What is a joint?
A joint is formed by the meeting of the ends of two or more bones connected to each other by special tissues. The knee joint, for example, is formed by the thighbone (called femur) and the shinbone (or tibia) and is a hinge joint. The hip joint is a ball-and-socket joint, formed by the ball-shaped upper end of the femur fitting into the socket of the pelvic bone.

The bone ends forming a joint are covered with a smooth layer of a special cushion called cartilage. It normally allows frictionless and pain-free movement. Arthritis damages the cartilage causing pain and stiffness in the joint. The joint is enclosed in a covering called capsule. On the inside of the capsule is a smooth lining (called synovium) which produces fluid that 'oils' the joint.

Are there different types of arthritis?
There are over 100 different types. Some common ones are

++ Osteoarthritis
++ Rheumatoid arthritis
++ Ankylosing spondylitis
++ Gout
++ Tuberculous arthritis

Why does arthritis occur?
The reason why most forms of arthritis occur is a matter of intense research and we don’t yet have all the answers. But the manner in which the joint gets damaged is known.

++ Osteoarthritis (OA), the cartilage gets thinned out just like the tyres of a car wear out with time and use. At first there is pain. Later the bone ends may actually rub against each other, causing stiffness. In severe cases, the bone ends become roughened and movement becomes difficult.

++ Rheumatoid arthritis (RA), an even more crippling condition, is an autoimmune disease. The joint lining (synovium) becomes inflamed as part of the body's faulty immune system and it attacks and destroys cartilage and bone.

++ Gout is usually the result of a defect in body chemistry with a painful buildup of uric acid crystals in the knees and big toes.

++ Ankylosing spondylitis is a kind of arthritis that affects the spine and joints such as the sacro-iliac joint (connecting the pelvic bones to the spine) and hip joints. The joints get inflamed and loose their flexibility. The joints become stiff (ankylosed).

Who gets arthritis?
OA usually occurs after the age of 50 and affects one in five people. It is twice as common in women, and most often damages the knee joint. Overweight people, those with previous injury to the joint, overuse or incorrect alignment between the bones (eg, bow legs) are more commonly affected. RA strikes 3% of women and 1% of men, usually between the ages of 20 and 55 years. Gout affects 3-4 persons per 1000. It is mostly seen in men over 35 years. Ankylosing spondylitis also mainly affects men, usually between the ages of 20 and 30 years.

What are the risk factors?
Like many unsolved diseases, arthritis is probably due to a combination of many factors. These include:

++ Age
++ Heredity (faulty genes)
++ Overweight
++ Injury or overuse
++ Faulty alignment of joints
++ Occupation and lifestyle
++ Infection

Can arthritis be prevented?
Although we still don’t know what causes arthritis, there is much that can be done to prevent it getting worse by:

++ Maintaining ideal body weight and
++ Avoiding joint damage, by carefully performing strenuous activity.

What are the warning signs?
The three main symptoms of arthritis are

++ Joint pain,
++ Stiffness or inability to move the joint normally, and
++ Swelling of the joint that last more than two weeks.

How is arthritis diagnosed?
To reduce the impact of arthritis, the key is early diagnosis. Doctors diagnose arthritis based on the pattern of symptoms, medical history, physical examination, and may ask for some tests and x-rays. Typical symptoms include pain after walking which may later occur even at rest, creaking sounds in the joint, difficulty in getting up from a chair, and pain on walking up and down stairs.

Can arthritis be cured?
Once the surface of the joint is damaged it is not usually possible to prevent arthritis from progressing. However, most forms of arthritis can be controlled with appropriate treatment.

How is arthritis treated?
Treatment must be tailored to the needs of each individual. There are different treatments for the various types of arthritis, and no two cases are exactly alike. The goals of treatment are:

(A) Joint Replacement which consists of replacing worn borne ends with artificial ones.

(B) Unicompartmental Knee Arthroplasty can be done in selected patients with Osteoarthritis affecting only half of the joint.

