Dr Rajeev K Sharma
M.S.(Orth),D.N.B.(Orth),F.I.C.S.
Sr. Consultant Orthopaedics & Joint Replacement Surgeon,
Indraprastha Apollo Hospital, New Delhi
Centre for Joint Disorders, C-139, Greater Kailash - Part I, New Delhi

Degenerative Arthritis is the fate of man kind, only the extent of involvement differs from individual to individual. This subject is the most ill-understood one in our population. Arthritis is a reality which needs to be understood and accepted. Effects of age are visible on our skin, greying of our hair and our diminishing sight. Similar effects are taking place in our joints. The difference is that changes in joints are taking place without being visible to our eyes, hence accepting them is little more difficult. The cartilage of the joint which is well congruent in younger years becomes eroded and irregular as the age progresses. The body reacts to this change and thus excess bone formation takes place, synovial fluid is collected and joint becomes swollen. Knee joint is affected more as 1) during walking knees have maximum stress of bearing our body weight, 2) in our part of the world, varus or inward bending deformity of knee is common due to genetic predisposition. More forces are concentrated on inner part of the knee while bearing weight, damaging the cartilage of the inner part of the knee faster.

There is no justification of denial of one’s present status. You should not be surprised if you are told that you have arthritis. If you are taking many painkiller tablets, not able to walk well, not able to perform daily routine comfortably, denying that you have a problem, is not a solution. Instead you must start working on the problem earlier in life if you want to maintain the life style of 20-40 yrs , after the age of 40 years.

This takes us to the measures one should take to deal with arthritis. Pain killers of ayurvedic, homaepathic or allopathic origin are not the answer. These are only temporary methods to take care of pains for a few hours, just as one takes paracetamol for malarial fever. Instead they expose you to the risk of gastric ulcers and a much serious problem of kidney damage. Singh et al have reported in American Journal of Medicine (105) 1998 that 1,07,000 patients are admitted annually for medicine related intestinal complications as a result of pain medicine intake. All pain relieving tablets cause kidney damage for sure. In rare cases even as little as 6 tablets can cause irreversible kidney damage, forcing one to go for repeated dialysis and kidney transplant. In USA it is illegal to prescribe pain medicines in the first visit to the doctor, while in our country even self medication is common. Most patients come to us for treatment in very late stages when they are finding it extremely difficult to walk or have severe deformities of limbs.

Common symptoms of arthritis are painful knee or hip joint and disturbed walking and limping. Common symptoms of knee arthritis are Pain, Swelling, Locking and Instability of knee joint. Pain is caused by stretching of joint capsule, subchondral bone cyst formation and stretching of ligaments. Commonly encountered arthritis are Degenerative Arthritis, Rheumatoid Arthritis, Seronegative Arthritis and Gouty Arthritis.

The conservative management starts with awareness about arthritis, use of wedges in shoes & braces and only occasional pain relieving medicines. Amongst pain relieving medicines NSAIDs ( brufen, voveran, nimulid, proxyvon etc) are best avoided. Paracetamol is a safer painkiller. First step methods are weight reduction and pursueing precautions like avoiding squatting , kneeling or sitting on floor. Stair climbing should be minimized. Weight reduction is an important strategy as obese men have 4 times occurrence of arthritis and obese women have 5 times occurrence. Physiotherapy is important as strong knee muscles reduce the strain on the joint cartilage. Heat therapy and IFT/Ultra sound are methods of physiotherapy which help reducing swelling of the inflamed joints. In common practice 95% patients do not need surgery and only 5% patients have indications for surgery. Out of this only 2% patients come forward for the surgery as there are wide spread myths about the surgery.

You need to take arthritis seriously when sleep discomfort starts, when you need to accept regular pain medicines, when you become overweight, when pain shuffles from one knee to other, when legs become BOW LEGS. One should think for surgery when arthritis is moderate to severe, when wear of joint is demonstrable by X rays. This is visible by weight bearing X rays of knee joints. Once arthritis is demonstrable surgical options can be considered. There are two surgical procedures which are important to be mentioned. One is arthroscopy and the other is Total Knee Arthroplasty or Replacement ( TKR). High Tibial Osteotomy which is a procedure to correct the inward angulation of leg is only useful in younger age group ( in 40’s) before the arthritis has set in. Once joint degeneration has occurred, this surgery has no role at all.

Arthroscopy is a small endoscopic procedure and a stitch less surgery. One needs only half a day admission in the hospital and can perform day to day routine from the next day of the surgery itself. It has palliative role in osteoarthritis rather than a curative one. It can improve locking of the joint and it does help in acute exacerbation of pain ’coz of degenerative meniscal tear. In some cases of early arthritis it works wonderfully well for a few years.

When knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities such as walking or climbing stairs. You may even begin to feel the pain while you are sitting or lying down. In such a condition, you may want to consider total knee replacement surgery. By resurfacing your knee’s damaged and wounded surfaces, total knee replacement surgery relieves your pain, corrects your leg deformity, and helps you resume your normal activities. One of the most important orthopaedic surgical advancements of this century, knee replacement was first performed in 1968. Improvement in surgical materials and techniques since then has greatly increased its effectiveness. About 267,000 total knee replacements are performed each year in the United States and a much larger number in the world as a whole. Joint Replacement is a very successful procedure in orthopaedic surgery today. Lately, joint reoplacement surgery in India has ushered into a new era. Various aspects of arthroplasty have been unfolded and many myths trashed. The expectations of our patients force us to overcome our limitations and provide better and better results. The major issues in the world today are, the use of Mobile Bearing Knee Implants (because of their documented longer survival rate), minimally invasive surgery and computer assisted surgery.

In our country many patients of primary arthritis of knee report for the treatment when their disability is severe and deformity grotesque. These cases can be divided as severe varus deformity, severe valgus deformity, severe flexion deformity, stiff knees, with bone defects and gross ligamentous laxities. The stability of implant is of paramount importance in order to achieve good and lasting results.

The decision for whether one should opt for this surgery should be a co-opted one between you, your family and your joint replacement surgeon. You should weigh the benefits of the surgery with respect to the problems you are facing. Knee Replacement (Total or Partial) does have a definitive and almost a complication free outcome in good hands. The LCS Mobile Bearing Knee that I am using does have a documented survival up to 25 years, because of its better design and relative mobility between the components, and larger contact area (1400 sq mm) as compared to Fixed Bearing (200 sq mm). This is the most suitable implant for relatively younger, active and obese patients. These days we are doing knee replacement surgery with just a 4” incision (minimally invasive surgery). One is allowed to go to the bathroom on the second day of the surgery, exercises on bed are started on the day of the surgery One needs to use walker for about 2 weeks. Usually in 3 to 4 weeks patients start performing normal routine like driving car, going to market etc. Recovery depends upon the quality of surgery done, determination of the patient and inputs of the surgeon. Usually in our patients a movement of 0* to 120*-140* is achieved after surgery.

Surgery is successful when it is done with the right indication and patient is asking for it. The age at which you should opt for surgery is not relevant. Surgery is an option when you have a significant problem and your surgeon (choosen carefully) confirms the same. There is no substance in suggestion that one should carry on suffering as long as one can and then go for surgery when the suffering is unbearable. It is not a sane advice. When options are available to have a pain free life why suffer?? Particularly when artificial knee implants ( mobile bearing knee) with life span of 22-25 years are available.

Our vision needs to be broadened, reality of aging has to be accepted and if needed treatment must be undertaken. Our mission should be to work in cohesion & make aging graceful for all. Arthritis is a manageable challenge, a planned & judicious treatment is important and early initiation is key to success.