In the ever-changing field of medicine, newer inventions and orthopedic techniques have enabled us to perform better and faster with each passing day. Whether it be the medicines or the implants we use, the focus is always on returning the patient to their pre-disease status at the earliest. In this aspect, mention must be made about the vast recent advances made in the field of Minimally Invasive Surgery (MIS). The objective of MIS is to perform complex and highly demanding surgeries through the smallest incisions possible thereby decreasing the immediate post-operative, as well as the long-term morbidity of the surgery significantly. Just like all other branches of modern surgery, trauma surgery too, has put MIS techniques to fruitful use.
A joint also called an articulation, is any place where adjacent bones come together (articulate with each other) to form a connection. The joint allows the bones to move freely but within controlled limits.
There are various types of joints in the body but among them, the synovial joints are the most common joint.
A key structural characteristic for a synovial joint is its joint cavity. This fluid-filled space is the site at which the articulating surfaces of the bones come into contact with each other. This gives the bones of a synovial joint the ability to move smoothly against each other, allowing for increased joint mobility.
Some joints, such as the knee, elbow, and shoulder, are self-lubricating, almost frictionless, and are able to withstand compression and maintain heavy loads while still executing smooth and precise movements. Other joints such as sutures between the bones of the skull permit very little movement (only during birth) in order to protect the brain and the sense organs.
In a joint, bones do not directly come into contact with each other. They are cushioned by cartilage that lines your joints (articular cartilage), synovial membranes around the joint and a lubricating fluid inside your joints (synovial fluid).
Muscles provide the force and strength to move the body. Coordination is directed by the brain but is affected by changes in the muscles and joints. Changes in the muscles, joints, and bones affect the posture and walk, and lead to weakness and slowed movement.
AGING CHANGES ON JOINTS AND MUSCLES
From about age 30, the density of bones begins to diminish in men and women. This loss of bone density accelerates in women after menopause. As a result, bones become more fragile and are more likely to break, especially in old age.
As people age, their joints are affected by changes in cartilage and in connective tissue. The cartilage inside a joint becomes thinner, and components of the cartilage (the proteoglycans—substances that help provide the cartilage’s resilience) become altered, which may make the joint less resilient and more susceptible to damage. Thus, in some people, the surfaces of the joint do not slide as well over each other as they used to. This process may lead to osteoarthritis or osteoarthrosis. Additionally, joints become stiffer because the connective tissue within ligaments and tendons becomes more rigid and brittle. This change also limits the range of motion of joints.
Loss of muscle (sarcopenia) is a process that starts around age 30 and progresses throughout life. In this process, the amount of muscle tissue and the number and size of muscle fibres gradually decrease. The result of sarcopenia is a gradual loss of muscle mass and muscle strength. This mild loss of muscle strength places increased stress on certain joints (such as the knees) and may predispose a person to arthritis or falling.
Symptoms of osteoarthritis can include:
- Pain• stiffness• a grating or grinding sensation (crepitus) when the joint moves• swelling (either hard or soft) • not being able to use the affected
Joint normally, which can make it difficult to do certain activities
(For example climbing stairs).
Exercise is one of the best ways to slow or prevent problems with the muscles, joints, and bones. A moderate exercise program can help you maintain strength, balance, and flexibility. Exercise helps the bones stay strong.
A Harvard Alumni Study has published a report that a caloric expenditure of >2000 kcal/day associated with 25% reduction in mortality, they even suggested that physical activity levels must be maintained THROUGHOUT life
Research shows that:
- Exercise can make bones stronger and help slow the rate of bone loss.
- Older people can increase muscle mass and strength through muscle-strengthening activities.
- Balance and coordination exercises, such as tai chi, can help reduce the risk of falls.
- Physical activity in later life may delay the progression of osteoporosis as it slows down the rate at which bone mineral density is reduced.
- Weight-bearing exercise, such as walking or weight training, is the best type of exercise for maintenance of bone mass. There is a suggestion that twisting or rotational movements, where the muscle attachments pull on the bone, are also beneficial.
- Older people who exercise in water (which is not weight bearing) may still experience increases in bone and muscle mass compared to sedentary older people.
Aerobic exercise is any exercise that increases your pulse rate and makes you short of breath (for example a brisk walk, swimming or using an exercise bike). Regular aerobic exercise should help you sleep better, is good for your general health and well-being, and can also reduce pain by raising the levels of pain-relieving hormones called endorphins.
- Stretching is another excellent way to help maintain joint flexibility.
See your doctor before you start any new physical activity program. If you haven’t exercised for a long time, are elderly or have a chronic disease (such as arthritis), your doctor, physiotherapist or exercise physiologist can help tailor an appropriate and safe exercise program for you.
