This article describes the evolution of replacement surgery to joint conservation in the West and its implications for India

There is a feverish spread of joint replacement surgery in the country. Everyone who is anyone is now talking about joint replacements as the panacea for pain.

Joint replacements have been around since before the second world war when English surgeons first attempted replacement surgery with metal on metal articulations at the hip. But it was in the early sixties that John Charnley first showed that hip replacements can be durable with his metal on plastic articulation and can be done by others other than the inventor (Sir John had this strict condition that nobody did his hip unless they were trained by him in his centre and the manufacturer would not sell the implants). He thereby ensured that well meaning enthusiastic adopters of his technology did not bring his hip into disrepute with failures.

Since then there has been a veritable explosion of developments in other joints. The Americans came out with knee replacements and then came replacements for shoulders/elbows/ankles/fingers and toes. Not all joint replacements are created equal. Hips and knees have been around the longest and hence we have enormous data demonstrating their success. Next came the shoulder and the elbow. Ankle replacements have been moderately successful but still cannot match the durability of their counterparts in the hip and knee.

Various series published by American and European surgeons have shown 95-97% survival at 10 years among knee and hip replacements. Put another way, the patient will know 15 years hence that his surgeon was good.

This frenzy of developments led to a geometric increase in replacement surgery in the West. With the enthusiastic adoption of joint replacements, inevitably there were instances of inappropriate selection of patients, done poorly by inexperienced surgeons which led to disaster. India has probably entered this phase.

In the West, Revision surgery is now a major percentage of knee and hip surgical practice. It is more expensive- requiring resources like bone banks to replace lost bone and experienced surgeons. Revision joint replacements are more extensive and done in much older patients and do not have similar survival statistics as the first primary replacement.

Hence the renewed interest in joint conservation surgery to prolong the life of the native joint for as long as possible until it is replaced.

Cartilage regeneration techniques like microfracture, cartilage cell transplantation, or cartilage-bone transplants either from the same knee or from a donor knee when done appropriately can prolong the native joint’s life sufficiently enough for at least a few years. This is especially good news for younger patients in their 40s and early 50s for whom a knee replacement at that stage will condemn them to at least one if not two revision surgeries in their lifetime, given the longevity of people with modern medicine.

Knees have three compartments –inner, outer and knee cap. Arthritis when localised to one compartment can either be treated by bone realignment to prevent arthritis in the other compartment or that compartment can be replaced in isolation. This kind of Unicondylar Knee Replacement(UKR) is an elegant solution which preserves the patient’s bone stock for a later Total Knee Replacement(TKR).

There are several types of UKRs. Oxford and St.Georg Sled from Europe have been around the longest with excellent survival rates of nearly 98% at 10 years for the Oxford knee, which was first developed in the University of Oxford-hence the name.

Such excellent results can only be obtained by careful selection of patients, meticulous technique and good long term follow up by the same surgeon. This gives the patient an extra decade of life without a major joint replacement.

Isolated knee cap replacements (Patello-Femoral joint arthroplasty – PFJA) are also a good answer to the sometimes vexing problem of knee cap arthritis with an otherwise pristine knee – in which case performing a TKR is unnecessary and unwarranted.

Again European joints like the Avon and Cartier have shown good results. A newer development is the Deuce from the USA which replaces two compartments including the patellofemoral joint.

When you consider the hip, resurfacing hip arthroplasty has the same advantage as the UKR in preserving bone. Prof Ganz in Bern, Switzerland has shown the importance of treating impingement at the hip early on to delay arthritis from developing.

In the shoulder, resurfacing implants like the Copeland or the shoulder cap developed by Miniaci from Cleveland USA again preserve bone for later total replacements.

Such developments show the importance that the orthopaedic community in the developed nations gives to the preservation of the natural joint. This has evolved from the earlier propensity of joint replacements at the drop of a proverbial hat.

However in a developing country like India, such options are expensive. The joint preservation options are not cheap by any means and are available only to those who understand the balance between quality of life issues and money. Furthermore, people who consider joint preservation should understand that these techniques can sometimes slow down arthritis and even give them the option of one primary replacement in their entire lifetime without the possibility of revision surgery. Like all operations, they come with complications like infection which if it happens can always be revised to a full joint replacement unlike an infected primary replacement which will require a full fledged Revision surgery with its attendant problems.

