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tailor made knee replacement. oxford unicompartmental knee replacement

Long gone is the era when we used to become homebound and depressed after end stage arthritis hit our knee.

We have become active and sporty in modern India. Our life expectancy has improved.

Some of us have become too busy in our day to day life. Hectic or sedentary? Difficult to say but surely lack of exercise and poor nutrition comes with it's penalty. 

Wear and tear of joints aka osteoarthritis has become very common as a result of above. We are living longer, some of us are getting injuries because of overactivity and some succumbing to lifestyle disease.

Knee joints are most commonly affected by osteoarthritis. why is that?

we humans enjoy an erect posture unlike most other animals. Our weightbearing knees let us enjoy all those sports and activities all our life but take the toll eventually.

They start wearing out.

interestingly the knee follows a pattern of wear and tear. Knee can be roughly divided in three compartments. inner, outer and knee cap

Most of us especially Indians have a slight bow in our shinbones (tibia) This causes more loading of the knee joint on the inner aspect  compared to outer aspect.

As the knee wears out more on the inner aspect the bow in the legs increases making us bowlegged.

We often see elderly people with bow legs. They have an advanced osteoarthritis of the knees which has caused the legs to bow because of asymmetrical wear.

Anyway, we doctors have always teamed up with our engineer friends to find solutions for worn out knees. Over last many decades we have been able to give people pain free knees to enjoy life.

When the arthritis starts we can advice various activity modifications and exercises. There are supplements to improve joint lubrication and keyhole surgery can tidy up the joint to make it last a bit longer.

However when the joint shows advanced arthritis these modalities cease to help.

That is when advanced engineering comes to our rescue.

Knee replacement design was pioneered in England and USA. Dr Insall played a critical role in defining the modern knee replacement.

Knee replacement aims at restoring the normal painfree functioning of the knee joint by replacing the worn out surface.

All three compartments are replaced.

There are three main components. A cap which covers lower end of thigh bone.

A base plate which replaces the top of the shin bone. A knee cap undersurface.

These components are fixed to the bone using an acrylic polymer which we cann bone cement.

Between these components is a long lasting bearing.

This is known as a total knee replacement popularly called a TKR.

In the last fifty years so many things have evolved.

we have understood the anatomy and geometry of the knee mush better. That has resulted in more anatomic designs of the prosthetic knees.

We have understood the dynamics of knee motion and the way we walk. This input has resulted in more natural feeling knee replacements.

The materials are evolving every decade.

We started with standard stainless steel alloys and we thought that's the best.

Then came cobalt-chrome, titanium alloys making our joints lighter and longer lasting.

Use of ceramics have increased the longevity further. I hope we have a knee which "never wears out" soon.

The fixation of the prosthesis to the bone has become more natural by use of various types of coatings like tantalum trabecular metal and hydroxyapatite.

The tools to perform surgery used to be precision engineered mechanical guides. We used to be very proud.

But computer navigation made these lovely tools a history.

Customized preplanned patient specific knee replacements made computers look primitive. Now all of this will be surpassed by use of orthopaedic robots.

Surgical techinique and training not only evolved by technology but modern surgical handicraft became minimally invasive.

Patients experience much less pain, they walk home quicker and they return to active life much sooner.

Mr Taylor came to me.

Keen golfer and sportsman.

About my age. instantly likeable person.

His knees were wearing out. Typical Indian mild bowlegs.

Wearing out only on the inner side.

He wanted to walk, cycle and golf.

He wished to lead active working life.

I examined him, did his xrays and scans.

Just the inner/ medial compartment worn out.

Outer compartment, kneecap, ligaments were in a pristine condition.

It was a long counselling session.

I offered him a very special solution.

Best of modern technology and surgical precision.

I decided to just replace the worn out medial compartment.

This is known as a "unicompartmental knee replacement"

Its also called "microplasty"

This very special technique was developed and perfected in Oxford England over last couple of decades.

It involves a delicate fine tuning of the worn out inner compartment by just removing precisely only the worn area.

Rest of the knee which is normal is preserved in its normal anatomoical functionality.

This is like a hybrid engine we see in high end cars today.

two different mechanisms married to each other functioning in unison for a great long term future.

Mr Taylor agreed to let me give him "tailor made" knees.

Because he was a man in a hurry with lots of commitments in a short span, I took another unusual decision in his case.

I operated on both his knees in a single sitting.

