Osgood Schlatter Disease of the Adolescent knee

Osgood Schlatter disease is the osteochondritis of the tibial tuberosity occurring in adolescent knees.
It causes pain and mild swelling just below the knee joint over the prominence in the front of the upper leg.
Patients complain of difficulty in running activities.
It is a developmental affection of the tibial tuberosity apophysis, and settles with completion of growth maturity, and fusion of the apophysis.
In severe case, patients may be offered splintage in the form of brace or plaster cast.
For those not responding to conservative trials, needling of the lesion triggers the cure.

Shoulder Injuries and Disorders- Frozen Shoulder

Frozen shoulder or the technical name Adhesive Capsulitis of Shoulder, mostly seen in middle aged women and diabetics, causes global loss of shoulder movements in all directions.
Usually a self limiting disease, but the prolonged disease course causes much disability.
Early cases should be managed by a course of physiotherapy.
In non- responding patients, manipulation under anesthesia after injecting and inflating the shoulder joint capsule with saline is an alternative.
Prolonged supervised physiotherapy is almost always necessary.

Shoulder Injuries and Disorders- Impingement Syndrome

Shoulder impingement syndrome causes limitation of shoulder movements in one or more directions, but never complete global loss of movements.
Also known as a "Painful arc syndrome"; when the arm is taken overhead in the window cleaning position, patient catches pain. Pain is reproduced on every attempt to do this manoeuvre.
The patholy lies in the reduction of space for the free excursion of the rotator cuff tendons mainly Supraspinatus, beneath the acromion process.
This may occur due to inflammation of tendon itself, due to thickening of acromion process of shoulder blade (scapula); or due to repetitive stress injuries of the rotator cuff.
Treatment of this disorder is mostly conservative.
Most patients respond to suitable modification of activity or local steroid infiltration.
In patients who are resistant to conservative trials, decompression of the sub-acromial space may be performed surgically (Acromioplasty).

Shoulder Injuries & Disorders : Acromioclavicular Joint Injuries

AC Joint injuries are common due to fall on out-stretched hand. They have significant impact in overhead activities and sports.
Patients with AC joint injuries have been classified into six types, with severity ranging from simple sprain to complete destruction of all supporting ligaments and marked displacement of the collar bone from its normal position.
Not all patients with AC joint injury need surgery.
Most patients wherein the AC joint remains even in partial contact may be managed by a sling support. For more severe injuries, a reconstruction of ligaments may be taken immediately after the injury or at a later date.

Collar Bone fracture : Is operation necessary ??

Collar bone (Clavicle) fracture occurs commonly due to indirect forces with fall on the out-stretched hand.
Most comon area of fractur is at the junction of inner 2/3 and outer 1/3. However, at times, the fracture occurs more outwards and closer to the shoulder joint. The latter presents a technically challenging scenario.

Most collar bone fractures can be treated without surgery. Usually a cuff and collar sing is provided for pain relief, and exercises are started after 4 weeks.
In certain situations, wherein the vascular or neural structures are in jeopardy due to pressure by fracture fragments, operation may be required. Surgery is also indicated in fractures occurring close to the shoulder joint.

With greater emphasis on cosmetic appearance, surgery is often demanded by young girls, who do not want a fracture bump. In such cases, a plate may be used with minimum surgical scar.

Non discogenic Backache : Facet joint Arthropathy

Most Sciatica is labelled to be because of a protruding disc (disc prolapse). However, there are other reasons to it. Making a correct diagnosis, is therefore important to correctly relieve the symptoms.
Pain due to disc disease are usually aggravated with forward bending; however, pain of facetal arthropathy is worsened by backward bending.
In case of Facetal Arthropathy, the facet joints become more blurred on the MRI images, with some enlargement and irregularity of the surrounding bones.
The treatment varies from supervised physiotherapy, to local injections to fusion surgery.
Physiotherapy focusses on building the tone of abdominal and back muscles, and general postural training.
Injection therapy includes local steroid infiltration in the facet joints; this procedure is performed with the help of portable xray control images. It offers rlief in 60-80 percent of patients.
The last resort to a troublesome facetal arthropathy is fusion surgery.

Gout and Pseudogout: Arthritis of crystal deposition

Gout is characterized by excessive uric acid levels in blood and deposition of sodium monourate crystals in the joint and subcutaneous tissues (tophi). The deposition of urate crystals and reaction with the white blood cells (phagocytes) incites the release of inflammatory mediators, which cause the characteristic pain and inflammation.

During an acute attack, the involved joint is red, inflamed and tender. The site of predilection is the 1st Meta-tarso-phalangeal joint of the great toe. However, in late stages other joints may be affected, particularly knee and ankle. Besides, there may be tophi deposition around elbow, or toes.

Treatment of an acute attack is primarily NSAIDs like Ibuprofen, Naproxen etc. Corticosteroids may be used orally or injected into the inflamed joint, provided there are no signs of infection. Another drug used to control acute attacks is Colchicine; use limited due to incidence of diarrhoea. For chronic attacks, the frequency may be reduced using Colchicine or other drugs like Probenecid and Allopurinol.

Another condition that sometimes mimics Gout, is Pseudogout.
The latter is characterized by deposition of CPPD crystals in the joints; and primarily involves the knee.

