Chapter 2 of Knee Deep in Pain Book by Zafar Hayat KhanPublisher: http://www.nouvellesante.com

CHAPTER-2

Hastening theInevitable

Figure-1. Thetis dipping the infant Achilles into the river Styx. Peter Paul Reubens. Museum Boijmans Van Beuningen, Rotterdam.

s mythical rivers go, they tend to run deeper and wider than the myth that gives them life. Invariably they end up intermingled with some religious ritual that derives

meaning from the myth and gives reason to the religion. The A

river Styx figures prominently in Greek mythology, simultaneously feared, hated, and held sacred, and is supposed to serve as the body of water that separates earthly beings from the afterlife. Only upon a mortal’s death, his or her soul, body, orboth would be ferried across the river to the other side, but never before. On the other hand, with the right connections, living mortals like the Middle Ages Italian poet, Dante Alighieri, could take a river boat cruise on the Styx, all expenses paid with Virgil, the famous Roman poet, playing the guide and host. (Please see Inferno chapter). 1

Things get a little complicated when gods and mortals join hands in marriage. Achilles was born of an immortal mother, Thetis, and a regular sort of guy, with even a more regular sort ofname, known as Peleus. Thus far, the goddess mother had burned all their children in attempts to confirm if they were indeed immortal, which sadly they were not. 2

When Achilles was born, mister regular kind of guy ‘Peleus’, her husband, stopped Thetis as she reached for the testing torch,and in his regular sort of tone suggested “look goddess, I worshipyou and all, but maybe we should have a different test for immortality…… perhaps do something else for a change…let us try throwing the baby in the water instead of stuffing him in the oven like you did with the others…. Jus’ sayin’. Besides we need this little demigod to grow up so Brad Pitt can fight for the glory of Greece, New York, and some day even go trash Troy, Michigan.” The mother liked the idea. She took the bouncing baby, and holding it by the ankle, bobbed him up and down in the river Styx. If he could not be immortal at least he could be invulnerable.

“Whom else [but Akhilleus] did a Nereis [Thetis] take be stealth through the Stygian waters and make his fair limbs

impenetrable to steel?" 3

For Achilles’ training, none other than the best would do. The parents sought out Chiron, the centaur who had coached the likes of Esculapius, Castor and Pollux, Hercules and Jason, totake the young boy under his tutelage.2

Chiron was known for his skills at medicine, music and art of war. He could probably also swat flies on his back with great precision using his thick, strong tail. He paid special attention toAchilles preparing him for combat.

When Paris stole Helen, another man’s wife and cravenly fled to Troy, he doomed his state to certain destruction. The son of Thetis, half-man, half-god warrior had two options; go to Troyand die in battle and become a hall of famer living in eternal fame and glory, or stay behind and live an unremarkable life. Needless to say, Achilles packed up both his heels and left promptly to join the war. Chiron’s pupil demonstrated his skills well at the height of the Trojan war, killing Hector, and dragginghis dead body behind a chariot for many days. Ultimately as predicted by his own mother, Achilles fell mortally wounded by an arrow shot by Paris, undoubtedly from behind, to his one areaof the body which did not touch the river Styx water; his heel.4

This tells us if we ever go for a dip in the Styx river in Alabama, they have one their too, we have to make sure we immerse ourselves completely, including the head, because we wouldn’t want our Achilles heel to be our head. But in reality for the rest of us mortals our Achilles heel is the knee.

In a sense, that is also what the Centers for Disease Control discovered. According to their findings 5 “knee osteoarthritis- is a common form of arthritis that wears away the cartilage cushioning the knee joint—is a leading cause of arthritis

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disability.”

If you are in conversation with a physicist, you would discover the concept of ‘entropy’ as generally being understood to be a measure of disorder or decay and as well, uncertainty. Born out of the steam engine days, the second law of thermodynamics states, that entropy, meaning decay and disorder, of a system, if left alone, increases to a maximum. The operative phrase here is: “if leftalone”.

The human body is far frombeing a closed system, yet when itcomes to entropy, arthritis wouldbe considered its poster child,fitting the classic definition ofentropy probably better than anyother model of decline.

Because of the mechanicsinvolved in the knee joint, it has become more acceptable to provide relief using metal and plastic parts implanted in diseasedknees. Research findings presented at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) revealed that more than 4.5 million Americans now have had total knee replacement (TKR). These surgeries have more than doubled in the last ten years but quite disturbingly the sharpest rise was found to be among younger patients.6

This startling revelation is consistent with findings from the study funded by the National Institutes of Health that employed data from the Centers of Disease Control to analyze future growth in knee osteoarthritis cases based on numbers from the previous two decades. It shows that knee osteoarthritis

SummaryA discussion on how, un-addressed, and unattended, knee related problems can very quickly compromise your quality of life, placing mobility, and independence at serious risk.Also questions on the back cover of the book regarding Total Knee Replacement, Arthrocentesis, and long term use of NSAIDs are answered here.

prevalence will be higher in ages up to 64 and lower in ages between 65, to 84. The sharpest rise is expected in the 35-44 and 45-54 age bands with 4 to 5 times as many cases compared to the1990’s decade. This demonstrates a marked and rapid shift in OAincidence trend from older patients to a younger population.

