some of these deformities can be compensated by the use of insoles with arch supports, soft padding and metatarsal supports (Fig. 16).

Separate metatarsal supports or heel cups can also be used inside the shoes (Fig. 17A & 17B).

For crowded and crooked toes, soft sponge or rubber separators may be inserted between the toes (Fig. 18),

or a splint for large toes can be used at night (Fig. 19).

People who are overweight and diabetic need special well padded shoes. All these orthoses canbe be purchsed readymade or custom made according to the individual needs. Splints and braces are made to help infants with congential defects or children who are victims of polio or other neuromusculoskeletal deformities. Corrective braces or jackets for scoliotic children are also custom made.

Walking Aids and Wheel Chairs :-

Walking sticks are available in 2 or 3 different varieties - simple sticks or those with tripod or quadripod bases. They are light weight and adjustable in height (Fig. 20A, 20B & 20C).

Light weight full crutches or foream / elbow crutches and walkers are also available (Figs. 21A, 21B & 21C).

New foldable wheel chairs are very convenient to use on smooth surfaces, at home, in the hospitals or rehabilitation centers. They have adjustable foot rests and brakes. More conventional metal frame chairs have removable large size and/or small wheels. They can be fitted with removable bowls and can be used as commodes too. (Fig. 22A & 22B).

Battery fitted self operable chairs can be imported from abroad. These are some of the commonly used and available orthoses. Many more can be tailor made to suit any specific needs. If a person loses a hand, arm, leg, foot, etc, due to industrial accident, road traffic accident, war casualty or other reasons, various types of prosthesis can be custom made. The science of making prostheses is so advanced these days that one cannot easily differentiate between artificial and natural limbs. They are easy to fit and convenient to use than those in earlier days.

(This article was based on information on internet, personal interviews with orthotics suppliers and manufactures' catalogs).

Total Knee & Hip Replacement

by Dr. Rahul A. Damle

This article provides information for you and your family regarding Total Knee and Hip Replacement surgeries. Please read and discuss the contents with your family before your Replacement surgery. The goal is to restore your Knee or Hip to a painless, functional status, and make your hospital stay as beneficial, informative and comfortable as possible.

Total Knee Replacement

Total Knee Replacement is a surgical procedure in which injured or damaged parts of the Knee joint are replaced with artificial parts. The ends of the thigh bone (femur) and the shin bone (tibia) are removed, and sometimes the underside of the Kneecap (patella) is also removed. The artificial parts are cemented into place. Your new Knee will consist of a metal shell on the end of the femur, a metal and plastic trough on the tibia, and if needed a plastic button in the Kneecap.

Who is a candidate for a Total Knee Replacement ?

Total Knee Replacements are usually performed on people suffering from severe Arthritic conditions. Most patients who have artificial Knees are over the age of 55, but the procedure is performed in younger people as well The circumstances vary somewhat, but generally you would be considered for a Total Knee Replacement if you have any of the below :

You have daily pain
Your pain is severe enough to restrict not only work and recreation, but also the ordinary activities of daily living
You have significant stiffness in the Knee
You have significant instability (constant giving way) of the Knee
You have significant deformity (lock Knees or bowlegs)

This is an elective surgery, it is not a matter of life or death. The decision to proceed with Total Knee Replacement surgery is ultimately yours. It is you who must accept the risks and potential complications. Please feel free to ask your doctor questions to assist you in your decision-making.

What can I expect from an artificial Knee ?

An important factor in deciding whether to have Total Knee Replacement surgery is understanding what the procedure can and cannot do. An artificial Knee is not a normal Knee, nor is it as good as a normal Knee If Replacement provides you with pain relief and if you do not have other health problems, you should be able to carry out many normal activities of daily living. About 90% of patients with stiff Knees before surgery will have better motion after a Total Knee Replacement. More than 90% of individuals who undergo Total Knee Replacement experience a dramatic reduction of Knee pain and a significant improvement in the ability to perform common activities of daily living. But Total Knee Replacement will not make you a super-athlete or allow you to do more than you could before you developed Arthritis Activities that overload the artificial Knee must be avoided. Some types of activities must be avoided for the rest of your life, including jogging and high impact sports

Patient's Expectations -

100% pain relief
100% normal walking pattern
Able to run and jump
Able to bend Knee fully
Knee will "last forever"
Knee will never get infected

Surgeon's Expectations -

80% - 100% pain relief
Trace of limp to 100% normal walking pattern
Should avoid running or jumping
Can bend to 100
Knee will last for about "10 - 15 years"
Occasionally Knee will get infected

How successful is Total Knee Replacement surgery ?