Ankylosing Spondylitis- Disease of the Young

Ankylosing spondylitis  or AS, is a form of arthritis that primarily affects the Sacroiliac joints and the spine, although other joints may become involved at advanced stages.
Progreesive stiffness and ossification of ligaments produces the characteristic forward stooped posture.AS can also cause inflammation, pain and stiffness in other areas of the body such as the  hip joints, ribs, heels etc. Sometimes the eyes may become involved (known as Iritis or Uveitis). 
Most patients complain of early morning stiffness that typically lasts for 30 minutes to 2 hours; improvement occurs with activity and stretching. AS is clinically characterized by exacerbations and remissions. Patient may remain symptom free for a long duration before the recurrence of symptoms. AS can be very debilitating, and in some cases, lead to disability.
Patients with positive HLA B-27 factor and a positive family history are at risk.
Treatment of AS depends upon the severity of symptoms. Patients with early and mild symptoms are best managed by supervised physiotherapy and stretching programmes.
Medications that reduce pain include NSAIDs ( Indomethacin, Naproxen ). TNF-blocking medications (Etanercept , Infliximab , Adalimumab ),  have been shown to be extremely effective for treating ankylosing spondylitis by stopping disease activity, decreasing inflammation, and improving spinal mobility.
Surgical treatment for AS is required in patients with severe Kyphosis (excessive dorsal curvature of spine), limitation of neck movement, or with ankylosed hips. 
Pedicle subtraction osteotomy may be performed at the spine to improve posture.


http://www.medicinenet.com/ankylosing_spondylitis/article.htm 

Ganglion Cysts

Ganglion cysts appear to arise often on the extensor aspect of the wrist and hand. They may be associated with the degenerative conditions of the joints. They may occur adjacent to joints, tendons, fascial planes, and within bone.

Usually soft in consistency, they may be firm to hard at times. These cysts are filled with gelatinous substance, which can be removed by a thick needle aspiration.The aspiration may be followed by steroid injection, or sometime hylase injection.

Surgery is required in recurrent cases, and it is important to excise the tail of the cyst up to the joint from which it seems to arise.


http://www.bonetumor.org/tumors-foot-and-ankle/ganglion-cyst-foot-and-ankle

Chronic Pain and Depression

Chronic musculo-skeletal pain syndromes are often associated with variable amount of depressive illnesses. Treatment of such patients purely by using analgesics often proves futile. A comprehensive approach with involvement of psychotherapist is often mandatory.

In a recent report, US-FDA had approved the use of Duloxetine hydrochloride for use in conjunction with nos-steroidal and opioid analgesics.
The molecule has been is use in India for some time now, and has given improved results when used together with analgesics.

Advanced Hip Arthritis

Pain in the hip joints with progressive limitation of activity is the predominant symptom in a case of advanced Hip arthritis. It may be a result of degenerative changes,/ inflammatory arthritis (RA),/ post-traumatic,/ Post AVN Hip etc.
The picture shows almost complete obliteration of both hip joint spaces (more on the right side).
This patient had a reasonable range of motion in left hip, so we decided to go for conservative management.

The right hip was much worse.
We discussed the options with the patient. The choice of surgery in this case is a Total Hip Replacement (THR). The various bearing options are- Metal on metal/ Ceramic on ceramic/ metal on UHMWPE/ ceramic on UHMWPE.
The choice of bearing depends upon patient factors and age.
Pl read the blog on bearing options regarding further details.

Fractures in Osteoporosis : How to treat ?

Most fractures associated with osteoporosis have occurred due to progressive weakening of the bone. This is also associated with generalized weakening of the bones elsewhere in the body, particularly the spine and the wrist.
So, any patient of osteoporosis presenting with fracture must be carefully assessed for fragility fractures elsewhere.
The second point of concern is, osteoporosis worsens with inactivity. So these patients must be made ambulatory at the earliest possible.
The third issue is regarding the stability of fixation, in such fractures. Osteoporotic bones are typically too soft to provide strong anchorage to screws and plates. This may be addressed either by using the newer locking plates or by cement augmentation of the standard screws and plates.

In patients with osteoporotic fractures, the treatment of osteoporosis must continue along with the care of fracture. This includes drugs like bisphosphonates, teri-paratide (forteo), calcitonin, calcium and vitamin D supplements. Adequate bracing should be done to the areas at risk of fragility fractures.

Hip Fractures in Elderly

Most fractures around the hip joint in elderly patients are associated with Osteoporosis.
It may involve the femoral neck or the Inter-trochanteric region of proximal Femur.
Usually the impact of trauma is trivial; hence many consider these fractures to occur as a result of progressive weakening of the bone and the ultimate give way.
The treatment of such fractures in elderly population demands a lot of analysis in terms of ambulatory status, level of osteoporosis, co-morbid illnesses, activity level etc.
Although, it is always prudent to preserve the host bone, but in certain medical circumstances, the risk of keeping the patient in bed for prolonged duration , far outweighs the complication associated with prosthetic replacement.
Prolonged recumbency may lead to pneumonia, urinary tract infections, and bed sores. The morbidity with these secondary complications often becomes more disabling than the fracture itself.
The options between preserving the host bone must therefore be carefully assessed against the objective of making the patient mobile at the earliest possible.

Medical Treatment: Avascular Necrosis (AVN) of Hip

for queries, pl contact

Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

AVN Hip is defined as the irreversible changes in the femoral head, as a result of the interuption to the blood supply. It commonly follows fracture of femoral neck/ prolonged steroid intake/ alcoholism/ muco-polysaccharidoses/ sicle cell anemia etc.
The femoral head gradually undergoes changes in the density and architecture, ultimately leading to degenerative arthritis of hip joint.
In late stages, when arthritis has already set in, the only effective treatment is a total joint arthroplasty.
However, in the early pre-collapse stages, there is some role for a group of drugs known as Bisphosphonates.
Alendronate is a commonly used drug of this group. these drugs are available in both tablet and injection form; and dosing schedule varies from once daily to once a year.
Numerous studies have advocated that bisphosphonates, when used in early AVN hip (Ficat & Arlet stage I/II), results in improvement of symptoms and prevents radiological worsening in atleast 60-70 percent of patients. However, this drug needs to be taken for a period of 18-24 months to show appreciable improvement.
The prominent side effect associated with this drug is reflux oesophagitis.

ACL Reconstruction

ACL reconstruction is required if the instability due to damaged ACL fibers is limiting the activity level of patient to a significant extent; or if the patient wants to pursue an active athletic activity/ sport.

ACL has two bands of fibers which interlace with each other.
Anteromedial and Posterolateral;
Of these, Posterolateral fibers are most important from patho-mechanical point of view.

