Arthritis means literally inflammation of a joint, this is usually associated with pain and swelling and stiffness and loss of function (for example difficulty walking and night pain). There are two main types of arthritis:
(a) Osteoarthritis
which is a degenerative condition of the joint due to multiple factors including genetic, developmental, biochemical and traumatic conditions. As osteoarthritis progresses the articular cartilage is lost from the joint, ultimately the patient finds for example with the knee that they are walking on bone instead of articular cartilage, this is very painful and disabling. Joint replacement may be required to relieve the problem. When the hip joint is involved, sleep is frequently disturbed by pain.
(b) Rheumatoid arthritis
this is a condition in which the lining of the joint, known as synovium, grows excessively and takes on a destructive property and destroys the articular cartilage of the joint. It tends to involve more than one joint, quite often symmetrically (for example, the knees) and it frequently starts in the feet or sometimes the hands. It is initially treated medically by the Rheumatologists but sometimes the joints are so badly damaged that they need to be replaced. Significant advances have been made in the early medical management of Rheumatoid Arthritis but sometimes surgery is required. In the early cases, removal of the synovial lining surgically (for example an arthroscopic synovectomy) may help to slow down the process and allow the joint to move more easily and help medication to become more successful.
(c) Psoriatic arthropathy
There are other causes of arthritis, such as psoriatic arthropathy which is found in patients with the skin condition psoriasis, this can affect knees and quite often the small joints at the end of the fingers. Other chemical dysfunctions such as gout may result in the deposition of crystals of uric acid in the joint, for example in the big toe or the knee joint, which are extremely painful and cause swelling of the joint. This type of arthritis is best treated medically in the first instance.
This means simply looking into a joint (“arthro” meaning joint and “scopy” meaning to look into). Modern technology, including fibre optics, lens and camera systems made it possible for Surgeons to look inside joints and identify problems which were previously unrecognised.
The first joint to be looked into regularly was the knee joint in the early 1980s, but now it is possible to look into the ankle joint and hip joint, the shoulder joint, the elbow and wrist joints.
Arthroscopy, firstly of the knee and secondly of the shoulder, are the most widely used treatment methods for these joints. Removal of a torn cartilage at knee arthroscopy can now be performed as a daycase with the patient making a rapid recovery within a matter of days or at the most a week or two.
Prior to arthroscopy, patients would often be in hospital for a week or ten days after the knee joint had been opened up surgically to remove a torn cartilage. Arthroscopy of joints has expanded our understanding of joint pathology considerably. Not all operative procedures can be performed arthroscopically, for example total joint replacement still requires the joint to be opened up in the traditional fashion.
Concerning the knee joint, it is possible to deal with torn meniscae, damage to the joint surface, removal of loose bodies and reconstruction of the cruciate ligaments arthroscopically, and in the shoulder joint it is possible to decompress shoulders suffering from impingement and undertake a wide variety of other procedures.
Arthroscopy of the ankle joint and hip joint tends to be confined to dealing with the consequences of early degenerative change such as roughness of the joint surface which is catching, tears of the labrum acetabularae, which is a reinforcing structure of the hip joint, or removal of loose bodies and loose flaps of articular cartilage.
Although a bunion can be removed surgically it may have the effect of destabilising the great toe. The ligaments which stop the great toe from collapsing towards the second toe extend over the bunion and if the bunion is going to be removed these ligaments need to be reconstructed and possibly tightened. Nonetheless, in some patients who have bunions removed the big toe drifts to the side and causes pressure on the second toe. If the joint between the foot and the great toe is working well then it is often better to perform an osteotomy, that is a realignment of the first metatarsal (the bone leading to the great toe) in an attempt to narrow the forefoot, this can be combined with removal of the bunion and reefing or tightening of the capsule.
The downside of this procedure is that the patient is generally required to wear a plaster on the foot for a period of six to eight weeks to allow the bony realignment to heal. In the end however the overall function is generally better following a realignment and many patients can resume sporting activites about three six months following surgery when the bone is strong again and the joint fully mobilised.
