Vijay Bhatia’s job in a grocery store involved standing for hours on his feet, sometimes for more than 12 hours. He did this enthusiastically for 13 years as he loved interacting with people. Then, a nagging pain and swelling developed in his knees. Neither anti-inflammatory drugs nor elastic kneecaps gave him any relief. He developed an awkward gait. Cortisone injections provided temporary respite but, all too soon, it was back to square one.
X-rays showed that he had osteoarthritis—his knee joints were worn out. He had to opt for knee replacements in March 2005. Though it meant he had to close down his shop, it still gave him a new lease of life. Today, at 60, Bhatia feels grateful for his reconstructed limbs. He has to regularly exercise to strengthen the muscles, avoid sitting cross-legged or standing for long.
Osteoarthritis is a degenerative disease that can strike you as early as 45, but it is generally much later. It mainly affects the hip and knee joints as these are used the most. As we age, the soft cartilage that acts as a cushion between bones wears away, increasing friction between the bones. Joint replacement specialist V.G. Suresh, at the Trichur Metropolitan Health Care Pvt. Ltd, Thrissur, says: “Osteoarthritis, like greying hair, cannot be prevented. All you can do is modify your lifestyle and not put any undue stress on your joints as you age.”
Osteoarthritis starts with a minor pain in joints such as the knee. Climbing a staircase becomes difficult. Slowly, the pain becomes worse. It becomes difficult to put any strain on the joint—when one carries weights, for example. Movements become limited. Changes in the weather have an effect on the pain, too. In the mornings, the joints feel stiff. Sometimes, there is inflammation accompanied by swelling.
Swelling indicates that the condition is not improving. It is caused as there is excess fluid secreted by the synovium cells, the result of the cartilage having degenerated.
Non-steroidal anti-inflammatory drugs can temporarily reduce pain and swelling. But, these must be used with caution as they can result in stomach ulcers and bleeding when taken over a prolonged period.
Sometimes, doctors advise an osteotomy. This is a surgical procedure that shifts the weight-bearing axis so that the pain reduces or disappears. It is not a permanent cure.
Artificial joint lubricants, such as hyaluronic acid, can be injected into the knee, but this is effective for only about six months. Sometimes, steroids are also directly injected into the bones. Glusamine and chondroitin (substances found in normal cartilage) capsules effect temporary repair in the initial stages.
Weight-relieving braces that transfer the burden of the weight from the knees to the hip are also now available. These are still being tried out and costs around Rs2 lakh.
Arthroplasty, which is the total or partial replacement of the deteriorated joint with an artificial one, is becoming common in India despite its cost. Hospitals charge around Rs1.75 lakh for the operation.
In the arthroscopy keyhole procedure, a small incision is made near the joint through which an arthoscope containing a light and a small camera is inserted. Looking at an enlarged image of the joint on a monitor, the surgeon flushes out the blood, fluid and loose debris from inside the joint. Then, he puts in fluid that will help lubricate the joints. But this is not a permanent cure. It provides relief only for a few months. Doctors advise that it should be judicially used for symptoms such as the locking of joints. In fact, some recent studies have questioned its effectiveness.
Benefits of exercise
Regular physiotherapy can improve joint mobility by strengthening muscles around the affected joint. Patients who exercise daily report that they find it easier to counter arthritis. Today, Bhatia cycles for 5-10km a day and keeps fit. He also does yoga daily. A few patients use braces to support weakened joints and make walking easier. But braces should be worn only on doctor’s advice.
Doctors at the All India Institute of Medical Sciences in New Delhi carried out an experiment in which the limbs of a rabbit were tied for six weeks. The cartilage degenerated. When the limbs were freed, the cartilage started regenerating, but had they extended the period beyond six weeks, the cartilage would have been permanently destroyed. Movement keeps the joints in good health.
P.K. Dave, director, Rockland Hospital, New Delhi, points out: “In urban India, people remain rooted to their workstations for the whole day. This sedentary lifestyle is an ideal breeding ground for arthritis. One way to beat it is by exercising. The more you move, the better. Walk daily for at least 20 minutes. Or swim—this is the best exercise for arthritis as all your joints move.”