Acl reconstruction is widely performed using two techniques viz.
1) Bone patellar tendon bone graft
2) Double bundle Hamstring graft

The superiority of one method over the other has not been proved conclusively, so far.

Most patient after ACL reconstruction return to pre-injury status after 6 weeks,and are allowed to pursue active sports after 6 months.

ACL reconstruction can now be performed as a day-care surgery.

Spondylosis, Spondylitis, Spondylolysis, Spondylolisthesis

There is a plethora of technical terms used to describe the various ailments of spine; often used inter-changebly, and more often mis-interpreted by the patients.
I want to offer a simple explanation to all these terms, to avoid every patient of neck pain or back pain, being labeled as spondylitis.

Spondylosis : This is used to define a degenerative condition of the spine, which usually develops in patients over 50 years of age; and is primarily related to changes as a result of wear and tear. This presents with prolonged duration of symptoms, worsening at a steady pace.

Spondylitis : Refers to the inflammation of the spinous process, as a result of infection or an immune mediated pathology e.g. Ankylosing Spondylitis.

Spondylolysis : It is a developmental or congenital disorder wherein there is a defect in the pars-interarticularis, defined as the segment of bone joining the two articular processes which participate in the formation of facet joints. It is usually considered to be a precursor of Spondylolisthesis.

Spondylolisthesis : The relative movement of one vertebrae over the one immediately below it. It may follow Spondylolysis, or may occur following trauma/ degenerative changes. This pathology may require surgical intervention, if the shift is more than 50 percent, and there is impending pressure on the spinal nerve roots.

Why Post-menopausal women are prone to Fractures

 

Women in their late forties start experiencing menopausal symptoms.
It happens due to lack or absence of the Ovarian hormones in the body.
As Ovarian hormones also help regulate the Calcium homeostasis, and play important role in maintaining bone quality; a decline in their levels produces a decline in bone mineral density.

Thus an irreversible process starts which leads to more destruction of the bone tissue micro-structure----ultimately leading to Osteoporosis.
Osteoporosis affects the whole skeletal system, however maximum damage is seen in the spine, hip joints and wrist.
Collapse fractures of the spine and the Colles' fracture at wrist, are the hallmarks of Osteoporotic fractures or Fragility fractures.

The incidence of such fractures may be significantly reduced by preventing/ treating Osteoporosis at an early stage.

High Heels and backache

Women using high heels often complain to be suffering from back pain. There is a definite co-relation in terms of the body mechanics.
When using high heels, the forefoot comes early in contact with the ground compared to the hindfoot. This causes abnormal stresses at multiple joints including the foot joints, ankle, knee and the lower spine.
Noe, the posture attained resembles that of a pregnant lady or an obese lady with protuberant abdomen.
This produces hyper-lordosis at the lower spine, and consequently the facet joints at the back of the vertebral column come under stress. This stress produces secondary degenerative changes in the facet joints, so called as Facet joint arthritis.
Similarly, the knee goes into Hyper-extension producing abnormal strain on the cruciate ligaments.
The ankle and foot also suffers excessive strain and presents as pain under the forefoot or at the front of ankle joint.
These changes may be prevented by reducing the duration of usage of such footwear, or by appropriate exercises to avoid damage.

Knee Arthroscopy

Knee Arthroscopy is a commonly performed procedure these days.

Advantages :
Minimal risk
Day care surgery
Key hole surgery
Better cosmesis

It is performed via two 1 cm incisions over both sides of the patellar tendon. One of the portals is used for the camera to look inside the joint, the second is used to introduce specialized instruments.

Common Knee disorders which can be succesfully treated with arthroscopy are
Meniscus tear
Loose body removal
Biopsy
Synovectomy
ACL Reconstruction

Knee Pain in Young Women

for queries, pl contact

Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Young women often complain about knee pain which limits their activity level and prevents them from engaging in competitive sports, aerobics and even dance classes.

They usually have pain when trying to stand up after sitting for a long time, or sometimes after squatting or cross leg sitting.

They are advised physiotherapy, to which some of them respond and others not.
The solution to the problem of knee pain lies in correct diagnosis !

A well described clinical entity often affecting young women and teenage girls is called as Chondromalacia patellae.
It develops due to micro damage to the cartilage lining inside the knee joint.

So, what do we do ??

Definitely, staying away from your favorite activities is not an answer.

Medical treatment for chondromalacia patellae is Chondro-protective drugs which are considered to help re-build the cartilage loss.
Glucosamine is one of the molecule, which is shown to show some benefit

Another, advice is to follow the physiotherapy exercises focussed in building the thigh and leg muscles; namely the Quadriceps and Hamstrings.

If, medical treatment fails, arthroscopy is an alternative option to treat the condition.

Chronic Exertional Compartment Syndrome

This entity usually happens in athletes who exert prolonged strenuous activities. Usually affects the calf muscles;
The person usually feels the tightness of calf and aggravation of pain with walking.
Most acute muscle spasms presenting in a similar fashion, usually respond to a course of pain killers and muscle relaxants;
however chronic exertional compartment syndrome may often require surgical release.

Cervical Radiculopathy in Pregnancy

Patients suffering from neck pain and radiating along one of the shoulder or the whole upper limb is a common scenario. But things get more complicated when it happens in the backdrop of Pregnancy or in lactating mothers.
Now, the limitations starts as most of the drugs we traditionally use to counter a cervical radiculopathy have a risk of crossing the placenta or getting excreted in the breast milk. Most of such drugs have been known to produce teratogenic effects in the fetus; or the least their safety has not been proven till date.
I had a consultation with the physiotherapist at our set up.
I believe the only remedy we can offer is a mix of Electrotherapy and support to the neck region with avoidance of all precipitating events.