++ to relieve pain
++ to maintain joint motion and
++ to prevent further joint damage

The treatment recommended by your doctor will be individualized and will depend on the type of arthritis, its severity, and your symptoms. It could include any combination of the following:

++ Dietary supplements: such as chondroitin sulphate and glucosamine, available as over-the-counter tablets, may help to repair partially damaged cartilage in osteoarthritis.

++ Medicines: Many drugs are available to reduce pain and inflammation. The simplest ones are paracetamol and aspirin. Others include non-steroidal anti-inflammatory drugs (called NSAIDs) like ibuprofen, piroxicam, indomethacin and diclofenac. They are best taken only for bad spells. More recently, medicines with lesser side-effects particularly on the stomach, such as meloxicam and celecoxib are also available. Local ointments may be prescribed. Occasionally an injection of cortisone into the joint may help. All these provide temporary relief of pain. For rheumatoid arthritis, there are many powerful drugs to control the disease and these include methotrexate, hydroxychloroquine and sulphasalazine.

++ Physiotherapy: includes exercises to strengthen muscles for supporting and protecting joints, exercises to maintain range of movement and flexibility of joints, heat or cold treatments for pain relief, and use of splints.

++ Surgery: If the pain or disability of arthritis cannot be controlled by the above means, there may be a case for one of the following operations.

Arthroscopy. Special instruments are used to look inside the joint through a small opening (keyhole surgery) and remove debris, loose pieces of bone, spurs, and torn menisci. However, it cannot replace the cartilage that is damaged or destroyed. Hence pain often returns after a variable period of time.

Osteotomy. This literally means 'the cutting of a bone'. This method is used to change the angle at which the bones forming the joint meet. It is used in younger patients with OA affecting only one half of the knee. The operation shifts the body weight onto the better half of the joint thereby relieving pain. However, relief is for a variable period of time depending on the state of the other half of the joint and how soon it begins to wears out.

Synovectomy. This literally means cutting out or removing the synovial lining. It is used in patients with early RA. It reduces pain and swelling by removing diseased synovium which eats the cartilage.

Arthrodesis means fusing or stiffening up the joint. This is rarely done because while it gets rid of the pain, it also takes away all movement occurring at the joint.

Joint Replacement which consists of replacing worn bone ends with artificial ones.

What can I do to help my arthritis?

There are 10 tips to manage arthritis:

1. Take charge - Keep a positive attitude. Learn as much as you can about the type of arthritis you have and what you can do to minimise the discomfort.

2. Exercise regularly - A regular, appropriate exercise programme designed with your arthritis in mind can help you effectively manage pain. Your doctor can help plan your program with the physiotherapist. Exercise under guidance, so you don't cause further damage or injury. Do not exercise acutely injured or inflamed joints.

3. Maintain normal body weight - Being overweight increases the risk for osteoarthritis. Losing weight helps reduce the stress on hips and knees. Eat right; keep fats, sugar, salt and fibre within recommended limits. There is no proof that any particular diet has an effect on arthritis.

4. Use your joints wisely - Learn how to perform tasks in ways that reduce stress on your painful joints. Protect joints from undue load.

5. Use assistive devices - Devices such as a walking stick, splints and braces can help stabilize joints, provide support and reduce pain by reducing the stress on hips and knees.

6. Use heat or cold treatments - Using heat or cold treatments can reduce the pain and stiffness of arthritis. Your doctor can teach you correct ways to use heat and cold for pain relief.

7. Take medicines wisely - Many types of medicines can help control the pain and swelling of arthritis. Work with your doctor to find the medications that suit you most.

8. Get enough sleep and practice relaxation techniques - Getting a good night's sleep restores your energy so you can better manage pain and rests your joints to reduce pain and swelling. Relaxation techniques (yoga) can help manage pain better.

9. Communicate - Don’t suffer alone; talk to family, friends and other patients. Find a doctor you like and trust with whom you can discuss problems and solutions.

