Arthroscopic Surgery at our KMC Speciality Hospital, Trichy, India: Key hole surgery

This is the article published in KMC News 2010

Arthroscopic surgery [Key hole Surgery] at our KMC Specialty hospital
Dr S Chockalingam FRCS, FRCS [Trauma and Ortho]

Joint replacements have now become the standard of care for advanced arthritis. These joint replacement surgeries for arthritis of knee, hip and shoulder have become common at our hospitals. The less known treatment method for joint pain in younger individuals will be discussed in this article.

This less known treatment method namely arthroscopic treatment for joint pain is now increasingly used in our city as in the Western world. An arthroscope is a telescope,[ type of endoscope] the size of a pen when introduced into the joint, helps us to evaluate the joint and introduce instruments to repair or remove the injured structures

Professor Kenji Takagi in Tokyo used a cystoscope back in 1919 to look inside the joint. Eugen Bircher a Swiss Politician/Army Physician is considered as the father of arthroscope where he used a thoracolaparascope to view the joint. Japanese surgeon Masaki Watanabe gets the credit for using arthroscopes for interventional procedures rather than for merely diagnosing the problems.

Advances in the fiber optics in the 1970s and 1980s have now helped to the current design of these arthroscopes which come in various small sizes for various joints. We now have this facility to treat joint problems and I have shown the use of this surgical technique in managing joint problems at KMC Speciality hospital

The following conditions are some of the patients who have been treated at KMC Speciality hospital with our state of the art instruments using this technique.
1. Diagnosis of unexplained knee pain where Tuberculous synovitis, synovial chondromatosis and other conditions and treatment of septic arthritis of all joints.
2. Meniscal tears:This is one of the commonest indication for this procedure. Even though sports injury is a common mechanism of these meniscal tears, it is fairly common in middle aged women and men in India.
3. Cruciate ligament tears. Ligament reconstruction of the anterior cruciate ligament done through this minimally invasive technique has perfected this reconstruction
4. Shoulder pathologies. The shoulder is only second to the knee in the numbers where this technique is being used here at our hospital. Decompression of the subacromial space and Shoulders that dislocate repeatedly are common indications
5. Ankle and other joint pathologies. So far we have treated variety of pathologies with this minimally invasive technique at KMC


Regards

Chockalingam

Arthroscopic Surgery at Trichy, Key hole surgery to joints, cartilage tears and ligament reconstruction

Trichy as I left over seventeen years has not changed much. I can say only few major developments and it is busier with more traffic. but still i can reach from point A to Point B in less than half an hour at any point of time of the day. This is great considering that it is one of the major second tier cities in India. It also boasts an international airport and a major Railway interlink Juncion.

The people are many, mostly small business and agriculture base in earnings. BHEL is still the largest industry in the region with so many allied engineering firms nearby and linked to BHEL. Education is one of the strong points of Trichy and it has not changed as it used to be. There are more good schools and the old schools still retain their place as mine ERHS School.

The health needs of the people is still largely filled by the specialists in their own area of expertise and many private hospitals are giving good quality treatment. However health awareness has increased dramatically and people are aware of surgical methods of treatment to cure their illness.

For Example, bypass surgeries and cataract surgeries are so common for people to resort to improve their quality of life. Ortho problems are recognized as needing specialist treatment. People resort to surgical treatment of fractures without hesitation as they recognize that this can return them to normality more surely and quickly as opposed to conventional immobilization methods

So what else has changed in Trichy. Arthroscopy was introduced when i did my postgraduation in the 1990s with only the telescope without the monitor. However I am able to provide the state of the art High Definition Arthroscopic surgery to most joints in our body for treatment purposes.This is essentially key hole surgery to the joints as what a laparascopy surgery to cure gallstones etc

My patients have benefited from meniscal surgery including arthroscopic repair, ligament surgery including arthroscopic anterior and posterior cruciate ligament reconstruction, shoulder surgery including arthroscopic Bankart's repair and rotator cuff repair, arthroscopic ankle decompressions, and so on.

Compare the surgeries i was performing in UK before i left over two years ago to practice in Trichy and I am able to deliver the same to our patients and people. This is apparent in the arthroscopic techniques and joint replacement surgery,i use more than in any other sub speciality of Orthopaedics.

This is what has changed in Trichy from my point of view. Seventeen years ago, arthroscopic surgery was literally unheard of in Trichy from patients Access or awareness. Now our patients in Trichy are benefited from this state of the art treatment facility at our hospital.

