Try These Surgeries for Arthritis: Arthroscopy, Synovectomy, Osteotomy

Arthroscopy

The arthroscope is the device that has opened up the knee and selected other joints to lights, cameras, and surgical implements -and all without opening them very wide. Through an incision as small as a quarter of an inch, a surgeon can now get the best pos­sible diagnostic picture of the inside of a joint, and, if necessary, perform surgery through another small hole with specially designed microtools.

The small scale of the procedure — the tiny incision, the short hospital stay — lead many people to believe that arthroscopy is a minor matter. But surgery via arthroscopy is still surgery and usually calls for general anesthesia. What's more, the recovery period may last just as long as recovery from other types of surgery, depending on what gets done with the arthroscope. If you hear of someone who is up and about the morning after, you can bet that person had little more than a diagnostic look-see with a local anesthetic.

Despite all the fanfare surrounding arthroscopy, however, espe­cially the exciting stories of world-class athletes whose careers were saved by arthroscopic surgery, participants had less success with it than with the other forms of surgery they rated. Some of the operations carried out with arthroscopy simply don't improve life as dramatically as a joint replacement, say, or a fusion proce­dure. Here are the things that surgeons can do with arthroscopy to help people with arthritis: remove debris from inside the joint, scrape off bone spurs, and take out the joint lining (synovium).

Synovectomy

In rheumatoid arthritis, the main culprit responsible for pain and swelling is thought to be the paper-thin membrane that surrounds and lubricates the joint, called the synovium. Inflammation can spur this membrane on to wild overgrowth, until it becomes so thick and unwieldy that it fills the joint space, puffs out the sur­rounding skin, moves bones, and ruptures tendons. As inflamma­tion rages, the synovium also secretes enzymes that eat up the cartilage. Little, wonder, then, that surgeons thought to stem the destruction by synovectomy — removing the synovium.

Synovectomy is not performedas frequently as it used to be, partly because doctors have found that the membrane often grows back. Even if the membrane does not overgrow the joint space again, the joint destruction may continue to get worse after syn­ovectomy.

Osteotomy

Osteotomy, for one, was a popular way to relieve hip and knee pain in the late 1950s and early 1960s, but it got upstaged by joint replacement. Now, it may be making a comeback, especially for people who are considered too young to receive an artificial joint.

Osteotomy entails cutting a bone to correct the alignment of the joint. At the knee, for example, if the thighbone and shin don't abut squarely, there may be too much stress on one part of the joint, and the cartilage and bone at the overloaded meeting place will wear unevenly. By cutting a wedge-shaped piece out of either bone, a surgeon may tip the balance, so to speak, and get the person's weight distributed evenly across the joint, the way it should be.

Other surgical procedures include attempts, most of them successful, to repair or release tendons and ligaments, and a couple of highly unusual procedures for rare complications of rheumatoid arthritis.

Arthritis: Stay Away from Negative Thinking

No matter what medications they took or other kinds of help they received, many arthritis sufferers counted their own positive outlook on life among their most potent weapons against arthritis. They complained little, although they have suffered much, and they believed that their attitude helped them feel and function far better than they otherwise might.

For although arthritis is a malady of the joints, it can also inflame anger, depression, and rob people of their self-esteem.

Arthritis is not caused by emotional problems, to be sure, but it kicks up a lot of strong feelings, and it can respond to feelings, too. Stress, for example, often makes arthritis symptoms flare, while the relief of stress may drive those symptoms into remission. Even when it comes to medical care, emotional factors seem to tip the odds in favor of benefiting from certain drugs or procedures. For it sometimes happens that two people with the same kind of arthritis, whose X-rays reveal identical degrees of joint damage, react quite differently to the same treatment — apparently because one has a positive mental outlook and the other feels beaten before beginning.

Emotional Fallout

It should be easy to understand, even from a healthy distance, how losing the ability to do what you've always done could make you furious, or sad, or both. Anyone should be able to see that being in pain is reason enough to get depressed occasionally. Yet some sufferers noted that most of their friends and family members do not appreciate their emotional turmoil, and definitely do not want to hear about it. Worse, some of their so-called friends implied that arthritis came about as the result of their internal upset, instead of the other way around.

