Juvenile Rheumatoid Arthritis (JRA)

What Is Arthritis?

Arthritis means "joint inflammation" and refers to a group of diseases that cause pain, swelling, stiffness, and loss of motion in the joints. "Arthritis" is often used as a more general term to refer to the more than 100 rheumatic diseases that may affect the joints but can also cause pain, swelling, and stiffness in other supporting structures of the body such as muscles, tendons, ligaments, and bones. Some rheumatic diseases can affect other parts of the body, including various internal organs. Children can develop almost all types of arthritis that affect adults, but the most common type that affects children is juvenile rheumatoid arthritis (JRA).

What Is Juvenile Rheumatoid Arthritis?

Juvenile rheumatoid arthritis is arthritis that causes joint inflammation and stiffness for more than 6 weeks in a child of 16 years of age or less. Inflammation causes redness, swelling, warmth, and soreness in the joints, although many children with JRA do not complain of joint pain. Any joint can be affected and inflammation may limit the mobility of affected joints. One type of JRA can also affect the internal organs. Doctors classify JRA into three types by the number of joints involved, the symptoms, and the presence or absence of certain antibodies found by a blood test. (Antibodies are special proteins made by the immune system.) These classifications help the doctor determine how the disease will progress and whether the internal organs or skin is affected.

• Pauciarticular (PAW-see-are-TICK-you-lar)--Pauciarticular means that four or fewer joints are affected. Pauciarticular is the most common form of JRA; about half of all children with JRA have this type. Pauciarticular disease typically affects large joints, such as the knees. Girls under age 8 are most likely to develop this type of JRA.

Some children have special kinds of antibodies in the blood. One is called antinuclear antibody (ANA) and one is called rheumatoid factor. Eye disease affects about 20 to 30 percent of children with pauciarticular JRA. Up to 80 percent of those with eye disease also test positive for ANA and the disease tends to develop at a particularly early age in these children. Regular examinations by an ophthalmologist (a doctor who specializes in eye diseases) are necessary to prevent serious eye problems such as iritis (inflammation of the iris, the colored part of the eye) or uveitis (inflammation of the uvea, or the inner eye). Some children with pauciarticular disease outgrow arthritis by adulthood, although eye problems can continue and joint symptoms may recur in some people.


• Polyarticular--About 30 percent of all children with JRA have polyarticular disease. In polyarticular disease, five or more joints are affected. The small joints, such as those in the hands and feet, are most commonly involved, but the disease may also affect large joints. Polyarticular JRA often is symmetrical; that is, it affects the same joint on both sides of the body. Some children with polyarticular disease have an antibody in their blood called IgM rheumatoid factor (RF). These children often have a more severe form of the disease, which doctors consider to be similar in many ways to adult rheumatoid arthritis.


• Systemic--Besides joint swelling, the systemic form of JRA is characterised by fever and a light skin rash, and may also affect internal organs such as the heart, liver, spleen, and lymph nodes. Doctors sometimes call it Still's disease. Almost all children with this type of JRA test negative for both RF and ANA. The systemic form affects 20 percent of all children with JRA. A small percentage of these children develop arthritis in many joints and can have severe arthritis that continues into adulthood.

What Causes Juvenile Rheumatoid Arthritis?

JRA is an autoimmune disorder, which means that the body mistakenly identifies some of its own cells and tissues as foreign. The immune system, which normally helps to fight off harmful, foreign substances such as bacteria or viruses, begins to attack healthy cells and tissues. The result is inflammation--marked by redness, heat, pain, and swelling. Doctors do not know why the immune system goes awry in children who develop JRA. Scientists suspect that it is a two-step process. First, something in a child's genetic makeup gives them a tendency to develop JRA; then an environmental factor, such as a virus, triggers the development of JRA.

What Are the Symptoms and Signs of Juvenile Rheumatoid Arthritis?

The most common symptom of all types of JRA is persistent joint swelling, pain, and stiffness that typically is worse in the morning or after a nap. The pain may limit movement of the affected joint although many children, especially younger ones, will not complain of pain. JRA commonly affects the knees and joints in the hands and feet. One of the earliest signs of JRA may be limping in the morning because of an affected knee. Besides joint symptoms, children with systemic JRA have a high fever and a light skin rash. The rash and fever may appear and disappear very quickly. Systemic JRA also may cause the lymph nodes located in the neck and other parts of the body to swell. In some cases (less than half), internal organs including the heart and, very rarely, the lungs may be involved.

Eye inflammation is a potentially severe complication that sometimes occurs in children with pauciarticular JRA. Eye diseases such as iritis and uveitis often are not present until some time after a child first develops JRA.

Typically, there are periods when the symptoms of JRA are better or disappear (remissions) and times when symptoms are worse (flare-ups). JRA is different in each child--some may have just one or two flare-ups and never have symptoms again, while others experience many flare-ups or even have symptoms that never go away.