Total Knee Replacement: India What we know and our Experience at KMC Hospitals Group

Total Knee Replacement: What we know and our Experience at KMC Hospitals Group
Dr S ChockalingamD.Ortho, FRCS [UK],FRCS [Tr & Ortho], Dr P R Ramasamy MS [Ortho], FRCS [UK]

This is an article I wrote for KMC News which is distributed to Referring and primary care doctors in Trichy Region on 14th December 2009

Total Knee Replacement is one of very successful and common Orthopaedic Operations we do at KMC Hospitals. The incidence of this surgery increasing in number reflects what is happening around the world.[Ref 1] The reason is why it is not more popular than it is at the moment is the cost of the surgery. This is obviously the point I would like to start of this brief about this surgery. The reason it is expensive at present to the reach of the common man is the technology that goes behind in the implant that is used.[ref 2]

The implant often made of strong Cobalt Chrome alloy, though titanium and ceramic are used in some designs. Any metal however polished, will have surface irregularities if one looks under the electron microscope. The surface finish and the material then become very important in reducing this irregularity and thus help in reducing the wear of the material with which this articulates.[Ref 3 and 4]

The material with this metal articulates is a specialized plastic called Ultra High Molecular Weight Polyethylene. Newer highly cross linked Polyethylene has come into use in hip replacement surgery.[ ref 5] However the quality of the Plastic used is controlled in the way this plastic insert is manufactured. This helps in the long term success of the knee replacement surgery.

The long term success of the knee replacement surgery is more important that looking at short term benefits of this surgery.[Ref 6] Any material placed between the end of the femur and tibia will relieve the arthritic pain. What is more important however is the durability of the material in staying without damaging the underlying bone!

The damage to the underlying bone is the worst scenario when faced with the failed knee replacement surgery. One fears this as the damage often starts without any warning such as pain. When one faces a failed knee replacement, the surgical challenges becomes daunting and more importantly becomes very expensive.
This brings me back to the opening paragraph of this brief, the cost of this joint replacement surgery.

A little bit more cost at the initial replacement surgery has been shown to reduce the chances of revision surgery in the long run. Revision surgery after total knee replacement is not something an ordinary individual can tackle not only as a patient but also financially. One cannot expect the Government to subsidize that cost as well as it will be impossible.

What we do at KMC Hospitals to ensure the long term success of this surgery are as follows.
We have a dedicated team involved in this surgery. The chances of infection developing after such surgery should be kept to absolute minimum and we do this by controlling the theatre environment and the personnel involved. We have only used prosthesis which has follow up data in the long run. Post operative protocols have now been developed to suit our working conditions. There are specific appropriate pain control and rehabilitation in place for these patients, both of which go hand in hand.

I have shown some examples of patients we have operated and what they look like and what they can do after such major surgery!

After total knee replacement this patient is able to sit cross legged! and riding a two wheeler at four weeks!, a patient works as a security at the age of 70 going to work by bicycle|!




Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005 Jul;87(7):1487-97.

Kester MA, Herrera L, Wang A, Essner A. Knee bearing technology: where is technology taking us? J Arthroplasty. 2007 Oct;22(7 Suppl 3):16-20

McEwen HM, Barnett PI, Bell CJ, Farrar R, Auger DD, Stone MH, Fisher J. The influence of design, materials and kinematics on the in vitro wear of total knee replacements. J Biomech. 2005 Feb;38(2):357-65.

Lancaster JG, Dowson D, Isaac GH, Fisher J The wear of ultra-high molecular weight polyethylene sliding on metallic and ceramic counterfaces representative of current femoral surfaces in joint replacement. Proc Inst Mech Eng H. 1997;211(1):17-24.

Wang A, Yau SS, Essner A, Herrera L, Manley M, Dumbleton J. A highly crosslinked UHMWPE for CR and PS total knee arthroplasties. J Arthroplasty. 2008 Jun;23(4):559-66. Epub 2008 Feb 13.

Ritter MA. The Anatomical Graduated Component total knee replacement: a long-term evaluation with 20-year survival analysis J Bone Joint Surg Br. 2009 Jun;91(6):745-9.
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The Proof is in the pudding: Awareness strategy adopted for Total Knee Replacement

10th June 2010
Total Knee Replacement is one of the successful surgeries, in Orthopaedics and Surgery in General. The surgery has the benefit of relieving one's pain and improving the quality of life for an individual. This can be proved by various quantification methods such as Joint Specific Scoring Systems, and Quality of Life improvement tools.