Doctors, too, have sometimes been guilty of blaming their patients for bringing on arthritis by virtue of their personality problems. It has been said that people develop arthritis because they are unable to express anger and therefore harbor hostility or resentment. But there is no evidence to support these stone-casting ideas.

It Couldn't Happen to Me

Younger people especially, who tend to think of arthritis as a disease of old age, may deny what is happening to them, as a way of dealing with the shock. Denying arthritis means denying its proper treatment as well, and actually making the condition worse as a result.

Denial, anger, anxiety, and depression are most often normal reactions to the challenge of adjusting to living with arthritis. Their normalcy, however, doesn't make them any easier to bear; and some physicians believe that depression and anxiety actually lower your tolerance for pain.

A Sense of Loss

The sense of loss is a frequent cause of depression, and that people must have a chance to recognize and grieve the loss before they can pick up and carry on. The loss can take any form. One person loses sight of himself - becoming a patient instead of a person. Another loses a job, and with it her whole social network.

Arthritis Treatment Tips: How Methotrexate Works

Methotrexate was developed for leukemia therapy in the 1940s, and a report of the first attempt to pit it against rheumatoid arthritis appeared in 1951 — more than fifty years ago. It has taken all this time for other studies to prove the claims of that first report. Methotrexate was once considered an experimental treatment for rheumatoid arthritis. Practitioners worried about its severe and potentially lethal side effects (more about these later), which become a tremendous concern for people with arthritis, who, unlike cancer patients, may take the medication for a long, long time.

In fact, as more and more rheumatologists have tried methotrexate on patients with the most destructive cases of rheumatoid arthritis, the drug has proved to be safer than they expected. The dread toxic reactions have not shown up as fre­quently or as severely as had been feared. This is probably because the dosage level used for arthritis is so much lower than the dosages required for cancer chemotherapy — about 1/100 of the amount.

Methotrexate is by all means along-termtreatment. It seems to perform a miracle within the first month or two of use for many people with arthritis, relieving even the most intractable pain and all but eliminating stiffness. A good number of these individuals keep on improving steadily as they continue the treatment over successive months, and they may stay on it for years. Withdraw the drug, however, as doctors have done in studies, and all signs of improvement vanish in a blazing flare-up within a few weeks.

Methotrexate works. That's the good news. And it works where all else has failed, because methotrexate is not given to anyone who hasn't already tried a whole series of strategies, typically including aspirin, other non-steroidal anti-inflammatory drugs, steroids, gold shots, and antimalarial drugs or penicillamine.

Methotrexate may be prescribed along with other drugs in treating your condition. Some drugs interact with methotrexate and particular care is needed with NSAIDs. You may only take these if they are prescribed to you by your doctor. Methotrexate is not a painkiller so if you are on painkillers you may continue to take them unless your doctor advises otherwise. Do not take 'over-the-counter' preparations without first discussing this with your doctor.

Just what, exactly, methotrexate does in rheumatoid arthritis remains a mystery; but then, no one can say for sure how most of the common arthritis drugs achieve their benefits. If they work,they are used. And while it would be very nice to know how they work, scientific understanding has not kept pace with practical experience.

The names applied to methotrexate and the other drugs in its class — they are called, by turns, cytotoxic drugs, immuno­suppressives, antimetabolites, and immunomodulatory drugs — all hint at their possible actions in the body. For example, 'cyto­toxic' means 'poisonous to the cells.' By interfering with cell reproduction, these drugs can halt the uncontrolled growth that characterizes cancer, or, as in rheumatoid arthritis, the runaway inflammation and destruction of the joints. Immunosuppressive' means they can damp the immune response. Since rheumatoid arthritis is believed to be an immune-system attack on one's own body, it stands to reason that suppressing the immune system might quiet the disease. Again, the mechanism by which methotrexate brings arthritis relief is simply not known.

