Dear Friends,

This is the fourth issue of Care clinic Health watch series. During the last few months many of you have given valued feedback and I hope I have changed quite a few things this time around. This issue deals with common misconceptions about the treatment of knee arthritis. I am taking liberty to add some non-orthopedic articles in this issue to make it more interesting. I read about anger management and found it very useful. I am writing a small article about anger management which I am sure you all will find useful. Dr. Deepraj Bhandarkar is a well known surgeon specializing in laparoscopic work and he was kind enough to write an article for this issue. Please let me know whether you like this idea of a few non-orthopedic articles in every issue. Happy reading!

Address : Care Clinic 4, Shankar Niwas, Dadasaheb Rege Marg, Behind Bank of Maharashtra, Shivaji Park, Mumbai - 4000028, India. Tel : 2444 5608 Mobile : 9870053033 E-mail : info@drarchik.com

What is anger?

Anger is a strong feeling of displeasure or hostility. Although anger is a basic human emotion, feeling angry can be a problem for many people. This is because many people believe:

nice people shouldn't be angry becoming angry means losing control. If others are angry at me, I must have hurt them in some way and am therefore responsible. Anger means the end of a relationship or the end of loving or being loved. Anger is sinful.

Some people have trouble controlling their behavior when they are angry and may do things that are hurtful or destructive. Others feel so guilty about their anger that they keep it inside and may even be unaware of feeling angry.

Pain, fatigue, poor sleep, emotional stress, alcohol or drug use, and mood disorders (like depression and bipolar disorder) all can lower your threshold for angry feelings and behavior. Whether you yell and hit or fume silently, long-term anger may be linked to both health problems and unhealthy relationships.

What physical changes occur when I get angry?

During an angry episode, your blood pressure and heart rate rise. After the "fight or flight" hormones released by anger are activated, some people do not return to normal right away, but stay in a state of alert hostility for awhile.

What kinds of difficulties do people with anger problems face?

People who express too much anger often end up feeling alone and distant from others because their sullen, hostile, or sarcastic behavior can make people turn away from them. A vicious circle is then set up: they feel angry because of the way others are reacting to their anger.

People who feel it is wrong to ever be angry often can be out of touch with other feelings and may be unable to feel joy or love. They may fear they would not be loved if others knew how much anger was inside them, so they continue to conceal it. Then, because anger can almost never be completely hidden, they may act it out by doing things like being late or not keeping promises.

How do problems with anger develop?

People who grew up in healthy families may quickly blow off steam and get over angry feelings. They resolve the conflict and move on.

But when there are serious problems within a family, everyone in the family may feel angry much of the time. The anger becomes a big problem and guilt about it adds to the problem. These people may experience frequent outbursts of anger and feel that their angry impulses are not under their control. Or they may have a "false self" set of behaviors as adults in which they are always "nice" and expect the same of others. In other words, people with a lot of anger inside may be either out of control or too controlled.

This means that for some people, the goal is to learn how to control their expressions of anger and to express anger less often. For others, the goal is to learn how to express anger more often. Both types of people should aim toward expressing anger verbally (rather than through actions) and in a controlled way.

How can I tell if I have problems with anger?

A good way to judge is something called the "cop at the elbow" rule. You may have a real physical or psychological disorder if you explode even when you could get in serious trouble, such as being arrested. However, you probably do not have a disorder if you act up only when there are no consequences. You may just need to learn more self-control.

In order to assess your level of anger, ask yourself the following questions :

• Do I easily lose patience with people?
• Do I often feel that life is unfair to me?
• Do I say threatening or nasty things when I am angry?
• Do I get angry enough to hit, throw, or kick things?
• When I really lose my temper, am I capable of slapping or hitting someone?
• What can I do when I get angry?

Talking with a sympathetic friend, spouse, health care provider, or therapist about life stresses can help to defuse anger.

Learn relaxation techniques. Slowing down your breathing, relaxing the entire body muscles one group at a time, and visualizing a comforting or pleasant scene are the three basics of relaxation.

Self-statements can also be helpful. These statements can replace old ways of thinking. Some helpful self-statements are :

• I am disappointed, but I can handle this without blowing up.
• This will pass, and I can take a few deep breaths while it does.
• I can relax my body, and not be upset.
• I am getting better at handling my anger as I get more practice.
• I don't need to prove myself here.
• Maybe this person is having a bad day.
• I do not have to let this bother me.