I use these tools in my practice to the standards followed in the UK Joint Replacement Units. The quality of improvement can be quantified in other methods such as QALY. This method shows that the qualtiy of life improvement for the years ahead is comparable to Cardiac Bypass Surgery and better than cataract surgery.

Remember these two surgeries compared are done more frequently than the Knee Replacement surgery. Hence when I started my practice, we sat down with the marketing department at KMC Speciality hospital and worked on a strategy to improve the awareness.

I decided one of the ways would be to take the outcome improvement to the public directly and orgnaised the meeting called Meet Our Patients. We called on the press to interact with my patients who had knee replacement directly with no preconditions.

Patients were more than happy to narrate their quality of life improvement directly to the press who in turn took to the public through their media.

Proof is in the pudding,Right!. We are now in the process of orangising the awareness of arthroscopy in joint problems. I am calling more than 100 of my patients who had arthroscopy of knees, shoulders,ankles, elbow at KMC Speciality to come and narrate their experiences directly to the press.

We are calling this Sports Injuries and Arthroscopy Awareness meeting and organised this sunday.

I will post more on this later.

Regards

Chockalingam

The Bone and Joint Decade 2000-2010, Ten years on........

This is an article I am writing for increasing the awareness of bone and joint disorders among the public and the medical community alike.I hope you find it useful

World Health Organisation [WHO] endorsed the launch of “Bone and Joint Decade [BJD]- 2000 to 2010” in Geneva in January 2000. The key goal is “to keep the people moving by prevention and treatment of bone and joint problems. This will in turn reduce the cost and the burden to the individuals, the carers and the society at large”.

BJD-India duly followed with National Action Network launched from Pune by eminent doctors. This was endorsed by the Government of India. As we are on the verge of this decade behind us, it is time for us to reflect and hence this article.

Arthritis affecting a joint such as knee and hips are very common in India. Every other person over the age of 65 in India is affected with arthritis. Unfortunately the treatment is not sought or often delayed.

The road traffic accidents are not only common, but also results in severely injured people. The deaths are frequent and multiple numbers of people are involved in the same accident. This is reflected in the Official statistics of the department of Road Transport and Highways, Government of India.

Unfortunately such affections of the bone and joints leave people with physical disability. The patients become dependent on the family and the society adding to the mental suffering. Some of the patients are left crippled due this pain. The true extent of their suffering is revealed in the limitation of their activities of daily living let alone their limitations in the society.

When one is not able to do even routine activities such as walking, secondary health problems arise. These include sedentary lives, increasing obesity, diabetes, high blood pressure and heart diseases. WHO recognised this growing trend in the society often leaving a financial burden.

Diet and exercise play important role in the health of our bone and joints as much as for our heart. Yet our life style had become sedentary. Increasing incidence of overweight and obesity has aggravated the bone and joint problem such as arthritis. Specific remedies for certain arthritis such as Rheumatoid are not sought. These lead to crippling deformities and disabilities. On the other hand, there is misuse of pain killers leading to other problems such as kidney failure.

Wearing a seat belt is the most effective way to prevent injuries when travelling in a car or a bus. Yet many of us remove the seat belts or consider it a hindrance to wear. Traffic rules and restrictions are rarely followed resulting in serious and disabling injuries.

“A painful advanced arthritic joint can be cured with a joint replacement” is a well known fact to many in a Western country such as UK. However people in our villages are left suffering due to the lack of awareness. This lack of awareness is present even in educated persons living in cosmopolitan cities.

With this launch of Bone and Joint Decade, WHO highlighted the need for the improvement in the diagnosis and treatment of such disorders. WHO encouraged prevention through education campaigns. Ten years on since the Bone and Joint Decade launch by the WHO, the real question had there been an any improvement at all ?

In spite of all being written early in this article, there is certainly more awareness created by this WHO initiative. The government of India through its participation in this Bone and Joint Decade has shown its commitment in prevention and treatment of these disabling conditions.

Government Welfare schemes helping them finance the treatment ensures that poor are not left alone in this treatment reach. One has to mention one such scheme for the people below the poverty line at this juncture which has benefited and continues to a huge number of financially disadvantaged section of our society.