Result are generally very good, most people are relieved of nearly all of their Knee pain. Approximately 90% of Total joints will last 12 - 15 years, depending on patient use and activity levels. This may vary from person to person

The goals of Total Knee Replacement are, in order of priority :

Pain relief
Standing and walking that is not limited by the Knee
Improved Knee motion
Improved Knee strength

How long do artificial Knees last ?

About 85% - 90% of Total Knee Replacements are successful up to 10 - 15 years. The major long term problem is loosening. This occurs because either the cement crumbles (as old mortar in a brick building) or the bone melts away (resorbs) from the cement.

Preparing for Surgery

Preparing for a Total Knee Replacement begins a few weeks ahead of the actual surgery date. Maintaining good physical health before your operation is important. Activities which will increase upper body strength will improve your ability to use a walker or crutches after the operation

Pre-operative Medical Check-up

During your pre-op visit, lab tests will be advised to ensure that you are in good general health. Chest x-rays and an ECG are obtained if you have not had one taken for six months or otherwise indicated. If at any time you become ill, such as with a cold or flu, you need to call your doctor. Remember, we want you to be in your best possible health The doctor will also make sure that a urinary tract infection is not present. Urinary tract infections are common, especially in older women, and often go undetected. Teeth need to be in good condition. An infected tooth or gum may also be a possible source of infection for the new Knee. The Orthopaedic surgeon may ask you to see a medical doctor You may be instructed to stop taking your anti-inflammatory medications (lbuprofen, aspirin, etc.) one week before surgery. Bring a written list of past surgeries and of the medications and dosages that you normally take at home A physician will also review your medical history and the medications that you take. He will listen to your heart and lungs, and do a general physical exam. He will check for any type of infection. If infection is found, surgery is generally delayed until the infection is cleared

Will I need blood ?

Many patients do require a blood transfusion of between 2 - 3 units (pints) of blood after a Total Knee Replacement. A family member or friend with the same blood type can donate. Of course, there is always blood available in the blood bank

What are the risks of Total Knee Replacement ?

Total Knee Replacement is a major operation. The effect of most complications is that you must stay in the hospital longer The most common complications are not directly related to the Knee and usually do not affect the result of the operations. These complications include urinary tract infection, blood clots in a leg, or blood clots in a lung

Infection : Infection can occur following any type of surgery. In order to minimize the potential for infection to occur at the time of surgery. Antibiotics are given before surgery and for about 10 days following the operation. Infection following Total Knee Replacement is of special concern because of the prosthetic components. The prosthetic components have no blood supply and this makes them susceptible to infection. If the prosthetic components become infected, additional surgery is almost always required in order to treat the infection

Persistent Pain : While more than 95% of patients have complete or nearly complete relief of pain following Total Knee Replacement, there are some patients with some persistent pain. In many cases, the pain resolves with time. In other cases a specific cause for the pain can be identified and treated

Blood Vessels and Nerves : There are several major blood vessels and nerves around the Knee. Rarely, a major blood vessel or nerve is injured during Total Knee Replacement surgery

Blood Clots : Blood clots can form in the large veins of the legs and pelvis following major surgery, such as Total Knee Replacement. It is possible for such a clot to break loose from the vein and travel to the heart. The clot can pass through the heart and into the lungs. This is called a Pulmonary Embolus

Myths & Facts about Total Knee Replacement

Too Old ?

