Adult Reconstructive Surgery: Knee and Hip Replacement

Dr. Sandeep Bhandari did his graduation from Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India. He did his Masters in Orthopedic Surgery from Manipal Hospital Bangalore, India. During his residency, he developed interest in Adult Reconstructive Surgery and did Fellowship at ISAKOS Training Center, Pune, India, headed by world-renowned Joint Replacement and Arthroscopy Surgeon Dr. Sachin Tapasvi. He also has Diploma in FIFA football medicine. He had extensive exposure in hip, knee, and shoulder replacement and knee and shoulder arthroscopy during his fellowship. With 14 years of extensive exposure in Orthopedics, he joined HAMS Hospital, Dhumbarahi, as Consultant Orthopedic, Arthroscopy and Joint Replacement Surgeon. Previously, he was a consultant in the Joint Replacement, Arthroscopy and Sports department at Grande International Hospital.

Many of us have heard our elderly relatives complain of ‘bad knees’ and seen them having difficulty walking around, climbing stairs, and more. This is a common complaint among the elderly, but thanks to modern medicine, this issue can be easily resolved today.The reason behind the joint issues that elderly people face is osteoarthritis. Hip and knee replacement surgeries are common orthopedic surgeries done to treat this issue. Osteoarthritis is the degeneration of joints. The cartilage between the joints, which helps you move your joint smoothly, erodes. This leads to severe pain when moving the joint, especially while walking. “Primary osteoarthritis is a natural process caused by aging, with most patients being above the age of sixty. It’s like the graying of your hair. There is nothing you can do to prevent it,” says Dr. Sandeep Bhandari, orthopedic surgeon at HAMS Hospital.

However, sometimes, other issues like untreated injuries or unknown trauma causing tearing of ligament or meniscus can also lead to early degeneration of the joints. Similarly, autoimmune diseases like rheumatoid arthritis can do likewise. This can lead to osteoarthritis even in younger people. This is called secondary osteoarthritis. However, it only makes up a small portion of the patient population.

In either case, joint replacement surgeries are the only solution to the problem.
Hip and Knee Replacement surgery started in the UK about 8 to 9 decades ago, and it was targeted towards the elderly population. “Because of degeneration of the joints due to aging, the elderly person cannot walk. The idea behind this surgery is to help these people walk again,” says Dr. Sandeep. Now, the procedure is done worldwide, and it is one of the most commonly done orthopedic surgeries in the world. Knee replacement surgeries are the most common, followed by hip replacement and shoulder replacement.

Once degeneration of the joints begin, slowly, the walking distance and speed of the patient decreases. “When the walking distance reduces significantly and the patient cannot even walk properly around their homes and neighborhood, then it is the right time to replace the knee or hip,” says the surgeon. He adds that osteoarthritis causes a significant decrease in the quality of life of the patient, as they are no longer mobile and independent. So, to improve the quality of life, they need joint replacement surgery.

“A lot of times, the elderly do not go to celebratory events like marriages or birthdays, not because they don’t want to, but because they cannot. They can no longer socialize properly due to their knees or hips. Sometimes, if their mobility is seriously compromised, they cannot even go to the bathroom alone. In such cases, families either need to hire a full-time nurse, or one of the family members needs to be a caretaker for the patient,” he says. “It creates a social problem for the patient, and sometimes for the family, as well. It seriously affects the quality of time. That’s why this surgery can be life-changing.”

Sometimes, osteoarthritis can also lead to other health complications. Walking is the most common form of exercise for the elderly. People with diseases like diabetes, hypertension, and COPD are advised to walk to strengthen their muscles and organs. But if they cannot walk and their mobility is compromised, they cannot exercise, and their health is further compromised. “Sometimes, because the patient’s balance is compromised due to knee pain, they may fall and further injure themselves,” adds Dr. Sandeep. This can lead to even less mobility, starting a vicious cycle.

Osteoarthritis can be divided into four different grades, depending on the level of degeneration of the joint. The grading goes from grade 1 to grade 4, with grade 4 being the most severe. The grading is done on the basis of X-ray. Usually, joint replacement is done in patients with grade 4 osteoarthritis. When the cartilage between the bones in the joint is completely worn out, it leads to severe pain and even knee deformation. That’s a grade 4 osteoarthritis, and it needs surgery. Although, sometimes, surgery is also done in grade 3 patients.

“Sometimes we see a grade 3 degeneration in the X-ray, but the patient feels pain beyond grade 4. In such cases, also, we replace the knee. Sometimes, the X-ray shows a grade 4 degeneration, but the patient is able to easily walk a kilometer, and they refuse to get the surgery. So, you have to treat the patient and not the X-ray,” he says. In some cases, the patients themselves understand the depth of their joint issues and ask for the surgery. According to him, these are the best patients, and “because they are motivated, they tend to recover faster.”

During the surgery, the degenerated part of the knee is removed, and the cartilage is replaced with a cobalt chromium alloy. The wear and tear on this alloy is very low, and it has an average lifespan of around 20 years. A highly compressed plastic called poly is also used between the metal alloy pieces to ease the movement of the joint after surgery.

Joint replacement surgery has a 98% success rate, with only 2% complication rate. Due to the high success rate, it is a common procedure. Most of the complications from this surgery are due to post-op complications like infection. However, they are manageable, and very rarely are they fatal. Dr. Sandeep advises that patients should use their judgment when selecting a hospital and should opt for a good hospital that is able to handle post-op complications, if necessary. He says that a good team of doctors and healthcare providers can minimize the chances of post-op complications. “Many people listen to one or two negative stories and refuse to get the surgery even when they desperately need it. But, this procedure has a very low complication rate,” he says, adding, “Just because road accidents happen doesn’t mean you stop travelling.”

After the surgery, rehabilitation and physiotherapy is needed for recovery. The patient usually spends the next five to seven post-operative days in the hospital. After that, they need to get physiotherapy in order to strengthen their muscles, improve balance, bend their knees, and regain full range of movement. They need to walk using a walker for the next two to three weeks. For the next two to six weeks, they walk with a stick. After that, they need no support. Hydrotherapy, where the patient exercises in water, or swims, is also a good idea post operation. The up-thrust in the water prevents stress to the joint, while the exercise helps strengthen the muscles. The patient is also on antibiotics for 2 to 3 days and blood thinners for a few weeks after surgery to prevent post-op complications.
While surgery is the only permanent solution to osteoarthritis, people can also opt for some other treatments, such as steroids, PRP, or injecting lubricants for temporary symptomatic relief. This can help people with grade 1 or 2 osteoarthritis temporarily, but it won’t help in the long term.

While osteoarthritis cannot be prevented, in case of secondary osteoarthritis, it can be slowed down. If all injuries causing trauma to the joints are treated immediately, and if diseases like rheumatoid arthritis are treated and managed in its early stage, it can slow degeneration of the joints and delay osteoarthritis.

For primary osteoarthritis, lifestyle modifications can help relieve complications caused by osteoarthritis. A major change that people can make is weight management. The more weight you add to the joints, the more stress it is under. Moreover, overweight and obese people may have issues with balance, which leads to injuries and fractures. This can also accelerate osteoarthritis. For people with osteoarthritis, simple changes like using a commode instead of a squat toilet, and living in the lower floors in their house instead of upper floors, can also help reduce the strain on their joints. These steps cannot reduce or slow osteoarthritis, but they can definitely help with pain management and reduce complications caused by this disease.

Overall, osteoarthritis is a natural process of aging, but through knee and hip replacement, people can now prevent this condition from affecting their quality of life.

 

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