More people are seeking treatment rather than neglecting these ailments. They are asking for the accurate diagnosis as much as the treatment itself. This is especially facilitated when they see others benefited due to the treatment options such as joint replacements. People have started to recognise the fact that “Early and appropriate treatment of injuries prevents long term disability”. Technological advances such as key hole treatment of joint problems with arthroscopy are now known.

Every year many hospitals follow the activity week to focus their year long efforts to the public in October[ 12th to 20th of October of 2010 for this year]. Many hospitals and doctors are conducting free camps to facilitate such an awareness. Their efforts should be lauded with reverence for the public service.

There is certainly a larger section of our public where the awareness has not reached as we still see a significant number of disabled people due to the bone and joint problems. Hence more concerted efforts should be done from the community in general and the medical community in particular.

Education in road traffic accident prevention should reach the “prospective road users” namely our children. Public awareness campaigns should increase in number and reach the inner villages. Medical schools should increase the training given to the doctors in dealing with bone and joint problems. There is a need for the entire community to celebrate this bone and joint week in October.

May I conclude this article saying that “Let the end of the Bone and joint Decade -2000-2010 herald a new beginning in spreading awareness of the increasing number of Bone and Joint problems. These are either preventable and when affected, many of them are certainly curable”

Dr S Chockalingam
Consultant Trauma and Orthopaedic Surgeon
KMC and KMC Speciality Hospitals,
Trichy

health awareness activities at Trichy

I am adding some of the articles written in press and some of the photos of the health awareness activities done at Trichy with KMC speciality and KMC hospitals.

Orthopaedic problems of bones and joints are many and we took on only four issues last year at KMC Speciality Hospital named by WHO bone and Joint Decade. they are 1. osteoporosis 2. arthritis 3. road traffic accidents 4. back and neck problems.

We have done Meet our Patients Meet where the press and the public could freely interact with our patients benefited from advanced ortho care treatment at KMC and KMC speciality hospitals.

We have done Bone and Joint Walk to raise awareness on Bone and joint problems as listed above.

We have given awareness talks to senior citizens who are pensioners in a standard format.

We have done first aid program to traffic personnel twice in the last two year to raise awareness on road traffic accidents 2. we have done many free orthopaedic consultations starting in march 2009 at KMC Speciality hospital both as camps and regular free clinics on Fridays for patients who cannot afford to attend a hospital such as ours. These have mainly targeted arthritic patients though osteoporosis and back problems have been covered.

We have done two ATLS type courses named Essentials of Initial Trauma Management at KMC Hospital for doctors sponsored entirely by KMC Hospital and all the consultants have gifted their time and efforts to teach the fundamental principles in trauma management.

I will elaborate all our activities in the next blog and list them and post more articles.

Regards

Chockalingam

Awareness article written on joint replacements

Article written on 24th December 2008

Advanced Ortho Treatment facilities at KMC Speciality Hospitals

Joint Replacements and Key Hole Surgery



What are joints and why do I get pain in my joints?

Joints are present when two bones meet allowing movement to occur.

The ends of bones are lined with a tissue called cartilage. This tissue is strong and smooth. This is lubricated with fluid in the joint.

Ligaments are tissues which hold the bones and allow movement in a certain direction.

Joints are damaged by commonly by diseases, injury, ageing or infection.

Problems with the joints are major causes of immobility and disability. We often see people who can only walk slowly, or for short distances due to pain due to the joint problems. Knee arthritis is very common as one gets old.







What is arthritis?

Arthritis means inflammation of joints. It can be due to many causes.

Your Orthopaedic Surgeon would be able to diagnose the cause of arthritis by taking a history from yourselves and examination. He would need to request specific tests if the cause is not clear by examination alone.






Is there a cure for my arthritis?

It depends on the cause of arthritis. The most common cause of arthritis is Osteoarthritis, which is wear and tear of the joint lining called cartilage with age alone. This can come earlier if there had been previous injury.

The treatment of joint disorders has greatly improved in the last thirty years in other countries and over the past ten years in India. This is partly due to the option of treatment with artificial joint replacements.

What are artificial joint replacements?

Artificial joints replace worn out [arthritic] joints. They are very commonly performed for pain and are very successful in relieving pain. Knees and hips are very commonly replaced, though artificial joint replacements are done for shoulder, elbow, hand and ankle as well.












How do they actually look like?

The picture shows some of the actual prostheses in joint replacements. These are not all inclusive as advanced designs are available for patients



What are current advances in joint replacements?