Normally I would do unicompartmental arthroplasty one knee at a time to allow a leisurely recovery time.

In his case I did bilateral single sitting unicompartmental arthroplasty. I believe a first one in Maharashtra.

knee replacement guidance

Total Knee Replacement on the horizon

There is a lot of fear when a surgery is advised for knee arthritis.

What is arthritis?

When the knee joint wears out we call it arthritis. This may be age related wear and tear (osteoarthritis) or inflammatory (rheumatoid).

The joint gradually wears out leading to loss of cartilage cover and an end stage arthritis which then needs some definitive and long lasting solution. Basically the worn out surface of the knee now needs to be replaced by a artificial surface called “KNEE REPLACEMENT”

Latest advances have made knee replacement an excellent long term solution for a pain free active life and a satisfying achievement for arthroplasty surgeons like myself.

In majority of patients we need to replace the entire knee surface with a total knee replacement (TKR)

In some patients where the joint has only one sided damage we can fine tune the joint by replacing only the worn out area. This is known as a Uni-compartmental knee replacement or a UKR. Its a very special technique with great results.

Such patients return to a normal life and its difficult for anyone to figure out that this individual was a arthritis patient.

Certain advances have made which I will expand on shortly. These advances have made the TKR more like your own natural knee joint, longer lasting and able to stand forces of some sports and recreational activity.

These are basic types of knee replacements

1. Standard total knee replacement (age old, tested with time and proven)
2. Stabilised (some ligaments can be sacrificed)
3. Cruciate retaining (tissue preserving)
4. HI-flex (allows more bending)
5. Rotating platform (design variation to reduce stresses)
6. medial pivot (mechanics like a normal knee joint)
7. Gender specific (specific designs for men and ladies. accommodates for tiny bones)
8. Oxynium/ceramic (long lasting coating on alloy)
9. Revision knee replacement (designed to be used when original knee replacement wears out)
10. Unicompartmental knee and microplasty (replaces just the worn out part leaving normal part untouched
11. highly cross linked polyethylene or vitamin E impregnated bearings.

Choice of replacement hardware for the surgeon is plenty. What is right for you is best advised by your surgeon according to your needs, age, activity levels and condition of your knee.

Anatomy 

The knee comprises the joint between the femur and the tibia but also the joint between the patella and the front of the femur. Either or all of these parts of the knee may be affected by arthritis to various degrees. 

Who Needs TKR and who doesnt?

Whoever has arthritis which has progressed to an end stage will have significant pain, need to take painkillers, reduced mobility, limp. These are the symptoms which decide on need of TKR. we don't necessarily wait for all these symptoms to appear. ability to sustain pain varies from person to person.

because of excellent technology and expertise available patients may choose to avail the benefit of surgery before symptoms get bad.

when symptoms are significant the effects on the knee are showing up. deformities arise and accordingly I have to plan the hardware.

What are the risks?

we do tests before surgery. They are bloodwork,  X-ray chest, ECG and Echocardiogram. this tells me about fitness. majority of patients are able to achieve fitness for a safe anaesthetic and surgery.

Often I do TKR on both knees in a single sitting.

Some patients with multiple medical problems like poor heart function or bad lungs are likely to have major complications and surgery may not be possible. However age is not a criterion. I have seen many old people with excellent and well preserved health. Such elderly candidates benefit immensely from TKR.

Can I choose the knee I want?

Certainly but only to an extent. You must rely on surgeon’s guidance to understand what type of TKR design is good for your future years of mobility and freedom from pain.

What if I don’t want TKR?

If you have end stage arthritis and unable to have TKR because of fitness problems then there may be a solution but it”s a difficult one. Fusion or arthrodesis of the knee can be done but along with pain all movement will be lost.

Not choosing to have the surgery because of fear will not allow me to help you much.

Surgical technique

My anaesthetist will either use a spinal - epidural anaesthetic or a general anaesthesia. depending upon what is safe for you.

once I prepare the knee with antiseptic solution an incision of 15 cm is made in front of the knee

If a uni or partial knee replacement is being performed, a smaller incision sometimes of only 5 cm in length may be used. 

Knee replacement is performed in following  steps. Whole procedure takes hour and half or so.