Knee Replacement is safe and successful at any age. With modern anesthesia, infection fighters, and the skill of experienced joint surgery specialists, you do not "have to live with the pain"

Too Young ?

Today's super-metals make artificial joints last longer than ever before. When performed properly, Knee Replacement can be expected to last 15 - 20 years. When the first Knee Replacement wears out, another new one can be put in. It's much like re-treading a tire or recapping a tooth

Too Overweight ?

For people with Knee Arthritis, it's almost impossible to lose weight when even simple walking is too painful. In fact, it's much easier to exercise and lose weight when Knees are pain'free after a Knee Replacement

Too Long To Recover ?

Patients are usually allowed to walk within a week after surgery. Discharge from the hospital is around the 10th day. Healing and recovery after Knee Replacement is generally complete in 12 weeks

Can surgery be done on Osteoporotic Patients ?

Patients with Osteoporotic bones can undergo the surgery. But the Knee has to be fitted with a special type of implant.

Total Hip Replacement

What is it?

Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two parts-the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the "ball" or head ol the thigh bone (femur). During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal.

These artificial pieces are implanted into healthy portions of the pelvis and thigh bones and affixed with a bone cement (methyl methacrylate) -'Cemented THR'.

An alternative hip prosthesis has been developed that does not require cement. This hip has the potential to allow bone to grow into it. This is called as Cementless THR.

ln some cases, only one of the two components (socket or stem) may be fixed with cement and the other is cementless. This would be called a "Hybrid" THR.

When do we consider total hip replacements?

Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or aseptic necrosis (a condition in which the bone of the hip ball dies). Most patients who have artificial hips are over 55 years of age, but the operation is occasionally performed on younger persons. Circumstances vary, but generally patients are considered for total hip replacernents if :

O pain is severe enough to restrict not only work and recreation, but also the ordinary activities of daily living;
O pain is not relieved by arthritis (anti-inflammatory) medicine, the use of a cane, and restricting activities;
O significant stiffness of the hip;
O x-rays show advanced arthritis, or other problems.

What can be expected of a total.hip replacement?

A total hip replacement will provide complete or nearly complete pain relief in 90 to 95 percent of patients. lt will allow patients to carry out many normal activities of daity living.

The surgeon's expectations after recovery are similar to those listed tor the knee replacement. Further, a patient can never sit in deep lounge chairs. lnternal rotation of the hip has to be avoided permanently. Occasionally the hip may dislocate and there will be + 1 cm change in length of leg.

How do artificial hips stand up over time?

As we noted earlier, 90 to 95 percent of hip replacements are successful up to 15 years. The major long-term problems are loosening or wear. Loosening occurs either because the cement crumbles (as old mortar in brick building) or because the bone melts away (resorbs) from the cement. Wear can occur in the plastic socket after some years. Small wear particles can cause inflammation resulting in thinning of the bone and risk of fracture.

The preparation for surgery, preopmedical check up, blood requirement during the surgery and the risks involved are similar to those for total knee replacement surgery. lt is to be remembered that total hip replacement is a major operation and if the complications are involved the hospital stay will be longer.

Just like your real hip, the artificial hip can dislocate (ball comes out of the socket). There is a greater risk just after surgery before the tissues have healed around the new joint, but there is always a risk. Your doctor will instruct you very carefully how to avoid activities and positions which may have tendency to cause hip dislocation.

Myths and facts about total hip replacement are very similar to those listed above for total knee replacement.

Surgery in rheumatological conditions

by Dr. Ajit N. Damle & Dr. Rahul A. Damle

Medical drug therapy & physical therapy (including physical therapy / rehabilitation programme / occupational therapy) form the basis of the treatment.

During the process of management of a case few surgical procedures form a part of the therapy.

The following are few procedures needed to establish a diagnosis & manage conditions.

These procedures are usually a day care ones, except arthrosporic procedures, where a short stay in a hospital is recommended.