The study notes: “If the currentOA incidence trend continues,nearly 6.5 million Americansbetween the ages of 35 and 84will be diagnosed withsymptomatic knee OA in thenext 10 years, with those aged 45-64 accounting for more than half (59%) of these incident cases. A resulting spike in the utilization of healthcare, specifically total knee replacements, could have a dramatic economic impactand place additional burden on the healthcare system.7

But is knee replacement the panacea? For some, for whom knee damage is extensive and irreversible, perhaps TKR may be the only answer. But one should not depend on it to be the ultimate solution for everyone. Granted, there is enthusiastic optimism for replacement surgeries based on recent successes. Better alloys and composites, techniques, and skills are contributing to a high rate of satisfaction for total joint replacements and failed primary operations are few and that ratetoo is possibly declining. But one has to swallow more than a grain of salt when you look at the evidence a little closer.

Even with successful surgeries there can be other issues. Underscoring this point is research done at the University of Delaware that followed more than 100 knee replacement patientsover two years and found that two thirds of the patients gained an average of 14 pounds compared to a control group who did

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TKRTotal Knee Replacement is a surgical procedure to replacethe knee joint. Also known as total knee arthroplasty or TKA. It involves replacing damaged bone and cartilage with metal and plastic parts.

not have surgery. Those who were not overweight before TKR experienced some weight gain but those who were already overweight saw a further gain in weight after the surgery.8

This finding puts to rest the long held notion, by clinicians and patients, that with a new artificial knee joint people will be able to exercise, stay fit, and lose weight. It didn’t happen. It goes further than that. Not only individuals followed in the study gained weight, they also placed more load on the non-operated leg, resulting in an increase of 21.6 kg in compressive forces on the joint. In addition it was observed the non operated limb had a loss in quadriceps strength.

You can imagine where this is going; a TKR recommendation for the other knee? Dr. Elena Losina, co-director of the Orthopedics and Arthritis Center for Outcomes Research at the Brigham and Women's Hospital in Boston and lead investigator of the earlier mentioned study 7 says; “…newly-diagnosed cases of knee osteoarthritis in younger individuals willlead to continued increases in the use of total knee replacement.” Given that excess weight is a risk factor for bad joints and younger people are going for TKR, surgeons now believe many patients could be candidates for repeat TKRs in their lifetime. 8

When was being young, ever a risk factor? Apparently when it comes to knee replacement being young is not exactlyan advantage. Here is the problem. Young people are more active, thus they are bound to put the artificial joints through somedemanding times. Well, when you go shopping for that new pair of Nike’s

make sure to get a fresh new set of condyles (see page 33). There appears noway out of it. Young,

inactive, and obese, or young and active, what would you prefer?Either way, chances are your are headed back under the knife to get a pair of new knees.

In a large follow-up study of 32,019 total knee replacements in the Finnish Arthroplasty Register it was found that being 55 years or less was associated with a higher risk of revision, especially for aseptic failure but surgeries had a higher survival rate for older people. For the lowest age group, 4o years or younger, prosthesis survival falls to about 83% by the 4th year, resulting in a repeat operation. The Finnish researchers

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Figure-2. Anatomia del corpo humano.Author: Valverde de Amusco, Juan (ca. 1525-ca. 1588). Rome: Ant. Salamanca and Antonio Lafrery, 1560.National Library of Medicine, Historical Anatomieson the Web.

recommend that patients who are less than 55 years of age, should consider TKR only in selected cases, and when no other option is available for relief from pain and dysfunction.” 9

This view is reinforced by the U.S. National Institutes of Health which says, “age younger than 55 at the time of TKR, male gender, diagnosis of Osteoarthritis, obesity, and presence of comorbid conditions are risk factors for revision.” 10

Since arthritis was long assumed to be an old age disease most of the studies conducted relate to people in their sixties and beyond. Now with new evidence of younger people sufferingfrom this problem, we can extrapolate from what we know aboutthe progression of this condition, and see how it applies to the rest of the population.

