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 skiers, footballers and rugby 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 dodgy; should I avoid running?

Not necessarily. Elite 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 mnths

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 conside undergoing a  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.

http://orthopedicsurgeon.blogspot.in/2017/03/knee-replacement-in-gurgaon-by-dr.html

Go easy on your workouts!

Kusum Kanojia, April 26, 2013, Deccan Herald News paper.

While exercising is good for a healthy lifestyle, too much of it can harm your body! Doctors warn that excessive exercising, particularly by beginners, may be dangerous for bones.

Dr Jayant Arora, orthopaedics consultant at Columbia Asia Hospital, Gurgaon, says in general exercising is good for the body. But it can come with negative effects if people go over board.  Read the full article at Deccans Herald online : 

http://www.deccanherald.com/content/328470/go-easy-your-workouts.html

http://www.healthydunia.com/article/194/31/smoking_can_aggravate_your_wound.html

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. 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. Dr Jayant Arora has been using Computer navigation to perfom Knee replacement surgery over last 6 years. It is especially useful in some patients with badly deformed knees.

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.

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.

 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. We No longher this technique for our routine cases at recent studies from USA show that using computer Navigation do not improvelong term results. Instead,  we now use a more advances technique called patient matched instyruments, 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.There are additional cost implications if you want us to use this technique.  Feel free to contact us if you need more information on this technique

Advancement in technique-Minimally Invasive Knee (MIS) surgery

We routinely perform Knee replacement surgery using a small incicion. This allows minimal pain , short hiospital stay and a quick recovery. But  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 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 hip replacement surgery for many years.

The traditional operation involves an incision that’s about eight inches long that goes down the front of the knee and leg. With the minimally invasive operation, the incision is about half as long. But the traditional and the minimally invasive operations have more in common than not. The surgeon still cuts away portions of the femur (thighbone) and the tibia (shin bone) that form the knee, and it still involves replacing them with a prosthesis that is designed to restore movement and decrease pain.

Some people find minimally invasive surgery appealing for cosmetic reasons—and it does result in a smaller scar. But the main selling points are less pain after the operation and a speedier recovery, so the benefits of knee replacement are experienced sooner and the recovery is quicker approximately by one month. Joint replacement is a big money maker that engenders a lot of competition for patients among surgeons and hospitals. Touting minimally invasive surgery as a suitable procedure for every patient is a way of drumming up business and borders on being unethical. I have come across a few patients with failed knee implants within 2-3 years after a MIS knee surgery due to poorly positioned implants

Minimally invasive surgery should be able to deliver on these promises: a smaller incision does mean less tissue damage. And proponents of the operations can point to some studies that have shown some advantages, such as shorter hospital stays and less blood loss. But replacing a knee isn’t like taking out a gall bladder. A device has to be implanted into the body. The jury is still very much out whether replacements done through smaller incisions will last as long and be as stable as those done through the larger incision… and this would only become clearer in coming 10 years.

As a surgeon who has done knee replacements using both approaches, I think that the surgeon should get clear view of the joint through an incision of “Sufficient Length” for proper placement of the prostheses and avoiding surgical complications. Now whether that incision is 4, 5 or 8 inches is irrrelevant and depends on the patient’s needs. Any day, I would not like to be struggling to properly place the implants through a tight smaller incison, just because I had promised a patient who is not suitable for MIS knee surgery. Such patient typically include obese patients especially short obese ladies, severe deformed legs like bowing and knock knees and in my practice there is no dearth of such patients, infact approximately 60% of patients that come to me for a knee replacement surgery are not suitable candidate for a MIS procedure.

There are other ways to reduce postoperative pain and speed recovery besides making a smaller incision. They range from injections of long-acting painkillers into the joint and surrounding tissues, to cold wraps around the joint, to “constant passive motion” machines that can be used in the days right after surgery to exercise the knee gently, keeping down swelling and stiffness.

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 !!!

MIS surgery has a definitive advantage in a small selected group of patients as recovery from knee replacement is painful — and always requires a lot of hard work. Anything that makes it easier for patients is welcome. As surgeons, it is important that rather than resorting to lure the unsuspected patients with a small incision surgery, we maintain sight of the ultimate goal to safely perform a reliable surgery to improve the quality of lives of our patients than to try and make an easy operation difficult!!

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 surgeries 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. Recovery after ACL reconstruction 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.

This is an epidemic which most of us be happy to bear through as it would take its roots from a bettter, healthier lifestyle of the population at large but would also lead to a better medal tally in the coming Olympic games.

Knee arthritis--Staying fit and active

Dr Jayant Arora, Consultant Orthopedic Surgeon, Columbia Asia Hospital, Gurgaon discusses various ways by which patients suffering from knee arthritis can remain active and enjoy their life with easy simple steps.

