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Jun29
HOMOEOPATHY for Anxiety in Children:
Children experience feelings of nervousness, fear, or worry from time to time; these feelings are part of a normal response to a stressful situation, but when they occur to such an extent that they interfere with normal life, children anxiety disorder may be the underlying cause.
Children anxiety disorder may be manifested by symptoms such as extreme nervousness, inability to concentrate, poor school performance, and physical symptoms like nausea, heart palpitations, headache, shortness of breath, and sweating. Children anxiety disorder can be the result of a recent traumatic or high-stress event such as a move to a new home and school, divorce of the parents, death of a pet or a loved one, or it can have no obvious environmental or emotional basis at all.
Anxiety disorder in children is treated most successfully the earlier treatment begins; treating anxiety may include a combination of talk therapy, positive reinforcement, and in some cases medications.
Symptoms of children anxiety disorder:
Anxiety disorder can be difficult to recognize, because symptoms are often attributed to other factors (like Social anxiety). Signs of extreme nervousness and restlessness, an inability to concentrate, poor school performance, difficulty relating to peers, irritability, and physical complaints such as nausea, upset stomach and frequent headaches may indicate an anxiety disorder.
Causes of children anxiety disorder:
Medical researchers have not yet fully uncovered the causes behind anxiety disorder. There is some suggestion of a hereditary link, as anxiety and other mental disorders tend to run in families, and studies have located small differences in areas of the brain that influence anxiety.
How to diagnose children anxiety disorder?
Anxiety diagnosis is based mainly on the observations by the doctor and parents of a child's behavior. While there are no laboratory tests that can pinpoint anxiety disorder, certain tests may be conducted to rule out another underlying medical cause for the symptoms.
Common categories of children anxiety disorder:
Some of the most common types of childhood anxiety disorders include obsessive-compulsive disorder, phobias (irrational and overwhelming fears), separation anxiety disorder, post traumatic stress disorder, and panic disorder,. These conditions usually affect children between the ages of 6 and 11.
Treatment: Treatment of anxiety in children is more effective the sooner it is addressed after the appearance of symptoms. The most common form of treatment for children anxiety disorder is psychotherapy and teaching positive reinforcement techniques; medicines may also be prescribed for children with anxiety.

A Case of separation anxiety:
Master Rahul, aged 9 yrs, studies in 3rd standard.
The child was apparently normal before he was brought for the consultation. He started developing the following symptoms when the school reopened after vacations.
Fear of being alone.
Difficulty in sleeping & he gets up frightened from sleep after which he is unable to sleep.
Frequently complaints of headache & stomach ache.
He refuses to go to school without the mother. Earlier he used to go in an auto with his friends.
Throws tantrum when mother returns home after dropping him at school.
Complaints of loose stools & attacks of breathlessness accompanied by anxiety.
Moves anxiously from place to place. Restless.
A recent traumatic event had occurred in the family where mother was hospitalized for a week.
The following line of treatment was adopted:
• Psychotherapy: This helped the child learn to understand his feelings and tolerate the separation to a more natural degree.
• Cognitive Behavioral Therapy: This taught the child to change the way he thinks about separation, allowing him to respond more appropriately to natural separation from the mother.
• Medication: Homoeopathic medicine (Ars Alb 200) was given. He recovered well with treatment. There were some brief recurrences of the anxiety, but the coping skills learned through treatment were effective at dealing with the problem when it came up the next time, making each instance shorter and more manageable until the anxiety disappeared completely. Child’s self esteem was strengthened through positive reinforcement. The whole family supported and helped the child as he is undergoing treatment.
Dr. Nahida M.Mulla.M.D (Hom) MACH
PRINCIPAL.
Professor of Repertory & PG Guide.
HOD Paediatric OPD.
Child Counsellor.
A.M.Shaikh Homoeopathic Medical College, Hospital & PG Research Centre, Nehru Nagar, Belgaum - 590010
E-Mail: drnahida_mulla@yahoo.com
Mobile: 09448814660.


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Jun29
"Talking About SEX"
As a Psychiatrist and Relationship Counselor I get the opportunity to meet a lot of people who are gracious enough to share with me, their deepest secrets.

SEX is one issue where both men and women are always hesitant to talk about.

Most of them, want to talk about it, but take sometime to be comfortable and open up their inner mind.

Restless thoughts regarding sex are like a monster that keeps eating the peace of mind, and that's why I encourage talking about your inner sexual feelings

The following statistics are a proof of how much Emotional Pain we could save the society from if we just spoke about SEX in a progressive way.

1. 54% men and 25% women think about sex on a daily basis. - Unable to express these thoughts leads to restlessness, anger and decreased concentration.

2. Average Married Indian couple has sex about 70-90 times a year.

At 1/3 of these encounters are a complete disaster with either one or both partners not being satisfied.

3. More than 80% women think of sexual activity as activity to prove they are loved.

4. More than 50% of women have fake an orgasm, just to keep their husband happy.

Many of these live under the "delusion" that they are able to satisfy not only their wife, but also go ahead and give wrong advice to other man

5. Lack of sexual satisfaction makes a woman feel unwanted, hopeless, restless and depressed.
Its one of the most common reasons for Clinically high levels of depression among married woman.