1. Tibia (leg bone) is shaped precisely horizontal to receive the base plate.
2. Femur (thigh bone) is shaped to receive the femoral cap. basic cut is parallel to Tibia cut
3. Ligaments are balanced during above steps so that the cuts remain perfectly parallel and knee can function as a hinge
4. patella (knee cap) is shaped to receive the patellar button
5. Trial components are fitted to ensure in tibia, femur and patella to ensure smooth and balanced motion
6. Final components are fitted with an acrylic polymer (bone-cement) which sets in 10 minutes to ready the knee for many years to come
7. wound is closed in layers after infiltrating pain killers.

The recovery from the operation requires about two to four days in hospital. In this time physiotherapy is commenced.

 Physiotherapy 

The day following surgery the physiotherapist will get you out of bed to commence walking with the help of crutches or a walking frame. 

Initially the leg will be placed on a continuous passive motion machine to gently move the knee through a pre-set range of motion. In addition, exercises to improve the strength of the quadriceps muscles are performed.

The machine will be removed soon for you to perform your own exercises. 

The physiotherapist will also begin to encourage you to bend the knee. Sitting over the side of the bed may assist. 

Early exercises and mobilising of the knee will cause some discomfort and swelling. However, this is normal and we have a pain team to look after your comfort.

After 5-10 days usually you are able to walk with minimal pain, with the assistance of sticks, crutches or a frame. You should be able to manage stairs with the assistance of a banister, and to care for yourself around the home. 

Whilst at home the exercise program of quadriceps exercises should be vigorously continued. Approximately 20 minutes couple of times a day will be ample. Out patient physiotherapy sessions should be arranged during this period. 

Various modern techniques to enhance the results.

1. Minimally Invasive Surgery: MIS

Minimally invasive surgery involves the use of not only smaller wound incisions but the tissues are anatomically preserved. 

These techniques usually result in significant advantages in respect to improve the speed of recovery, speed of mobilisation, shorten hospital stay reduce the period off work and reduce the time until functional and sporting activities can be resumed. The techniques also usually reduce the amount of post-operative pain experienced and the need for post-operative pain relief and analgesia.

special instrumentation to enable surgery to be undertaken. 

2. computerised navigation

the geometric cuts in the bone are calibrated using classic mechanical instruments which are precise.

However use of computerised navigation during the surgery can improve on the precision even further.

here the readings from the patients knee are relayed to a computer which then guides us precisely.

when we perform surgery on youngsters or if the case is very difficult this navigation is immensely useful.

3. virtual surgery or patient specific (customised) knee replacement

its like doing your homework the before school.

a CT scan of your knee is used to get a 3D print. This 3D life sized model is used to predetermine the cuts on the bone.

Once this homework is complete the surgery is completely planned even before patient is in hospital.

It ensures a precisely performed TKR and any difficulties in surgery anticipated well before the actual operation.

4. Robotics- 

one step ahead of customisation. ultimate precision attained by using a surgeon controlled robot to perform certain mechanical steps of surgery

Results and Complications 

Modern techniques and technology ensure that the complication rate is minimal. Beside the anaesthetic risks, which are very low, infection that involves the joint is less than 1:100. This would present as the knee becoming hot, swollen, throbbing and painful after 2-4 days, or alternatively at any period thereafter. Venous thrombosis is in the order of 1:50. To avoid thrombosis anti-coagulant therapy will be given for a short period after the operation. Generally, the results of knee replacement are excellent and as good as or better than hip replacement. 

I expect that a knee replacement should, if cared for, last 15 years in over 90% of patients. After joint replacement, in order to avoid infection of the new joint, all infections or dirty wounds must be adequately treated with antibiotics. A yearly review should be undertaken. This is to ensure that the prosthesis is not becoming loose.  

Gym supplements protein

India is getting muscular in more ways than one!

We are seeing modern gyms in all neighbourhoods now.
Our cricketeers and bollywood icons looks fitter, brawnier with sculpted muscles to envy of most men.
we think why not me?
we start gymming and find that months of pumping iron does not get us anywhere near rhitik or salman.
we start thinking.........should we take supplements?

protein supplements are perhaps one of the common ones available. as long as there are no other additives in it they may be safe.
\those come in various forms ranging from simple protein bars and shakes to specialist products which contain not only proteins but also creatine or testosterone boosters.

proteins are building blocks of human body. Our muscles are mainly made of protein. Thats the simple logic of needing protein to build up protein.
our body undergoes constant turnover. all our body tissues are constantly being renewed and refreshed. waste products of protein metabolism are removed from the body via kidneys.