Interferential therapy has shown consistently good results in patients with neuritis or radicular pain. Although, the safety of IFT in Pregnancy has not been conclusively proven, it is supposed to be least harmful, when we need to balance between risks and benefits.
It may be combined with posture training, Neck Isometric exercises and Cervical Collar. All these contribute in symptomatic improvement.
Drugs like Gabapentin and Pregabalin should be avoided at all costs, due to inherent risk of teratogenecity, unless we have more studies to support its usage.

Wrist Pain - Dequervain's Disease

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Most individuals working regularly on computer keyboards or using power tools which produces strong vibrations, complain of pain over the outer aspect of the wrist and particularly over the base of the thumb.

This is usually mild but sometimes, patient complain of severe incapacitating pain which gets aggravated with gripping movements or even holding a pen.

One of the important reasons for such pain is DeQuervain's disease.
It involves tenosynovitis (inflammation of tendon sheaths) of the tendons lying at the base of thumb on the back of wrist.

The inflammation causes a constriction in the tendon sheath, and interferes with the smooth excursion of tendon within its sheath.

It is more commonly seen in association with Diabetes Mellitus, Rheumatoid Arthritis or Hypothyroidism.
Patients presenting with this disorder are usually the working population with high demands and work pressure.

The treatment of DeQuervain's disease is usually conservative.
The patients is started on anti-inflammatory medications; and Ultrasonic therapy of the tendon sheath. Most patients do fairly well with this therapy. Usually a short course of 5 to 7 sittings is required.

In patients, not responding to above treatment, the tendon sheath can be infiltrated with locally acting steroid. This does not produce any systemic side effect. However, the treatment success results are 60 - 80 percent.

In patients who fail to respond to a course of anti-inflammatory medications/ physiotherapy or injections, they fall into the category of cases requiring surgical intervention.

Surgery is effective way to treat resistant cases. The tendon sheath is opened through an incision at the base of thumb on the back of wrist. Important step during surgery is to isolate and protect the Superficial Radial Nerve which provides sensory inputs to the back of hand. If the nerve is accidentally cut, it may produce an embarrassingly painful neuroma.

To conclude, most patients may be managed with conservative or minimally invasive therapies. Surgery, however is the last resort providing effective, short, daycare cure.

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Frozen Shoulder - Adhesive Capsulitis Shoulder - Signs/ Symptoms/ Diagnosis/ Treatment

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Frozen Shoulder or Adhesive Capsulitis of Shoulder as is technically called, is an inflammatory disorder of the shoulder joint capsule. It produces global restriction of shoulder movements.

Most patients in their 30's to 50's age often present as progressive pain and stiffness of the shoulder joint, which starts as a painful shoulder and later produces stiffness. Usually the symptoms range from weeks to months. Usually, patients do not remember any precipitating event before the start of symptoms.

Diabetics are the worst hit. Although, it may occur in any individual, patients with Uncontrolled Diabetes Mellitus tend to suffer more often.

The important point of differentiation is between Frozen shoulder and other more serious pathologies involving the shoulder joint.

The common differentials include- Rotator Cuff Tear, Impingement syndrome and Septic Arthritis.

Rotator cuff tear usually happens in the young active individual; although degenerative tears in elderly are also described. It produces weakness of movements in the plane of action of the affected muscle group.

Impingement syndrome produces pain on sideways elevation of the upper limb; it may happen due to inflammation of the rotator cuff tendons or abnormal bony overgrowth limiting the free excursion of the tendons around the shoulder joint.

Septic Arthritis has a fulminant course associated with systemic signs - like fever, swelling and redness of shoulder joint.

Frozen shoulder is a self limiting disorder; unless associated with another pathology.
It has three distinct phases, characterized by pain, stiffness and then resolution of symptoms. The typical duration of phases is 3-6 months.

Because Frozen shoulder or Adhesive capsulitis is a self limiting disease, the treatment is directed at supportive care.

Most patients respond well to a short course of anti-inflammatory medication in the painful phase. This is the phase which is most troublesome.

In the stiffness phase, aggressive physiotherapy may be started to improve shoulder range of movements.

In some patients who do not respond to physiotherapy, manipulation of shoulder under anesthesia may be preformed. This is done after injecting the shoulder with local anesthetic solution and physiological saline.

Shoulder arthroscopy is another options for patients suffering with recurrent adhesions and shoulder stiffness.

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Plantar Fascitis - Heel Pain - Diagnosis & Treatment

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Heel Pain is a common disorder affecting people who generally have to walk or stand for long hours. It is also commonly seen in ladies wearing high heels. More common in Diabetics, and patients with high uric acid levels or in seronegative spondylo-arthropathies.

One of the common causes of Heel pain is Plantar Fascitis - Inflammation of the plantar fascia. Plantar fascia is attached at one end to the heel bone (Calcaneum), and the other end fans out and is attached to the base of toes.

Inflammation usually occurs due to un-due strain on the fascia, either because of the improper foot wear, or prolonged standing, excessive body weight or sometimes due to bone over growth on the undersurface of heel bone (Calcaneal spur).

Symptoms-

Patients usually complain of pain at the base of heel or deep to the heel pad. Pain gets aggravated with prolonged standing or walking. Often, the start pain on taking the first step is a typical clinical presentation.

Treatment-

1. In obese patients, the treatment starts with the efforts towards weight reduction.

2. Contrast Bath - Dipping the affected foot alternately in warm and cold water.

3. Foot wear modification such as use of soft cushion heel insoles.

4. Local Ultrasonic therapy or Interferential therapy may sometimes offer benefit; and should be tried prior to injection or surgery.

5. Local Steroid injections provide short term relief; blood sugar estimation is mandatory before steroid injections. Does not produce systemic side effects. May be repeated every 4-6 months for 3-4 times.

6. Surgery- In patients not responding to the above treatment, and those with a large Calcaneal spur, the bony overgrowth may be surgically removed.

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Elbow Pain - Tennis Elbow

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Tennis Elbow or Lateral Epicondylitis got its fame when one of our best cricketers Sachin Tendulkar reported his symptoms. He had pain in the outer aspect of his elbow and had difficulty in gripping the cricket bat.