This is also one of the prime reasons for woman looking to have extra-marital relationships.

6. 80% of Men doubt their sexual capacity at least once in life. Most of them are not happy with their sexual performance, but scared to talk about the same to a professional.
Majority of the advice they get from friends, family or wife increases their restlessness.

7. 2/3 people feel they don't have enough satisfying sex. But lack of proper emotional communication leads to the same.

8. A great majority of men use sex as a way to show their "macho" or "male" supremacy over their female partner.
Henceforth sexual activity becomes a ego tussle.

9. Mutual respect plays a vital role in a satisfying sex life.
82% of sexually satisfied say they feel respected and loved by their partner during sex.

59% are looking for more love and romance in the act.

10. A great majority Indian males and females only focus on the sexual intercourse phase of sex.
Build-up, Fore-play, after-play, experimentation phases are never talked about.

Sex is a beautiful and divine activity. It's a gift of god to increase happiness, increase body immunity, decrease body pains provided it has the right mixture of LOVE to it..

If an individual is not Lovingly Sexually satisfied he/she will fall prey to psychological problems like restlessness, depression, sleep disturbance, body pains, masturbation addiction, pornography (both visual and reading) addiction, increased need to seek satisfaction outside relationship.

Dont just have sex... HAVE LOVING SEX.....AND ENJOY IT COMPLETELY.....

for any further query feel free to email me....


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Jun27
St. Paul’s Medal Awarded to Dr. Mahesh Desai of MPUH Nadiad
MULJIBHAI PATEL UROLOGICAL HOSPITAL, NADIAD

St. Paul’s Medal Awarded to Dr. Mahesh Desai of MPUH Nadiad

Dr. Mahesh Desai, Medical Director and Managing Trustee of MPUH, Nadiad was yesterday awarded the prestigious 'St.Paul's Medal 2012' by the British Association of Urological Surgeons (BAUS) during its Annual Scientific Meeting held in the Scottish Exhibition and Conference Centre (SECC) in Glasgow. The Medal is awarded to distinguished colleagues from overseas whose contributions to the Association in particular, or to Urology in general, BAUS Council particularly wishes to appreciate and honour. Since the inception of this Medal in 1989, Dr Mahesh Desai is only the second Indian honoured with this international recognition.

It may be recalled, last year, Dr. Mahesh Desai had become the first Indian to assume the Office of the President of Societe Internationale d’Urologie (SIU), and the President-elect of the Endourological Society Inc.


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Jun27
Dr Teri Browne, Social Worker, USA delivered a Guest Lecture at MPUH Nadiad
Muljibhai Patel Urological Hospital, Nadiad

Dr Teri Browne, Social Worker, USA delivered a Guest Lecture at MPUH Nadiad

Dr. Sujata Rajapurkar, Medical Social Worker and Transplant Coordinator, MPUH Nadiad, organized a Guest Lecture by Dr.Teri Browne, PhD on 11 June 2012 at the JPAC auditorium. Dr.Browne, a Certified Nephrology Social Worker, HIV Test Counselor & Certified Rape Crisis Counselor, currently is an Assistant Professor at the University of South Carolina College of Social Work, USA. She is serving as a member in more than 30 Organizations, Journals, and as an Editorial board member of the United Network for Organ Sharing (UNOS) Consensus Conference. She is also an editor of “Handbook of Health Social Work” which is a very comprehensive reference book for Health Social Workers. Dr. Sujata Rajapurkar in her welcome speech informed that like everywhere else in the world, India is also experiencing an epidemic of Chronic Kidney Disease. Nephrology Social Workers empower patients to cope through counselling & education. Dr. Sujata Rajapurkar has addresses issues of kidney disease patients at national & international meetings. The role of Social Worker & Transplant Co-ordinator in facilitating kidney transplant is like an axis of the wheel of multidisciplinary transplant team by constantly sharpening his / her skills in helping the patients.

Students and Faculties of various schools of social work of Anand and Vallabh Vidya Nagar, namely Department of Social Work-Sardar Patel University, Anand Institute of Social Work, N.S. Patel Arts College, Institute of Language Studies and Applied Sciences (IILSAS) actively participated. Sixty Students and ten distinguished faculty members along with Doctors, Para-medical Staff and the Medical Social Workers from other hospitals attended the lecture. Dr. Browne spoke about “How Nephrology Social Workers can Help Improve Patient Outcomes”. She observed that patients who suffer from kidney failure of this region must be having very tough time to adhere to fluid restrictions due to excessive heat. Dr. Browne emphasized upon many psychosocial barriers to patient outcomes. She identified ten important Nephrology Social Work tasks : patient education, evaluation and assessment, group work, constant team collaboration, case management, assist patients with obtaining maximum rehabilitative status, emotional support and counseling, in-service education, quality assurance & patient advocacy. Medical Social Workers can help interdisciplinary team in addressing the barriers and help improve patients outcomes. Dr. Teri Browne was felicitated by MPUH’s Medical Director & Managing Trustee Dr. Mahesh Desai. Dr. Sishir Gang Chairman of Department of Nephrology in his speech appreciated the contribution of Medical Social Work & Transplant co-ordinators in the treatment of patients suffering from kidney diseases. The program concluded with the vote of thanks by Asst. Medical Social Worker Mrs. Jincy Sibu. The audience had a very interesting interactive session with Dr.Teri Browne.