So, what are the chances ofsomeone experiencing disabilitydown the road if they havearthritic knees? Apparentlyplenty! In a 1996 paper titled‘Prognosis of osteoarthritis’published in the Annals of theRheumatic Diseases (ARD), aninternational peer-reviewedjournal, Dr. M. C. Hochberg, writes, 11 those who have arthritis accompanied by knee pain are at significantly greater risk of disability compared to those that do not suffer from this condition, with women being at even a higher risk than men. 12,

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As one would expect, disability risk rises amongst people who are already suffering from heart or lung disease, and then develop arthritis. 14 Talking about co-morbidities, obesity

Arthrocentesisinvolves the extraction of fluid from the joint using a sterile needle and syringe.Also known as joint aspiration, its primary purpose is to examine the fluid for signs of infection, gout, and other rheumatoid disorders. It is also used for detecting protein, glucose, and white cell counts.

remains king. In a study of a group of women suffering from arthritis in one knee, with average age of 57 years, 47% of those who’s BMI exceeded 26, developed arthritis in the other knee as well. This compared to second knee incidence in only 10% of women with a BMI below 23. 15

But does presence of obesity also add to the problem? the overwhelming and resounding answer is, yes. Apparently even standard treatments can be confounded, compounding the effects of obesity and showing unexpected results. A high BMI complicates things even further in the presence of other factors. For instance joint space narrowing, a key measure of joint disease, may worsen with daily consumption of non-steroidal anti-inflammatory drugs. 16

You would think a common procedure in the doctor’s office for analysis of disease would be fairly harmless. Right? Well thatdepends on how closely you are related to Kung Fu Panda’s physique. For the answer, if sounding a gong means an emphaticyes, and a buzzer sound means an alarming no; be prepared to hear a long, uninterrupted, exceedingly annoying buzz. This test,known as Arthrocentesis, itself becomes a problem as it is also implicated in joint narrowing when obesity is already present, “…factors which correlated with worsening of joint space narrowingwere; presence of obesity, a greater number of joints affected by osteoarthritis, daily consumption ofnon-steroidal anti-inflammatory drugs, and having undergone a synovial fluid aspiration.” 17

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Where overall health of any part, organ, or limb in the human body is absolutely essential; the leg and its proper functioning are critical to mobility, and thus, quality of life. Without healthy knees to support correct gait and posture it would be difficult enough, but if our joint health gets compromised for any reason,it can seriously limit ourmobility. And if leg injury leadsto permanent disability, theresulting lack of exercise maycompromise other parts of thebody leading to, among manyother complications, bloodcirculation problems as well asatrophying of muscles.

In the year 2000, TheFinnish Centre forInterdisciplinary Gerontology, incentral Finland at theDepartment of PhysicalEducation, in the University ofJyväskylä published an interesting study formulated from structured interviews in 1988, and revisited it again, 8 years later in 1996. 19

The objective was to find if mobility impairment was a predictor of dependence and mortality. Subjects between the ages of 65 to 84 were ranked into four groups;

A- Mobile and Active , B- Mobile and Sedentary, C- Impaired (Mobility) but Active, and D- Impaired (Mobility) and Sedentary.

Upon analysis, findings showed the relative risk of death compared to the Mobile-Active (A) group was two times greater

Muscle atrophyis the wasting or loss of muscle tissue. The cause is disuse, which can either be voluntary, or due to trauma injury or disease. Disuse atrophy is due to lack of physical activity and affects people who sit or lie for long hours. This can be reversed with nutrition and regular exercise. Injury due to trauma or disease to a nerve that controls a muscle can cause damage to themuscle by deactivating it. This type of muscle atrophy tends to occur more suddenly than disuse atrophy. 18

in the Impaired-Active (C) group and three times greater in the Impaired-Sedentary (D) group.

But here is the surprise. The risk of death did not differ between groups A and B. Both groups had intact mobility. Even though one would expect the Impaired-Active group to do at least as well as the Mobile-Sedentary group but it did not. Both A and B groups had one thing in common; mobility. This tells us we must never lose our mobility at any cost, hence, presenting a very strong case for keeping our legs in excellent health.

Does mobility affect anything else? The same center at the University of Jyväskylä, Finland, conducted research to study if mobility status and physical activity could be reliable predictors of depressive symptoms among community-dwelling older adults. Comparing populations against individuals who had goodmobility and were physically active they found mobility-disabledsubjects with a sedentary life-style had 2.44 times the risk for depressive symptoms. This probably is not a surprise. But what about the group that had a physically active life-style but was mobility-disabled? The risk for depressive symptoms was 1.99; still quite high.

Again, as in the earlier study, it was mobility that seemed to be the more dominant factor and not physical activity when it came to depression.20

What about arthritis’ interference with other conditions? Physicians treating stroke victims try to get them to quickly regain maximum possible ability including motor function, balance, mobility, and simple activity of daily living. It is commonfor patients to become tired in the first few days during recovery. But in the presence of arthritis, patients recovering from stroke find rehabilitation attempts involving exercises to be frustrating,

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thereby prolonging recovery which could lead to failure in regaining maximum functionality. 21

A serious concern for us should be the fact that the Finnish studies were done on older populations. If the newly discovered demographic shift to younger patients in the American Academyof Orthopaedic Surgeons’ presentation were to use projections based on Finnish studies, it would paint a bleak picture for the future.

For citations please see pages 258 through 261 in the Bibliography section