Surgical modalities should be appropriate for disease as well as the age of the patient: Dr Kaushal C Malhan

The number of patients with arthritis who are going to be there in India is going to be hugely more than anywhere else in the world. The expected estimates say that India will have nearly 15 percent of the world arthritis population by 2025.

In an interview with ETHealthworld, Dr Kaushal C Malhan, Consultant Orthopaedic Surgeon, Fortis Hospital, Mulund, Mumbai, talks on why there are increasing cases of people suffering from arthritis today. Edited excerpts:

How do you see the arthritis scenario is India as compared to the West?

Arthritis has changed over the last many years. When I returned to India about 13 years back, we saw completely different demographics of arthritis than we see today. We used to see patient who were much older (aged 60-65) coming for surgery but now unfortunately the problem is going into the younger patients.

Today we are seeing patient at the age of 40-50 coming and demanding surgery because their joints are really worn out and their condition is really bad. This has actually happened all over the world and it was suggested in the WHO report that India has a much younger population than the rest of the world.

The number of patients with arthritis who are going to be there in India is going to be hugely more than anywhere else in the world. The expected estimates say that we will probably have nearly 15 percent of the world arthritis population by 2025. This is going to be a tall order in terms of management problem, logistics and economics of the whole issue and therefore it is very important that we look at it very seriously.

Tell us about the changing treatment modalities in arthritis.

Joint replacement surgery is purely working on the parts which are bad in the knee or hip. You have to deliver the good and give the patient a new joint. This should be done in a manner that you do as less collateral damage as possible and you do not damage the good parts. That is how we have moved from total joint replacement to partial joint replacement.

The options for the treatment of arthritis would vary depending upon how bad the arthritis is and its type. It is essential to establish whether it is inflammatory, early arthritis or end stage disease.

The role of surgery comes when you are in the end stage or you are at a stage where you can actually foresee that if we do not make an intervention at this stage then the patient will face a problem or greater degree of complications. There are many different types of options like medications, exercises and lifestyle modifications. I think these are key things in the early stages and these need to be looked at seriously.

One of the main factors contributing to the rise of the arthritis in the younger generation is the fact that we have a more sedentary life and the environmental changes. I think there is a role for those basic things to start with. Things like viscosupplementation where lot of people may not be aware that in early or moderate disease one can actually give gel injections. These are actually synovial fluid injections which you can give in various joints and lubricate them so that you can keep the joint going for much longer. This along with local exercise and local modalities of exercise can do a great deal.

If you have a situation where the patients have gone beyond this stage and they are now in end stage disease, then one need to look at surgical modalities. It is very important that we understand as doctors that the surgical modalities will have to be appropriate to not just the disease but also the age of the patient because the kind of disease, expectation and recuperating ability that a 40-50 year old patient would have is completely different from a 70 year old patient.

How do you ensure better and faster recovery for patients with arthritis?

Here in India I saw that the patients with arthritis were much younger and I was drawn into trying to do joint replacements of knees and hips in a manner where we would be encroaching on normal tissues much less.

We would be putting in joints which would be taking out much less bone. The advantages that it has are faster recovery, better mobility and you go home much faster so the cost of treatment also goes down. The most important thing is that you return to work which the patient are most demanding.

Indian patients are generally more averse to surgery, they want less pain and they want to get back faster. The key thing is to do the surgery in a manner that you don’t damage the tissues inside and that starts with the incision, goes down to how you expose the tissues, how you deliver the elements that are bad inside, what kind of implants you use and how much bones you damage.

Where is orthopaedic surgery placed in medical tourism?

Medical tourism is quite big nowadays and it can be divided into patients who would come from the Middle East, African countries and the West. We also have patient coming us from the Canada, US, UK, demanding surgeries which in their own countries would cost many times more.

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Are you suffering from tennis elbow? Here’s all that you need to know

The name is misleading as most people who have it, did not attain it by playing tennis.

Tennis elbow is a tender condition that occurs when tendons in your elbow are burdened, usually by tedious motions of the arm and wrist. The name is misleading as most people who have it, did not attain it by playing tennis. Technically, it is also known as “Lateral Epicondylitis”, and is usually a result of inflammation just above the elbow joint, on the outer side of the arm. Pain can also be experienced in other areas of the elbow and forearm.