Diagnostic procedures :

1. Knee aspiration :

Knee is easily accessible joint, with synovial fluid. Aspiration / tapping is done, as a diagnostic method to get the fluid sample. In case of a tense effusion, to relieve the pain, tapping is done. Often the immune response is lower & hence this procedure is better carried out in an operation room. The fluid chemistry / microscopic examination to know presence of crystals, etc. culture to know, if some germs are present / immunological tests etc. can be directly carried out.

2. Synovial biopsy :

This procedure involves removal of a piece from the lining in a joint to carry out histological diagnosis of the disease. This helps to confirm or exclude certain conditions.

3. Arthroscopic biopsy & debridement :

Earlier an open biopsy was done. Now a days arthroscopic assessment & biopsy is done.

Therapeutic Procedures :

1. Synovectomy :

In addition to biopsy, the excess hypertrophy of the synovium (the lining membrane)can be removed.

The diseased synovium (The lining membrane) is removed and it helps to prevent erosions of the cartilage and is a good benefit.

Instead of an open procedure, when done thro an arthroscope, the incision (cut) is smaller with less tissue damage and hence, the recovery is rapid, with good return of the range of the joint movement. The recovery is thus, rapid & usually assured, with minimal chance of development of joint stiffness.

2. IntraArticular Steroid Injection :

In osteoarthrosis or Rheumatoid disease, as anti inflammatory drug, injection of intra articular steroid injection offers a good relief in pain & swelling. However, the duration of the relief offered, varies from person to person. It is usually recommended once or at the most two times.

3. Local Steroid Infiltration :

In conditions like enthesopathy (inflammation of ends of muscles), / Tennis elbow / bursal calcification in the shoulder area / inflammation of tendon sheaths / ganglion etc. this procedure offers good symptomatic relief.

FRACTURES IN RHEUMATOLOGICAL CONDITIONS

In addition to the above procedures, often some major procedures are needed at some stage of the disease. The common ones would be discussed now.

1. Fractures around the hip :

Due to - osteoporosis lack of coordination falls in the elderly are known to occur, resulting in a hip fracture.

If a fracture is just below the ball of the joint (Head femur) the bone end needs to be replaced. Following this early weight bearing is possible within a week or so.

If a fracture occurs little below, then the bone ends are fixed to each other with metal devices & early mobilization (if not weight bearing) is possible.

The aim of both the above procedures is to prevent complications of prolonged rest 1 bed / prevent joint stiffness etc. and of course relief of pain.

2. Stress Fracture :

In a foot, due to osteoporosis & repeated minimal stress on the bones, bone may yield and lead to a painful foot. First X-ray may be normal & in a following X-ray film the fracture healing makes its appearance. Often a bone or a joint may be deformed, due to the pathological changes in and around a joint, leading to angular deformity. Continued weight bearing in such a situation adds untoward stress on the adjoining bone and lead to a slow yield of the bone, called a stress fracture. Only X-ray diagnosis is uncertain and a nuclear scan and / or an MRI will confirm the condition. Usually it is a practice to treat such an injury in a foot non operatively by a plaster support. However, in a long bone, especially in the shin bone called the Tibia, with a deformity, it is better to offer surgical method primarily by internal fixation for early mobilization and assured union of the fracture.

3. Fractures around a joint :

It is advisable to carry out internal fixation with metal devices to reposition the bone ends to achieve a good return of function. The supportive drug therapy to correct & prevent further osteoporosis is very much necessary. This also makes the person aware of the condition and to prevent further likelihood of another fracture.

4. Correction of deformities in the limbs :

Soft tissue contractors do occur, due to muscle imbalance. Traction / surgical correction, followed by immobilization & rehabilitation offers a good outcome, if timely carried out.

MAJOR SURGICAL PROCEDURES :

1. Foot Arthrodesis :

Arthrodesis is fusing two bone ends, making it one. In foot, deformity of toes is common, due to muscle imbalance. Development of callosities (skin thickenings) with infection leads to many problems. Including fungal infections in between the toes. Removal of the bone ends cartilage & opposing the bone ends in correct position leads to a pain-free and cosmetically & functionally a pleasing appearance. Once the bone ends heal well, the area becomes pain-free. This procedure is rewarding in forefoot & the wrist. As the toes are well aligned, the incidence of fungal infection / callosities reduces.