10. Seek medical attention early so that treatment can be started before too much damage is done.

What is likely to happen in the future?
Arthritis does not always get worse. It may reach a peak after a few years and stay there or only get a little worse. In others, it may progress as the years go by becoming very painful and disabling. One cannot predict the outcome in individual cases. However, when arthritis really gets worse then one may need to consider joint replacement surgery.

In cases of Osteoarthritis affecting the knee there is another option, Uni-compartmental knee Arthroplasty. This is a minimally invasive operation which offers immediate relief of pain, quick recovery and rapid return to an active and normal lifestyle.

Only those with arthritis know how painful it is and how debilitating the pain can be. Until a few years ago, persons with severe arthritis suffered agonizing pain, had to limit their activities, were disabled and often became bedridden and housebound. Joint replacement surgery offers relief from the pain and an improved quality of life.

Remarkable advances have been made in joint replacement technology over the last few years. the materials are long-lasting and durable. The surgical technique has become better. As a result, joint replacement operations are now among the most successful of all operations - provided they are performed in well-equipped centers by surgeons specially trained and experienced in performing these highly technical operations.

In this operation, the damaged bone ends and cartilage are replaced with artificial surfaces. These usually consist of two parts that are shaped like the normal bone ends and designed to restore function and movement like the normal joint while getting rid of pain.

Why is Joint Replacement necessary?
Once cartilage is badly damaged there is no known treatment to make it grow again and function normally. The bare bone ends without cartilage rub against each other producing pain and later become roughened leading to difficulty in movement. At this stage joint replacement surgery remains the only option.

How do I know when I am ready for Joint Replacement?
When all other methods of treatment have been tried and have failed to relieve pain and disability, and when arthritis has affected one’s quality of life, then joint replacement must be considered. You must decide when the time is right for this surgery along with your doctor. You are probably the best judge of when you need an operation - when the pain becomes so chronic, so constant and so crippling that nothing seems to help. You will know when you are ready. Ideally your age should be over 60-65 years although patients with RA and some other conditions may need surgery at a younger age.

What are the benefits of Joint Replacement?
Once healing is complete, you will reap the benefits of surgery such as:

++ Freedom from pain
++ Easier movement and mobility
++ Increased leg strength
++ Improved quality of life through greater independence
++ Ability to return to most pastimes (walking, swimming, golf, etc).
++ Which joints can be replaced?

The hip and knee joints are most commonly replaced. Worldwide over 500,000 replacement operations are performed each year. Shoulder, elbow and small joints of the hand can also be replaced but this is done less often.

What are the new joints made of?
The artificial joint consists of a special metal part on one side and dense plastic (polyethylene) on the other side usually fixed to bone with special bone cement. The materials are well tolerated by the body and rarely cause any reaction or allergy. Imported joints cost more but have been successfully used for 10-20 years. Hundreds of different models of joints are available. Some perform better and have superior results to others.

What are the preparations for surgery?
Before surgery, you need to:

++ Undergo a complete medical check-up and some tests (blood tests, x-rays,
     ECG, etc)
++ Stop or start some drugs before surgery
++ Learn specific exercises to speed your recovery
++ Lose excess weight
++ Stop smoking

What type of anaesthesia is needed?
Surgery may be carried out under

general anaesthesia when the patient is made fully unconscious or
spinal or epidural anaesthesia when only the legs are made numb.
The decision depends partly on the medical condition and preference of the patient, and the judgment of the doctor giving the anaesthesia.

Will the operation be painful?
With modern techniques of anaesthesia and better medication available, pain can be very well controlled during the operation (which lasts 1-2 hours) and afterwards. After the first few days, the need for pain medication reduces considerably and usually there is very little or no pain by the time the patient is ready to go home.

What to expect after surgery?
You will be in bed for the first day after surgery, with a drip providing intravenous fluids and tubes to allow injections to be given. There will be one or two tubes (drains) coming out from the dressing around the operated part. You will be advised to keep your leg on a pillow and start exercises for the leg right away. Over the next few days, most tubes will be removed and more exercises started. Standing and walking will commence in a day or two, initially with a walker, and later with a stick or crutches. Periodically the dressing will be changed to check the progress of wound healing. Stitches (or staples) will be removed usually at the end of two weeks.

