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Get a leg up

   
Dr Ting holds the world record for treating the most osteo-arthritis knees, over 25,000 of them, and he's also the inventor of the BPro watch which reads blood pressure over 24 hours.

The Business Times, April 27, 2008

Suffering from worn-out, osteo-arthritic knees? CHEAH UI-HOON finds out how to avoid knee replacement surgery

A SINGAPORE doctor holds a surprising record in medicine: for having treated the most osteo-arthritic - or worn-out - knees with viscosupplementation in the world. He has treated over 25,000 knees since he discovered viscosupplementation (VSP) in 1991. The holder of that record is Ting Choon Meng, a general practitioner with a penchant for pioneering new approaches to medical problems. He is also the inventor of the BPro watch which reads blood pressure over 24 hours.

He published a handbook for doctors recently, and the essential information for those with osteo-arthritic (OA) knees is that there is hope for rehabilitation without having to go for knee replacement therapy.

Osteo-arthritis is actually a misnomer, says Dr Ting. 'Osteo-arthritis isn't a form of arthritis per se. All other forms of arthritis indicates an inflammation, hence the '-itis' at the end of the term.

However, osteo-arthritis doesn't refer to an inflamed condition but a degenerative disease. 'OA knees, for example, is a result of wear and tear. It's different from someone who suffers from acute inflammation like rheumatoid arthritis. Having said that, during the course of osteo-arthritis, there will be episodes of acute inflammation,' adds Dr Ting.

But what is degenerating? The cartilage layer that's around the knees, he points out.

As most of us know, the cartilage around the knees is most crucial for there to be 'cushioning' between the knee joints. Cartilage can wear out over time, resulting in the start of osteo-arthritis.

'OA of the knees is very common. I'd say that about half of people over 65 years old will suffer from osteo-arthritis. After that, the next most common form of OA is that of the hips,' says Dr Ting. And OA, unfortunately, is very insidious, highlights Dr Ting. 'It can develop from a primary injury like a road traffic accident,' he says.

But if OA didn't stem from another condition, then primary OA affects those who're generally overweight, who're elderly, and who have malaligned knees such as those who have 'O' shaped knees, or 'A' shaped knees - conditions which see the wearing out of the inner part and outer part of the knees respectively.

'OA knees are like love affairs,' quips Dr Ting. 'They are ongoing processes that grow with time.'

The role of synovial fluid

The thing about cartilage is that it's nourished by synovial fluid. Synovial fluid, produced by a synovial membrane which lines the whole joint, provides lubrication during low impact movement, and shock absorption during high impact activities.

'Many studies have shown that the initiating process of OA changes starts with the change and deterioration of the synovial fluid properties,' says Dr Ting.

As a result, 'diseased' synovial fluid cannot perform either the function of elasticity (lubrication) and viscosity (shock-absorption).

Because of that, micro fractures develop in cartilage and that causes acute inflammation and persistant pain. 'At its start, these micro fractures can't be seen in X-rays,' he says. Then diseased synovial fluid seeps in through the cracks, damaged areas widen, cartilage layer thins off, and deformity and malalignment worsens.

To date, the only treatment in Western medicine is to take painkillers or go for surgery. 'Western medicine just doesn't have much to offer, especially in the early stage of OA,' says Dr Ting, pointing out that continuous consumption of painkillers has its side effects.


   
   Tackling the source: With viscosupplementation, patients get diseased synovial fluid drawn out from their knees, and a replacement viscoelastic fluid injected in

He also cautions against steroid treatments as patients can become dependent on it. And the problem with total knee replacement is that many of the elderly aren't good candidates for surgery, as they typically suffer from conditions such as high blood pressure, diabetes, high cholesterol and have high risk of stroke.

'Younger patients - those who're in their 40s, for instance - aren't good candidates either, because knee replacements typically last only for 10 years,' he says.

Enter viscosupplementation. 'There's very solid scientific basis to this, and we've seen OA 'reverse' itself,' says Dr Ting, whose first patient 17 years ago still has good knees.

Of course, treating patients with VSP in the early stages of OA sees more result, but even in later stages, VSP can help.

The basis of VSP is to replace the diseased synovial fluid. 'VSP treats the disease at the root thus breaking the vicious circle,' he notes.

The raw material for viscosupplements is hyaluronic acid. Long chains of glucosamine molecules are strung together to form hyaluronic acid, which is the basic building structure of synovial fluid.

Patients typically get diseased synovial fluid drawn out from their knees, and then a replacement viscoelastic fluid is injected in. The injections are given once a week for three weeks, after which the doctor monitors their progress over a six-month period.

In the 17 years he has administered VSP, Dr Ting noticed that patients start to feel less pain (because the root problem of viscosity and elasticity is solved) and the VSP also helps to kickstart the production of healthier and normal synovial fluid.

The damaging process is thus reversed in the synovial membrane, and the cartilage layer is nourished, even to the extent that new cartilage cells might be grown.

'There is an animal model to show this and it is not unreasonable to assume that this can also occur in man,' says Dr Ting.

Pioneering VSP in Singapore

In Singapore, Dr Ting was among the handful of doctors to start using VSP in 1991. 'At this time, VSP was unheard of locally,' he recalls. As it wasn't a standard drug, permission had to be obtained from the Drug Administration Department for every patient he was going to inject.

Hyalgan was brought in by Fidia Research Lab, whose parent company was more known for ice-cream making technology rather than medical technology!

In Europe however, Hyalgan was readily available over the counter, as one of his resourceful patients had sought the help of an airline stewardess to buy it for her.

In the early 90s, Dr Ting had to develop his own protocol, which he managed to do in the mid-90s, after treating about 2,000 knees. This resulted in 'Ting's Score' - a set of criteria with different signs and symptoms. In the late 90s, although the Ministry of Health approved a new product, Synvisc, for use by orthopaedic surgeons only, Dr Ting continued practising VSP as a general practitioner.

He also started introducing VSP to other joints - ankles, hips, shoulders, elbows which have Temporal Mandibular Joint - as his confidence increased, he said. Today, VSP can also be administered to patients with burnt-out rheumatoid arthritis and secondary OA in knees or wrists. He has even started administering single-dose injections of VSP, based on patient need and condition.

The key is diagnosing OA knees correctly, he stresses, as there can be other causes of knee pain such as an infection or a gout attack. Pain is an indicator, classically experienced during weight-bearing activities like walking or climbing stairs.

Also common is patients complaining of pulling pain in the knees at night. X-rays of knees should be taken while standing, to check the distance of the joint space. 'X-ray findings of joint space distance is a powerful predictor of the outcome of VSP,' says Dr Ting.

Compared with painkillers and steroidal injections, VSP is definitely superior, concludes Dr Ting. 'And for most patients, it buys time for a patient to make lifestyle changes and ponder if surgery is totally necessary.'

Dr Ting Choon Meng's clinic is T&T Family Health Clinic & Surgery located at 181 Kitchener Road #01-36/38,
Parkroyal Hotel Shopping Arcade, Tel:
6293-4071

What is osteo-arthritis?

  • It's due to wear and tear of the knee cartilage

  • It's characterised by joint pain, tenderness, limitation of movement and variable degrees of local inflammation

  • It's usually linked to ageing

  • Essentially affects hip and knee joints



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