How Your Mind Can Make or Break Your Arthritis Pain Relief Easier

Mental Attitude

Your attitude to your arthritis and your expectations about it are two major factors in determining how much effect arthritis has on your life. Anxiety, pain and fatigue are all associated with feelings of depression. It's very easy to let yourself become more and more miser­able and less able to cope with your daily activities.

There are many ways to help lift yourself out of this cycle, but the first big step is for you to decide that you want to help yourself. Friends and relatives, church and community groups, counsellors, your doctor and other health professionals can all give you guidance, but you are the one who is ultimately in control of your own life and your attitude towards it. Once you have a positive focus, you will probably find that your arthritis no longer bothers you to the same degree.

Stress

Have you found that your arthritis is worse when you are under physi­cal or emotional stress? This is very common. It seems that when we try to push ourselves too far our bodies start to give way at their weak­est links. For people with arthritis, this is their joints.

Sometimes the onset of rheumatoid arthritis coincides with a period of severe stress in a person's life. This is not to say that stress causes arthritis, but it is possibly a contributing factor. And once you have arthritis, it is certainly affected by stress. Medicine today is acknowl­edging the close relationship between our minds and our bodies.

Of course, it is impossible to rid yourself of all stress in your life. The unexpected can always happen. But you can try to eliminate many unnecessary day-to-day stresses by:

• planning ahead
• being realistic about time and your capabilities
• assessing your priorities
• sharing the responsibilities
• asking for help
• practising your relaxation.

Another Form of Arthritis: Ankylosing Spondylitis

Ankylosing spondylitis is not a common form of arthritis, but it is one in which exercise plays a key part. The main feature of ankylosing spondylitis is stiffness of the spine, which can become completely rigid if the disease is not properly managed.

Ankylosing spondylitis is more prevalent amongst men than women, and it usually affects younger people (15-25 years old). Often, however, symptoms are not recognized as ankylosing spondylitis until I he person is a bit older.

Ankylosing spondylitis is different from other arthritic conditions in that it affects structures outside the joint, rather than inside. It starts with inflammation of the ends of the ligaments where they attach to the bone. The joint most commonly involved is the sacroiliac joint, the joint between the bottom of the spine and the pelvis.

The first symptom of ankylosing spondylitis is usually stiffness and pain in the lower back. The inflammation gradually spreads to the joints further up the spine and may affect the attachment of the ribs to the spine. It may spread down to the hips, but only rarely are the other joints of the limbs involved.

The inflammation causes pain and stiffness, but this is not the end of the problem. After a while, bony outgrowths spread along the ligaments forming a solid bridge between the two bones. Obviously, this means that the joint cannot move. The only benefit is that it is no longer painful. This fusion of the joints of the spine is what leads to the rigid 'poker back' so characteristic of ankylosing spondylitis. However, good management helps prevent the disease progressing this far. Most people are able to lead very active normal lives.

Exercise and Ankylosing Spondylitis

Exercise is the key to the successful management of ankylosing spondylitis. It is essential to keep the affected joints as mobile as possible. This involves a consistent active exercise program. Also, you need to be aware of your posture at all times - even when you are sleeping! If the bones are going to fuse together, you want them to be in the most functional position possible.

Tips on Surgery and Joint Replacements for Arthritis Sufferers

What kind of replacement will I get? Surgeons choose styles of knees from a wide array of models. The choice of joint implant depends a lot on the type and degree of destruction in the ori­ginal joint, not to mention the surgeon's personal preference. At some hospitals, in fact, surgeons work with bio-engineers to help put their own ideas for new joint designs into production.

What happens after surgery? The implanting of the new joint is only the beginning of a successful replacement. Physiotherapy is the next phase, and it covers everything from teaching you how to use crutches or a walker to demonstrating and supervising exercises that will strengthen the muscles that make your new knee go. (These muscles, including the quadriceps at the front of the thigh and hamstrings at the back, may be quite weak if pain has kept you inactive before surgery.) The exercises participants describe include both active movements, such as extending the knee while wearing small weights around the ankle, and passive motion. Even after the patients left the hospital, they returned two or three times a week for physiotherapy and then continued exercising regularly on their own, mostly by walking, swimming, or riding a bike.