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Jun24
SPONTANEITY AND NAMASMARAN: DR. SHRINIWAS KASHALIKAR
SPONTANEITY AND NAMASMARAN: DR. SHRINIWAS KASHALIKAR

NAMASMARAN is admired, appreciated and advised by hundreds of saints.
But apparently; few fortunate are haunted by the mystery of NAMA, fewer pursue it and still fewer persist on it! Amongst these; very few are convinced of its cosmic benevolence and take it upon them to spread the glory of NAMA.
But there is nothing to despair; as the experience, conviction and joy of NAMA; go on multiplying and deepening endlessly. The beginners as well as the veterans; all; have a spontaneous spring of ambrosia to manifest and nurture the mankind and the universe; at appropriate time.
Practitioners of NAMASMARAN actually go on “digging within them”; and in the course of time (and at appropriate time); the spontaneous spring of ambrosia begins to break open into a fountain. This gives indescribable, innate and yet universally benevolent ecstasy!
One may not believe in all this; but verify; if one wishes; the power of NAMASMARAN; by practice!


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Jun24
SAKALPA AND NAMASMARAN: DR. SHRINIWAS KASHALIKAR
SAKALPA AND NAMASMARAN: DR. SHRINIWAS KASHALIKAR

How can we do anything; if we don’t have purpose or mission?
In fact; can we; in day to day life; possibly do anything; without purpose and plan?
Whether we are students, teachers, administrators, farmers or policy makers; is it not true that we have purpose and plan?
How to reconcile this with the 2nd shloka in 6th chapter of Gita?
Practice of NAMASMARAN gradually lets us know that; sankalpa; is a product of individual identity.
The discrepancy between what is; or appears to be; and what ‘we” want, or don’t want; creates a sankalpa.
When we are dead as individuals; the sankalpa dies.
Just as the Sun does have sankalpa of sunrise and Rain does not have sankalpa of rainfall; when we merge with the past, present and future; i.e. God’s wish; there is nothing to wish. God’s sankalpa automatically becomes our sankalpa.
This is a very difficult, evolved and accurate state of being. It is almost indescribable and hence it is innate and very personal. But it is non-personal too; as there is no individual consideration or motive! It is a state in which practitioners of NAMASMARAN live eternally…


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Jun22
NAMASMARAN AND UNIVERSE
ऐसे माझेनि नामघोशे
नाही करिती विश्वाची दु:ख्खे

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कही एकाधेनि वैकुंठा जावे
ते तिही वैकुंठचि केले आघवे
ऐसे नामघोष गौरवे
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ज्ञानेश्वरी 9 वा अध्याय


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Jun22
KNEE BRACES AND SPLINTING IN KNEE OSTEOARTHRITIS
KNEE BRACES AND SPLINTING IN KNEE OSTEOARTHRITIS

Introduction :
Knee brace can be used to stabilize the joint thus reducing further damage and pain. Methods of preventing and treating knee injuries have changed with the rapid development and refinement of knee braces. Prophylactic knee braces are designed to protect uninjured knees from valgus stresses that could damage the medial collateral ligaments1. However, no conclusive evidence supports their effectiveness, and they are not recommended for regular use. Functional knee braces are intended to stabilize knees during rotational and anteroposterior forces. They offer a useful adjunct to the treatment and rehabilitation of ligamentous knee injuries2.
Types of Knee Braces:
Functional Knee Braces
Functional knee braces are designed to substitute for damaged ligaments. For example, a patient who sustains an ACL tear may be offered a knee brace to wear in efforts to allow certain activities without surgery. Most patients who are concerned about knee braces already have a knee ligament injury. These patients would be interested in the functional knee braces. These functional knee braces are designed to compensate for a torn knee ligament1.
Prophylactic Knee Braces
Prophylactic knee braces are used to prevent knee injuries. Prophylactic knee braces are worn by athletes who participate in some high-risk sports in an effort to minimize their risk of sustaining a knee injury1.

How Knee Braces are useful Osteoarthritic Patients?

While nothing can cure osteoarthritis, this brace can help a person return to the type of activities he or she loves2,3.


The Knee Brace for osteoarthritis knee support works by:
• Redistributing the weight and joint alignment. This is done by a process called ‘off-loading’ which takes the direct weight off the joint. This allows the leg to move more naturally3,4.
• Bi-Axial hinge gives the brace more flexibility and the ability to better fit the leg comfortably.
• Load sensor helps the device to determine the forces being applied by the brace5.
• With the relief from pain and better stability, the brace allows for an increase in leg functions, which leads to building up the muscles around the joint5.
• More mobility reduces stiffness in the morning, allowing more activity during the day, and reduced pain when at rest4,5.
This knee brace is light weight and easily adjustable by the patient. It offers a 20 degree increase in range of motion and a 4-point dynamic leverage system. The knee support brace has many arthritis friendly features and is commended for its ease-of-use3,5.