Older adults are the fastest-growing segment of the population
- As the older adult population increases in number, there is considerable impact on health care and economic aspects of society
- Observational studies suggest that physical activity may increase the quantity and quality of life
It’s never too late to start living an active lifestyle and enjoying the benefits.
Dr. Ashwin Narasimhaprasad
Specialist in Orthopaedics
Aster Clinic, Muteena (DMPC)
Though there isn’t yet a cure for arthritis, there is still a great deal that can be done to relieve pain
What is Arthritis?
Arthritis affects millions of people worldwide and has a considerable impact on the lives of those with arthritis. The word rheumatism is a term used in a broader sense to describe aches and pains in joints, bones, and muscles. Arthritis refers to inflammation within the joint but it can also be due to inflammation of the tendons and ligaments surrounding the joint.
What are the symptoms?
The most common symptom is a pain in the joints, which can be mild to severe causing disability. The pain can be associated with stiffness of the joints, which is worse in the morning on waking up. Some may have pain and stiff- ness in the entire body too, and at times there can be swelling of the affected joints also. Arthritis dam- ages the surface of the joint and at times the underlying bone. If not treated, the disease progresses and causes a destruction of the joint that can result in deformities. Arthritis can also affect the skin and multiple organs.
The most common symptom is a pain in the joints, which can be mild to severe causing disability. The pain can be associated with stiffness of the joints, which is worse in the morning on waking up. Some may have pain and stiff- ness in the entire body too, and at times there can be swelling of the affected joints also. Arthritis dam- ages the surface of the joint and at times the underlying bone. If not treated, the disease progresses and causes the destruction of the joint that can result in deformities. Arthritis can also affect the skin and multiple organs.
Types of Arthritis
There are over 100 different types of arthritis. The two most common ones are osteoarthritis and rheumatoid arthritis. Oth- ers include gout, ankylosing spondylitis, juvenile arthritis, and systemic lupus erythematosus (lupus). Arthritis can be caused by infections too, though such cases have been extremely rare.
- The most common arthritis — osteoarthritis (degenerative joint disease), also referred to as OA affects middle age to elderly people. The spine and weight-bearing joints such as the knees, ankles and hips are more frequently affected by osteoarthritis. Osteoarthritis of the fingers thumbs and wrists reduces grip strength and ability to perform everyday tasks such as writing, picking up things household work, etc. OA is a leading cause of disability in the elderly.
- Rheumatoid arthritis is the commonest type of inflammatory arthritis affecting nearly one percent of the population, of which three-fourth are women. The wrist, joints of the fingers and feet involved more than others. Rheumatoid arthritis tends to strike in the prime of life between the ages of 30 and 50 years and can have a devastating impact on quality of life and one’s ability to carry out everyday tasks.
- Ankylosing spondylitis (AS) is another form of inflammatory arthritis that affects the joints of the spine. It causes back pain and stiffness and usually affects young men.
- Psoriatic arthritis is a type of arthritis that occurs in people who have a skin rash called psoriasis. This usually develops between the ages of 35 and 50 years but can begin in childhood also.
- Arthritis in children is termed as juvenile arthritis and can start as early as infancy.
Though there isn’t yet a cure for arthritis, there is still a great deal that can be done to relieve the symptoms of arthritis and enable one to live with arthritis. The ear- lier the treatment is begun, themore effective it is. Treatment has to be tailored to the needs of each individual because the severity, impact, and type of arthritis are different from person to person. Drug therapy treats various symptoms of arthritis like analgesics and anti- inflammatory, which eventually relieves pain and stiffness. Drugs, which suppress inflammation, the disease modifying drugs, and the DMARDS are the mainstay in the treatment of inflammatory arthritis. These include oral and inject- able preparations. The medications are beneficial but have to be taken under the regular supervision of the rheumatologist.
Lifestyle Changes in Arthritis
For those with arthritis, regular ex- exercise is very important. The joints should be put through a full range of movement at least once a day. This retains mobility, reduces pain, relieves stress, keeps the muscles strong and protects the joints. Stiff joints, if not exercised regularly, become stiffer and end in deformity, which may require surgical correction. Instructions for the exercise regimen can be obtained from the physiotherapist because improper exercise can damage the joints. Rest is also important, especially during flares when there is a lot of inflammation. Exercise and rest have to be balanced.
For people with arthritis, it is important to maintain the body weight within the normal range, overweight puts extra strain on the joints. Following a healthy diet with plenty of fibre and fruit, avoiding too much of meat or ani- mal fat helps maintain the weight and feel better. It is better to avoid or limit alcohol as the drugs pre- scribed for arthritis can interact with alcohol.
