Wockhardt Hospitals Blog

Doctor's Name: Dr Sawant Milind
FRCS Orth, FRCS(Edin), FRCS(Glasg), MS Orth, FCPS Orth, D Orth, DNB Orth.
Knee Surgeon

The advent of new treatment modalities in medicine brings with it the opportunity to develop better clinical outcomes, while emphasizing a higher level of comfort and safety to our patients. You will, find in the pages of The Specialist, the acumen and expertise of our highly accomplished clinicalteams in Cardiology/Cardiac Surgery, Neurology/Neurosurgery, Orthopaedics, GI & Advanced Laparoscopic surgery besides Womens health.

‘The Specialist’ is a part of our Clinical Knowledge Series which we hope to share with with fellow doctors and medical fraternity on our latest clinical outcomes across various specialties.In this issue, we have some interesting case studies in all our core specialities mainly Heart care, Brain & Spine, Bone and joint and digestive care.

Rheumatoid arthritis is a well known systematic inflammatory disease wherein arthritis of synovial joints is a major component. This disease is common in females and affects during third, fourth and fifth decades of their life. Initially the disease starts with pain and joint stiffness in small joints of hand and later involves big joints like hip, knee, shoulder and elbow. In an advanced rheumatoid arthritis all the joints of the body are involved.

Treatment of rheumatoid arthritis is ideally to be done by rheumatologist. Start with NSAIDS and later go on to combination therapy of DMARDS (steroids, methotrexate, leflunomide, sulfasalazine chloroquine and oral gold salts).

An Orthopedics role comes only after joint pain/ swelling and deformity are not controlled by medical treatment.

With advent of new implants, good operation theatres, laminar flow and surgical expertise, it is possible to perform joint replacements even in severely deformed joints which was thought impossible previously.

A 58 year old female patient consulted us with severe knee pain for four years. She was a known case of rheumatoid arthritis on medical treatment,she was unable to stand or walk and had severe pain on bending the knee.

This lady was poorly nourished and anemic. Local examination of both knees revealed that she has wind-swipe deformity. Right knee was in 30 varus deformity and range of movement was 0-90. Left knee was in 40 valgus and further valgus till 70. Range of movement was 0-30. X-ray of right knee showed severe varus deformity with medical tibial condyle defect and lateral subluxation of tibia. Left knee - severe valgus deformity with central tibial bone defect and lateral patellar subluxation.

Patient was admitted and complete pre-operative work done. The team of Orthopaedic surgeons headed by Dr. Sanjay Pai, Rheumatologist .A total knee replacement was done in a staged manner. First the right knee with varus deformity was operated using a revision total knee replacement implants. After five days, the left knee with severe valgus deformity was operated. Post operative period was uneventful and without complications.

The patient was mobilized on the third day with walker and was discharged on the sixth day. On the 12th day, the patient was able to walk without support, able to climb stairs and do her daily activities.

Movement is triggered through the pyramidal system, the basal ganglia and the cerebellum in the brain.These are discrete parts of the brain which perform specific but different functions, which are wired to each other for the performance of normal movement. The movement disorders are a diverse group of pathological dysfunctions in the nervous system, giving rise to any of these: an abnormal movement, a paucity of movement, an abnormality of muscle tone or a disturbance in posturalreflex.

The common movement disorders are Tremors, Chorea, Parkinson's disease, Dystonia and Writer's cramp.

The patient gives a detailed history of what has been occurring in terms of the symptoms. The investigation is followed by a neurological physical examination. Scales are used(basically written proformas) to assess the severity and type of movement disorder. Various movement sequences are recorded on video as a baseline before any treatment, to later compare the patient's performance in specific functions. This is followed by basic bloods tests, a CT/ MRI brain scan and EEG or EMG along with some specific tests that may be needed, depending on the diagnostic possibilities that the physician is thinking of.

1) Medications: Medications that either stimulate or inhibit the specific receptors for central nervous system chemicals (neurotransmitters) are the mainstay of treating such disorders

2) Botulinum toxin injection: This toxin is injected into muscles to partially paralyze them, and thereby control the abnormal movement.Several sites are injected in one sitting, and several such sessions may be required at 4 week intervals.

3) Stereotactic surgery: After detailed visualisation using CT/ MRI and mapping the brain, ablation (destruction) of certain parts of the brain nuclei and/ or its circuits will generally give relief from the abnormal movement.

4) Deep brain stimulation: The position of the basal ganglia nuclei are identified using CT/ MRI brain scans. Electrodes are placed onto specific brain nuclei and electrical signals are sent from a generator placed under the skin, in the chest. The patient has the option of controlling the current from the generator, for symptom relief.

The first task of the physician is to arrive at a diagnosis, or a highly probable diagnosis, using variouslines of investigation.The best line of treatment: Each patient would need to be tried on a specific combination of drugs which may vary from 1 to 3 months, to assess the best outcome with drug management.

Specific Medical Concerns on Movement Disorders

Following this minor adjustment in drug dosages may be required once every three months
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Likely outcomes: It is usually expected that the abnormal movement decreases to a remarkable extent. If the problem had been one of rigidity and paucity of movement, then movements should be more easily performed. A small sub-set of patients are not likely to improve on medications, for which deep brain stimulation or Stereotactic surgery should be considered to give optimal relief.

Movement disorders are generally progressive degenerative disorders, which means that the pathological course cannot be greatly altered, though significant improvement in function can be provided. However, the goal of management is to provide optimal relief and restore normal functionality, with the least side effects and thereby significantly improve the quality of life for the patients.

source:

The Department of Neurology at Wockhardt Hospitals

Dr. Chandran Gnanamuthu ,MD, DM, FIAN, FAAN DM PhD (Neuro Sciences)
Dr. C. Udaya Shankar,Specialist in Movement Disorder
Dr. Vijay Chockan,Consultant Neurologist Consultant Neurologist Consultant Neurophysiologist