This operation is undertaken as a daycase under a local anaesthetic. There is a small risk of damage to the delicate motor branch of the median nerve which supplies some of the muscles at the base of the thumb and this can cause weakness of the hand. In elderly patients with severe carpal tunnel syndrome motor weakness presenting prior to the operation seldom recovers following surgery.
Surgery in this context arrests further deterioration of the hand but does not restore the hand to normal. It is better to have your carpal tunnel syndrome decompressed early if possible before motor or muscle weakness becomes established. The wound needs to be kept dry for two weeks and protected for a further two to four weeks (eg from gardening or using tools).
There are different types of cartilage. Articular cartilage covers the ends of the bones of a synovial joint to give the mammalian synovial joint a lower coefficient of friction than any man-made engineered articulation. In the section on arthritis it was explained that if the cartilage is lost from the end of the joint then arthritis tends to develop. The other type of cartilage is fibrocartilage, which forms a shock-absorbing structure in the knee, known by footballers as “the cartilage”; this has entered common parlance so that most patients who refer to their cartilage tend to mean their knee cartilage, which is more correctly referred to as a meniscus.
The “footballer’s cartilage” or meniscus in the knee joint helps lubrication and load-bearing in the joint and it is very strong at transmitting direct load. If, however, there is a twisting injury to the knee joint then the cartilage fibres are not terribly strong at resisting torque, and the cartilage may tear. This causes a problem because it may lock the knee or cause the knee to give way.
The knee generally swells up and becomes painful and the individual is no longer able to partake in sporting activities and may even be barely able to walk. Cartilage tears sel
dom go awa
y of their own accord altho
ugh some tears at the very edge of the cartilage may heal, given rest.
Cartilage tears can generally be diagnosed on an MRI scan (magnetic resonance imaging scan). If the cartilage tear is causing locking, giving way, pain and loss of function of the joint then it is appropriate to recommend arthroscopy of the knee to either repair the torn cartilage or remove the damaged fragments if it is damaged beyond repair or if the cartilage tear involves the avascular part of the cartilage (where there is no blood supply).
Recovery following arthroscopy, provided there has been no other damage to the knee joint, is usually rapid and a sportsman may well be able to return to his sports within a few days, other patients within a few weeks, provided the problem is dealt with promptly. The longer the cartilage tear is left before treatment, the longer it takes to recover.
It is a sad fact of life that within a few years of skeletal maturation (late teens) the first signs of degenerative change can be observed. This appears in the first instance as a chemical, for example, molecular breakdown or degeneration but is generally not symptomatic until the fourth, fifth and sixth decades of life.
Degeneration is a normal part of life and, for reasons which are not entirely clear, degeneration seems to affect some patients more than others.
There are some factors which are known to accelerate the appearance of degenerative change, for example, a professional footballer may, at the age of 40, have knees which look as though they belong to a 60-year old. It is interesting to note that some patients with quite advanced degenerative change seem not to be troubled by it, whilst other patients with relatively minor degenerative changes may find the symptoms intolerable.
If conservative treatment fails to relieve the sympyoms then the tight tendon sheath which is restricting the movement of the (extensor pollicis brevis and abductor pollicis longus) tendons of the thumb can be released at the wrist under a local anaesthetic as a daycase.
There is a small risk of damage to one of the cutaneous (sensory) branches of the radial nerve which supplies the skin at the base of the thumb. This may be permanent and can occasionally give rise to a painful neuroma (or swelling on a nerve) at the operation site. The patient is encouraged to move the thumb following the operation to prevent the tendon from getting stuck again.
Surgery is best performed under a general anaesthetic. It can be done as a daycase although the hand must be elevated overnight following surgery and for two weeks afterwards to minimise the risk of swelling of the fingers which in turn results in stiffness.