Chronic anterior shoulder instability following a first time shoulder dislocation reduced and treated conservatively varies in incidence from 100% to 0.24%, depending upon variables like capsular laxity, competitive or non-competitive athletes and bony defects acquired during the prior dislocation.
The chronic anterior shoulder instability can be very much and painful to the patient and leads to fear in sing the affected arm in overhead activities. Surgery is indicated if patients are unable or unwilling to change their occupation or avoid participating in high-risk sports or they have recurrent dislocations.
Surgical options vary from simple labral reattachment, capsular plication or capsular shaft procedures arthroscopic or open. With new surgical techniques and improved anchor design the outcome has improved much better or equal to traditional open surgeries.
But in patients with high recurrence or fracture following capsular procedures is associated pre-operatively like bony bankarts lesion, large hill sachs lesion etc. where the bony defect has to be addressed for the success. The procedure for failed capsular procedure and high risk category procedure of choice is to modify latarject.
In our hospital past one and half year, we have done three cases of modified latarjet, where all the patients had a history of dislocation of the shoulder. More than 20 times previous years and has radiologic evidence of bony bankarts, lesion in one, large hill sachs lesion in one and combined in one.
All these patients have been operated by modified latarjets procedure in which a 7cm incision in the anterior shoulder and coracoid bone block with short head Coracobrachialis biceps is transferred to the prepared anterior inferior glenoid and fixed with two screws along with repair of the anterior-inferior shoulder capsule with coracoaromial ligament. In this procedure, we get extended glenoid surface for translation of humeral head.
Coracobrachialis biceps acting as a dynamic sling in the anterior inferior part when joint is in abduction and external rotation position and reinforcement of anterior capsule by the corache acromial ligament.
What is the prevalence of knee and joint conditions in the UAE?
Knee Pain is one of the most common complaints these days among people of all age groups. Every individual experiences this issue at some point in their life. The level of pain also varies in each individual. For some, the pain may be so extreme that it limits daily activities and in others, it may not be as severe and may not be so much of a hindrance in their daily life. In both cases, what people fail to realize is that they are dealing with a condition that needs to be attended to and not ignored at all.
In your opinion, what are the main causes of these problems?
Knee pain is a very common issue that can happen at either the knee joint, the knee cap or the ligaments of the knee. There is not just one particular reason for the cause of knee pain because the knee has various parts. It could be caused due to physical injuries that occurred during some physical activity, continuous injury, a mechanical problem like dislocation of the knee cap, obesity or because of a certain condition like arthritis. Arthritis is a very common cause of knee pain which is further divided into different kinds like Septic Arthritis caused by a bacteria attacking the joint, Post-traumatic Arthritis which may develop years after having a knee injury etc. Most of the time body movements do not pose a problem but constant wear and tear or injury are what leads to severe pain. The knee is the largest joint in the body. The bones inside the knee joint are covered by an articular cartilage which provides a smooth gliding surfacing for joint movements. When any of this is disturbed the body reacts in the form of pain.
Does the lack of exposure to sun rays and vitamin D deficiency play a role in the prevalence of knee and joint conditions?
Vitamin D is extremely necessary for the body to absorb calcium and promote bone growth. Deficiency of Vitamin D results in soft and fragile bones in children which lead to rickets causing bowed legs and other skeletal deformities whereas in adults misshapen bones leads to a condition called Osteomalacia. Vitamin D deficiency also causes a lot of other health problems including obesity. Since knee and joint conditions are prevalent in people of all ages, the amount of Vitamin D requirement also varies. Aged people need more Vitamin D than the younger ones, dark-skinned people need more than the fair skinned, overweight people also need it more. Vitamin D is not a vitamin because a vitamin is something our body cannot make and hence needs to be provided by something we eat or with supplements. Our body can make Vitamin D from exposure to sunlight. People with very low Vitamin D are more likely to develop bone or joint pains. Rickets, Osteomalacia, and Osteoporosis are the most common bone disorders found in adults. Osteomalacia is caused by a defect in the bone-building process and Osteoporosis results from the weakening of a previously constructed bone.
How many patients visit Aster Hospital for these types of consultations? And what is the percentage of these patients who undergo surgical procedures?
Aster provides comprehensive Orthopedic care including surgical and non-surgical care. We are equipped with state of the art equipment and procedures and offer advanced procedures in various fields to give our patients the best treatment. Aster has a number of experienced and respected orthopedic specialists who have to their credit the knowledge and expertise in their field.
What are the precautionary measures to avoid knee and joint injuries?
