THE BEST KNEE SURGERY

We are surrounded by fast- growing technology all around and often find it difficult to keep pace. Twenty five years ago, talking to another person involved booking a trunk call and waiting endlessly. Todayone can share pictures with an entire group of people while on the move. Development has revolutionised every aspect of life and healthcare is no different. Howeverit is not that keeping in contact over mobile phones betters relationships between people. Nothing can replace a one to one meeting and a face to face conversation. Similarly as regards a medical problem, even though vast knowledge could be available on the Internet by uploading reports, thorough clinical examination by a good doctor is irreplaceable and invaluable.

Surgeries on joints have improved the quality of life of millions of patients worldwide and are now rated among the best of all types of planned surgery. Like some people accept technology more easily than others, there are many who would rather suffer a lot of disability than go through surgery for fear of becoming worse. At the same time, there is a plethora of sites advertising different treatments claiming success, which would definitely confuse people. There is often no mechanism of getting the correct scientific and evidence based information.In this scenario, I have tried to address certain issues below on aspects related to surgery. As surgical techniques have evolved, concrete proof on each of these aspects has emerged, that too not in relation to a small group of patients but in various different environments all around the world.

To have or not to have surgery

There are few causes for which surgery is absolutely and urgently necessary on knees e.g. Fractures when the blood vessels are injured as well. Recommendation for surgery should be made only after discussing the merits and demerits of the procedure, and that too after clinical examination, not on the basis of reports. Commercialisation of healthcare has brought about practises where patients are coerced into immediate/ early surgery. There is evidence that most cases of ligament injury will not do well with immediate unplanned surgery, even Arthroscopy. If done immediately after knee injuries, they cause more stiffness and pain. In knee injuries where there are none or minor fractures, early rehabilitation by return to movement of the knee is the key. The majority of ligament injuries heal on their own. Splints, plasters or knee caps are grossly overused. They are known to weaken the muscles over time and would cause further predisposition to injury or worsen arthritis in the case of the young or older patient respectively. Correct rehabilitation after an injury should make the knee feel 70-80% better. One must pay attention to symptoms if present about a month or later after injury and consult the right specialist at that stage. If seemingly minor problems are neglected, they can progress to irreversible joint damage over time. Many people get arthritis very early in this country as mechanisms for recognition of early damage are not in place.

In the case of arthritis, we see various remedies- both operative and non- operative being advertised. Before going for any of these, one must question the scientific proof and explore side effects. Any knee pain is described as arthritis. In my practice most 40 to 60 year olds presenting with knee pain are due to muscular problems or moderate arthritis at the most, which can be very well managed without surgery. In such cases exercises have a better role than medications. Traditional systems of medicine can work very well if implemented in pure holistic form, without mixing treatments.

Surgery – joint replacementon the other hand, is not for any joint pain. It works very well for pain and disability associated with severe end stage arthritis I.e. Bone surfaces badly destroyed, not otherwise. There is a lot of research on unsuccessful joint replacement surgery and specialists practising exclusively in this field could reasonably predict after careful discussion and examination whether a patient might benefit or not.The commonest reason for unsatisfied patients is improper selection of patient for surgery. When the arthritis is severe, it is pointless to roam around looking for ‘magic’ cures, as different medicines (allopathic or traditional medicine) all have a side effect profile. Arthroscopy (keyhole surgery) is something with almost no risk, but works well for ligament and cartilage injuries, not for arthritis. If advised at age of 40 or less, there is little to think against it as there is no risk or downside to it. In fact, it can be done as a day case with no overnight hospital stay. Rehabilitation in such case should be quick and the person can even get back to work within a week– seems like hardly any surgery at all. On the other hand, keyhole surgery after the age of 40 may not always be so advantageous, as the presence of arthritis might make it’s success limited.

