Dr M K Mam
‘Prevention of deformity in degenerative disease’ Bone and Joint day is celebrated all over India by the Indian Orthopaedic Association (IOA) and all its state chapters on 4th of August every year since 2012. The primary aim is to create awareness among people about the bone health, various orthopaedic illnesses which can be prevented or treated and be useful to the society. It was on this day in 2012 the then President of IOA asked members to have at least one free surgery for poor patient and that activity is taken care of every year on that day. We have public awareness programs at state chapters to sensitize the society about the increasing impact of bone and joint disorders, how to prevent and treat them. People are educated about the importance of maintaining a sound bone health and what all can be done for it. The activities that are usually organised include health education programmes for general public highlighting bone health- having stronger bones, free surgeries for deserving patients by the members, free Bone Mineral Density (BMD) camps etc. We usually have a week long activities from 1st. to 7th August– Bone and Joint week.
Bone and Joint day is not a mere celebration, the day gives orthopaedic fraternity an opportunity to reassess and evaluate their performance and usefulness to the society. It gives an opportunity to introspect and think about their role in the society in improving bone health of the people, in prevention and / treatment of bone and joint disorders that is cost effective and within the reach of a common man. It gives us an opportunity to honestly look into ourselves to find how far we are fulfilling the social obligations and what all can be done to make it better.
This year the theme of observing the day is ‘Prevention of deformity in degenerative disease’. Degenerative disease also known as osteoarthritis (OA) is the most common problem in the middle aged and older people. Weight bearing joints especially Knee is very commonly affected by it. Certainly, it is one of the common causes of long term disability, functional impairment and impaired quality of life in most of the people. It is a major health problem that has a significant economic impact as the cost involved in the treatment- medical, surgical, physiotherapy etc. is tremendous. There occurs progressive degeneration of articular cartilage that covers the ends of the bones and makes up the joint. As the disease advances there occur progressive deformities in the joint like the fixed flexion deformity i.e. knee joint is bent and cannot be straightened. In addition there occurs angular deformity and the most commonly we have a fixed varus or bowing at knee joint. As disease progresses , the deformities increase and with it joint instability, contractures and muscle atrophy develop, and all this leads to lot of functional impairment. Such deformities are very commonly seen in our patients of OA knees as most of them present late because of one or other reason. These problems certainly affect the results of treatment and increase the chances of complications. It is essential that we try and take all necessary steps to help to prevent having these deformities and improve the outcome of the treatment.
a) Maintaining an ideal weight: Overweight certainly puts additional load and stress on the joints especially of knees and hips. It increases risk of OA, worsens the already existing OA and its after effects. Each additional kilogram of the body weight increases compressive load over the knee roughly by 2 to 4 kilograms. Studies show that overweight people have higher rates of knee OA than non-overweight people and it is severe and progressive. As such, keeping the weight under control is very essential not only for the joints- knees and hips but also for the overall health of a person. Yes, weight reduction is certainly a challenge. It is easy said than done, however it is not impossible if we understand its significance and then work on it religiously. We have to have strategies that are individualised for the person.
b) Healthy diet: Adequate supply of appropriate nutritional components like calcium, vitamins D and C, phosphorus and proteins are important for the growth and development of the bones and joints. Calcium is the most important mineral for the normal growth and development of the bones. Deficiency of calcium also affects the functioning of cartilage cells. Men aged 50-70 years should consume 1000 mg per day of calcium and the women age 51 and older and men age 71 and older should consume 1200 mg per day. It is always good to meet our requirements by eating calcium rich foods and have supplements only when we do not get it through diet. Vitamin D is important for calcium absorption and mineralization of bones. It is also associated with regeneration of the cartilage. Its deficiency increases the risk of OA in some studies and its supplementation may be protective in OA. An intake of 800 to 1000 international units of vitamin D per day for adults is recommended.
c) Regular weight bearing exercise: Weight bearing exercises i.e. when bones and muscles work against gravity and resistance, certainly make the bones, joints and muscles stronger. Regular exercise increases the lubrication to the cartilage of the joint and reduces stiffness and pain. Research has shown that absence of loading results in atrophy- thinning of articular cartilage. Exercise certainly improves range of motion , flexibility and function of the joints. Unfortunately most of our patients are reluctant to do exercises, so it is our duty to explain and educate them about the importance of doing exercises. Exercises also help in reducing weight and overall general wellbeing of a person. Most important thing is that exercise has to be a regular lifelong activity, of sufficient duration and intensity depending on person’s age, severity of the disease and functional capabilities. Exercise is to be avoided especially when joint is acutely inflamed.
d) Improve muscle strength: Strengthening of muscles is important as strong muscles provide movement and stability to the joint, thereby help in reducing the risk of OA and its after affects. Muscle weakness of thigh muscles especially quadriceps puts knee to an increased risk of OA and its progression. It is good to have a well-designed exercise programme for strengthening of muscles especially quadriceps and hamstrings for OA of knee joint.
e) Yoga: Yoga builds muscle strength, increases range of movements ,improves balance and relaxes mind. Studies have shown positive effects of yoga in OA knee with a meaningful reduction in pain, improvement in physical functions and mobility. Good thing is that yoga is feasible, acceptable, and safe for patients with OA knee. However, further research in the form of random controlled trials with larger sample size is needed to make the things very clear. Yoga has to be done under an expert’s guidance.
f) Avoid overuse or misuse of the joint: Continuous repeated movements and tasks, overworking of joints in certain occupations does hasten the development of OA. Jobs requiring frequent work in knee bending, squatting or kneeling position increases risk of OA knee. Excessive squatting and sitting cross legged in day to day activities in our people especially the females could be one of the reasons for increased incidence of knee OA in our country. Taking necessary precautions like activity modification etc. can help reduce the risk of OA and help in its prevention.
g) Use of appropriate braces: Use of assistive walking devices such as knee brace, splint, walking stick or walker help in moderate to severe cases. Braces might somewhat unload the joints by shifting the weight from the most damaged portion of the joint. Supportive aids provide stability and improve symptoms, joint function and activities of daily living. Soft soled well cushioned shoes do help as they act as impact absorber and may be reducing load on knee.
h) Avoid joint injuries: Any injury of the joint like intra articular fracture, meniscus tear, ligamentous injury or pre-existing deformity of knee or hip does increase the risk of OA and progression. Injury is the most important modifiable risk factor in OA of knee. As for as possible we should try to avoid injury to a joint and whenever we have it, it should be properly treated. Similarly any disease of the joint like infection, rheumatoid arthritis, crystal-gouty arthritis, haemophilia etc. makes the joint prone to secondary OA and its after effects like deformities etc. We should not take the things lightly, instead have a proper treatment as and when there is any injury or an affliction of the joint.
i) Correct the malalignment: Any malalignment of the joint adversely affects the load bearing of the joint, increases the chances of OA and its progression. When there is bowing – varus deformity of knee , loading increases on inner side of the joint and this certainly increases the degeneration of the joint. As such we should correct any malalignment of the joint at the earliest as it helps in redistributing load from more degenerated area to relatively normal cartilage and stimulates formation of new cartilage.
j) Consult the doctor early: It is very essential that we stop self-medication ,consult the doctor at the earliest and have the proper treatment so as to have better outcome and reduce the chances of the likely complications. Education of the people in this regard is very essential.
(The author is Formerly, Vice Principal, Prof. & Head of Orthpaedics, Christian Medical College, Ludhiana , Punjab Past President, North Zone Orthopaedic Association)
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