WHAT HAS CHANGED IN REGARD TO JOINT REPLACEMENT SURGERY?

Total Knee and Total Hip replacements are highly successful operations that can dramatically improve the quality of life of a person riddled with end- stage arthritis. An increasing number of people are having these now as the technology and expertise has become easily available across our country. At the same time, the rapid expansion of the Healthcare industry in India has led to mushrooming of several facilities, all of which market their wares quite aggressively. In this scenario, it is possible that the opinion seeking patient is offered the solution that is available within the premises of the particular healthcare facility rather than the treatment which might be best suited for that patient’s specific needs. It is therefore important that one is aware of the options available when at the receptive end of this gamble.

First of all, replacement surgery works for severe arthritis that has caused significant pain and disability. If there are symptoms from early or mild arthritis, there are a variety of non- surgical treatments like exercise, medications and injections which must be explored. A thorough consultation with a specialist helps decide which option is the best suited for a particular individual. Similarly, Total Joint Replacement works well in people over the age of 60 years. At younger ages with severe arthritis, surgical options like bone re-alignment and Partial Joint Replacement exist.

Joint Replacement is an elective procedure and must never be decided upon in a hurry. It must never be forced upon an individual or the success and satisfaction will be less, as any operation involves going through pain and risk. At the same time, new developments have enabled many of the previous myths associated with such procedures to wane.

For patients wanting to undergo such surgery, there are good services available in most Indian cities. There are an increasing number of dedicated firms doing exclusive work, where the standards are bound to be better. At the same time, I would discourage people from travelling too far to have these procedures undertaken at the more famous centres, as travelling back home soon after such surgeries is not without risk. Similarly, one must be in a position to manage stairs within three to four days of surgery too, unless one has not been doing stairs at all before. Only with a reasonable amount of independence, usually achieved within four to five days of surgery is a patient deemed fit to leave hospital, as we cannot guarantee good rehabilitation with the currently available infrastructure of home care services. The cost of surgery varies a lot with the city and set up. However, it does not mean that increased cost would guarantee important things like theatre standards (having a separate theatre for clean planned cases), water impervious drapes, etc. What materials are being used should be transparent and patients must demand for records of what is implanted into their bodies.

Patients in our country are given a choice of “Indian” or “Imported” prostheses. There is however a large armamentarium of prostheses available from across the world. We have some very good quality prostheses manufactured in India now. Similarly, there are ones manufactured abroad with less sound engineering. Every joint replacement surgeon should ideally be comfortable using a range of prostheses. The question to tackle is the disability experienced by the individual person leading to joint replacement. Design of prosthesis should be selected as per that very need. Differently manufactured prostheses are based on different engineering. The pattern of movement allowed by each prosthesis is thereby slightly different. Different designs of prostheses can hence be chosen to suit the individual patients’ specific needs and to match their pattern of arthritis. The price often depends on an individual companies marketing strategies. Expensive pricing certainly does not equate with better design always.

Even though an operation of this nature is a large attack on the body, there is worldwide evidence that shows better results when patients are made to get up and walk right from the day of surgery. With the patient visiting the toilet on the day, urinary catheterisation can be avoided. Patients even manage stairs in a couple of days. Hospital stay and complications like infection thereby are much reduced. Modern techniques of pre- operative medication and anaesthesia combined with sound surgical measures make this ‘Enhanced Recovery’ possible. As these procedures are planned, we have the opportunity to optimise the patient’s status before the surgery.

The technique of making a patient walk early has been used in reputed centres worldwide for the last three to five years with documented success and decreased complication rates as compared to the conventional technique. At the same time, marketing sometimes go over the top and advertise Joint Replacement as ‘day surgery.’ A technique is good and viable when it can be reproduced easily for most patients undergoing Joint Replacement, not for a select few younger and fitter ones. Even in a smaller setup in Mangalore, we have employed this over the last six months, and 100% of our patients of ages between 62 and 79 have stood up and taken a few steps on the day of surgery.

Elective surgery is an entirely different ball game as compared to emergency or traditional fracture related orthopaedic operations. It is a matter of changing the quality of somebody’s day- to- day life. Seemingly small alterations in technique can hence make a large difference in rehabilitation of a patient into their desired life activity following joint replacement procedures. With the increasing scale of these operations across our country, it is imperative that dedicated units offering such services incorporate the best standards of care and rehabilitation.

The author Dr. Yogeesh D. Kamat is a Consultant Hip & Knee Specialist Orthopaedic Surgeon. He practises exclusively in Joint Replacement, Arthroscopy and Sports Injury related to the lower limb joints and is available at KMC Hospital

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