An osteoarthritis patient should discuss using the brace or any other such appliance with his or her doctor first and understand what activities can be attempted before using such a device.7


What to expect from a Osteoarthritis (OA) knee brace?

• Braces cannot cure OA and may not be right for everyone. However, it is a viable solution for many people. The ideal candidates are typically active people who are motivated to strengthen their muscles and willing to wear a brace to realize the benefits of this form of treatment8.

• Discuss treatment goals with your doctor and others on your health care team before you get a brace5,7.

• Don’t expect a brace to feel good from the start. It may take from a week to a month to get used to how the brace feels on your leg. Be patient. It took a long time for your knee OA to develop9.

• Bracing has come close to eliminating pain for some people with knee OA, while others experience moderate relief2,6.
The Appropriate Knee Brace for You
There are different kinds of knee braces and it's important for your doctor or a health professional to help decide which knee brace might be appropriate for you10. Three knee components to consider are:
• medial (on the inside of the knee joint)
• lateral (on the outside of the knee joint)
• patellofemoral (behind the kneecap)
Usually knee braces are recommended for patients who have cartilage loss in one component of the knee, also known as unicompartmental knee damage. Osteoarthritis most commonly develops in the medial component8.
Types of Knee Braces Used in Knee OA
Single-piece sleeves made of neoprene, an elastic-rubbery material, are the most simple knee braces. The knee brace is pulled on over the foot of the affected leg and is placed over the knee where it provides compression, warmth, and support. This type of knee brace is for mild to moderate osteoarthritis and it is available over the counter in most drug stores. The fit should be snug9,10.
An unloader brace is a semi-rigid knee brace made from molded plastic and foam. Steel struts inserted on the sides limit lateral knee movement and add stability11. This brace is custom-fit to each individual patient for whom it is prescribed (usually patients with medial component osteoarthritis). Essentially, it relieves pain by transferring pressure from the inside to the outside part of the knee9.
The unloader knee brace can also be designed for patients with cartilage damage in the lateral component of the knee, as well as patients with severe osteoarthritis of the knee who are looking for temporary pain relief while they wait to have knee replacement surgery. To purchase an unloader knee brace, the patient must obtain a prescription from an orthopedic doctor, and the brace must be purchased at a store specializing in orthotics10.
Experts suggest that patients allow a week to one month to adjust to how the unloader brace feels. Right from the start, don't expect comfort. It takes a little time. Experts also warn patients about becoming too reliant on the unloader brace12. Take it off from time to time so you can exercise and strengthen muscles. It's also important to remember that a knee brace is just one part of a patient's treatment regimen. Don't disregard other aspects of your treatment regimen without first talking to your doctor

Splints in Knee Osteoarthritis..
The various types of knee splints differ in use, style, and complexity. The simplest knee brace is a neoprene sleeve. Neoprene sleeves are most useful if you have mild arthritis and your primary purpose is to reduce pain and swelling. This device does not provide alignment correction or structural support for the knee joint, although it may contribute some input to joint proprioception.
For realignment purposes, you can get several types of knee braces over the counter or custom fit by an orthotist. Custom fit braces are molded to your size and are usually of a higher quality; they are sometimes adjustable. Such braces are more expensive than over-the-counter braces, which have fewer options for adjusting fit11,13. Realignment goals vary because they are based on your personal biomechanics. They include bicompartment, patellofemoral, and tibiofemoral realignment 13.
For some people, the goal of using a knee brace may be ligament protection. I recommend that you see someone qualified to determine which type of brace meets your needs and to fit you properly11. Proper fit of a knee brace is essential, as an improper fit not only fails to realign the joint but also may lead to further joint damage. A gentleman I know used a brace for several years to reduce the pain in his knee during tennis, his preferred mode of exercise. Tennis puts lateral and torsional stresses on the knees, so a brace is a good way to reduce these stresses, which can damage arthritic knees7.

How Splinting Helps in Osteoarthritis KNEE ?
Many athletes wear braces or splints on their knee to help protect it from further injury. Wearing one may be all the knee needs, but only your ahead, a physical therapist can help you heal your knee and then teach you how to strengthen your knee after6,7,8.
Medications are an option that help many people. Your doctor may prescribe anti-inflammatories to reduce swelling inside the knee, reducing the irritation and pain. Analgesics, pain killers, may also be used. Depending on the injury, the knee may benefit from an injection of a corticosteroid directly into the joint6,7.
Immobilizing the knee is done in most traumatic knee injuries. By putting it in a splint, you can’t injure it any further through movement and the knee has a chance to heal6,8.