Staying physically active and keeping the body fit is the best way to avoid the risk of knee pain or injury. However, in certain cases, knee problems caused by a particular activity or by accident cannot be avoided as they can’t be foreseen. There are certain preventive measures that can be taken to avoid any serious knee or joint issue. Firstly, being healthy by eating a balanced diet and maintaining a healthy weight to avoid excess stress on the knee. Secondly, always wearing sensible shoes that fit perfectly and offer the right kind of support because this helps maintain the leg alignment when walking. Wearing insoles in shoes to maintain a balanced body posture is also advisable. These are two things that people generally tend to ignore because they don’t realize how wearing the right fit shoe helps avoid serious consequences. Stretching the thigh muscles before beginning an activity reduces tension on the tendons and relieves pressure on the knee during the activity. Certain exercise routines can be followed that aid in strengthening the leg muscles. Taking the stairs up is a very good practice, riding a bicycle is a good way to make the leg muscles stronger. Weights are also a way to strengthen the leg muscles supporting the knee but these workouts need to be done under the supervision of a trainer. Sudden change in workout routines should be avoided, the intensity and duration of the activity should always be changed with a gradual build up. Opting for workouts that are strong but of low impact to the knee is recommended. A physiotherapist should be consulted for exercises.
What are the symptoms that patients need to be aware of that call for consulting a specialist?
Knee Pain that is caused as a result of a strenuous activity and that is usual could be managed at home itself or one that is caused because of a minor injury could be self- observed for a day or two and then the required steps can be taken. However, if you are suffering from extreme pain it is better to seek medical help. When unsure of whether or not to consult a doctor, some symptoms that need to be taken into consideration are continuous pain that lasts for days or weeks, any form of swelling or redness around the knee, any feeling of instability in the joints, acute injuries discomfort or difficulty in walking etc. On experiencing any of these symptoms it is best to consult an orthopedic specialist who as per diagnosis will suggest the necessary treatment.
UAE residents and medical tourists complain of the high costs associated with orthopedic surgery especially if they do not have insurance. What is your comment on that? (Might be good to highlight that Aster provides affordable high-quality health care which is in line with the group’s vision.)
The Department of Orthopaedics at Aster Hospital is a state-of-the-art facility offering comprehensive care to patients of all ages. We have an exceptional team of doctors comprising orthopedic surgeons and physical medicine experts who have the experience and expertise to handle various cases and are supported by specialty-trained nurses, patient counselors and physical rehabilitation therapists. They follow international treatment protocols to ensure optimal, evidence-based care to patients, at affordable prices as compared to the other hospitals in Dubai.
Orthopedic surgery procedures performed in Aster Hospital are cost effective compared to the surgery cost in other developed nations. Besides the cost, patients save time and getting the treatment is very convenient and fast. Countries that operate public health-care systems, such as Canada, U.S., and the U.K. often have long waiting periods for certain operations.
Aster DM Healthcare is committed to providing world-class Healthcare, at affordable costs. Lack of insurance cover or its limitations is faced by citizens in all countries. Patients are finding that insurance either does not cover orthopedic surgery (such as knee or hip replacement), or limits the choice of the facility, surgeon, or prosthetics to be used.
Does Aster Hospital provide attractive healthcare packages that encourage medical tourism?
Aster Hospital offers comprehensive treatment plans and wellness packages for patients that are coming from other countries. The packages have detailed inclusions and exclusions, making it easy for medical tourists to select a treatment that is suited to their budget. To further assist overseas medical tourists, we assist with travel requirements including visa requirements (if needed) and the option of booking both hotel stays and return flights. Patients can Skype with our doctors and discuss their treatment plans before they plan their travel. On arrival, a representative of the team will receive the patient at the Airport and we provide transport to Hospital or Hotel as per the admission plan. A Guest Relation Executive will complete formalities like registration, admission and signing of the consent forms and so on. Interpretation and translation services are also available on request. Post treatment, patients can keep in touch with our medical team for follow-up once they are back in their country.
Knee and joint pain is now common among the youth as well and is not restricted to the elderly, what are the causes for this?
Knee pain is very generic, it doesn’t limit itself to people of a particular age. Knee and joint pain are rather common among the youth because of various underlying reasons. A lot of young individuals who are involved in any form of physical activity or those who are very actively involved in sports suffer from knee and joint pain. The pain will be experienced gradually and will flare up on repeated flexing on the knee. In such cases the causes may be inappropriate training (gym) techniques or excess sports activities, ignoring certain injuries leaving them to recover on their own, inflexibility of the thigh muscles supporting knee movement etc. There are also other causes for knee pain in teenagers and young adults. In today’s day and age, children prefer to stay at home and watch TV or play on their mobiles rather than going out for some physical activity which leads to obesity. An inactive lifestyle is a core contributor to aches and pain. Physical demands at home and work have become lesser owing to technological advancements and conveniences.
Dr. Ranjith Narayan
Orthopaedic Specialist, Aster Hospital