Tennis Elbow is a common cause of Elbow pain in people engaged in repetitive forearm rotational activities. Common in sportsmen- Lawn Tennis players, Badminton players and Cricketers.

It occurs due to degeneration in the fibres of origin of one of the forearm muscles, namely Extensor Carpi Radialis brevis which runs between the lower end of the arm to the wrist joint

Symptoms- Pain over elbow outer aspect; aggravated with gripping and squeezing movements.

Signs- Tenderness over Lateral Epicondyle of Humerus.
Pain aggravated with passive stretching of forearm muscles.

Treatment-

1. Physiotherapy - Ultrasonic therapy or Interferential therapy over the point of maximum pain helps relieve the pain.

2. In patients not responding to physiotherapy, steroid injection may be infiltrated locally. This offers a temporary short term relief.

3. Tennis elbow splint helps in reducing the strain in the affected muscle. It should be worn over the maximum width of forearm, approximately 2 inch below the elbow joint.

4. In resistant cases, a manipulation under anesthesia may be performed.

5. Surgery is the last resort if the symptoms are not responding to any of the above mentioned manoeuvers. In this, the origin fibres of Extensor Carpi Radialis brevis may be surgically opened and debrided.

Patients need to avoid certain provocative movements in the region of Elbow joint for a period of 4-6 weeks after surgery.

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Scaphoid Fractures : The Diagnostic Dilemma

Scaphoid fractures usually occur due to a fall on the out-stretched hand. Most patients complain of pain in the wrist with difficulty in gripping objects.

The biggest problem in diagnosis is that- Most Scaphoid fractures may not be apparent on the initial X-ray. So, the patients are often treated as a case of Wrist Sprain.

Clinical suspicion is the guide to treatment.

Signs- Tenderness in the Anatomical Snuff Box between the tendons on the back of wrist at the base of thumb.

For patients presenting with significant pain and positive signs, a Scaphoid cast should be applied at the first evaluation even if the Xray findings are negative. X-ray repeated after 10 days to 2 weeks may show a fracture line across the Scaphoid. If repeat Xray does not show any fracture line at 3 weeks, the plaster may be safely removes and crepe bandage applied.

Most un-displaced fractures can be managed conservatively with a plaster cast for a period ranging from 10-12 weeks. Serial weekly x rays are done to diagnose re-displacement within the plaster.

For displaced Scaphoid fractures or those that re-displace within the plaster, surgery may be required for good results. Poorly treated fractures may go into non-union; this causes persistent weakness in grip strength.

Surgery is performed for displaced fractures or established non-unions.
It consists of exposure of the fracture and stabilization with screws which are sunk underneath the surface.
For non-unions, bone grafting may also be required in addition to fixation with a Herbert screw.

Poorly treated cases may cause Degenerative arthritis of the wrist joint in late stages.

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AVN Hip - Symptoms/ Diagnosis/ Tests/ Treatment

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

A 30-35 year young patient enters my clinic with a limping gait. He complains of pain in his Right hip joint especially while attempting to squat or sit cross legged. His wife describes numerous night awakenings due to sudden painful spasms. The pain has been there for almost 6 months now, and is worsening every week.

I asked for an X-ray of both the hip joints.

The X-ray did not reveal anything significant. So, I asked for an MRI of the hip joints.
Now, the sequence of events started. There was evidence of Avascular necrosis of Femur Head in Right hip joint.

Avascular Necrosis of Hip or AVN as often used by Orthopaedic surgeons, describes damage to the Femur head (upper end of thigh bone) which forms an articulation with the Acetabulum (socket).
It produces pain in the Hip joint which gets aggravated with movements and in late stages blocks all movements due to florid arthritis.

Now, the important questions are
A) What do we do now ?
B) What will be the long term fate ?

AVN is presumed to be caused by raised Intra-osseous pressure within the femur head; which eventually causes destruction of bone cells resulting in collapse and later degenerative arthritis.

If presented early, the femoral head may be preserved by use of certain drugs which prevent bone destruction. These drugs have shown good improvement if continued over a period of 2-3 years.

If there are changes in the femoral head, or persistent pain; moderate relief may be obtained by core decompression of the femoral head and neck. This supposedly reduces intra-osseous pressure and preserves femoral head viability. However, there is no warranty against worsening of status.

In late stages, when the arthritis supervenes, the only option left is Total Hip Replacement.
Hip Resurfacing procedures often advocated, may not be viable in most cases because the quality of bone in the femoral neck is often compromised in such patients.

Elbow Pain : Tennis Elbow

Tennis Elbow or Lateral Epicondylitis got its fame when one of our best cricketer Sachin Tendulkar reported his symptoms. He had pain in the outer aspect of his elbow and had difficulty in gripping the cricket bat.

Tennis Elbow is a common cause of Elbow pain in people engaged in repetitive forearm rotational activities.
Common in sportsmen- Lawn Tennis players, Badminton players and Cricketers.

It occurs due to degeneration in the fibres of origin of one of the forearm muscles, namely Extensor Carpi Radialis brevis which runs between the lower end of the arm to the wrist joint

Symptoms- Pain over elbow outer aspect; aggravated with gripping and squeezing movements.

Signs- Tenderness over Lateral Epicondyle of Humerus.
Pain aggravated with passive stretching of forearm muscles.

Treatment-

1. Physiotherapy - Ultrasonic therapy or Interferential therapy over the point of maximum pain helps relieve the pain.

2. In patients not responding to physiotherapy, steroid injection may be infiltrated locally. This offers a temporary short term relief.

3. Tennis elbow splint helps in reducing the strain in the affected muscle. It should be worn over the maximum width of forearm, approximately 2 inch below the elbow joint.

4. In resistant cases, a manipulation under anesthesia may be performed.

5. Surgery is the last resort if the symptoms are not responding to any of the above mentioned manoeuvers. In this, the origin fibres of Extensor Carpi Radialis brevis may be surgically opened and debrided.