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Jun22
Hyaluronic acid in osteoarthritis
Hyaluronic acid in osteoarthritis
Osteoarthritis(OA) is a degenerative joint disease and is thought to be wear and tear of joint as part of an aging process.There are 2 types of OA,primary and secondary.Primary OA occurs in a joint de novo.It occurs in elderly and mostly in weight-bearing joints such as knee and hip.This is more common.Secondary OA occurs due to an underlying primary disease of the joint which leads to the degeneration of the joint.It can occur at any age and occurs commonly at the hip. Osteoarthritis is characterized by a loss of articular cartilage, which has a highly limited capacity to heal itself. Along with these cartilage changes, a reduction in the elastic and viscous properties of the synovial fluid occurs. The molecular weight and concentration of the naturally occurring hyaluronic acid decreases. Theoretically, this loss of elastoviscosity decreases the lubrication and protection of the joint tissues and is one postulated mechanism of pain production in osteoarthritis.1,2 Pharmacologic treatment generally consists of analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Physical therapy can be used, with exercises to maintain range of motion and strength. Intra-articular corticosteroid injections are often used for transient symptom relief. When conservative measures fail, surgical treatments limited to arthroscopic debridement, osteotomies to redistribute load and total joint replacements have been the only options until recently.
Intraarticular injections of hyaluronic acid is a viscosupplementation that is newly available options for patients with symptomatic knee osteoarthritis.The increase in viscoelasticity of the synovial fluid seems to play a role.The indications for viscosupplementation can be considered for use in patients who have significant residual symptoms despite traditional nonpharmacologic and pharmacologic treatments.Patients who are intolerant of traditional treatments can be considered these injections.
Viscosupplementation
The concept of viscosupplementation is based on pathologic changes of synovial fluid hyaluronic acid with its decrease molecular weight and supplementation.Two hyaluronic acid products are currently available in the United States: naturally occurring hyaluronan (Hyalgan) and synthetic hylan G-F 20 (Synvisc). Hylans are cross-linked hyaluronic acids, which gives them a higher molecular weight and increased elastoviscous properties. The higher molecular weight of hylan may make it more efficacious than hyaluronic acid because of its enhanced elastoviscous properties and its longer period of residence in the joint space (i.e., slower resorption)3. The exact mechanism of action of viscosupplementation is not well known. Although restoration of the elastoviscous properties of synovial fluid seems to be the most logical explanation, other mechanisms must exist. The actual period that the injected hyaluronic acid product stays within the joint space is on the order of hours to days, but the time of clinical efficacy is often on the order of months.4 Other possible mechanisms to explain the long-lasting effect of viscosupplementation include anti-inflammatory and antinociceptive properties, or stimulation of in vivo hyaluronic acid synthesis by the exogenously injected hyaluronic acid.5
Clinical studies of hyaluronan
Multiple studies have been conducted to assess the efficacy of intra-articular hyaluronan injections. Initial studies6-8 in the 1970s and 1980s demonstrated benefits for hyaluronan-injected knees. More recently, Dahlberg and colleagues,9 and Henderson and coworkers,10 in randomized, double-blind placebo-controlled trials found no benefit from intra-articular hyaluronan over placebo. Lohmander and associates11 similarly found no significant differences between overall treatment and placebo groups; however, a subgroup analysis of patients more than 60 years of age with more severe symptoms revealed beneficial effects from the hyaluronan injections. In contrast to these recent trials, which demonstrated no or minimal beneficial effects from intra-articular hyaluronan, other randomized controlled studies12-14 suggest overall beneficial effects of hyaluronan over placebo. Another study15 demonstrated efficacy of hyaluronan in a randomized blinded trial, with the treatment group showing more improvement than the placebo group and a group taking oral naproxen.
Clinical studies of cross-linked hylan
A summary of four clinical trials performed in Germany using cross-linked hylan16 demonstrated excellent results in 71 percent of hylan-treated patients, compared with 29 percent of placebo-treated patients. After six months, 53 percent of hylan-treated patients still reported excellent pain relief, compared with 22 percent of the placebo-treated patients. In a double-blind, randomized placebo-controlled trial using hylan,17 it was found that 39 to 71 percent of hylan-treated patients were symptom free at 26 weeks compared with 13 to 45 percent of placebo-treated patients. Another study18 compared intra-articular hylan with NSAID therapy in a randomized blinded trial. Hylan was found to be as effective as NSAID therapy at 12 weeks and was superior to NSAID therapy at 26 weeks. In addition, findings from a clinical practice19 showed that 80 percent of 458 knees injected with hylan had a positive response, and the average duration of efficacy was 8.2 months.
Adverse effects of intraarticular hyaluronic acid
Rates of adverse reaction has been low.The most frequent adverse reaction to this treatment is transient localised pain or effusion which is resolved within one to three days.There were no systemic effects attributed to hyaluronic acid.There are also reports on cases of induced pseudogout20.No long term side effects have been reported21.
Indications
Intra-articular hyaluronic acid injections should be considered in patients with significantly symptomatic osteoarthritis who have not responded adequately to standard nonpharmacologic and pharmacologic treatments or are intolerant of these therapies (e.g., gastrointestinal problems related to anti-inflammatory medications).2,14,15 Patients who are not candidates for total knee replacement or who have failed previous knee surgery for their arthritis, such as arthroscopic debridement, may also be candidates for viscosupplementation. Total knee replacement in younger patients may be delayed with the use of hyaluronic acid22.
Injection technique
Hyalgan is supplied in 2-mL vials (one injection per vial) or prefilled syringes, and Synvisc is supplied in 2-mL prefilled syringes. The recommended injection schedule is one injection per week for five weeks for Hyalgan, and one injection per week for three weeks for Synvisc. Repeat courses of viscosupplementation can be performed after six months. A knee joint can be injected several ways. One approach is to have the patient lie supine on the examination table with the knee flexed 90 degrees. In this position, the anterior portions of the medial and lateral joint lines can easily be palpated as dimples just medial or lateral to the inferior pole of the patella. Often, the medial joint line is easier to palpate and define and can be chosen as the site of injection. Alternatively, the knee joint can be approached with the knee extended, again with the patient lying supin. Most commonly the superolateral edge of the patella is the site of injection, but other quadrants of the knee near the patellar edges can also be chosen. With this approach (knee in extended position), the needle is generally aimed under the patella.
Actual injection site can be marked with a fingernail imprint or the barrel of a pen. Next, sterile preparation with a povidone iodine preparation (Betadine) and alcohol can be performed. A 22- to 25-gauge needle can be used for the injection. Local anesthesia with lidocaine before the injection can be used, but with a small gauge needle this is not always necessary. Alternatively, an ethyl chloride spray can be used for local anesthesia. Following puncture through the skin and into the joint space, the injection is accomplished. If resistance is encountered, redirection of the needle may be necessary.
If effusion is present, aspiration of the joint is recommended before the injection to prevent dilution of the injected hyaluronic acid. The aspiration can be performed at the same site as the injection, as previously described. The same needle can be left in place and used for the aspiration and the injection. Aspiration may require a larger bore needle, such as an 18- or 20-gauge needle. Following local anesthesia with intradermal lidocaine or ethyl chloride spray, the needle can be placed into the joint for aspiration. When aspiration is completed, hemostat clamps can be used to grasp and stabilize the needle, while the aspiration syringe is detached from the needle. The syringe containing hyaluronic acid can then be attached to the same stabilized needle followed by injection. No excessive weight-bearing physical activity should take place for one to two days following injection.