Some children with JRA may have growth problems. Depending on the severity of the disease and the joints involved, growth in affected joints may be too fast or too slow, causing one leg or arm to be longer than the other. Overall growth may also be slowed. Doctors are exploring the use of growth hormones to treat this problem. JRA also may cause joints to grow unevenly or to one side.

How Is Juvenile Rheumatoid Arthritis Diagnosed?

Doctors usually suspect JRA, along with several other possible conditions, when they see children with persistent joint pain or swelling, unexplained skin rashes and fever, or swelling of lymph nodes or inflammation of internal organs. A diagnosis of JRA also is considered in children with an unexplained limp or excessive clumsiness.

No one test can be used to diagnose JRA. A doctor diagnoses JRA by carefully examining the patient and considering the patient's medical history, the results of laboratory tests, and x rays that help rule out other conditions.

• Symptoms--One important consideration in diagnosing JRA is the length of time that symptoms have been present. Joint swelling or pain must last for at least 6 weeks for the doctor to consider a diagnosis of JRA. Because this factor is so important, it may be useful to keep a record of the symptoms, when they first appeared, and when they are worse or better.


• Laboratory tests--Laboratory tests, usually blood tests, cannot by themselves provide the doctor with a clear diagnosis. But these tests can be used to help rule out other conditions and to help classify the type of JRA that a patient has. Blood may be taken to test for RF and ANA, and to determine the erythrocyte sedimentation rate (ESR).


• ANA is found in the blood more often than RF, and both are found in only a small portion of JRA patients. The RF test helps the doctor tell the difference among the three types of JRA.


• ESR is a test that measures how quickly red blood cells fall to the bottom of a test tube. Some people with rheumatic disease have an elevated ESR or "sed rate" (cells fall quickly to the bottom of the test tube), showing that there is inflammation in the body. Not all children with active joint inflammation have an elevated ESR.


• X rays--X rays are needed if the doctor suspects injury to the bone or unusual bone development. Early in the disease, some x rays can show cartilage damage. In general, x rays are more useful later in the disease, when bones may be affected.


• Other diseases--Because there are many causes of joint pain and swelling, the doctor must rule out other conditions before diagnosing JRA. These include physical injury, bacterial or viral infection, Lyme disease, inflammatory bowel disease, lupus, dermatomyositis, and some forms of cancer. The doctor may use additional laboratory tests to help rule out these and other possible conditions.

What Are the Treatments?

The special expertise of rheumatologists in caring for patients with JRA is extremely valuable. Paediatric rheumatologists are trained in both paediatrics and rheumatology and are best equipped to deal with the complex problems of children with arthritis and other rheumatic diseases. However, there are very few such specialists, and some areas of the country have none at all. In such circumstances, a team approach involving the child's paediatrician and a rheumatologist with experience in both adult and paediatric rheumatic disease provides optimal care for children with arthritis. Other important members of the team include physical therapists and occupational therapists.

The main goals of treatment are to preserve a high level of physical and social functioning and maintain a good quality of life. To achieve these goals, doctors recommend treatments to reduce swelling; maintain full movement in the affected joints; relieve pain; and identify, treat, and prevent complications. Most children with JRA need medication and physical therapy to reach these goals.

Several types of medication are available to treat JRA:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)--Aspirin, ibuprofen, and naproxen or naproxen sodium are examples of NSAIDs. They often are the first type of medication used. Most doctors do not treat children with aspirin because of the possibility that it will cause bleeding problems, stomach upset, liver problems, or Reye's syndrome. But for some children, aspirin in the correct dose (measured by blood test) can control JRA symptoms effectively with few serious side effects.

If the doctor prefers not to use aspirin, other NSAIDs are available. For example, in addition to those mentioned above, diclofenac and tolmetin are available with a doctor's prescription. Studies show that these medications are as effective as aspirin with fewer side effects. An upset stomach is the most common complaint. Any side effects should be reported to the doctor, who may change the type or amount of medication.


• Disease-modifying anti-rheumatic drugs (DMARDs)--If NSAIDs do not relieve symptoms of JRA, the doctor is likely to prescribe this type of medication. DMARDs slow the progression of JRA, but because they take weeks or months to relieve symptoms, they often are taken with an NSAID. Various types of DMARDs are available. Doctors are likely to use one type of DMARD, methotrexate, for children with JRA.

Researchers have learned that methotrexate is safe and effective for some children with rheumatoid arthritis whose symptoms are not relieved by other medications. Because only small doses of methotrexate are needed to relieve arthritis symptoms, potentially dangerous side effects rarely occur. The most serious complication is liver damage, but it can be avoided with regular blood screening tests and doctor followup. Careful monitoring for side effects is important for people taking methotrexate. When side effects are noticed early, the doctor can reduce the dose and eliminate side effects.