How long do I need to stay in hospital?
Most patients can go home within one week and return for removal of sutures two weeks after the operation.

How soon will I recover? After a hip or knee replacement you will be made to stand and begin walking in a day or two after the operation. Initially, you will be given a walker, crutches or stick. By 4-6 weeks, most patients can walk unaided, climb stairs and can do most daily activities independently. This depends to some extent on the condition of the other leg, muscle strength and one's motivation to perform exercises, which play a vital role in the recovery process.

Will I need physiotherapy afterwards?
The exercises are quite simple and not as painful as some people believe. Only in some severe cases is extensive physiotherapy needed. Most patients are taught the exercises while in hospital and can do them easily at home on their own. Rarely is physiotherapy needed after a month.

How successful is Joint Replacement?
As the new surfaces are artificial, there is no pain on movement. Results are very good in 9 out of 10 people and last for 10-15 years. Indeed, joint replacement is the most successful operation for severe arthritis provided the following three requirements are satisfied:

++ It is performed properly by surgeons specifically trained and experienced to
     perform replacement surgery
++ It is carried out in a well-equipped centre with appropriate facilities
++ It is done in a person who is well motivated, understands the limitations, and
     follows instructions.
++ In what way will my new joint be different?

Initially the knee may feel a little different. However, soon you will become used to it and will even forget that you have had an artificial joint implanted.

What are the possible risks and complications?
If you are in average health, the risk of dying from the operation is so slight that it is no greater than the normal risk associated with everyday activities. Every care is taken to prevent complications, but sometimes they are unavoidable.

Infection of the new joint is the most severe complication that may occur. The risk of infection is minimum - less than 1% - if the operation is performed in specially-designed operation theatres with laminar airflow, by using special gowns and other advanced techniques. If infection does not respond to antibiotics, a further operation may be needed to remove the new joint. By advanced techniques another joint may be inserted after an interval. Care must also be taken that infection elsewhere in your body is treated so that it does not spread to the joint.
Loosening of the joint may occur but, if it occurs at all, it is usually after many years of good use of the part and may be seen in 5-10% patients after 10-15 years or more. Sometimes it is due to poor technique, and sometimes due to overuse by the patient who has not followed instructions. If it causes pain, revision of the replacement may be required.
Blood clots may occur in the veins of the legs due to many factors. Your doctor will take precautions to reduce the risks and will explain these measures to you.
Dislocation of one of the components may occur. This is commoner after hip than knee replacement and occurs in 1-2% cases. Following instructions carefully in the first few weeks can greatly reduce the chance of this happening.
Wear occurs to some extent in all joint replacements. Wear depends on the design and quality of the materials, the load on them (your weight and activity level) and length of time since they were implanted. Only if excessive wear occurs and causes loosening does it need revision.
How can I increase my chances for success?

Choose a surgeon who is a specialist in joint replacement surgery and does them regularly and frequently, not once in a while.
Make sure that the operation theatre is appropriate for joint replacement surgery.
Ensure that the surgeon is going to use good quality parts.
Meet with and talk to several other patients who have been operated upon by the surgeon performing your operation.
Follow the instructions given by your surgeon.
What are the do’s and don’ts after Joint Replacement?

Walk as much as you want, play golf, swim and even dance.
Avoid strenuous sports, such as singles tennis or running.
Do not squat or sit on the floor.
Keep your weight under control.
Watch for and prevent infection of any kind particularly urinary and dental infections.
Regularly follow-up and visit your surgeon as advised by him to ensure the long-term success of your operation.
Always check with your surgeon when in doubt.