References:

1. Marshall KW. Viscosupplementation for osteoarthritis: current status, unresolved issues and future directions. J Rheumatol 1998;25:2056-8.
2. George E. Intra-articular hyaluronan treatment for osteoarthritis. Ann Rheum Dis 1998;57:637-40.
3. Wobig M, Bach G, Beks P, Dickhut A, Runzheimer J, Schwieger G, et al. The role of elastoviscosity in the efficacy of viscosupplementation for osteoarthritis of the knee: a comparison of hylan G-F 20 and a lower-molecular-weight hyaluronan. Clin Ther 1999;21:1549-62.
4. Cohen MD. Hyaluronic acid treatment (viscosupplementation) for OA of the knee. Bull Rheum Dis 1998;47:4-7.
5. Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the treatment of osteoarthritis. J Rheumatol 1993;20(suppl 39):3-9.
6. Peyron JG, Balazs EA. Preliminary clinical assessment of Na-hyaluronate injection into human arthritic joints. Pathol Biol [Paris] 1974;22:731-6.
7. Weiss C, Balazs EA, St. Onge R, Denlinger JL. Clinical studies of the intraarticular injection of HealonR (sodium hyaluronate) in the treatment of osteoarthritis of human knees. Osteoarthritis symposium. Palm Aire, Fla., October 20-22, 1980. Semin Arthritis Rheum. 1981;11(suppl 1):143-4.
8. Peyron JG. Intraarticular hyaluronan injections in the treatment of osteoarthritis: state-of-the-art review. J Rheumatol 1993;39(suppl):10-5.
9. Dahlberg L, Lohmander LS, Ryd L. Intraarticular injections of hyaluronan in patients with cartilage abnormalities and knee pain. A one-year double-blind, placebo-controlled study. Arthritis Rheum 1994;37:521-8.
10. Henderson EB, Smith EC, Pegley F, Blake DR. Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: a randomised single centre double-blind placebo-controlled trial of 91 patients demonstrating lack of efficacy. Ann Rheum Dis 1994;53:529-34.
11. Lohmander LS, Dalen N, Englund G, Hamalainen M, Jensen EM, Karlsson K, et al. Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomised, double blind, placebo controlled multicentre trial. Hyaluronan Mulicentre Trial Group. Ann Rheum Dis 1996;55:424-31.
12. Dougados M, Nguyen M, Listrat V, Amor B. High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial. Osteoarthritis Cart 1993;1:97-103.
13. Puhl W, Bernau A, Greiling H, Kopcke W, Pforringer W, Steck KJ, et al. Intraarticular sodium hyaluronate in osteoarthritis of the knee: a multicentre double-blind study. Osteoarthritis Cart 1993;1:233-41.
14. Listrat V, Ayral X, Paternello F, Bonvarlet JP, Simonnet J, Amor B, et al. Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee. Osteoarthritis Cart 1997;5:153-60.
15. Altman RD, Moskowitz R. Intraarticular sodium hyaluronate (Hyalgan) in the treatment of patients with osteoarthritis of the knee: a randomized clinical trial. J Rheumatol 1998;25:2203-12 [Published erratum appears in J Rheumatol 1999;26:1216].
16. Adams ME. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. J Rheumatol (suppl) 1993;39:16-8.
17. Wobig M, Dickhut A, Maier R, Vetter G. Viscosupplementation with hylan G-F 20: a 26-week controlled trial of efficacy and safety in the osteoarthritic knee. Clin Ther 1998;20:410-23.
18. Adams ME, Atkinson MH, Lussier AJ, Schulz JI, Siminovitch KA, Wade JP, et al. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthritis Cart 1995;3:213-25.
19. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85.
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Jun22
Medial Compartment Arthritis
Medial Compartment Arthritis
Etiology
Osteoarthritis of the knee usually occurs secondary to mechanical factors, which include partial or complete meniscectomy, femoral osteonecrosis, lower extremity trauma, ligamentous laxity, obesity, and lower extremity malalignment.[1,2]
Pathophysiology
With removal of approximately one third of the meniscus, increased force is transferred directly to the tibial articular surface.[ 3]The joint also becomes less congruent and is not able to disperse the force across the joint. Both of these factors increase contact stresses, which can lead to articular cartilage damage and subsequent osteoarthritis.[3,4,5]
Results from multiple laboratory studies have shown that abnormal alignment also leads to abnormal contact stress. Ogata et al, Wu et al, and Reimann performed similar studies in which a varus stress was placed across the knee.[12] Each study documented degeneration of the articular cartilage in the medial compartment. The injury to the articular cartilage occurs in the deeper layers without any surface evidence of injury.[11,12]
Fractures of the tibial shaft and plateau may lead to subsequent lower extremity malalignment. Most clinicians accept less than 10° of angulation in tibial shaft fractures. For instance, residual varus angulation increases contact stresses across the medial compartment of the knee. Tibial plateau fractures also may lead to medial compartment osteoarthritis. The arthritis in this instance is due to direct articular cartilage damage caused by the intraarticular fracture.
Ligamentous laxity also is a cause of medial compartment osteoarthritis. Anterior cruciate and/or lateral collateral ligamentous laxity or incompetence has been implicated as causes for medial compartment osteoarthrosis. ACL-deficient knees allow for anterior subluxation of the tibia on the femur. This leads to increased shear force upon the articular cartilage, which leads to early degeneration of the articular surface.