Timing

Surgery, if and when advised, should be planned with a clear understanding of what is wrong and what one aims to achieve. The practice of admitting a patient in hospital first, deciding on joint surgery and undertaking it with no clear idea of timelines must be condemned, as results are far poorer in scientific literature across the world. The best results are when a patient has had enough opportunity to contemplate what they are undergoing, had discussions with close family and friends who will contribute towards their support and rehabilitation after surgery.
There is enough proof to show that knee surgery is not as successful when a patient is not themselves ready to undergo it. Hence no one should be forced unless they make the choice on their own accord.Most timings can be planned as per family logistics over a few months’ time.

Investigations and MRI
Development has brought about endless tests which are easily available even in smaller cities. Blood tests and MRI of knees are recommended at a very early and often unnecessary stage. These often do not contribute anything towards the patients’ treatment and reportscommonly have errors when the MRIs are low resolution poor quality images. There is also a known limit of diagnostic accuracy with these and errors in imaging could be 20% or higher. I would like to strongly stress that any blood test report or image in the world has relevance only in the clinical context I.e. if it can be correlated with a problem following discussion with and examination of the patient.
If and when the same patient presents for surgery, MRI done many months in advance might be irrelevant if the clinical picture has changed by then. Hence I would strongly advise patients to know from their specialist doctor why a specific test or MRI is being requested and whether it is likely to result in surgery, with the urgency thereof. If the patient has logistic constraints or is keen to try non- surgical treatment, there is often no need to undertake MRI. It could be postponed to a time when situations change.

Worsening the situation
There’s no doubt that overt advertisement of healthcare commodities confuse patients when they have to make a choice for their treatment. The easy way found by most is to take various opinions from multiple places and compare costs. There is nothing wrong in seeking opinions from practitioners of different principles too. However patient compliance with all the treatmentsin such cases is often very low. One must therefore follow advice given by the doctor for the recommended period before deciding whether it works or not.
The onus is on the patient to approach a particular practitioner. Instead of roaming randomly from pillar to postand taking a mixture of treatments from different places, often resulting in greater side effects than benefit. A literate person could check whether the doctor being approached is the best suited for their specific problem in terms of speciality practice. When comparing prices, the patient must ensure that they are comparing like and like. There is no point in compromising on certain theatre standards purely to decrease the cost and also cut corners by undertaking certain surgeries in theatres not correctly equipped. Bigger setups could cost more but would certainly be safe. Technical details are difficult to explain to patients. It will help patients to frankly discuss above matters with their respective specialist and understand nuances rather than run around with half baked knowledge. There are different ways of decreasing costs which can be discussed as per the individual’s problem.

Cost of Surgeryand Implants
Many patients are convinced that they want ‘imported’ implants, but would like compromise on other aspects in hospital to reduce the cost. This notion is incorrectly founded, as there are now some good quality implants being manufactured indigenously. There are similarly a number of implants manufactured abroad that do not have much scientific research backing.
In my practice, it is not expense, but clinical need that determines what implant a patient should have. There are various implant designs registered successful in the long term on international joint registries. It is best to select one of these or an indigenous one based on similar engineering design principles, which every joint surgeon must be well versed with. Within these, there are cheaper and more expensive options.
There are packages available in most specialist centres where costs can be cut. It is not worth further compromising on these in smaller setups as risks of complications then increase drastically.There are schemes available through which the State pays a major chunk of the cost, even when the patient is not previously medically insured.

Recovery after Surgery, Blood transfusion and ICU stay
Best practice techniques internationally have enabled ‘Enhanced Recovery’ in planned joint surgeries I.e. Patients walk the same day of surgery and achieve a level of activity that they can manage independently at home following discharge. This technique has shown immense cost benefit by reduction of hospital stay and the requirement for additional rehabilitation measures at home after release from hospital.
Similarly, with modern techniques, we have seen that requirement for blood transfusion after surgery in our practice is less than 5%. ICU stay is ‘0’ for straight primary operations. There are guidelines established in specialty centres around the world for joint surgeries so as to minimise complications.These methods have revolutionised such apparently ‘major’ surgery. It is not worth doing such surgeries if these standards are not adhered to. Every patient undergoing joint surgery can have access to world best practice standards.

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