While not exercising makes you prone to arthritis, so does overactivity. If your job requires you to stand all the time, there is a lot of wear and tear on the knee joints, which remain locked for long periods. The solution is to move around occasionally.
Doctors say women are affected more by osteoarthritis and at an earlier age. “Women think they are active as they work all the time in the house, but walking around the house is not walking. Lack of proper exercise makes them obese and that aggravates osteoarthritis,” says Sunny Pazhayattil, former head, department of orthopaedics, Medical College, Thrissur.
Komalavalli Menon, 68, had led a very active life as a health officer in various parts of Kerala. When she retired, she started supervising her farmland and plantations. Two years ago, she experienced severe pain in her right knee. Supporting herself with a stick, she could barely walk. As normal movement became almost impossible, she felt paralyzed. She thought her busy life had come to an end.
She was diagnosed with severe osteoarthritis and advised a knee replacement. Her children and relatives were apprehensive but Menon was clear that knee replacement was the solution. “I wanted to live a normal life and walk freely,” she said.
Premkumar, associate professor at Amla Medical College, Thrissur, says knee replacement is a highly beneficial surgery that can change a patient’s life. “Patients usually try to put off the first knee replacement surgery as long as possible. But, if the patient is just 40, it is worth replacing the knee,” he says.
The knees are the most affected. Says Dr Dave, who was awarded a Padma Shri for his pioneering work in orthopaedics: “Most Indians in rural areas do not seem to suffer from osteoarthritis of the hips. This is because they are constantly using the hip joints when they squat. This preserves the integrity of the cartilage.” Adds V.I. Simon, head, orthopaedics, West Fort Hospital, Thrissur: “Obesity, misaligned joints after an accident, previous injuries, alcoholism and smoking cause early degeneration of cartilage.”
In many cases, doctors resort to osteotomy, which is basically realigning a joint that has shifted back to its normal position or realigning the bone properly so that the weight can be shifted to the centre of the joint and not on one side. This can ensure years of pain-free life to the patient.
Though many opt for joint replacements, some try to delay it as artificial joints usually last for a limited period—between 10 and 25 years—depending on how you look after them. After that, a revision arthroplasty can be done where the prosthesis can be changed or repaired. Says Bhatia: “I always have a ‘handle with care’ label in my head as far as my knees are concerned.”
Hope in research
S.K.S. Marya, director, Orthopedics and Institute of Joint Replacement Surgery, Max Healthcare, New Delhi, says new research and breakthroughs have changed the lives of patients.
Dr Marya, who has authored a book on knee replacement, says scientific advances are also helping to prevent cartilage breakdown. Now, cartilage rejuvenation medicines such as glucosamine hydrochloride and chondroitine sulfate are available. Cartilage transplants can also be done where cartilage from better, healthier areas are cultured and then transplanted to the defective area.
Dr Marya who has done more than 4,000 joint replacements, says modern research has helped to innovatively regrow the cartilage cells in a process called ACI (Artificial Cartilage Implantation). A small bit of the patient’s healthy cartilage is taken out, grown in the lab and then put in the worn out part.
This helps to counter some local wear and tear of the cartilage, not for the whole worn- out knee. The newer type of joint replacements today allow a greater degree of mobility: activities like cycling become possible.
Arthritis of the hip destroys the smooth moving surfaces of the joints. Now, the destroyed linings can be replaced by highly specialized components. In a refined process using computers, absolute precision is possible for joint replacements.
The Articular Surface Replacement in hip surgery today removes only the damaged lining. Patients can, therefore, even play tennis or other sports.
Technological advances today help to properly align and balance tissues that ultimately increase the life of the replaced joint. They also eliminate the possibility of human error during surgery and resulting complications.
Scientific advances in surgical techniques, understanding of metallurgy and advances in joint replacement research have helped doctors make the artificial joints last longer. Today, various techniques such as cemented, non-cemented and hybrid joints where only one side is cemented, are used, depending on the patient’s age and the condition of the bone.
Knee replacements do not come cheap. An operation costs around Rs1.75 lakh in the metros and a bit less in smaller cities. Asks Menon: “Why should a prosthesis cost so much? If knee replacements were cheaper, this could benefit so many. With advances in technology and health care, this should be possible. Once I start walking normally, I am going to find out why replacements are so expensive and if the government can step in to help.”
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