What risks do I face? Total joint replacement is major surgery and patients face all the known risks of being put under general anesthesia or numbed with a spinal. Over the long run, the special risk of replacement is the possibility that the new joint will come loose and the pain return.

Loosening is the most common risk with joint replacements, but infection is the most serious. It is quite rare today, thanks to the extreme precautions taken at most hospitals. Despite all the safeguards, infection can sometimes undermine the new joint by spreading to it from some other part of the body days or weeks after the operation.

When surgeons set about performing re-replacement of implants that have loosened, they often discover that a mem­brane has grown all around the cement, resembling the synovial membrane that normally surrounds the joint. Inside the mem­brane they find tiny particles of PMMA cement — and evidence that the membrane is doing chemical battle with these particles, releasing substances that cause the bone around the cement to retreat, or reabsorb, and the implant to grow progressively looser.

Relieve Arthritis Pain through Unconventional Methods

Many types of professional pain-treating equipment seen in hospitals and practitioners' offices also is available for home use. If you have advice from your physicians and therapists, you can use devices that stimulate your nerves electric­ally (TENS units, for Transcutaneous Electrical Nerve Stimulation); made them aware of some internal bodily rhythm (biofeedback); stretched them out (traction); or turned them upside down (gravity inversion).

Sometimes called 'electric aspirin,' TENS units are small but complex machines that can give a gentle analgesic jolt. The unit itself, about the size of a transistor radio, generates electrical impulses. It attaches to your body via wires and electrodes taped to your skin at certain points, depending on where you hurt. No one knows exactly how or why it works, and the effects vary from one person to the next.

The equipment used for biofeedback can be as elaborate as a computer, as simple as a thermometer. In operation, the machinery gives you feedback, in the form of light or sound, for example, that tells you how well you are controlling your internal biology.With practice, you can learn how to decrease your pain by raising your body temperature, and you can avoid pain and stiffness by using biofeedback to relieve tension. If you want to learn biofeedback, look for a reliable teacher, perhaps a psych­ologist who is familiar with the technique.

If you're really serious, you can own and use the gravity-inversion equipment that was fairly popular a few years ago. It allows you to lie down and then turn yourself upside down for ten minutes a day, which relieves the pain in your spine.

Warning: Don't attempt traction (or inversion traction) on yourself without the direction of a physician or a physical therapist.

Meditation, Self-Hypnosis, and Other Mind-Control Techniques

Believing in the power of the mind over the body, many arthritis sufferers use some formal technique for guiding their thoughts away from pain. The basic philosophy here is "Heal thyself," and "I can overcome." Some find that the deep concentration required for these techniques serves to distract their minds from the pain in their joints. Others feel so relaxed after practicing meditation or self-hypnosis that they are less troubled by pain, and actually managed to think their pain away. This is not to say that their pain was imaginary, or so minor that it could be easily quelled. Rather, it seems to reinforce the mind/brain's ability to gener­ate its own internal pain-relieving drugs, called endorphins.

Endorsements include a wide range of mental techniques, from training in Transcendental Meditation, to seeing a psychologist for instruction in self-hypnosis, to simple visualization exercises that originate in their own fantasies

If you would like to try your own form of meditation, give yourself the benefit of solitude and privacy for at least ten or twenty minutes a day. Take the phone off the hook, too. Pick your most comfortable position, so that you'll be able to relax your body; In fact, some people's entire 'meditation' consists of consciously trying to relax each body part in order, from the forehead to the toes, or vice versa. Closing your eyes and breath­ing deeply and evenly are also important. Deep breathing, like relaxing, is such potent medicine for some people that they can feel relief just by focusing their minds on inhaling and exhaling, perhaps repeating a sound or word with every breath. The more you practice meditation, proponents say, the better you get at it, and the better it can make you feel. For some participants, prayer confers the same benefits.