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.