Torsional deformities of the tibia and femur have a clinical association with the onset of medial compartment degenerative changes. The torsion may be present on the tibial or femoral side of the knee. This may lead to varus angulation and increased contact stresses across the articular cartilage of the medial joint space, which leads to accelerated medial compartment osteoarthritis.
Presentation
Patients generally present with a chief symptom of pain in the knee that has worsened over time. Patients state that the knee generally feels worse in the morning when they awaken and that the knee pain generally lessens with some activity. As their activity increases during the day, so does their pain. Patients may state that anti-inflammatory drugs help alleviate the pain. Patients frequently describe pain on the inside (genu varum) or outside (genu valgum) of the knee if unicompartmental arthritis is the cause of their symptoms.[9,10,11]
History and physical examination are crucial in making the diagnosis. It is important to ascertain whether trauma to the knee has occurred, indicating an old history of fracture, articular damage, and/or ligamentous injury and malalignment. A history of pain in other joints may alert the physician to an etiology of inflammatory arthritis or bilateral lower extremity malalignment.[9,10]
Physical examination may reveal varus or valgus alignment of the knee. Pain over the medial joint line may indicate a meniscus tear or degenerative changes within the medial compartment.[12] Patellar tendon tenderness also may indicate medial joint degeneration, as well as possible patellar tendon pathology. Patients may have crepitus in the knee. Range of motion (ROM) of the knee may be decreased compared to the opposite side. Fixed flexion contractures are uncommon but may occur in patients with tibiofemoral osteoarthritis. Evaluation of ligamentous stability is important. The integrity of the cruciate ligaments and collateral ligamentous stability may determine the feasible treatment options.[12,13,14,15]
Determining whether the patient with varus or valgus alignment of the knee can be passively corrected to neutral is of key importance.[14] Again, this aids in determining the surgical options for treatment of medial compartment disease.
Treatment Modalities
Multiple treatment options are available for isolated medial compartment osteoarthritis of the knee. Surgical intervention is indicated when conservative therapies have failed. Conservative therapies include nonsteroidal anti-inflammatory drugs (NSAIDs), joint viscosupplementation, unloading braces, and physical therapy.
Arthroscopy
The first operative procedure is knee arthroscopy. Arthroscopy is indicated for patients in whom conservative therapy has failed who want the most minimal surgical procedure available. Arthroscopy usually is used as a temporizing measure until definitive surgical treatment is undertaken. Knee arthroscopy sometimes is indicated as a diagnostic procedure to determine a treatment pathway or may be utilized in conjunction with a definitive procedure. Arthroscopy of the knee has not been shown to slow the course of osteoarthritis of the knee; however, it has been demonstrated to provide pain relief. The period of pain relief ranges from 6 months to a few years.[9 ]
Osteotomy
High tibial osteotomy (HTO) is indicated in patients younger than 60 years (ideally in their sixth decade of life) who are in labor-intensive fields and experience activity-related pain with a varus alignment of the knee. The arthritis in the medial compartment must be noninflammatory, and the patient should have no patellofemoral symptoms. Certain criteria regarding ligamentous stability and presence of minimal flexion contracture must be met. If this procedure is used alone, it should be considered a temporizing measure because joint resurfacing ultimately may be required.[5,13 ]
Arthroplasty
Unicompartmental knee arthroplasty is a surgical procedure used to relieve arthritis in one of the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may reduce post-operative pain and have a shorter recovery period than a total knee replacements.[8] Also, UKA may have a smaller incision because the implants may be smaller.[8] Unicompartmental knee arthroplasty (UKA) is indicated in patients who are older than 60 years who have sedentary lifestyles, and were also performed for patients with age less than 60years noninflammatory arthritis, and pain with weight bearing[19]. Patients may have patellofemoral disease but usually are asymptomatic in that compartment. Symptomatic patellofemoral disease is a contraindication to the procedure. Ligamentous stability, weight, and coronal deformity of less than 15° also are considered. TKA is indicated in patients older than 65 years who have somewhat sedentary lifestyles and symptomatic arthritis in 2 or 3 compartments. The arthritis may be posttraumatic, degenerative, or inflammatory.[8,10,14,15,16,17 ,18, 19]