Patients need to avoid certain provocative movements in the region of Elbow joint for a period of 4-6 weeks after surgery.

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Carpal Tunnel Syndrome in Computer Users

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

The present time belongs to the generation of young, talented professionals who work at long stretches to meet deadlines. A large segment of those are the ones handling the the extensions of the human arm-
The keyboard.
A major surge in the number of software professionals whether working in IT industries, or BPOs and call centers, has brought an increase in the people consulting physicians for occupational hazards associated with computer usage.

Carpal Tunnel syndrome is a disorder mostly affecting young people working on keyboards.
This happens due to pressure on the Median nerve which is encased in a fibrous sheath on the anterior (front) aspect of the wrist.

The patients usually complain of pain and abnormal sensations in the hand, particularly the index finger. In long-standing cases there may be weakness of thumb movements or numbness in the index finger tip.

The important differential being a Cervical Disc prolapse (slipped disc), which may produce similar symptoms, and also affects the same population.

So, the next question is: How do we Diagnose?

Carpal tunnel syndrome diagnosis is made using the nerve conduction velocity studies and Electromyography (study of the effect of electrical stimulation on muscle contraction). A clinical test which may suggest the diagnosis is- reproduction of symptoms when the wrist is acutely bent forwards.

Most patients of Carpal Tunnel syndrome can be treated by slight modification in work place environment, a role Ergonomics has to play (The article on Ergonomics throws greater emphasis on this topic).

In resistant cases, the the fibrous sheath of Median nerve may be injected with a dose of local steroid.

Patients who do not respond to steroid injections, may be treated by surgery.
The fibrous sheath of Median nerve is opened through an incision in the palm. The procedure can be effectively performed under local anesthesia, and the patients may go home the same day.

To summarize, Carpal Tunnel syndrome may be prevented by Ergonomic modifications, if however; it produces embarrassing symptoms, it can be effectively treated. Medicines do not have a reliably proven role in the treatment; although sometimes, Vitamin B6 (Pyridoxine) is prescribed.

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Hip Joint Replacement - Expectations/ Limitations

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Hip Replacement is a surgery commonly performed in Orthopedic practice, wherein the hip joint is changed to a new modular bearing providing painless articulation.

The common indications of a Hip Replacement surgery are:
1. Hip Joint Arthritis- either degenerative or inflammatory pathology.
2. Fracture Neck Femur (upper end of thigh bone)
3. Malformed hip Joint- a disease of the childhood
4. Loss of blood supply (Avascular Necrosis)

The definite indication of Hip Replacement is - Painful hip joint with radiological evidence of obliteration of joint space. Only exclusion is Fracture Neck Femur; wherein a partial change of the bearing component may be performed.

Patients usually have a number of queries regarding;
a) Will the pain go?
b) How much time do I need to stay in Hospital; and how much time off work ?
c) Do I need to come back again for a possible surgery ?
d) What happens to the metal inside my body ?
e) What precautions I need to take, and for how long ?

I will try to offer explanations to every question one by one...

The foremost concern is PAIN.
After a hip replacement, the pain due to arthritis usually subsides in 4-6 weeks. Thereafter, there may be occasional reminders of pain after unaccustomed activity. If however, the pain re-appears after a prolonged pain free period; or the pain tends to worsen progressively, there is a definite cause for concern. This requires an urgent evaluation by the Orthopedic surgeon.

As regards hospital stay, the usual duration is 1 week. The timing of going back to previous level of activity depends upon the type of Hip replacement - Cemented/ Un-cemented; and the quality of bone stock. Usually patients may resume office and sedentary work after 4-6 weeks.

The typical longevity of a Hip replacement depends upon- quality of bone/ level of physical activity/ Age/ body weight/ technique of surgery. Most hip replacements survive an average of 15-20 years. However, a large number of variables affecting longevity prevents accurate survival analysis.

The metal typically used in a Hip Replacement is non - reacting to body fluids. It may be Stainless Steel/ Titanium alloy, Cobalt - chrome alloy. The bearing surface is important factor in survival. Ceramic-on Ceramic and Metal-on Metal the the favored ones in current practice.

The most important of all, are the precautions to be taken by the patient himself. Dislocation of the new joint is a potential risk. extremes of movements should be avoided under all circumstances.

To summarize, it is important to understand the advantages/ limitations of a Hip replacement and to expect a reasonable goal before undergoing surgery. In a properly selected patient, it offers significant improvement in the quality of life and activity level.

The discussion on the relative performance of different bearing surfaces in hip replacement, will be discussed in subsequent posts.

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Ergonomics For Software Personnel

Software professionals contribute a significant proportion to the young workforce of the industry. They often spend long hours, working on computers in awkward positions; have stringent deadlines to meet, and are among the most common group who present in Orthopaedic clinics with symptoms as bizarre as tiredness and inability to concentrate; to specific disorders like Disc Prolapse or Carpal Tunnel syndrome.

There lies a co-relation between the environment they work in, the pressure they endure at workplace, and the psychosomatic disorders, thy suffer from. Even the employing authority have to shell out large proportion of money towards medical liability. Hence, something which helps both the individual and the company, definitely helps in the long run towards curbing the expense graph.

The role of Ergonomics comes to play. It entails modifications in the workplace environment, towards limiting the work associated illness. The common symptoms with which this population present, include Backache, Neck and shoulder pain, Lethargy, Inability to concentrate, Wrist pain and numbness, Thumb pain, Elbow pain etc.

Let us focus on them one by one. Backache may occur either due to acute injury or due to repetitive stress. Acute episodes usually result in a Prolapse Intervertebral Disc syndrome, wherein, patients complain of severe backache with radiation along the thigh and leg. A history of weight lifting may or may not be evident. Repetitive stress in the form of poor posture while sitting affects the muscle tone and produces a dull discomfort.