• Corticosteroids--In children with very severe JRA, stronger medicines may be needed to stop serious symptoms such as inflammation of the sac around the heart (pericarditis). Corticosteroids like prednisone may be added to the treatment plan to control severe symptoms. This medication can be given either intravenously (directly into the vein) or by mouth. Corticosteroids can interfere with a child's normal growth and can cause other side effects, such as a round face, weakened bones, and increased susceptibility to infections. Once the medication controls severe symptoms, the doctor may reduce the dose gradually and eventually stop it completely. Because it can be dangerous to stop taking corticosteroids suddenly, it is important that the patient carefully follow the doctor's instructions about how to take or reduce the dose.


• Biologic agents--Children with polyarticular JRA who have gotten little relief from other drugs may be given one of a new class of drug treatments called "biologic agents." Etanercept (Enbrel), for example, is such an agent. It blocks the actions of tumour necrosis factor, a naturally occurring protein in the body that helps cause inflammation.


• Physical therapy--Exercise is an important part of a child's treatment plan. It can help to maintain muscle tone and preserve and recover the range of motion of the joints. A physiatrist (rehabilitation specialist) or a physical therapist can design an appropriate exercise programme for a person with JRA. The specialist also may recommend using splints and other devices to help maintain normal bone and joint growth.


• Complementary and alternative medicine--Many adults seek alternative ways of treating arthritis, such as special diets or supplements. Although these methods may not be harmful in and of themselves, no research to date shows that they help. Some people have tried acupuncture, in which thin needles are inserted at specific points in the body. Others have tried glucosamine and chondroitin sulfate, two natural substances found in and around cartilage cells, for osteoarthritis of the knee.

Some alternative or complementary approaches may help a child to cope with or reduce some of the stress of living with a chronic illness. If the doctor feels the approach has value and will not harm the child, it can be incorporated into the treatment plan. However, it is important not to neglect regular health care or treatment of serious symptoms.

How Can the Family Help a Child Live Well With JRA?

JRA affects the entire family who must cope with the special challenges of this disease. JRA can strain a child's participation in social and after-school activities and make school work more difficult. There are several things that family members can do to help the child do well physically and emotionally.

• Treat the child as normally as possible.


• Ensure that the child receives appropriate medical care and follows the doctor's instructions. Many treatment options are available, and because JRA is different in each child, what works for one may not work for another. If the medications that the doctor prescribes do not relieve symptoms or if they cause unpleasant side effects, patients and parents should discuss other choices with their doctor. A person with JRA can be more active when symptoms are controlled.


• Encourage exercise and physical therapy for the child. For many young people, exercise and physical therapy play important roles in managing JRA. Parents can arrange for children to participate in activities that the doctor recommends. During symptom-free periods, many doctors suggest playing team sports or doing other activities to help keep the joints strong and flexible and to provide play time with other children and encourage appropriate social development.


• Work closely with the school to develop a suitable lesson plan for the child and to educate the teacher and the child's classmates about JRA. (See the end of this booklet for information about Kids on the Block, Inc., a programme that uses puppets to illustrate how juvenile arthritis can affect school, sports, friends, and family.) Some children with JRA may be absent from school for prolonged periods and need to have the teacher send assignments home. Some minor changes such as an extra set of books, or leaving class a few minutes early to get to the next class on time can be a great help. With proper attention, most children progress normally through school.


• Explain to the child that getting JRA is nobody's fault. Some children believe that JRA is a punishment for something they did.


• Consider joining a support group. The American Juvenile Arthritis Organization runs support groups for people with JRA and their families. Support group meetings provide the chance to talk to other young people and parents of children with JRA and may help a child and the family cope with the condition.


• Work with therapists or social workers to adapt more easily to the lifestyle change JRA may bring.

Do Children With Juvenile Rheumatoid Arthritis Have To Limit Activities?

Although pain sometimes limits physical activity, exercise is important to reduce the symptoms of JRA and maintain function and range of motion of the joints. Most children with JRA can take part fully in physical activities and sports when their symptoms are under control. During a disease flare-up, however, the doctor may advise limiting certain activities depending on the joints involved. Once the flare-up is over, a child can start regular activities again.

Swimming is particularly useful because it uses many joints and muscles without putting weight on the joints. A doctor or physical therapist can recommend exercises and activities.

For more details please contact:

Dr. Prateek Gupta (Senior Surgeon)

Arthroscopy Surgery Clinic

C2/5 Safdarjung Development Area (SDA),

Aurobindo Marg, New Delhi - 110016

INDIA

Telephones: +91 9810852876, +91 11 26517776

24 x 7 Helpline & Appointment: +91 9810633876

Email: sportsmedicinedelhi@yahoo.com,

sportsmedicineclinics@gmail.com

Website:http://www.sportsmedicineclinicdelhi.com/arthroscopy.htm,

http://www.sportsmedicineclinicdelhi.com,

http://www.arthroscopysurgeryindia.com

Juvenile Osteoporosis

Osteoporosis literally means “porous bone.” It is a disease characterised by too little bone formation or excessive bone loss or a combination of both. People with osteoporosis have an increased risk of fractures. It is most common in older people, especially older women.