Time-outs can also be useful. When you feel yourself getting tense or frustrated, say to the other person, "I'm beginning to feel angry and I need a time-out." Time-outs work best in this way :

• Designate a specific amount of time (15 minutes to 1 hour).
• Leave the situation (for instance, walk into another room).
• Calm yourself mentally with deep breathing and self-statements.
• Do some non aggressive physical exercise such as walking, jogging, or bicycling.

Return to the situation, only continuing the discussion if the anger does not return. If the anger returns, take another time-out. Do not use drinking or drugs as a way to cope during the time-out.

What is a healthy way to feel and deal with anger?

Feeling healthy anger involves five steps :

• Feel it without judging it. Admit to yourself that you are angry and note where in your body you are feeling it (such as a pounding heart or sweaty palms).
• Question it. Ask yourself about its true cause (like hurt feelings or fear).
  Express it, using "I" statements and words rather than by using blaming "you" statements.
• Learn to use it to make positive changes in your life (for example, by changing jobs).
• Let it go. Concentrate on releasing the anger and feeling calm again.

How does anger management help?

Using anger management tools can enhance your self-esteem. Situations that had been out of control can now be handled confidently. Assertiveness can replace aggressiveness or passive silence when dealing with others. You may find it helpful to share this information on anger with your partner or family members, so that they have the same understanding of anger that you do. If anger is part of a psychological disorder, you should seek help from your doctor.

What is gallbladder?

Gallbladder is a pear-shaped organ attached to the undersurface of the liver. Its main function is to collect and store bile (a digestive liquid) produced by the liver. After eating, the gallbladder contracts and releases the bile. The bile is carried via a small tube called the cystic duct and then larger tubes called bile ducts into the small intestine where it helps in the digestion.

What are gallstones and how are they formed?

Gallstones are solid clumps of cholesterol or pigment material that form in the gallbladder. When the concentration of bile components like cholesterol or bile pigments increases, they precipitate to form solid crystals. These crystals then stick together and form gallstones. Why some people form gallstones is not clearly known, and therefore there is nothing one can do or avoid in the diet to prevent the gallstones from forming.

What symptoms do patients with gallstones experience?

Patients with gallstones often get severe abdominal pain - in the right upper side - particularly after eating fatty food. If a gallstone blocks the common bile duct, jaundice (yellowing of the skin) can develop. Patients with gallstones may also suffer complications such as infection and inflammation of the gallbladder (cholecystitis) or of the pancreas (pancreatitis). Some people who have gallstones have no symptoms and these people are said to have so-called "silent" gallstones.

How are gallstones diagnosed?

Gallstones are usually diagnosed by a relatively simple test called ultrasonography. In this test a jelly is applied to the skin and a probe is moved over the abdominal wall to capture images of the internal organs.

How are gallstones treated?

Not all patients who have gallstones require surgery. In most instances those who do not have any symptoms (silent gallstones) may not require treatment. However, a decision not to operate should be taken only after consulting a specialist because when left alone gallstones are likely to cause complications.

Once a patient develops symptoms because of gallstones they do not go away on their own. Some patients can be temporarily managed with medicines or by making dietary adjustments, such as cutting down on fat intake. However, this treatment is not a permanent solution to the problem. Treatment with homeopathic or ayurvedic medicines is never able to dissolve gallstones. Taking these types of medicines in the hope that the gallstones will "melt away" carries the risk of the patient developing serious complications. Surgical removal of the gallbladder (cholecystectomy) is the best treatment for patients in whom the gallstones cause symptoms.

What are the side effects of removing the gallbladder?

It is important to understand that a gallbladder that forms gallstones is a diseased organ and is not functioning normally. Therefore removal of such a diseased gallbladder is not associated with any side effects. Over a period of time, the function of storage of bile is taken over by the bile ducts and there is no impairment of the digestive process.

How was the gallbladder operation performed in the past?

In the past, the gallbladder was removed by making a large incision on the abdomen (open cholecystectomy). This incision invariably caused a lot of pain after the operation and as a result the patient had to stay in the hospital for about week. Even after discharge the overall recovery required several weeks. The risk of infection was higher in this larger incision.

How is the gallbladder operation performed around the world today?

Today, all over the world the removal of gallbladder is performed by laparoscopic cholecystectomy. Instead of a fifteen to twenty cm incision of an open operation, the laparoscopic cholecystectomy is carried out through four small punctures each of which is ½ to 1 cm in length. As the incisions are small, the pain after the operation is minimal and therefore the recovery is much faster. The chances of infection in the incisions are almost negligible.