The main risk of excision of a Dupuytren’s Contracture is damage to the delicate digital nerves which supply sensation to the fingers. The patient needs to be warned that there is a small risk of numbness or sensitivity of the finger following this surgery. There is also a small, remote risk of damage to the circulation to the finger, although this is far less common than damage to the nerve. If the circulation to the finger is lost after removal of the Dupuytren’s Contracture then it is remotely possible that the finger may need to be amputated. Most Orthopaedic Surgeons will not experience this problem throughout their working lifetime.
Following removal of the contracted band of palmar fascia (Dupuytren’s Contracture) it is usually necessary to perform Z-plasties or lengthening procedures of the skin. This is because the skin has also shortened or contracted. These are plastic surgical procedures involving the swinging and transfer of flaps. Sometimes the viability of the flap is compromised and an area of skin may die, requiring subsequent grafting or healing by what is known as secondary intention, that means taking some considerable time for the wound to heal,. Most patients are surprised by how long it takes them to get over the surgery for a Dupuytren’s Contracture and do not realise that, if the finger has been held down for six months or a year, it is not going to suddenly spring back into action once the Dupuytren’s Contracture is removed.
Physiotherapy is required before the wounds have fully healed to assist the mobilisation of the stiff finger. If physiotherapy is delayed until the surgical wound has fully healed then the finger may remain permanently stiff and the full potential for recovery will have been lost. Both the patient and the Surgeon need to be patient and allow sufficient time for recovery to occur.
Durolane is the latest Hyaluronic Acid injection licensed for use in early arthritis of the knees. One of the first Hyaluronic Acid injection to be marketed was Hyalgen which required five weekly injections. Synvisc required a total of three injections but Durolane requires only one injection.
It can cause slight discomfort and swelling of the knee for a couple of weeks and is effective in a significant proportion of patients, reducing the dull ache, night pain and stiffness associated with early arthritis.
It can help to reduce the swelling. It is best used following an arthroscopy which addressed mechanical problems such as torn fragments of cartilage and loose chondral flaps. It is reported to last for six months but in some patients seems to last longer.
Golfer’s Elbow seldom requires surgery, since it usually responds to medical treatment. If however surgery is undertaken, it is a small operation to release the origin of the common flexor muscles from the inner aspect of the elbow joint. This can be done as a daycase and is probably best performed under a general anaesthetic. The ulnar nerve passes very close to the operation site.
The ulnar nerve innovates almost all the small muscles of the hand and is responsible for fine manual dexterity. It is vital that the ulnar nerve is protected throughout the operation but the patient does need to be warned of the risk of ulnar nerve damage at the time of a Golfer’s Elbow release. The author has seen a patient treated by acupuncture for golfer’s elbow with significant ulna nerve damage.
Replacement of the hip joint, knee joint and shoulder joint are well tried and tested techniques which bring about significant and lasting benefits to patients. Joint replacement of the ankle and elbow are more demanding techniques practised only by a limited number of Specialists with, at present, variable results.
The patients should discuss carefully what can be expected from an elbow or ankle joint replacement before proceeding with surgery. Other joints can be replaced, such as the wrist joint, finger joints, the great toe joint. It is also possible to replace cervical discs and lumbar discs with artificial disc replacements. These are at present undergoing a trial period but seem to be growing in popularity.
Arthroscopy of the knee joint is generally performed as a daycase under a general anaesthetic. It is possible to deal with cartilage tears, remove loose bodies, smooth off rough areas on the joint surface, reconstruct the cruciate ligaments arthroscopically.
Recovery period varies with which arthroscopic procedure is undertaken, For example, after a partial meniscectomy the recovery period is anywhere between 2 to 3 days and 2 to 3 weeks, depending on age and pre-operative fitness. After an anterior cruciate ligament reconstruction however the recovery period is in total 12 months.
Arthroscopy of the knee joint is generally performed as a daycase under a general anaesthetic. It is possible to deal with cartilage tears, remove loose bodies, smooth off rough areas on the joint surface, reconstruct the cruciate ligaments arthroscopically.
Recovery period varies with which arthroscopic procedure is undertaken, For example, after a partial meniscectomy the recovery period is anywhere between 2 to 3 days and 2 to 3 weeks, depending on age and pre-operative fitness. After an anterior cruciate ligament reconstruction however the recovery period is in total 12 months.