Carotid reconstruction was first performed by Eastcott et al. at St. Mary's Hospital, London, in 1954. However, it took nearly four decades until trial evidence became available to show that carotid endarterectomy was better than best medical treatment in patients with amaurosis fugax or hemispheric symptoms, transient ischaemic attacks, or stroke who had made a good recovery and whose symptoms were caused by severe carotid bifurcation stenosis (>70% with the North American Symptomatic Carotid Endarterectomy Trial [NASCET] method or >80% with the European Carotid Surgery Trial [ECST] method). The two-year risk of stroke in the medical arm of NASCET was 26% compared with 9% in those who underwent endarterectomy. Subsequently, the NASCET trialists reported that endarterectomy reduces the five-year risk of stroke in moderate stenosis (50%–69%) from 22.2% to 15.7%. A recent meta-analysis of the NASCET and ECST trials showed that benefit from surgery was greatest in men, patients aged 75 years or older, and those randomised within two weeks after their last ischaemic event, and fell rapidly with increasing delay.
Surgery is usually performed at six weeks if there is good recovery, but there is a tendency to perform it earlier in patients with transient ischaemic attacks or strokes with good recovery when CT brain scan shows no infarct. Surgery reduces the risk of stroke by 50% even if the event occurred more than six months previously, as shown by the Medical Research Council Asymptomatic Carotid Surgery Trial .
While recovering from stroke and awaiting carotid endarterectomy, aspirin even at a low dose of 75 mg daily reduces the risk of recurrence. .

March 09, 2009

Researchers in London have discovered a way to stop cancer cells from spreading, which may prevent the spread of the disease in about 90 per cent patients.

Scientists at the Institute of Cancer Research, a constituent college of the University of London, say that rather than concentrating on stopping the formation on tumours, they focused on singling out the enzyme that allows cancer to spread throughout the body.

The researchers say that their groundbreaking study led to the discovery that an enzyme called LOX is crucial in promoting the spread of the disease throughout a patient's body.

Lead researcher Dr Janine Erler called her team's discovery "the crucial missing piece in the jigsaw we have been searching for".

She claimed that her team was the first to have identified any such key enzyme.

"This discovery provides real hope that we can develop a drug to fight it. If we can interrupt the body's ability to prepare new locations for the cancer to spread to, we can prevent metastasis," the Daily Express quoted her as saying.

While studying breast cancer in mice, Janine's team has found that in the absence of the LOX enzyme, full name lysyl oxidase, new environments in the body would be too hostile for the cancer to grow.

The research group, which includes scientists from Stanford University, are confident that it will apply to humans and other cancer types.

Janine and her colleagues now plan to use their findings to develop drugs that can block this enzyme.

She hopes that this discovery will lead to a potential new treatment for cancer within five years.

Dr R P Shukla MD
Consultant physician & Diabetologist
Nazareth Hospital
Allahabad UP
Phone-9415214008
website-www.rpshukla.vpweb.com




Diabetes foot care



Alternative Names
Foot care for diabetics

Information
If you have diabetes you are more prone to foot problems, because the disease can damage your blood vessels and nerves. This, in turn, may make you less able to sense injury or pressure on your foot. You may not notice a foot injury until severe infection develops.

Diabetes also changes the immune system, decreasing the body's ability to fight infection. Small infections may rapidly progress to death of the skin and other tissues (necrosis). Amputation of the affected limb may be needed to save the patient's life. Improved blood sugar control can help prevent foot problems.

If you have diabetes, you are at higher risk for developing foot problems if you:

Are male

Have eye, kidney, or heart problems

Have had diabetes more than 10 years

Have poor blood glucose control

If you have diabetes, get a foot exam at least twice a year by your health care provider and learn whether you have nerve damage.

To prevent injury to the feet, check and care for your feet EVERY DAY, especially if you already have known nerve or blood vessel damage or current foot problems. Follow the instructions below.

DAILY CARE ROUTINE

Check your feet every day. Inspect the top, sides, soles, heels, and between the toes.

Wash your feet every day with lukewarm water and mild soap. Strong soaps may damage the skin.

Test the temperature of the water before putting your feet in, because the normal ability to sense hot temperature is usually impaired in people with diabetes. Burns can easily occur.

Gently and thoroughly dry the feet, particularly between the toes. Infections can develop in moist areas.

Because of skin changes linked with diabetes, the feet may become very dry and may crack, possibly causing an infection. After bathing the feet, soften dry skin with lotion, petroleum jelly, lanolin, or oil. Do not put lotion between your toes.