ABOVE:X-ray taken before arthroplasty(AP view and Lateral View)
BELOW: X-ray taken after arthroplasty(AP view and Lateral View)


Partial Knee Resurfacing Implant compared to a Total Knee Replacement Implant
Citation:
1. Birmingham TB, Kramer JF, Kirkley A, et al. Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control. Rheumatology (Oxford). Mar 2001;40(3):285-9. [Medline].
2. Dearborn JT, Eakin CL, Skinner HB. Medial compartment arthrosis of the knee. Am J Orthop. Jan 1996;25(1):18-26. [Medline].
3. Grelsamer RP. Unicompartmental osteoarthrosis of the knee. J Bone Joint Surg Am. Feb 1995;77(2):278-92. [Medline].
4. Gross AE, McKee NH, Pritzker KP, Langer F. Reconstruction of skeletal deficits at the knee. A comprehensive osteochondral transplant program. Clin Orthop. Apr 1983;(174):96-106. [Medline].
5. Jackson RW. Surgical treatment. Osteotomy and unicompartmental arthroplasty. Am J Knee Surg. Winter 1998;11(1):55-7. [Medline].
6. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am. Apr 1999;81(4):539-48. [Medline].
7. Lindenfeld TN, Hewett TE, Andriacchi TP. Joint loading with valgus bracing in patients with varus gonarthrosis. Clin Orthop. Nov 1997;(344):290-7. [Medline].
8. Borus T, Thornhill T (January 2008). "Unicompartmental knee arthroplasty". J Am Acad Orthop Surg 16 (1): 9–18. PMID 18180388
9. Marwin SE, Siegel JA. Unicompartmental Gonarthrosis of the Knee: The Role of Unicompartmental Knee Arthroplasty. Orthopedic Special Edition. 1999;5(2):57-60.
10. Moseley JB Jr, Wray NP, Kuykendall D, et al. Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study. Am J Sports Med. Jan-Feb 1996;24(1):28-34. [Medline].
11. Squire MW, Callaghan JJ, Goetz DD, et al. Unicompartmental knee replacement. A minimum 15 year followup study. Clin Orthop. Oct 1999;(367):61-72. [Medline].
12. Bingham CO 3rd, Buckland-Wright JC, Garnero P, Cohen SB, Dougados M, Adami S, et al. Risedronate decreases biochemical markers of cartilage degradation but does not decrease symptoms or slow radiographic progression in patients with medial compartment osteoarthritis of the knee: results of the two-year multinational knee osteoarthritis structural arthritis study. Arthritis Rheum. Nov 2006;54(11):3494-507. [Medline].
13. Reimann I. Experimental osteoarthritis of the knee in rabbits induced by alteration of the load-bearing. Acta Orthop Scand. 1973;44(4):496-504. [Medline].
14. Niemeyer P, Koestler W, Kaehny C, Kreuz PC, Brooks CJ, Strohm PC, et al. Two-year results of open-wedge high tibial osteotomy with fixation by medial plate fixator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy. Jul 2008;24(7):796-804. [Medline].
15. Bert JM. 10-year survivorship of metal-backed, unicompartmental arthroplasty. J Arthroplasty. Dec 1998;13(8):901-5. [Medline].
16. Fu FH, Harner CD, Vince KG. Knee surgery. Vol 2. Williams & Wilkins;1994:1061-255.
17. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am. Jan 1989;71(1):145-50. [Medline].
18. Emerson RH Jr, Higgins LL. Unicompartmental knee arthroplasty with the oxford prosthesis in patients with medial compartment arthritis. J Bone Joint Surg Am. Jan 2008;90(1):118-22. [Medline].
19. Frankowski JJ, Watkins-Castillo S, Sculco TP, et al.Primary total hip and total knee arthroplasty projectionfor the US population to the year 2030. AmericanAcademy of Orthopaedic Surgeons; John Wiley &Sons, Inc; 2002. Updated: Sep 12, 2008


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