Only part of the knee replaced as shown in the picture below. Advances in metallurgy and materials in the prosthetic design are available to a patient in Trichy. Management before and after surgery has changed over the past few years. The surgeon at KMC Speciality would use the up to date management practised in UK due to his recent return from England.






Are these new or experimental?

No. These have been successfully performed for over thirty years. The joints are manufactured by advanced engineering methods. They are made of very high quality metal, ceramic and polyethylene. Over 60000 patients are receiving these prostheses by surgery in one year in Australia alone [2003-2004 figures]

Who will perform this at KMC and what is his experience

The surgery would be performed by a senior surgeon who has returned to Trichy after more than fifteen years of experience in UK. He has performed surgeries routinely for the past seven years as a senior surgeon. He had been practising in the largest centre for joint Replacements in UK where more than 4200 patients are treated per year alone [2007 figures]



He has performed research in this field in UK. This has been published and his article which is commonly quoted in the international literature.


“ Outcome of cemented-v-cementless fixation of femoral component in TKR with the identification of radiological signs for the prediction of failure
THE KNEE Dec 1; 7(4): 233-238 2000”

Is this treatment without any problems?

This treatment is very successful in relieving pain. However some patients can have complications. The surgery performed by an experienced surgeon can reduce the complications. Hence it is essential to know your Doctor and his experience who performs this surgery.


Will I be able to walk without limp and will my joint move normally after surgery?

As pain goes your walking will actually improve than before surgery. Hip replacement patients return to normality sooner even though it is a deeper joint. Knee replacement patients will return comparatively slower, however there would be no difference in the success of this surgery.

Treatment after surgery improves the success greatly and your Surgeon would advise you accordingly.

What Should I do?

If you or someone you know suffers from joint pain, please understand that one should not have to live with pain.

Not all patients with joint pain will need joint replacements.

Other causes of joint pain can be treatable completely by medication such as gouty arthritis. Some of the patients’ joint pain can be treated by medication such as Rheumatoid arthritis, though surgery can remarkably change one’s life with surgery.
Other patients can be treated by key hole surgery to the joints.

What is key hole surgery of knee?

I am sure you are aware of sportsmen twisting their knee and disappear from the sports scene for couple of months before returning to normality. They often sustain cartilage injuries which are treatable by key hole surgery. Surprisingly quite a lot of general population have cartilage problems, but choose to live with pain. They can also be treated by key hole surgery.

Open Doors For More Patients:Raising Awareness of Knee replacement in rural India

The Fourth of September 2010

We decided to make a video of one of my patients who had a knee replacement. The video showed the impact this operation can make to a lady in a rural place in India. This video raises awareness significantly of a disability which is silently crippling people in India. With so many other life threatening issues and health hazards, the disability due to arthritis is not well known or written.

Arthritis not only limits one's walking ability, also disables a person in activities of daily living. I quantify my patients' disability tailored to Indian conditions and also use international scoring systems. But seeing is believing and for the public, there could not be any better educational method than a video play back.

please visit the sugam charity web site from the useful links site to view this video.

Warm Regards

Chockalingam

BONE AND JOINT WALK TRICHY

Dear Everyone, we conducted successfully the first ever bone and joint walk in Trichy. it was well covered by newspapers locally and in The Hindu and The New Indian Express. first let me share some photos through our web site. further to my previous blog on bone and joint awareness problems in India. we focused our efforts to improve among the general public.

The bone and joint walk is essentially an effort to group people who had benefitted by bone and joint surgery and primarily joint replacements. this is based on the model we use regularly in UK called Hip and Knee walk. this shows that patients can function especially normal walking which is what had been missing in their day to day life. we take for granted walking is possible for everyone. but then when u see these arthritic patients who are unable to walk even indoors ,u realize that how lucky we are.

to be able to give that ability to walk without pain is why we go further to bring complex and yet successful treatment like knee and hip replacements to patients. when u are able to do for people in Trichy where i had studied and able to provide the treatment for patients from your native place and surrounding villages, it gives satisfaction. is it not the reason why chose Medicine as my career. to be able to help other people.

Bone and Joint Decade and BJD week 2010

Welcome everyone and posting after a long time.
2000 to 2010 had been the bone and joint decade as recognized by the WHO. it was to improve the awareness of the musculoskeletal disorders widely. this was endorsed by many countries including India. Pune Declaration showed the commitment from India. The october second week is the bone and joint week and for this year it is 12th to 20th of october.

please remember the major Bone and joint problems we are facing are road traffic accidents, osteoporosis, spine disorders and arthritis.