Ask your health care provider to show you how to care for your toenails. Soak your feet in lukewarm water to soften the nail before trimming. Cut the nail straight across, because curved nails are more likely to become ingrown.

Exercise daily to promote good circulation. Avoid sitting with legs crossed or standing in one position for long periods of time.

If you smoke, stop. It decreases blood flow to the feet.

TIPS ON SHOES AND SOCKS

Wear shoes at all times to protect your feet from injury. Otherwise, if you have poor vision and less ability to feel pain, you may not notice minor cuts or bumps.

Wear comfortable, well-fitting shoes. Never buy shoes that do not fit properly, expecting the shoes to stretch with time. Nerve damage may prevent you from being able to sense pressure from improperly fitting shoes.

Check the inside of your shoes for rough areas or torn pieces that can cause irritation.

Change your shoes after 5 hours of wearing during the day to alternate pressure points.

Avoid wearing thong sandals or stockings with seams that can cause pressure points.

Wear clean dry socks or non-binding panty hose every day. Socks may provide an extra layer of protection between the shoe and your foot.

Wear socks to bed if your feet are cold. In cold weather, wear warm socks and limit your exposure to the cold to prevent frostbite.

MORE HELPFUL TIPS

Avoid using antiseptic solutions on your feet since these can burn and injure skin.

Avoid applying a heating pad or hot water bottle to the feet. Avoid hot pavement or hot sandy beaches.

Report sores, changes, or signs of infection to your doctor immediately. Report all blisters, bruises, cuts, sores, or areas of redness.

Remove shoes and socks during visits to your health care provider. This is a reminder that you need a foot exam.

Make an appointment with a podiatrist to treat foot problems or to have corns or calluses removed. Never attempt to treat these yourself using over-the-counter remedies.

If obesity prevents you from being physically able to inspect your feet, ask a family member, neighbor, or visiting nurse to perform this important check.

References
American Diabetes Asociation. Standards of medical care in diabetes—2007. Diabetes Care. 2007; 30(Suppl.1):S4-S41.

American Diabetes Asociation. Standards of medical care in diabetes -- 2008. Diabetes Care. 2008;31:S12-S54.

Hunt D. Foot ulcers and amputations in diabetes. Clin Evid. 2006;(15):576-584.

American Diabetes Asociation (ADA). Standards of medical care in diabetes. IV. Prevention/delay of type 2 diabetes. Diabetes Care. 2007;30:S7-S8.

Inzuchhi SE and Sherwin RS. Type 2 diabetes mellitus. In: Goldman L and Ausiello D, eds. Goldman: Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 248.




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Review Date: 6/17/2008
Reviewed By: Elizabeth H. Holt, MD, PhD, Asistant Profesor of Medicine, Section of Endocrinology and Metabolism, Yale University. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.



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Nothing is more stunning than a beautiful bride in a beautiful dress with a beautiful smile. If you are getting married, what better way to prepare for your big day than having your teeth whitened or smile designing if needed? Remember…those photos will last forever. Here are some of the most common dental procedures brides-to-be can consider;
• Smile designing using Bonding or Laminates
• Porcelain Crowns
• Teeth whitening (Zoom!)
Composite restorations and bonding Procedures in which decay is removed and the tooth is repaired with a material that closely matches your natural tooth color. Bonding is an effective method used to correct a malformation of otherwise healthy tooth structure.
Porcelain Veneers A custom-made porcelain sheath that is attached directly to the facial surface of teeth. Veneers are extremely effective in producing a uniformly white smile. Veneers are used to mask misshapen, stained, chipped or cracked teeth.
Zoom! Teeth whitening If you tired of your not-so-white teeth? The latest procedures are virtually pain-free, fast and easy. The most common procedure for brides looking for a quick fix. Teeth whitening is one of the hottest cosmetic dental procedures today. The Zoom! Whitening system, as is a good example of a product that ranks high in all of these areas. Zoom! has been proven to make your teeth about eight shades whiter in as little as 45 minutes, and the results are long-lasting.
Crowns and Bridges Sometimes one or more teeth are diseased or lost and need to be extensively repaired or replaced. A number of materials are available to meet each patient’s aesthetic and budgetary requirements. Recent launch for crown and bridge is LAVA (All- ceramic) for best strength, fit and esthetics.
Dr. Vinod Chandel MDS. (Prosthodontics) AIIMS New Delhi
Advanced Dental Care,Prosthodontic and Implant Centre
SCO 157/1 Sector 37-C, Chandigarh
Phone no. 2691001, 09815131898