Osteoporosis is rare in children and adolescents. When it does occur, it is usually caused by an underlying medical disorder or by medications used to treat the disorder. This is called secondary osteoporosis. Sometimes, however, there is no identifiable cause of osteoporosis in a child. This is known as idiopathic osteoporosis.

No matter what causes it, juvenile osteoporosis can be a significant problem because it occurs during the child’s prime bone-building years. From birth through young adulthood, children steadily accumulate bone mass, which peaks sometime before age 30. The greater their peak bone mass, the lower their risk for osteoporosis later in life. After their mid-30s, bone mass typically begins to decline – very slowly at first but increasing in their 50s and 60s. Both heredity and lifestyle choices – especially the amount of calcium in the diet and the level of physical activity – influence the development of peak bone mass and the rate at which bone is lost later in life.

Secondary Osteoporosis

Secondary osteoporosis, which can affect both adults and children, results from another primary disorder or therapy. Some examples are included in the box below.

Disorders, Medications, and Behaviors That May Affect Bone Mass : Primary Disorders Juvenile rheumatoid arthritis Diabetes Osteogenesis imperfecta Hyperthyroidism Hyperparathyroidism Cushing’s syndrome Malabsorption syndromes Anorexia nervosa Kidney disease Medications Anticonvulsants (e.g., for epilepsy) Corticosteroids (e.g., for rheumatoid arthritis, asthma) Immunosuppressive agents (e.g., for cancer) Behaviors Prolonged inactivity or immobility Inadequate nutrition (especially calcium, vitamin D) Excessive exercise leading to amenorrhea (absence of periods) Smoking Alcohol abuse This is not a complete list. The cause of a child’s osteoporosis can best be determined with the help of his or her physician.

As the primary condition, juvenile rheumatoid arthritis provides a good illustration of the possible causes of secondary osteoporosis. In some cases, the disease process itself can cause osteoporosis. For example, some studies have found that children with juvenile rheumatoid arthritis have bone mass that is lower than expected, especially near the joints affected by arthritis. In other cases, medication used to treat the primary disorder may reduce bone mass. For example, drugs such as prednisone, used to treat severe cases of juvenile rheumatoid arthritis, negatively affect bone mass. Finally, some behaviours associated with the primary disorder may lead to bone loss or a reduction in bone formation. For example, a child with juvenile rheumatoid arthritis may avoid physical activity, which is necessary for building and maintaining bone mass, because it may aggravate his or her condition or cause pain.

The best course of action when a child has secondary osteoporosis is to identify and treat the underlying disorder. In the case of medication-induced juvenile osteoporosis, it is best to treat the primary disorder with the lowest effective dose of the osteoporosis-inducing medication. If an alternative medication is available and effective, the child’s doctor may also consider prescribing it. Like all children, those with secondary osteoporosis also need a diet rich in calcium and vitamin D, and as much physical activity as possible given the limitations of the primary disorder.

Idiopathic Juvenile Osteoporosis

Idiopathic juvenile osteoporosis (IJO) is a primary condition of no known cause. It is diagnosed after the physician has excluded other causes of juvenile osteoporosis, including primary diseases or medical therapies known to cause bone loss. As of 1997, 150 cases have been reported in the medical literature.

This rare form of osteoporosis typically occurs in previously healthy children just before the onset of puberty. The average age of onset is 7 years, with a range of 1 to 13 years. The good news is that most children experience a complete recovery of bone.

Clinical features: The first sign of IJO is usually pain in the lower back, hips, and feet, often accompanied by difficulty walking. There may also be knee and ankle pain and fractures of the lower extremities. Physical malformations also may be present. These include abnormal curvature of the upper spine (kyphosis), loss of height, a sunken chest, or a limp. These physical malformations are sometimes reversible after the IJO has run its course.

X rays of children with IJO often show low bone density, fractures of the weight-bearing bones, and collapsed or misshapen vertebrae. However, conventional x rays may not be able to detect osteoporosis until significant bone mass has already been lost. Newer methods such as dual-energy x-ray absorptiometry (DXA), dual photon absorptiometry (DPA), and quantitative computed tomography (CAT scans) allow for earlier and more accurate diagnosis of low bone mass. These are noninvasive, painless tests a bit like x rays.

Treatment: There is no established medical or surgical therapy for juvenile osteoporosis, and, in some cases, there may be no need for treatment because the condition usually goes away spontaneously. However, early diagnosis of juvenile osteoporosis is important so that steps can be taken to protect the child’s spine and other bones from fracture until remission occurs. These steps may include physical therapy, using crutches, avoiding unsafe weight-bearing activities, and other supportive care. A well-balanced diet rich in calcium and vitamin D is also important. In severe, long-lasting cases of juvenile osteoporosis, some medications called bisphosphonates, approved by the Food and Drug Administration for the treatment of osteoporosis in adults, have been given to children experimentally.