The development of tennis elbow can often be traced to methods of using the forearm muscles which control the hand and wrist movements. These muscles are used to perform actions like straightening the fingers, bending the wrist upwards and rolling the forearm into a palms-up position. Sudden impact or even less force on a repetitive basis can eventually damage the tissues. Without rest and time for the tissue to heal, strained tendons can become permanently weakened and painful. This also weakens the grip strength.

ALSO READ | Experience pain in the neck and shoulder area? These simple exercises will help bring relief

Individuals usually ignore this condition for long periods before seeking medical help mostly because the symptoms are mild and often disappear with rest. Self-medication with locally available pain medication gives satisfactory relief in the early stages, as a result doctor’s counsel is only sought when the pain starts to affect work and becomes intolerable.

“About 1 per cent of cases last more than one year; this occurs often in patients who do not respond positively to non-invasive treatment options. For such patients, steroid injections, Platelet Rich Plasma (PRP) injections locally or rarely, or surgery might be a solution,”said Dr Kaushal Malhan, Director of Orthopaedic Surgery, Fortis Hospital, Mulund.

Prevention:

Tasks linked with tennis elbow should be identified and modified to reduce the risk of serious injury. One of the greatest concerns is the overuse of fingers, wrists, and forearms in repetitive motions involving forceful movement, awkward postures, and lack of rest.

Avoid jobs that place extreme force, strain on muscles of the forearm. Timely attention typically reduces the development of a serious problem. The most important steps in treatment include:

*Identifying problematic activities and avoiding them
*Correction of incorrect postures and motions
*Use of ice packs or medication such as oral or topical non-steroidal, anti-inflammatory drugs (NSAIDS), as prescribed by your doctor, to reduce the inflammation or pain
*Exercise regimen such as gentle stretches, eccentric and concentric strengthening
*Physiotherapy to boost the healing process, restore the elbow to its highest level of function, and assist the person in returning to work

“Avoiding activities that cause elbow pain is vital to its treatment. Often known as ‘self-limiting’, the pain and discomfort ultimately disappear when people change or avoid activities that cause pain. Support pads and elbow braces may also be worn for short term pain relief,” he adds.

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Tennis Elbow: Understanding its problems and knowing preventive measures

Dr Kaushal Malhan, Director of Orthopaedic Surgery, Fortis Hospital, Mulund, shares his insights about the tennis elbow injury and how it can be prevented

Tennis Elbow is a tender condition that occurs when tendons in the elbow are burdened, usually by the tedious arm and wrist motions. The name is misleading, as most people who have it, did not attain it by playing tennis.

Technically, it is also known as lateral epicondylitis. It is a result of inflammation just above the elbow joint, on the outer side of the arm. Pain can be experienced in other areas of the elbow and forearm.

Often, the development of tennis elbow can be traced to methods of using the forearm muscles, which control the hand and wrist movements. These muscles are used to perform actions like straightening the fingers, bending the wrist upwards and rolling the forearm into a palms-up position.

A sudden impact and even of lesser force, on a repetitive basis, can damage the tissues, in the same way as rope becomes frayed. Without rest and time for heal, strained tendons can become permanently weakened and can be painful; it also weakens the strength of the grip.

Individuals usually ignore the condition for long periods before seeking medical help, mostly because the symptoms are mild and often disappear with a little rest.

Pain relievers can give temporary relief in the initial basis. Doctor’s counsel is sought when the pain starts to affect the work and become intolerable.

About 1% of the cases last more than a year; this occurs in patients who do not respond positively to non-invasive treatment options. For such patients, steroid injections, Platelet Rich Plasma (PRP) injections locally or rarely, surgery might be a solution.

Prevention

Tasks linked with tennis elbow should be identified and modified to reduce the risk of serious injury.

One of the concerns is the overuse of fingers, wrists, and forearms in repetitive work involving forceful movement, awkward postures, and lack of rest.

Avoid jobs that place extreme force, the strain on muscles of the forearm. Timely attention reduces the development of a problem.

The most significant steps in treatment include:

  • Identify problematic activities and avoid them
  • Correction of incorrect postures and motions
  • Use of ice packs or medication such as oral or topical non-steroidal, anti-inflammatory drugs (NSAIDs), as prescribed by your doctor, to reduce the inflammation or pain
  • Exercise regimen such as gentle stretches, eccentric and concentric strengthening
  • Physiotherapy to boost the healing process, restore the elbow to its highest level of function, and assist the person in returning to work

Avoiding activities that cause elbow pain is vital to the treatment of Tennis Elbow. Often known as self-limiting, pain, and discomfort ultimately disappear when people change or avoid activities that cause pain. Support pads and elbow braces may also be worn for short term pain relief.