The modification required is- Adequate back and neck support in the office chair, with hips and knees at 90 degrees, and the spine supported along its entire length with provisions for the lumbar and cervical lordosis curves. Neck pain similarly may arise due to a disc pathology or general loss of muscle tone. It can be corrected by adequate neck extension, intermittent neck stretching and isometric exrcises.

Another common complaint is pain in the wrist or thumb, or strain near the elbow. The wrist pain usually develops due to repetitive stress during typing manouevres while working on a keyboard. It produces compression of the Median nerve (Carpal Tunnel syndrome). The thumb pain may be due to Inflammation of the tendon sheath (De Quervain's disease). Elbow pain may occur due to Lateral (Tennis Elbow) or Medial Epicondylitis (Golfer's elbow).
All these symptom complexes may be avoided or treated by modification of the keyboard pad position and the position of the seat arm rest.

Such minor modifications, help the company a great way in reducing the medical cost burden; and keep the employee better motivated at workplace.

Osteoporosis - Are We a Victim?

Osteoporosis is defined by WHO as a reduction in bone mineral density, more than two standard deviations below the corresponding age and sex matched control. It is usually defined as a disease involving elderly women who are post-menopausal. This is clearly one of the biggest subset of the patient spectrum. But, in addition, it may affect elderly men as well. And is some pathological conditions, it may affect much younger population. So, by far, nobody is immune to this disorder.

Among the many contributing factors that precipitate osteoporosis, the most important is prolonged immobility. Post-menopausal women (due to lack of estrogen), prolonged steroid therapy, anti-convulsive therapy, hypo- or hyperthyroidism, and alcoholism are among the common causes of osteoporosis.

A backache is the commonest complaint. In some patients, the diagnosis is first made when they present with a fracture of the vertebral body (most common), lower end radius (forearm) or fracture neck femur (hip). Such patients need treatment for the fracture and continued long-term prophylaxis to prevent subsequent similar events.

The golden rule to prevent osteoporosis is exercise.

This helps in adequate channelization of the Calcium and Vitamin D reserves of the body. Along with Calcium and Vitamin D supplementation in diet, and medication that block bone eating cell activity help restore the balance. Women in post-menopausal age group may need Hormone Replacement Therapy.

The medical treatment for osteoporosis includes the following categories:
1. Calcium and Vitamin D supplementation- Up to 1500 mg of Calcium in divided doses with 400 I.U. of vitamin D per day.
2. Estrogen supplementation- In post-menopausal women suffering with osteoporosis
3. Bisphosphonates- Osteophos in daily or weekly or even monthly depot injection may be administered.
4. Calcitonin- Nasal spray in the dose of 200 I.U. per day
5. Parathyroid Hormone- A novel drug with good result is low dose para-thyroid hormone (Forteo); drawback is cost.

The usual duration of therapy is 18-24 months, and Dual Energy X-ray Absorption (DEXA) scan is a good guide to both diagnosis and following treatment efficacy. Osteoporosis of men is a well known entity now. Usually considered as a disorder of women, it may affect men as well in all age groups. In elderly, it is often labeled as senile osteoporosis.

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Slipped Disc Affecting Young IT Professionals

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

A young IT professional presented to my clinic yesterday, with complaints of acute onset backache for 1 week, which often goes down his Right leg, and some funny sensations over his sole of feet. He remembered having worked overtime to meet deadlines, often slumping in his office chair, and constantly focusing on his computer screen.
He did not really give me a history of having done some sort of weight lifting. But he confessed, that he could not follow any exercise regimen due to work pressure.

I asked for an X-ray, which showed signs of muscle spasm in his lower back. I ordered for an MRI of the lower back. His MRI showed bulge of the inter-vertebral disc at L4-L5 (between 4th and 5th Lumbar vertebra of the lower back). His symptoms were readily explained with the finding.

The question is why did it all happen?

Prolapse Inter-vertebral Disc Syndrome or Slipped Disc, as we commonly call it; is a very common disorder affecting young population. A little insight into the cause- Our spine has vertebra aligned on top of each other with a cushion like substance called Inter-vertebral disc in between the vertebrae. The spinal cord and nerves pass along the back of vertebral bodies, encased in a well formed bony column. If the disc crosses its normal circumference, it may produce pressure on the spinal cord or the nerves producing so called Sciatica.

Usually a patient gives history of sudden jerk, or lifting weights; but sometimes it may happen without an obvious precipitating factor. The usual contributing factor include- Poor muscle tone, Abnormal posture while sitting, or lifting objects. Cigarette smoking whether active or passive increases the propensity and severity of a disc prolapse.

Acute disc prolapse should initially be treated with a short period of rest, followed by supervised physiotherapy, and modification of activity. In patient presenting with severe pain not responding to conservative plan, the bulging portion of the disc is removed through surgery; or it may be decompressed by thermal-coagulation.

Surgery is mandatory for patients presenting with a neurological deficit in the area of nerve supply. Ozone therapy is a new modality, with specific indications and less predictable results.

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Knee ligament and meniscus Injuries

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Sports injury accounting for meniscus or ligament injuries of the knee are common owing to high activity levels. Usually, the patient is a young adult presenting with acute onset pain and swelling of the knee, with sensation of give way while climbing up or downstairs.Young patients often wish to pursue active sports, which makes newer research into the treatment modalities, a prime necessity.

Meniscus Injuries usually present with knee effusion, may cause locking episodes and/or persistent pain along the joint line. Patient usually complain of inability to put full weight over the affected limb. The medial or the inner side meniscus is more prone to injury owing to specific anatomy and peripheral attachments. Ligaments that stabilize the knee include the Anterior and Posterior Cruciate ligaments. They prevent abnormal translation between the Tibia (leg bone) and Femur (thigh bone). An injury to the ligaments may cause a feeling of give way.

The diagnosis can be ascertained with reasonable certainty using Magnetic Resonance Imaging. However, sometimes the findings may not be confirmatory, and an arthroscopy of the joint is required. Knee arthroscopy may be performed both to diagnose and to treat the condition.