However, in large joints, especially the knee, due to bone loss & deformities, the union may not take place & the procedure is less rewarding. However, in a failed joint replacement, one may have to consider this, especially following a knee replacement.

This is a primary procedures of choice in foot & wrist joints. While in the knee, joint replacement is of first choice. If it fails then the hardware is removed this procedure is done as a salvage procedure.

2. Resection Arthroplasty :

In toes joints, where they are destroyed, deformed, the function may not be satisfactory. Then the bone ends are removed and in due course the area is filled with stiff fibrous tissues and the toe is well aligned, with a good function. This procedure is usually rewarding in foot deformities and not in large joints.

3. Total joint replacement :

This procedure provides a stable, pain-free & mobile joint with a good functional range. The result is predictable & can last for at least ten years.

ADVANTAGES :

1. Pain-free joint with a good function & range.

2. Limb alignment is better a gait improves.

3. Chances of a stress fracture developing is less, due to improved weight bearing axis.

TECHNIQUE :

The ends of the damaged & deformed joints are removed & replaced with artificial material. Usually a metal component on one side and a polythene component on the other side. The material is bonded to the host bone with a plastic bond called bone cement. This procedure offers a stable & pain-free joint with a good functional status, lasting for at least ten years. The newly constructed joint needs to be used with care as in rheumatological conditions, where the bone is soft, loosening is more common than others.

INDICATIONS FOR A JOINT REPLACEMENT :

1. Severe persistent pain.

2. Loss of the joint function.

3. Deformity.

4. Compromised function & quality of life are the basic indications.

5. On X-ray evidence of destruction of the joint cartilage.

The patient needs to be totally evaluated, prior to offering this alternative by the physician & surgeon as a team. The gravity of the procedure, chances of complications which may develop, need to be discussed with the patient & the family members.

CONTRAINDICATIONS FOR A JOINT REPLACEMENT :

1. Local infection in the skin / joint.

2. Neuropathic joint, where the muscle control is poor.

3. Poor, adherent skin condition.

4. Previous repeated surgical procedures.

5. Bone loss, which may make structural reconstruction difficult.

6. General condition, including the nutrition of the patient, who may not stand the procedure.

7. Limb condition & blood perfusion of the limb.

8. Advanced arterial disease.

BENEFITS ACHIEVED WITH A JOINT REPLACEMENT :

1. Relief of pain.

2. Improved range of motion.

3. Stability of the joint, leading to a better gait.

INDIVIDUAL JOINTS

KNEE :

Pre operative joint status : deformities / ligament laxity / existing range of motion / skin condition / prior surgery done if any need to be evaluated. X-ray examination shows the bone status / bone loss front either side of the joint. In a too lax or too stiff a joint the surgery is challenging to offer a stable joint with good range.

FINGERS :

lf preoperative range is fair, deformities moderate & the muscles working well, then replacement of few joint can be offered.

WRIST :

In a manual worker a fusion of the joint is a better option than joint replacement.

ELBOW :

Often the elbow is stiff & painful. The use of an elbow is important in those who need a stick or a walker to ambulate. In selected cases, after elbow replacement, the joint can become pain-free, allowing a good quality of life. The relief is especially in those who lead not so active a life.

SHOULDER :

Painful limitation of motion is the usual presentation. Due to the disease, the tendons around the shoulder are worn out and may be torn even. Their reconstruction may not be possible. A painful shoulder joint can be made pain-free after a joint replacement. However restoration of the range of motion may not be satisfactory, due to the tendons status.

CARE AFTER A JOINT REPLACEMENT :

1. Must follow the surgeon's advice, as to what can be done & what is to be avoided.

2. After a hip or a knee replacement, though one may be able to do, it is recommended not to sit cross legged / sit on a low chair / squat, etc. Such activities may cause early loosening of the joint material, making a revision necessary, which could be more difficult than the primary procedure.