How is laparoscopic cholecystectomy performed?

It is important to note that laparoscopic cholecystectomy is a major operation performed under general anaesthesia. The surgeon passes a cannula (a narrow tube) into the abdomen in the region of the umbilicus. A telescope connected to a camera and a cable carrying bright light is passed inside the abdomen through the cannula. The camera is connected to a television monitor so that a magnified view of the patient's internal organs appears on the screen. The surgeon and his team conduct the operation by observing the television screen. The surgeon then inserts other cannula and passes long, thin instruments inside the abdomen through them. Using these instruments the gallbladder is separated from its attachments and is removed through one of the openings. After removal of the gallbladder, the small incisions are closed with a few stitches.

What if the operation cannot be performed by the laparoscopic method?

In a small proportion of patients (1% - 3%) during the operation the surgeon may decide to convert the laparoscopic operation to a traditional open one. This is required if the organs cannot be visualized safely or handled effectively. Conversion to an open operation is never considered a complication. In fact, it reflects a sound judgement on the part of the surgeon who is interested in safeguarding the patient's safety.

What happens after laparoscopic cholecystectomy?

The patient does experience some amount of pain for about 12 - 24 hours after laparoscopic cholecystectomy depending on individual tolerance. Also, some nausea and vomiting is not uncommon in the first 12 hours. Patients are always given medications to relieve the pain and take care of the nausea. Usually, the patient is allowed to drink fluids within 6 to 8 hours of surgery and is able to have meals from the day after surgery. Activity is dependent on how the patient feels, but all patients are encouraged to get up and walk as soon as they are comfortable. Most patients go home within a 48 hours two to three after laparoscopic cholecystectomy as compared to five to seven day following the traditional open operation. Some patients, particularly the elderly and those with other medical problems like diabetes may have to stay in the hospital a little longer. In general, patients recover completely within 7 to 10 days.

How soon can a patient go back to work?

In our society patients often prefer to take things easy for weeks after any operation because of a fear that they may harm themselves by being active. After laparoscopic cholecystectomy the recovery is quite rapid. Soon after returning home the patients are allowed all activities they feel comfortable with. Depending on the nature of their job, most patients are able to return to work within ten to fifteen days following a laparoscopic cholecystectomy. Patients with light, desk jobs usually return in a few days while those involved in heavy lifting may require a little more time.

Are there any risks involved in laparoscopic cholecystectomy?

While there are risks associated with any kind of operation, the vast majority of patients undergoing laparoscopic cholecystectomy experience no complications. It is important to remember that before undergoing any type of surgery - whether laparoscopic or traditional - it is important to make sure that the surgeon performing the operation is well trained and experienced. In the hands of such surgeons the risks of laparoscopic cholecystectomy are negligible.

Is laparoscopic cholecystectomy very expensive?

In the minds of people there are certain misconceptions about laparoscopic surgery - one of them being that this surgery is affordable only to the rich. However, today laparoscopic surgery is offered at hospitals ranging from small charitable ones to large private corporate hospitals. Depending on the hospital and the type of room the patient chooses for admission, the cost of operation does vary but this is comparable to the cost of open cholecystectomy.

Thus it can be said that laparoscopic cholecystectomy is a technique that has truly revolutionized the treatment of patients with gallstones. It should be comforting for the patients to know that they need no longer dread the pain after a gallbladder operation and be anxious about long stay in the hospital.

Dr Deepraj S. Bhandarkar
MS, FRCS, FICS, FAIS, FACG. Dip. Laparoscopic Surgery (France)

Laparoscopic and Gastrointestinal Surgeon Mobile : 9821014939 E-mail : deeprajbhandarkar@hotmail.com

Knee Arthritis - Myths, Realities and Treatment Options

Knee osteoarthritis is one of the commonest problems faced by everyone. It is common because it is nothing else but age related "wear and tear" of the joint. There is however a strong genetic involvement, too, and hence patients from the same age group may have a varying degree of arthritis.

The figure below shows the anatomy of the normal knee joint. The blue lining at end of the bones is known as the cartilage. In real life the cartilage looks like the inner side of a tender coconut i.e.; white, smooth and soft. The two "C" shaped blue structures are the menisci which act like shock absorbers. During the aging process the menisci wear out and slowly the cartilage shows tiny cracks and finally the whole cartilage wears off. Finally one gets deformities like "bow legs" where bones start rubbing against each other

Osteoarthritis is a slow process and takes ages to develop. A mild pain on the inner side of the joint which is typically noted while getting up from a squatting position or while climbing stairs are the first signs of developing arthritis. Many of us experience this at around 40-45 years of life and most of us ignore it! We all age but the degree of arthritis varies from patient to patient in the same age group.