Prognosis: Most children with IJO experience a complete recovery of bone tissue. Although growth may be somewhat impaired during the acute phase of the disorder, normal growth resumes – and catch-up growth often occurs – afterward. Unfortunately, in some cases, IJO can result in permanent disability such as curvature of the upper spine (kyphoscoliosis) or a collapse of the rib cage.

Distinguishing Juvenile Osteoporosis from Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is a rare genetic disorder that, like juvenile osteoporosis, is characterised by bones that break easily, often from little or no apparent cause. However, OI is caused by a problem with the quantity or quality of bone collagen resulting from a genetic defect.

Most children with OI never attain normal bone mass and so suffer from secondary osteoporosis as well. There are several distinct forms of OI, representing extreme variations in severity. For example, a person with OI may have as few as 10 or as many as several hundred fractures in a lifetime. While the number of people affected with OI in the United States is unknown, the best estimate suggests a minimum of 20,000 and possibly as many as 50,000. The clinical features of OI and their severity vary greatly from person to person. Many individuals with OI have only some, not all, of the clinical features. Children with milder OI, in particular, may have few obvious clinical symptoms. The most common features of OI include:

• bones that fracture easily
• ligament laxity (hypermobile joints) and low muscle strength
• family history of OI (present in about 65 percent of cases)
• small stature in moderate and severe types
• sclera (“whites” of the eyes) tinted blue, purple, or gray in about 50 percent of cases
• possible hearing loss in late childhood or early adult years and
• possible brittle teeth (known as dentinogenesis imperfecta).

The features that most often distinguish OI from juvenile osteoporosis are the family history of the disease and the blue,purple, or gray scleracommonly found in patients with OI. Distinguishing between OI and IJO may require genetic testing or, in some cases, bone biopsy.

For more details please contact:

Dr. Prateek Gupta (Senior Surgeon)

Arthroscopy Surgery Clinic

C2/5 Safdarjung Development Area (SDA),

Aurobindo Marg, New Delhi - 110016

INDIA

Telephones: +91 9810852876, +91 11 26517776

24 x 7 Helpline & Appointment: +91 9810633876

Email: sportsmedicinedelhi@yahoo.com,

sportsmedicineclinics@gmail.com

Website:http://www.sportsmedicineclinicdelhi.com/arthroscopy.htm,

http://www.sportsmedicineclinicdelhi.com,

http://www.arthroscopysurgeryindia.com

Joint Replacement Surgery

What Is Joint Replacement Surgery?

Joint replacement surgery is removing a damaged joint and putting in a new one. A joint is where two or more bones come together, like the knee, hip, and shoulder. The surgery is usually done by a doctor called an orthopaedic (or-tho-PEE-dik) surgeon. Sometimes, the surgeon will not remove the whole joint, but will only replace or fix the damaged parts.

The doctor may suggest a joint replacement to improve how you live. Replacing a joint can help you relieve pain and move and feel better. Joints that can be replaced include the shoulders, fingers, ankles, and elbows. Hips and knees are replaced most often.

What Can Happen to My Joints?

Joints can be damaged by arthritis and other diseases, injuries, or other causes. Arthritis or simply years of use may cause the joint to wear away. This can cause pain, stiffness, and swelling. Bones are alive, and need blood to be healthy, grow, and repair themselves. Diseases and damage inside a joint can limit blood flow, causing problems.

What Is a New Joint Like?

A new joint, called a prosthesis (praas-THEE-sis), can be made of plastic, metal, or both. It may be cemented into place or not cemented, so that your bone will grow into it. Both methods may be combined to keep the new joint in place.

A cemented joint is used more often in older people who do not move around as much and in people with “weak” bones. The cement holds the new joint to the bone. An uncemented joint is often recommended for younger, more active people and those with good bone quality. It may take longer to heal, because it takes longer for bone to grow and attach to it.

New joints generally last at least 10 to 15 years. Therefore, younger patients may need to have the same damaged joint replaced more than once.

Do Many People Have Joints Replaced?

Joint replacement is becoming more common. About 435,000 Americans have a hip or knee replaced each year. Research has shown that even if you are older, joint replacement can help you move around and feel better.

Any surgery has risks. Risks of joint surgery will depend on your health before surgery, how severe your arthritis is, and the type of surgery done. More hospitals and doctors have been replacing joints for several decades, and this experience results in better patient outcomes. For answers to their questions, some people talk with their doctors, or someone who has had the surgery. A doctor specializing in joints will probably work with you before, during, and after surgery to make sure you heal quickly and recover successfully.

Do I Need to Have My Joint Replaced?

Only a doctor can tell if you need a joint replaced. He or she will look at your joint with an x-ray machine or other machines. The doctor may put a small, lighted tube (arthroscope) into your joint to look for damage. A small sample of your tissue could also be tested.