Meniscus tears at some location, and if presenting within a week may be repaired using arthroscopic techniques. This provides good long term results. If presenting late, or extensive tear, the torn portion is resected by arthroscopic technique, leaving a thin intact rim. Meniscus tears, if not treated properly have been known to contribute to development of arthritis.

Ligament tears may be treated with physiotherapy or surgical intervention. Tears associated with bony island should be treated surgically on urgent basis. Mid-substance tears do not heal by themselves, and need reconstruction. Ligament reconstructions should be delayed for 4-6 week, and aggressive physiotherapy should be done in the meantime.

Anteior Cruciate Ligament(ACL) reconstruction is one of the commonly performed surgeries by Orthopaedic surgeons handling sports injuries. It can be reconstructed using tendons from the inner aspect of knee or from the patellar ligament (knee cap region). Both offer equally satisfying results, however Patellar tendon bone graft offers better biological bone to bone incorporation. Meniscus transplants from cadaver donors is the new technology in the closet.

Patients usually require a 6 month period before they can get back to contact sports, with prolonged supervised intensive physiotherapy. Important to understand that, not all patients with Meniscus tear or ligament tear need surgery. However, timely performed arthroscopy helps in early rehabilitation.

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Cervical Spondylosis

Cervical Spondylosis, as we Orthopaedicians describe, is the degenerative change in the Cervical spine vertebrae often presenting on X-ray film as excess bone formation at the vertebral body margins, due to a chronic degenerative pathology. So, a young patient with acute onset neck pain, being diagnosed as Cervical Spondylosis is a Misnomer.

An X-ray film of the Neck is a good basic test to diagnose Cervical spondylosis. It often presents with Chronic, dull aching pain which aggravates with extremes of movement. Using a collar provides more psychological reassurance, than actually treating the pathology. A soft/ hard collar is more effective in treating acute muscle spasms of the neck usually precipitated by some injury or an acute disc prolapse. In such cases, we suggest restriction of neck movements to prevent further injury.

Two more synonymous terms that need a mention are- Spondylitis, and Spondylolisthesis. The former is an inflammation of the spinous processes of the vertebra, while the latter suggests abnormal translation of one vertebra over another leading to a loss of sagittal balance.

The preferred treatment for a Cervical Spondylosis is supervised physiotherapy. Gentle stretching exercises along with Isometric exercises of the neck help in improving the muscle tone of para-vertebral muscles. Heat therapy in the form of Interferential therapy (IFT) and Ultrasonic therapy also help relieve the symptoms.

Patients with long- standing symptoms often develop multiple level disc bulges with dessication (dryness of disc), as evident on the MRI. If severe, it may produce compression on the exiting nerve root and produce tingling and numbness in the upper limbs.

Surgical treatment is suitable to those with single or two level disc bulges, wherein a fusion of the vertebrae may be performed with or without instrumentation.

Cervical disc replacement is a novel treatment offered to those with single level disc prolapse, and without excessive facet joint arthritis. It offers reasonable movement at the vertebral interface, and is better tolerated by the younger active population.

Osteoarthritis Knee - Are We Being Overdiagnosed?

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

Patients with knee pain now comprise of at least 30 percent of Orthopaedic practice in urban population. The clinical presentation varies from subtle knee pain arising after activity to severe incapacitating pain which limits the activity of an individual to household.

Osteoarthritis Knee usually affects men and women in their fifties or sixties. It has a genetic predisposition, but more important factors are excessive weight, lack of exercise, sedentary lifestyle, previous trauma. The importance of weight reduction and regular activity can not be over-emphasized. Most patients offer pain as the limiting factor in their willingness to comply with the physiotherapy and exercise regimen.

Osteoarthritis develops due to progressive loss in the cartilage layer of the articular surface, mediated by chemical markers like Interleukins; and by lack of glycoproteins in the synovial fluid. Gradually, the two articular surfaces come in contact with each other, and the pathology migrates from a chemical to purely mechanical one.

Radiographs serve an important role in diagnosis. Loss of joint space and formation of osteophytes makes for an easy diagnosis.

The treatments offered for Osteoarthritis knee vary from- Physiotherapy/ Analgesics/ Bracing - to Arthroscopy- to Knee Replacement.

Early Osteoarthritis knee wherein the joint space is still preserved, and there is minimal osteophyte formation; can be succesfully managed with painkillers and Supplementation of Inflammtory marker inhibitors. The role of Glycosaminoglycans is debatable.

In patients who present with moderate to severe pain, there is limited role of Arthroscopic joint lavage; wherein the joint is entered via two small 1 cm incisions, and the interior is visualized with a camera. this offers a short term relief, but provides a good alternative for patients who are medically unfit to undergo major operations.

Patients with severe arthritis, are usually offered Joint Replacement as a definitive solution. The most important factor in the success of a knee replacement is good patient selection. A patient with good compliance for physiotherapy and having a knee pain which is substantially limiting his quality of life is a good candidate for surgery.

The availability of technology has made knee replacement one of the commonly performed surgeries in Orthopaedic practice. The options include a Unicondylar knee Replacement or a Total Knee Replacement. The former is advocated for patients with a single compartment involvement, and those with mild deformities. Total knee Replacement is offered for a bi- or tri- compartmental arthritis.

The technical options among the various types of Knee replacement implants include- (a) Cruciate Substituting, (b) Cruciate retaining. The former involve resection of the Anterior Cruciate ligament and substitution by an inbuilt mechanism in the implant design. The latter involves retention of the Anterior Cruciate ligament. Rotating platform designs are also popular these days.

The important judgment regarding the various types depends on the status of knee deformity, and the functional status of ligaments.

Total Knee replacement is one of the commonly performed surgeries today. The note of caution need to be exercised both on the part of the patient and the treating surgeon to restrain the influence of market forces in making the correct judgment. Total knee replacement offers significant improvement in the patient's status, provided the selection criteria are strictly adhered to. A few complications that need special mention include- Deep vein thrombosis, Pulmonary Embolism, Infection, Implant Loosening.