Apart from genetics there are many other factors which speed up the process of degeneration. We all know that we can not change our genes but we can alter certain other factors. Load is one of the important factors and our weight is borne by our knees! Therefore keeping one's weight under check obviously helps. Another important point to note that the load borne by the knees while working against the gravity is six times the body weight. We orthopedic surgeons hence advise all patients with advanced arthritis to avoid climbing too many stairs and to avoid sitting on the floor because this involves 6 times extra load! This also means that if you are 10 kilos overweight then the knees carry 60 kg extra load while you climb stairs!

Many patients are told by their wise relatives to ignore this advice stating "you will forget to sit down forever" or "your body habits will change forever". Please understand the scientific reason behind this advice. Similarly we advise elderly arthritic patients to use a walking stick. Use of a walking stick reduces the load on the knee by 50%! In reality my patients refuse to use a stick since they feel ashamed to use one!

There is another myth that diet has a role to play in preventing arthritis. It is wise to remember that no diet will stop ageing! There are however few important points to remember though. A diet which can make you put on weight is obviously to be avoided. Anti oxidants are useful in our diet to prevent the damage caused by free radicals. Tea, carrots etc. which we regularly eat are good source of antioxidants and there is no need to consume expensive tablets!

Regular exercises are also very important to keep our muscles stronger. Stronger muscles support and load the knee better and prevent injuries.

In a nutshell I can say that following points are important in delaying the onset of the arthritis

• Regular Exercise
• Maintaining weight at the ideal level
• Once symptoms are noted avoid excessive loading viz. stairs and sitting on the floor.
• Always have a balanced diet

Let's now turn to the remedies and the myths which surround these treatment options one by one.

Medicines

I see patients popping pills on their own and nobody thinks twice before popping a "combiflam"! I must warn everyone here that all these drugs which are grouped under a common heading " Non-steroidal anti-inflammatory "drugs can damage our kidneys permanently. Please be careful and do not take drugs on your own. The safest bet is to take plain paracetamol for pain relief (Crocin or Metacin). Some patients feel that allopathic drugs are dangerous and take fast relief powders dispensed by quacks. I have got these powders routinely analyzed and they all have steroids in them! A popular "vaidya baba" in south Bombay sells "Sandhivat" tablets and there is a queue of 200 patients daily! On laboratory analysis they had pure steroids as the one and only ingredient!

Dietary Supplements

Glucosamine and Chondroitin sulphate are one of the most popular supplements used and prescribed. They are sold over the counter in the American supermarkets and loving sons and daughters send huge bottles of these "wonder drugs". Boswella is another popular drug sold by chains like Amway. Esterified fish oils have now joined this group.

These drugs fortunately do not have any side effects; however they may or may not act in the way it is advertised. They do not have any role at all in patients with advanced arthritis or in those whom we have already suggested a knee replacement. I have always noted that these drugs are sold primarily to patients who actually need a replacement of their knee! All patients dutifully take these drugs in the hope that a surgery will be avoided.

Knee Caps

Almost every single elderly person owns one of these popular caps. A support to an inflamed knee obviously helps BUT a long term use actually is detrimental to the knee. A long term use of any brace causes the knee muscle to loose their strength. A brace has to worn under supervision of a qualified orthopedic surgeon. I also see lot of patients buying expensive (3000 Rs) braces in a camp arranged by quacks. 400 to 500 patients are supplied with these braces which are again purchased in the hope that they will avoid a surgery. These quacks (none of them are even qualified orthotists) make these braces so rigid that the knee damage is accelerated! Then there are magnetic and other special belts, but remember that nothing can stop aging and all these are useless.

Injections

Orthopedic surgeons occasionally inject steroids and sometimes special injections like Hyluronic acid. Under no circumstances a joint should be injected by anyone else than a qualified orthopedic surgeon. I have recently done an arthroscopy in a patient who received an injection from her rheumatologist. The injection was given right inside the cartilage which got destroyed and this lady had a huge defect in the cartilage. Hyluronic acid injections are much safer and but expensive. Hyluronic acid injections are effective only if used in well selected cases. Once again it is important to realize that these injections are not alternatives to surgery.