After looking at your joint, the doctor may say that you should consider exercise, walking aids like braces or canes, physical therapy, or medicines and supplements. Medicines for arthritis include drugs that reduce inflammation. Depending on the type of arthritis, the doctor may prescribe corticosteroids or other drugs. However, all drugs may cause side effects, including bone loss.

If these treatments do not work, the doctor may suggest an operation called an osteotomy (aas-tee-AAHT-oh-me), where the surgeon “aligns” the joint. Here, the surgeon cuts the bone or bones around the joint to improve alignment. This may be simpler than replacing a joint, but it may take longer to recover. However, it is not commonly done today.

Joint replacement is often the answer if you have constant pain and can’t move the joint well; for example, if you have trouble with things like walking, climbing stairs, and taking a bath.

What Happens During Surgery?

First, the surgical team will give you medicine so you won’t feel pain (anaesthesia). The medicine may block the pain only in one part of the body (regional), or it may put your whole body to sleep (general). The team will then replace the damaged joint with a prosthesis.

Each surgery is different. How long it takes depends on how badly the joint is damaged and how the surgery is done. To replace a knee or a hip takes about 2 hours or less, unless there are complicating factors. After surgery, you will be moved to a recovery room for 1 to 2 hours until you are fully awake or the numbness goes away.

What Happens After Surgery?

With knee or hip surgery, you may be able to go home in 3–5 days. If you are elderly or have additional handicaps, you may then need to spend several weeks in an intermediate care facility before going home. How long you stay in the hospital will be determined by you and your team of doctors.

After hip or knee replacement, you will often stand and begin walking sometimes even the day of surgery. At first, you will walk with a walker or crutches. You may have some temporary pain in the new joint because your muscles are weak from not being used. Also, your body is healing. The pain can be helped with medicines and should end in a few weeks or months.

Physical therapy can begin the day after surgery to help strengthen the muscles around the new joint and help you regain motion in the joint. If you have your shoulder joint replaced, you can usually begin exercising the same day of your surgery! A physical therapist will help you with gentle, range-of-motion exercises. Before you leave the hospital (usually two or three days after surgery), your therapist will show you how to use a pulley device to help bend and extend your arm.

Will My Surgery Be Successful?

The success of your surgery depends a lot on what you do when you come home. Follow your doctor’s advice about what you eat, what medicines to take, and how to exercise. Talk with your doctor about any pain or trouble moving.

Joint replacement is usually a success in more than 90 percent of people who have it. When problems do occur, most are treatable. Possible problems include:

• Infection – Areas in the wound or around the new joint may get infected. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound are usually treated with drugs. Deep infections may need a second operation to treat the infection or replace the joint.


• Blood Clots – If your blood moves too slowly, it may begin to form lumps of blood parts called clots. If pain and swelling develop in your legs after hip or knee surgery, blood clots may be the cause. The doctor may suggest drugs to make your blood thin, or special stockings, exercises, and/or boots to help your blood move faster. If swelling, redness, or pain occurs in your leg after you leave the hospital, contact your doctor right away.


• Loosening – The new joint may loosen, causing pain. If the loosening is bad, you may need another operation. New ways to attach the joint to the bone should help.


• Dislocation – Sometimes after hip or other joint replacement, the ball of the prosthesis can come out of its socket. In most cases, the hip can be corrected without surgery. A brace may be worn for a while if a dislocation occurs.


• Wear – Some wear can be found in all joint replacements. Too much wear may help cause loosening. The doctor may need to operate again if the prosthesis comes loose. Sometimes, the plastic can wear thin, and the doctor may just replace the plastic and not the whole joint.


• Nerve and Blood Vessel Injury – Nerves near the replaced joint may be damaged during surgery, but this does not happen often. Over time, the damage often improves and may disappear. Blood vessels may also be injured.

As you move your new joint and let your muscles grow strong again, pain will lessen, flexibility will increase, and movement will improve.

For more details please contact:

Dr. Prateek Gupta (Senior Surgeon)

Arthroscopy Surgery Clinic

C2/5 Safdarjung Development Area (SDA),

Aurobindo Marg, New Delhi - 110016

INDIA

Telephones: +91 9810852876, +91 11 26517776

24 x 7 Helpline & Appointment: +91 9810633876

Email: sportsmedicinedelhi@yahoo.com,

sportsmedicineclinics@gmail.com

Website:http://www.sportsmedicineclinicdelhi.com/arthroscopy.htm,

http://www.sportsmedicineclinicdelhi.com,

http://www.arthroscopysurgeryindia.com

Hip Replacement & Hip Replacement Surgery

What Is a Hip Replacement?

Hip replacement, or arthroplasty, is a surgical procedure in which the diseased parts of the hip joint are removed and replaced with new, artificial parts. These artificial parts are called the prosthesis. The goals of hip replacement surgery are to improve mobility by relieving pain and improve function of the hip joint.

Who Should Have Hip Replacement Surgery?