Will my new joint last forever?
It may last up to 20 years providing you are careful with it - and techniques are getting better and better all the time. Most older persons can expect their total joint replacement to last the rest of their lifetime, giving them years of pain-free living that would otherwise not have been possible. Younger patients may need a second replacement - called revision surgery. The first joint is removed and a new one can be inserted. Materials and techniques are constantly improving and the future is bright for those who choose to have a joint replacement.

Shoulder Replacement

The shoulder is a ball-and-socket joint. Shoulder Replacement is required most commonly for rheumatoid arthritis, severe fractures and fracture-dislocations, and osteoarthritis. In some conditions only the ball is replaced, in others both ball and socket are replaced.

Elbow Replacement

This operation is done for rheumatoid arthritis and elbows that have been severely damaged by prior injury (such as fractures or disclocations).

Hip Replacement

Commonly this operation is done for certain type of hip fractures, avascular necrosis, ankylosing spondylitis and rheumatoid arthritis.

Unicompartmental Knee Replacement

This lesser known operation can only be done in selected patients who have osteoarthritis affecting only one half (called compartment) of the knee joint. It is in many ways a superior option to the older operation of tibial osteotomy.

Total Knee Replacement

Most commonly performed for Osteoarthritis affecting all three parts (compartments) of the knee, it is also done for rheumatoid arthritis, gout, and occasionally for arthritis following severe trauma to the knee.

Revision Joint Replacement

The best results of Joint Replacement are when it is done correctly the first time. However, due to loosening after many years or infection setting into the joint, repeat surgery (called Revision) may be required. With advanced techniques, the results are almost as good as if done for the first time.

How do I proceed further if I think I need Joint Replacement?
If you have severe pain from arthritis and want a better quality of life, make up your mind whether you might need joint replacement after asking yourself six questions:

++ Am I suffering from intolerable pain?
++ Is it getting worse over the last few weeks or months?
++ Is the pain constantly troubling me, even when I am sitting or sleeping?
     Am I unable to carry out my daily activities and do things that I like (such as
     going out to meet people, taking long walks, etc.)?
++ Is no treatment that I have tried really helping me?
++ Is this how I want to live the rest of my life?
     If the answer to questions 1-5 is "Yes" and the answer to the last question
     is "No", then you must consult a specialist doctor who can help you.

How do I choose a specialist in this field?
Find a good specialist you like and one you can talk to comfortably. He should be experienced in arthritis surgery and should be a specialist in Joint Replacement surgery and doing lots of them regularly. Results are better if surgeons do more than 100 replacements a year. Select your specialist carefully even if you have to travel a long distance to see him. Take your time and remember, there is never any rush to get admitted and have surgery urgently. Make sure your doctor has enough time for you, talks in simple language that you understand, explains and listens to you. To get the most out of your doctor, communicate well with him.

Prepare: Write your questions down and have a clear idea why you are visiting him. If possible prepare a summary of your history, symptoms, treatments tried, side-effects, etc. Take with you all your x-rays and previous medical reports.

Ask: questions about your diagnosis, tests, treatment options, future outlook and follow-up visits.

Repeat: anything important the doctor has told you to double-check that there is no misunderstanding.

Take action: Make sure you understand what to do next. If in doubt, do not hesitate to ask for a second opinion. Most good doctors will not feel offended and will even suggest some other names.

Five questions to ask your doctor
Can I undergo an operation with my medical condition and specific circumstances?
Will Joint Replacement improve my condition?
What are the specific risks in my case?
What will happen if I do not choose to have an operation?
Can I meet and speak with several people who have had the operation?
Once you have come so far you the last thing left is…

Making up your mind: They conquer who believe they can
We have tried to give you plenty of facts. Read them. Digest them. The possession of facts is knowledge; the use of them is wisdom; the choice of them, education. The choice is yours. Choose wisely.

The power within you and the support that lies behind you are infinitely greater than the problem that lies ahead of you.

Remember, where you are today is the result of choices you made yesterday. But where you will be tomorrow will be the result of decisions you will make today.

For Detailed Dossier on Joint Replacement Surgery, please write to us at  mktg@mediescapes.com