3. There is a large hardware, which is a foreign body. Hence whenever one may have suspected infection anywhere in the body, like a sore throat, nail bed infection / abscess anywhere, please inform & see the surgeon, who operated. At this stage one needs to take a course of antibiotics, to avoid infection from other site setting & affecting the joint parts.

COMPLICATIONS OF A JOINT REPLACEMENT :
(Especially after hip & knee replacement)

1. DEEP VENOUS THROMBOSIS :

Development of clots in the veins of the legs. This leads to swollen legs & the clot may cause a blockage in the lungs and even lead to a death. Preventive anti coagulant drugs are given after an operation, but still the complication can occur.

2. INFECTION :

This is often seen in associated diabetes / after immunosuppressive drugs and in those with lower resistance in general. Even after exercising all the possible care such an episode may occur more in cases of rheumatoid disease than inosteoarthrosis.

I. Acute infection :

Develops in an early period after the surgery and may need reoperation & wound wash etc. In some case removal of the prosthesis and reimplanting at a later date may be required.

II. Late infection :

Develops few months after good initial recovery. Usually the infection is secondary to infection elsewhere (from a different source) like urinary track / intestines / teeth / skin, etc. Hence after any joint replacement the patient is always advised to report after any infection anywhere in the body, so the necessary care & antibiotic administration can be arranged to prevent such an episode.

3. PERI PROSTHETIC FRACTURES :

A fall after joint replacement, may cause a fracture around the prosthesis and needs to be operated to align & stabilize the bones.

PREOPERATIVE ASSESSMENT :

Patients suffering from a rheumatological condition have usually low resistance to infection and low body reserves. Patient history, clinical examination along with preoperative medical evaluation / laboratory tests need to be done. Associated diseases like diabetes / cardiac & respiratory status need to be assessed by the physician and anesthesiologist. This would help to identify possible post-operative complications likely to arise and the necessary care can be taken. All this needs to be discussed with the patient & the family, especially likelihood of post-operative intensive care management.

1. The skin : Total evaluation is necessary in physical examination. Presence of any skin infection anywhere on the body has to be attended to. The wound healing is usually slow especially in those, where subcutaneous fat is less. Post-operative pressure sores (bed sores) are to be avoided.

2. Methotrexate & any other irnmuno-suppressive dugs and aspirin are better stopped two weeks prior to the surgery and may be resumed two weeks after the surgery.

3. Duration of anesthesia needed and the type. A regional anesthesia is usually better tolerated and the incidence of lung complications is likely to be less.

4. In rheumatoid arthritis, the neck vertebrae joints may be lax and cause partial dislocation. This has to be assessed pre-operatively.

5. In certain cases of spine stiffness, inserting a tube in the wind-pipe may be difficult and special precaution called fibre optic intubation may have to be kept ready. In such cases chances of developing lung complication is more.

6. In elderly male patients, possibility of prostatic disease and chances of post-op urinary retention be kept in mind.

7. Body hydration in general : is very important to maintain a good blood volume in the system and maintain a good level of blood pressure during and after the surgery.

8. Presence of acidity (Peptic ulceration) be known, because such a case may develop bleeding from the stomach due to the stress of the surgery. Usually prophylactic drugs are given.

POST OPERATIVE STATE :

1. In the elderly, transitional confusional state may prevail for a few days. Inspite of maintenance of good balances of the system, this does happen. Disorientation due to unfamiliar atmosphere, time & space etc. does occur.

2. Transient paralysis of some nerves : after correction of some limb deformities, may occur. This could be due to nerve stretching following deformity correction or being in one position during the surgery.

3. Thrombo - embolic disease : in persons with low activity level, the circulation is at a low ebb. During the postoperative state the rest in bed may add to the slow blood circulation and may develop clots in the legs. The clot may migrate & create blockade in the lungs, heart or the brain. Hence during the post-op period some drugs are given to delay the blood coagulation process. Leg active exercises / elastic leg stockings etc help to keep the incidence lower.

4. Fat embolism :

After surgery on long bones / joints especially in the young well built persons, the bone marrow fat may be liberated into the circulation and may cause blockage in the lung and / or brain circulation.