The most common reason that people have hip replacement surgery is the wearing down of the hip joint that results from osteoarthritis. Other conditions, such as rheumatoid arthritis (a chronic inflammatory disease that causes joint pain, stiffness, and swelling), avascular necrosis (loss of bone caused by insufficient blood supply), injury, and bone tumours also may lead to breakdown of the hip joint and the need for hip replacement surgery.

Before suggesting hip replacement surgery, the doctor is likely to try walking aids such as a cane, or non-surgical therapies such as medication and physical therapy. These therapies are not always effective in relieving pain and improving the function of the hip joint. Hip replacement may be an option if persistent pain and disability interfere with daily activities. Before a doctor recommends hip replacement, joint damage should be detectable on x rays.

In the past, hip replacement surgery was an option primarily for people over 60 years of age. Typically, older people are less active and put less strain on the artificial hip than do younger, more active people. In recent years, however, doctors have found that hip replacement surgery can be very successful in younger people as well. New technology has improved the artificial parts, allowing them to withstand more stress and strain. A more important factor than age in determining the success of hip replacement is the overall health and activity level of the patient.

For some people who would otherwise qualify, hip replacement may be problematic. For example, people with chronic diseases such as those that result in severe muscle weakness or Parkinson's disease are more likely than people without chronic diseases to damage or dislocate an artificial hip. Because people who are at high risk for infections or in poor health are less likely to recover successfully, doctors may not recommend hip replacement surgery for these patients.

What Are Alternatives to Total Hip Replacement?

Before considering a total hip replacement, the doctor may try other methods of treatment, such as an exercise programme and medication. An exercise programme can strengthen the muscles in the hip joint and sometimes improve positioning of the hip and relieve pain.

The doctor also may treat inflammation in the hip with nonsteroidal anti-inflammatory drugs, or NSAIDs. Some common NSAIDs are aspirin and ibuprofen. NSAIDs also include Celebrex, one of the so-called COX-2 inhibitors that block an enzyme known to cause an inflammatory response. Many of these medications are available without a prescription, although a doctor also can prescribe NSAIDs in stronger doses.

In a small number of cases, the doctor may prescribe corticosteroids, such as prednisone or cortisone, if NSAIDs do not relieve pain. Corticosteroids reduce joint inflammation and are frequently used to treat rheumatic diseases such as rheumatoid arthritis. Corticosteroids are not always a treatment option because they can cause further damage to the bones in the joint. Some people experience side effects from corticosteroids such as increased appetite, weight gain, and lower resistance to infections. A doctor must prescribe and monitor corticosteroid treatment. Because corticosteroids alter the body's natural hormone production, patients should not stop taking them suddenly and should follow the doctor's instructions for discontinuing treatment.

If physical therapy and medication do not relieve pain and improve joint function, the doctor may suggest corrective surgery that is less complex than a hip replacement, such as an osteotomy. Osteotomy is surgical repositioning of the joint. The surgeon cuts away damaged bone and tissue and restores the joint to its proper position. The goal of this surgery is to restore the joint to its correct position, which helps to distribute weight evenly in the joint. For some people, an osteotomy relieves pain. Recovery from an osteotomy takes 6 to 12 months. After an osteotomy, the function of the hip joint may continue to worsen and the patient may need additional treatment. The length of time before another surgery is needed varies greatly and depends on the condition of the joint before the procedure.

What Does Hip Replacement Surgery Involve?

The hip joint is located where the upper end of the femur meets the acetabulum. The femur, or thigh bone, looks like a long stem with a ball on the end. The acetabulum is a socket or cup-like structure in the pelvis, or hip bone. This "ball and socket" arrangement allows a wide range of motion, including sitting, standing, walking, and other daily activities.

During hip replacement, the surgeon removes the diseased bone tissue and cartilage from the hip joint. The healthy parts of the hip are left intact. Then the surgeon replaces the head of the femur (the ball) and the acetabulum (the socket) with new, artificial parts. The new hip is made of materials that allow a natural, gliding motion of the joint. Hip replacement surgery usually lasts 2 to 3 hours.

Sometimes the surgeon will use a special glue, or cement, to bond the new parts of the hip joint to the existing, healthy bone. This is referred to as a "cemented" procedure. In an uncemented procedure, the artificial parts are made of porous material that allows the patient's own bone to grow into the pores and hold the new parts in place. Doctors sometimes use a "hybrid" replacement, which consists of a cemented femur part and an uncemented acetabular part.

Is a Cemented or Uncemented Prosthesis Better?

Cemented prostheses were developed 40 years ago. Uncemented prostheses were developed about 20 years ago to try to avoid the possibility of loosening parts and the breaking off of cement particles, which sometimes happen in the cemented replacement. Because each person's condition is unique, the doctor and patient must weigh the advantages and disadvantages to decide which type of prosthesis is better.

For some people, an uncemented prosthesis may last longer than cemented replacements because there is no cement that can break away. And, if the patient needs an additional hip replacement (which is likely in younger people), also known as a revision, the surgery sometimes is easier if the person has an uncemented prosthesis.