Physiotherapy

Physiotherapy to many patient means exercises and to some it means yoga! Physiotherapy consists of two important parts. One part does involve exercises, which are tailored according to a patient's need. Normally exercises are prescribed by the treating orthopedic surgeon and taught or supervised by the physiotherapist. In conditions like osteoarthritis of the knee these exercises are to be done life long. Many patients do it for 10 to 15 days and forget about them! Exercises are given to increase or build up the strength of the thigh (quadriceps) muscle and one needs a minimum 6 weeks to build up the required muscle mass. A good muscle control loads the joint well and helps to reduce the pain in arthritic joints. It is also important to do these exercises on a routine basis even if there is no pain. The most important point to remember is that exercises have no side effects like drugs and they do not cost anything!

The second part of the physiotherapy is also known as "modalities" or to the common man as "lights". Physiotherapists use various machines which give out rays of different wavelengths e.g. short wave diathermy and these help to reduce pain. These modalities again are without any serious side effects. I have seen patients going directly to the physiotherapists and "asking" for physiotherapy! Please remember that the physiotherapy routine works best in the recovery stage when pain is under control. It is mandatory that an orthopedic surgeon has scrutinized the knee carefully.

Since there are no side effects involved the physiotherapy routine can be repeated any time.

Surgery

A surgery is generally advised as the last resort and there are many different surgeries performed according to the stage in which the patient presents. A totally worn out knee will eventually need to be replaced i.e. a total knee joint replacement. The word total has a particular meaning here i.e. both the compartments between the thigh and the leg bone as well as the knee cap are replaced. This is important because we now have a facility to replace only the worn out compartment viz. unicompartmental knee replacement. We can as a rule of thumb say that all other surgeries apart from total knee replacement surgery are basically surgeries to delay the total knee replacement. A replaced joint also eventually wears out in about 15 to 20 years and hence it is important to perform the total knee replacement as late as possible. This calculation is important because the patient then undergoes only one surgery in his life time. If a replaced joint wears out it too can be replaced but it is always better to have one surgery rather than two!

Bow leg deformity in an 87 year old lady	87 year old lady after surgery.

In a young arthritic patient we can perform an Osteotomy to realign the bowed or bent knee. Osteotomy means cutting the bone to realign it. In an old medically unfit patient who can not undergo a knee replacement we do an arthroscopic washout (inserting a telescope and washing the knee joint). We can also replace only "half" or the "involved" knee which is popularly known as "uni-compartmental" knee replacement. A uni compartmental knee finally gets converted to a total knee replacement and similarly an Osteotomy just delays the inevitable knee replacement.

Myths about the joint replacement surgery

Scientific data and our clinical experience have now proved beyond doubt that the operation of total knee replacement is one of the most successful operations performed across all specialties. A simple cataract operation or an operation for hernia has a bigger complication rate than this surgery. The failure rate of a replacement surgery is as low as 2%.

Let us look at the common misconceptions surrounding this very successful surgery. A large number of patients are worried about there age vis-a vis a successful surgery. I have to remind you all that arthritis is a disease of the aging population and the average age of patients undergoing a knee replacement is 65 years. Anesthesia techniques have developed so much that there is hardly any risk involved in the surgery. Apart from the risk the advances in the anesthesia techniques have made this surgery virtually painless. Almost all surgeries are done under what is known as "combined spinal-epidural" anesthesia. Patients are therefore awake during the entire operation. The epidural analgesia is continued for 3 days after the surgery to make sure that there is no pain.

The second most important myth is that it takes 3 months to recover from the surgery! The reality is that patients get discharged on the 7th day after the surgery and go home not only walking but climbing the stairs! There is no physiotherapy required at home and most of our patients walk unaided within a month.

It is worth mentioning that patients who need replacement for both the knees can be operated for both the knees at the same sitting. This "one stage" surgery has many benefits. The most important benefit is that the patient undergoes only one anesthesia. The total stay in the hospital is halved and this culminates into a massive saving on the hospital bill as well.

I actually recommend all my prospective patients to talk to patients who have undergone replacement surgeries in the past. This simple exercise most of the times reduces anxiety and clears all doubts.

Conclusion

• Knee arthritis is unavoidable since it is related to aging.
• Though the wear and tear can not be prevented it can definitely be slowed down.
• Genetics plays an important part in knee arthritis.
• Regular exercises with good balanced diet and good lifestyle can delay the onset of this condition.
• Recent advances in surgical techniques, anesthesia and engineering have converted the surgery of joint replacement to a safe, painless and long lasting solution to this painful and debilitating condition.