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Younger woman in urban areas more prone to arthritis

Evidence shows that osteoarthritis is commoner in urban areas, as against rural areas, and may be one of the reasons for an increasing trend in younger people

It is a known fact that arthritis is seen more commonly amongst women. Recently, it has been noted that the age of osteoarthritis is lowering rapidly

Statistics reveal that osteoarthritis will soon be the number one ailment having trounced heavyweights like cardiac disease, cancer and AIDS

The burden of osteoarthritis in young women patients is going to be a compelling problem in the next few years. The cause for high incidence of osteoarthritis in women is however not fully understood.

  • There are multiple factors like genes, obesity, lifestyle, food habits, injury, and joint biomechanics that play an important role
  • Changing food habits, pollution and adoption of sedentary lifestyle are thought to contribute to this rural-urban disparity
  • Incorrect and inappropriate exercise programmes, lack of stretching, impact exercises, poor quality footwear and prolonged high heels can lead to joint injuries and early arthritis
  • The increasing incidence of obesity has probably also in a significant manner, contributed to the increasing incidence of osteoarthritis. Obesity rates are 54% higher among adults with arthritis compared to those without the condition.

Genetic factors play a huge role in early onset of arthritis, but, continue to be an as yet non-modifiable entity.

This may well be the reason for a higher incidence of arthritis in women, especially at a younger age. Nearly 15% of women who experience moderate to severe effects are below the age of 45.

Treatment

Advanced surgical options provide targeted therapy with better long term solutions suitable for the changing patient profile.

Unicompartmental knee resurfacing changes only the diseased area of the Knee, unlike a Total Knee Replacement (TKR) surgery. Done through a very small incision, this operation allows quick recovery and full function.

Total Knee and Hip Replacements done using a Tissue Preserving method. Unlike conventional techniques our Tissue Preserving Total Knee Replacement (TPTKR) technique preserves healthy bone, ligaments and does not violate muscle tissue.

The focus is on quicker recovery and preserving tissue so as to leave options open for the future

The author is a senior Knee and Hip Surgeon at Fortis Hospital, Mulund

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Bedridden For Over 2 Years, This Teen Can Pursue Her Doctor Dream Again

I am unable to express how difficult this phase was for me,” says Zinatu Umar, recounting the ordeal she underwent after accident in September 2016.

A Nigerian teen, who was left bedridden over two years ago after a near-fatal crash, is all set to give a fresh impetus to her dream of becoming a doctor.

19-year-old Zinatu Umar can soon walk again “normally”, her doctor says, after she underwent a surgery in Mumbai.

“I am unable to express how difficult this phase was for me,” says Zinatu, recounting the ordeal she underwent after her accident in September 2016.

She was with her school friends when the vehicle they were in met with an accident. Zinatu was rushed to a local hospital in Nigeria where the doctors revealed she had suffered injuries in her hips, legs and feet.

At that time, she was discharged after her femur was plated (bone extended from hip to the knee) and a grip was put in place for the hip to function. But she had to undergo another surgery in February 2017 and local doctors recommended a corrective procedure for her hip deformity. However, her condition worsened.

Her hip sticking out of the socket due to damage to the ball and socket had left her bed-ridden.

Doctors in Nigeria were doubtful if her condition would improve but her father, a civil servant, did not lose hope and brought her to Mumbai after some internet research.

“Zinatu Umar was being looked after by her father and sister constantly, who were very optimistic about her recovery,” says Dr Kaushal Malhan, Senior Knee And Hip Surgeon at Fortis Hospital, Mulud, Mumbai, who recommended Total Hip Replacement (THR) and reconstruction surgery for her. Total hip replacement and reconstructive surgery is a procedure where the damaged ball and socket of the hip joint are completely removed and are replaced with locally available bones.

“After operation, she is now able to walk by putting half her weight on the knees by using crutches; has been put on medications and will soon return home, start going to school and continue with her further studies,” Dr Malhan said. The 2.5 hour-long surgery was successful with an implantation of the new ball and socket to the affected hip.

Zinatu, who is excited about leading a normal life all over again, says, “The pain has now disappeared and I look forward to walking normally like before. I will soon go back to school and pursue my dream of becoming a doctor.”

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