Post-op confusion, reduced blood pressure, breathlessness, etc. indicate this and would need I.C.U. care and ventilation therapy.

5. Other medical conditions :

Control of diabetes / cardiac state / lung care / exercise therapy / nutrition and adequate hydration / regular turning in the bed to prevent bed sores / maintaining a positive attitude, etc. are a few things that needs attention for a better & early outcome in general.

6. Rehabilitation Programme :

The therapist in conjunction with the treating surgeon should encourage & help the patient for exercises / mobilization / strengthening of muscles, etc. At appropriate stage ambulation as advised by the surgeon can be carried out.

SUMMARY :

Correct selection of a patient and the required procedure, preoperative assessment by the entire team / execution of the operative procedure and good post-op care, along with a therapist would offer a good outcome.

NECK PAIN

by Dr. Suniti Shotriya

Pain in the neck is one of the commonest problems of health that one encounters in day to day life. It is in fact more common than common cold. 2/3rd of the population suffers from neck pain regularly. It is not a disease by itself but it can disturb a person's day to day life to a great extent. Neck or cervical spine is a pivot joint at its junction. As Atlas (the Greek God) had held the Earth on his shoulder, similarly the small odontoid process which measures just half an inch, bears the weight of the entire skull. Its mechanism of functioning is most complex and the biomechanics of its movements are very gentle and graceful. In bipedal human posture the spine is called upon to transmit the weight of the body to the ground, that is why it is provided with curves to sustain this stress for many years. Along with weight bearing, it performs movements almost 536 times a day! This puts tremendous stress on this joint and makes it vulnerable to early degenerative changes. In addition to this, faulty postures, poor body mechanics, incorrect working habits, injuries to spine, lack of proper exercise and mental stress hastens the wear and tear process.

Osteoarthritis is the result of this process which worsens with age. In Rheumatoid arthritis, acute inflammation of soft tissues leads to their damage and makes the spine unstable.

SIGNS AND SYMPTOMS : -

It can start as a catch in the neck along with continuous pain which becomes recurrent. Pain in the neck and stiffness felt early in the morning are the initial signs. In severe cases the pain is excruciating and can radiate to the hands.

Numbness and tingling in the fingers is also common. In chronic cases pain is almost always present with restriction of neck movements. It can also lead to the disturbance of sleep and upset work and daily activities of a person.

TREATMENT

ACUTE STAGE calls for the medication to relieve pain and inflammation. Hot fomentation, rest and avoiding certain positions also help relieve pain and discomfort. Physiotherapy treatment includes different modalities depending upon the symptoms. They are shortwave diathermy, cervical traction, interferential therapy, TENS and ultrasound. Manipulation and mobilization techniques are also used.

LONG TERM MANAGEMENT

There is no permanent cure for this condition. Relapse is almost certain. But to reduce the frequency of relapse, certain lifestyle changes are needed. It is more important what not to do rather than what to do.

INSTUCTIONS TO PREVENT NECK PAIN

DON'T'S

1] Avoid using a thick pillow while sleeping.
2] Avoid reading or watching T.V in the sleeping position.
3] Avoid lifting any weight on your head and lifting weight with your hands.
4] Avoid performing 'SHIRSASAN' when having neck pain.
5] Avoid driving for prolonged time.
6] Avoid excessive forward bending while doing any form of house or office work.

DO'S

1] Take adequate rest and hot water fomentation.
2] Relaxation techniques of the body to be practiced.
3] Use correct body mechanics.
4] Faulty posture should be corrected.
5] Exercise regularly-safe exercise to be instructed by a physio /occupational therapist.
6] Have a positive mental attitude.

These are some of the exercises commonly advised to maintain the mobility of the neck and to strengthen the muscles around it.

Physiotherapy & Rheumatoid Arthritis

Back Pain

Orthopaedic support for bones & joints

Total Knee & Hip Replacement

Exercise For Knees & Hips

Surgery in rheumatological conditions

NECK PAIN