There are small risks attached to surgery such as infection, nerve problems down the arm, pain - stiffness in the neck, stiffness of the shoulder, and failure to resolve the original problem.
If physiotherapy and nerve root injections and epidurals fail to relieve the problem then surgery may be suggested. This will consist either of decompressing a tight spinal canal due to spinal stenosis or removing a prolapsed intervertebral disc or possibly both procedures combined into one. The purpose of the operation is to relieve pressure on the sciatic nerve roots. The operation is 80 – 90% successful at easing or relieving leg pain but only 60% reliable at reducing back pain. There is a small risk (10%) that the symptoms may be no better following surgery. There is an even smaller risk (5%) that the symptoms may be worse following surgery, such as increased back pain or increased leg pain.
There is a very small but significant risk of developing a cauda equina syndrome following surgery, that is paralysis of the nerves to the bladder and bowel. This results in incontinence or loss of control of urine and/or faeces. This is extremely rare but it is important to know of this risk and discuss this with your Surgeon before submitting to surgery. A cauda equina syndrome may be permanent. It should be noted that a cauda equina syndrome may develop without surgery in the case of large discs or very tight stenosis (narrowing of the spinal canal).
There are small risks of infection, deep vein thrombosis and pulmonary embolus following spinal surgery and patients are generally provided with prophylactic antibiotics and some patients are given prophylactic anticoagulants following surgery. You need to dicuss the potential benefits and risks of surgery with your Surgeon before agreeing to undergo surgery. No-one wishes to undergo spinal surgery and it is only used as a last resort and the vast majority of patients undergoing spinal surgery are delighted with the outcome.
Bony outgrowths underneath the acromion and the acromioclavicular joint at the top of the shoulder may cause damage to the muscles controlling shoulder movement, resulting in pain especially at night time and restriction of movement. The usual restriction is inability to raise the arm above the head. Surgery can be undertaken (if physiotherapy and injection therapy fails) to remove the extra bone and take away part of the acromioclavicular joint to relieve pain from this source.
This surgery is 80% successful if undertaken as an open procedure which leaves a scar. Decompression can be undertaken as an Arthroscopic procedure (leaving very small scars) but is then only 70% successful at relieving the problem. When the rotator cuff muscle has been damaged to the point where it is torn or ruptured then this will need to be repaired at the same time. Recovery from impingement surgery without muscle tear tends to take about 6 weeks, although it can occur within one week. Where muscle repair is undertaken at the same time, the recovery takes much longer and extends up to 6 months and in some cases, up to 12 months before the final result is achieved. During the first 3 months following repair of the rotator cuff muscles the patient is advised not to use the shoulder joint, to allow the muscles to heal.
Should conservative treatment fail, the tennis elbow can be treated surgically by release of the common extensor origin, that is the point at which all the muscles arise from the outer aspect of the elbow, relieving tension at that point.
The operation is about 80% successful and can be done as a daycase under a general anaesthetic. A sling is worn for a few days and the sutures removed at two weeks.
Surgery can be undertaken as a daycase to release the A1 pulley, to allow the finger to move freely. The hand is bandaged for a week or so and during this time the patient is encouraged to move their fingers to prevent the trigger finger catching again.
Treatment is 80 – 90% effective at relieving the problem permanently. There is a small risk of infection and a small risk of damage toone of the fine digital neres n the hand which could result in some finger numbness.
Arthroscopy of the knee joint is generally performed as a daycase under a general anaesthetic. It is possible to deal with cartilage tears, remove loose bodies, smooth off rough areas on the joint surface, reconstruct the cruciate ligaments arthroscopically.
Recovery period varies with which arthroscopic procedure is undertaken, For example, after a partial meniscectomy the recovery period is anywhere between 2 to 3 days and 2 to 3 weeks, depending on age and pre-operative fitness. After an anterior cruciate ligament reconstruction however the recovery period is in total 12 months.
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