The primary disadvantage of an uncemented prosthesis is the extended recovery period. Because it takes a long time for the natural bone to grow and attach to the prosthesis, people with uncemented replacements must limit activities for up to 3 months to protect the hip joint. The process of natural bone growth also can cause thigh pain for several months after the surgery.

Research has proven the effectiveness of cemented prostheses to reduce pain and increase joint mobility. These results usually are noticeable immediately after surgery. Cemented replacements are more frequently used than cementless ones for older, less active people and people with weak bones, such as those who have osteoporosis.

What Can Be Expected Immediately After Surgery?

Patients are allowed only limited movement immediately after hip replacement surgery. When the patient is in bed, the hip usually is braced with pillows or a special device that holds the hip in the correct position. The patient may receive fluids through an intravenous tube to replace fluids lost during surgery. There also may be a tube located near the incision to drain fluid and a tube (catheter) may be used to drain urine until the patient is able to use the bathroom. The doctor will prescribe medicine for pain or discomfort.

How Long Are Recovery and Rehabilitation?

On the day after surgery or sometimes on the day of surgery, therapists will teach the patient exercises that will improve recovery. A respiratory therapist may ask the patient to breathe deeply, cough, or blow into a simple device that measures lung capacity. These exercises reduce the collection of fluid in the lungs after surgery.

A physical therapist may teach the patient exercises, such as contracting and relaxing certain muscles, that can strengthen the hip. Because the new, artificial hip has a more limited range of movement than an undiseased hip, the physical therapist also will teach the patient proper techniques for simple activities of daily living, such as bending and sitting, to prevent injury to the new hip. As early as 1 to 2 days after surgery, a patient may be able to sit on the edge of the bed, stand, and even walk with assistance.

Usually, people do not spend more than 10 days in the hospital after hip replacement surgery. Full recovery from the surgery takes about 3 to 6 months, depending on the type of surgery, the overall health of the patient, and the success of rehabilitation.

What Are Possible Complications of Hip Replacement Surgery?

According to the American Academy of Orthopaedic Surgeons, approximately 120,000 hip replacement operations are performed each year in the United States and less than 10 percent require further surgery. New technology and advances in surgical techniques have greatly reduced the risks involved with hip replacements.

The most common problem that may happen soon after hip replacement surgery is hip dislocation. Because the artificial ball and socket are smaller than the normal ones, the ball can become dislodged from the socket if the hip is placed in certain positions. The most dangerous position usually is pulling the knees up to the chest.

The most common later complication of hip replacement surgery is an inflammatory reaction to tiny particles that gradually wear off of the artificial joint surfaces and are absorbed by the surrounding tissues. The inflammation may trigger the action of special cells that eat away some of the bone, causing the implant to loosen. To treat this complication, the doctor may use anti-inflammatory medications or recommend revision surgery (replacement of an artificial joint). Medical scientists are experimenting with new materials that last longer and cause less inflammation.

Less common complications of hip replacement surgery include infection, blood clots, and heterotopic bone formation (bone growth beyond the normal edges of bone).

When Is Revision Surgery Necessary?

Hip replacement is one of the most successful orthopaedic surgeries performed--more than 90 percent of people who have hip replacement surgery will never need revision surgery. However, because more younger people are having hip replacements, and wearing away of the joint surface becomes a problem after 15 to 20 years, revision surgery is becoming more common. Revision surgery is more difficult than first-time hip replacement surgery, and the outcome is generally not as good, so it is important to explore all available options before having additional surgery.

Doctors consider revision surgery for two reasons: if medication and lifestyle changes do not relieve pain and disability, or if x rays of the hip show that damage has occurred to the artificial hip that must be corrected before it is too late for a successful revision. This surgery is usually considered only when bone loss, wearing of the joint surfaces, or joint loosening shows up on an x ray. Other possible reasons for revision surgery include fracture, dislocation of the artificial parts, and infection.

What Types of Exercise Are Most Suitable for Someone With a Total Hip Replacement?

Proper exercise can reduce joint pain and stiffness and increase flexibility and muscle strength. People who have an artificial hip should talk to their doctor or physical therapist about developing an appropriate exercise programme. Most exercise programs begin with safe range-of-motion activities and muscle strengthening exercises. The doctor or therapist will decide when the patient can move on to more demanding activities. Many doctors recommend avoiding high-impact activities, such as basketball, jogging, and tennis. These activities can damage the new hip or cause loosening of its parts. Some recommended exercises are cross-country skiing, swimming, walking, and stationary bicycling. These exercises can increase muscle strength and cardiovascular fitness without injuring the new hip.

For more details please contact:

Dr. Prateek Gupta (Senior Surgeon)

Arthroscopy Surgery Clinic

C2/5 Safdarjung Development Area (SDA),

Aurobindo Marg, New Delhi - 110016

INDIA

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