You enjoy your morning walk, but you find yourself wincing from knee pain. If this gets any worse, you fear that you may need to drastically reduce your activity level!

In older adults, a common source of knee pain is osteoarthritis, often referred to as wear-and-tear arthritis. Osteoarthritis involves gradual damage or wearing away of the smooth cartilage that covers the joint. Osteoarthritis pain can be felt deep inside the joint or on the side of the knee. Arthritis can also occur under the knee cap (patella). This usually causes pain around or under the kneecap and may cause you to stop your exercise routine or avoid activities that you once enjoyed. Pain from knee arthritis is often worse when you first start moving in the morning or briefly after a period of inactivity. It may also be worse when going up or down a step — or may increase with overuse. Additional signs and symptoms may include stiffness of the joint, a feeling that the joint is unstable, swelling, or a feeling of clicking, grinding or locking within the joint.

Don’t let your knee let you down.

Consult your doctor if you have severe knee pain or persistent knee pain that’s bothering you or interfering with your day-to-day life. There are many potential causes of knee pain other than osteoarthritis explains Dr Jayant Arora. Diagnosis requires a detailed physical examination and possible X-rays or other imaging tests and blood tests.

Addressing osteoarthritis of the knee often starts with:

Strengthening — This is the cornerstone of knee joint therapy. Strengthening the muscles around your knee and hip helps support the joint. This can help make the joint more stable and give the muscles a greater role in absorbing stresses exerted on the joint. Strengthening of the front thigh (quadriceps) muscles appears to be of particular important in preventing the loss of cartilage in those with arthritis of the patella.

Weight loss — Being overweight puts extra strain on knee joints. Losing weight can make it easier to walk and climb stairs.

Low-impact exercise routine — Physical fitness is an important part of managing knee arthritis. Regular aerobic exercise can improve pain and function and help you gain strength and maintain a healthy weight. Your doctor may recommend low-impact activities such as swimming, cycling or walking, which put less strain on your knees than do higher impact activities. You may not be able to do everything you once did, but a well planned exercise routine along with other pain-relieving techniques can greatly improve your ability to be active with less pain and limitation.

Relieving pain flare-ups — If your knee arthritis flares up, try periodically icing your knee with a cloth-wrapped cold pack. Total knee rest may be fine for up to a day, but it’s usually best to keep the joint— and your body — moving in the least aggravating way you can.

Medications —Pain medications, such as Paracetamol, Ibuprofen or other similar anti-inflamatory medications can help ease arthritis pain. Talk to your doctor if you feel the need to take pain medication often. Regular or daily use can cause serious side effects for some. The prescription gel containing diclofenac , a topical anti-inflammatory drug that can be rubbed directly on the skin around the knee. Topical anti-inflammatory drugs appear to cause fewer side effects than do oral drugs of a similar class, such as ibuprofen or naproxen.

Joint Supplements - Glucosamine sulfate and chondroitin are commonly used. These supplements may provide at least some pain relief in moderately advanced knee arthritis in some people. Studies are conflicting about the effectiveness of these drugs. If you decide to take these supplements, consider trying them for a 12-week trial period. If it seems to be helping by then, you may want to keep taking it. If it’s not, you can stop taking the supplements.

Knee Supports — Various types of knee braces can help compress the joint and reduce swelling or realign the joint to lighten pressure in certain areas. Bracing can be fairly effective at reducing pain, providing a feeling of “support,” and for some people, improving walking ability.

Footwear modifications —A shoe with a soft, cushioned heel can help absorb some of the impact of walking. Your doctor may recommend placing a wedge in your shoe heel to take pressure off the areas of your knee that are involved with arthritis.

When your symptoms do not get well controlled with above measures, additional options may include:

Knee injections — One type of injection uses an anti-inflammatory corticosteroid. This may provide pain relief for up to a few months. Typically, injections are limited to no more than three a year. A second type known as viscosupplementation, involves injecting into the joint a thick, natural fluid (hyaluronic acid) that may help lubricate the joint and possibly reduce inflammation. It doesn’t offer immediate pain relief, but improvement in pain and function that may last up to a year.

Joint Preservation Techniques - These techniques are indicated especially in younger patients with cartilage damage. Various procedures can be done to regenerate the cartilage and to delay progression of the knee arthritis. These procedures include cartilage transplantation (OATS and ACI), Microfracture technique, High tibial osteotomy. Stem cells taken from the pelvic bone have also shown good prospects in cartilage healing in certain patients.

Joint replacement surgery —

This is an important option of last resort for advanced osteoarthritis. Extensive joint damage typically requires a total knee replacement. However, you may be a candidate for a partial knee joint replacement if only certain parts of the joint are damaged. This is usually a less extensive procedure than is total knee replacement and often results in a quicker recovery.