so we need strong kidneys in able to cope up with increased turnover of protein metabolism.

if you are planning to resort to any supplements to enhance your gymming, simply reading on the tin of the supplements may not be enough.

you must consult your physician whether it is safe for you.

protein shakes can be loaded with calories which are fine for fit youngsters but not if you have tendency for diabetes. read about the carbohydrate content.

shakes purely consisting of protein may be fine in recommended doses provided your kidneys work well. But then drink plenty water when you are on such regime. plenty water keeps kidneys flushed.

occassionally there may be steroids or hormones added into these formulations. for a lay individual this is a strict no no. these will do damage in long term.

bottomline...pure protein shakes are safe as long as you are fit and well hydrated. happy gymming

--
Dr Sachin Bhonsle MS(orth) ; FRCS(Glasg, UK)
Senior Consultant Orthopaedic Surgeon
Fortis Hospitals

Mulund, Mumbai, 400076
INDIA

simple backpain in youngsters

Everyone sufferes from backpain at some stage in their life. On day to day basis this common orthopaedic condition can be a cause of loss of livelihood as well as earnings.

What is important to know is that correct approach can help us to get a much better quality of life and almost avoid the aches and pain.

In today’s fast moving life backpain has not only become more common but I am also seeing young and fit individuals coming up with problems. I really feel bad about this and as a doctor I feel my role lies in educating masses in addition to treating the back problems.

Classically the causes of backpain have been age related wear and tear also known as spondylosis; problems with back cushion which we call slipped disc; instability in the vertebral joints ; certain diseases like infections (TB) and cancers.

What is more worrying is the new trend for back pain caused by lack of sunlight resulting into vitamin D deficiency ; poor posture ; lack of exercise; being overweight; junk food and nutritional deficiencies; poor lifestyle with alcohol and tobacco usage.

In the good old days youngsters would have plenty of sporting and outdoor activities during student days.

Foundations of the body with good bone structure would be laid down by healthy balanced diet, sunlight exposure topping up vitamin D and exercise building solid bone stock as well as strong muscles.

Today young guys working long hours neither get sunlight nor any exercise.

Constant usage of smartphones with flexed neck leads to neck and back strain.

Poor sitting positioning and standing position in kitchen will lead to muscle fatigue and backpain.

Watching TV sleeping in crooked posture cause problems.

Poor diet, alcohol and tobacco contributes to above posture by draining valuable resources.

My message to everyone.

Have balanced diet and sunlight exposure. If sunlight exposure is not possible talk to me about Vitamin D.
You MUST exercise! If difficult park your vehicle one km away and walk to work. (Get off one bus stop before)
Look after your posture while working, driving, using phone and at home.

Cut out bad habits.

arthritis in india

1.      Prevalence of arthritis in India - 

roughly 20% adults in India have some type of arthritis. thats 1 in 5 adults.

arthritis includes osteoarthritis, rheumatoid arthritis, gout, SLE, Lupus, sero-negative arthritis and other miscellaneous types.

the prevalence is more or less the same in general compared to western countries but there are differences in presentation. differences as follows.

Indians mostly have bowed (varus) tibiae. This leads to predominantly a medial osteoarthritis causing exaggerated bowing. Such patients are commonly seen to be walking with a waddling gait with enormous bow legs. Its defined as a "varus thrust gait"

In spite of such bad deformities indians tend to have well preserved bending of their knees. In general Indians have very flexible knees compared to Caucasians.

primary Osteoarthritis of hips is virtually unheard of in native Indians. 

rheumatoid arthritis of poly articular variety is less common than in western countries.

also rheumatoid arthritis with juvenile onset and systemic involvement is less common.

certain rarer forms of arthritis like "ochranosis" is virtually non existant in India

but certain rarer forms like "sickle cell disease related arthritis" are more common

2.      Projections of prevalence in next ten years

the arthritis will be on rise in the coming decade because of multiple reasons.

mainly increasing life expectancy, increasing obesity and alcohol abuse.

sedentary habits in cities may see earlier onset of arthritis.

3.      What are the main diagnostic tools used for diagnosis in India

diagnostic tools are standard.

clinical examination and history taking is gold standard.

xrays, scans and lab tests are useful tools.

management of trauma

success in management of trauma is not easy to achieve.

having highly trained and experienced trauma surgeon is the pivotal part.

the jig saw puzzle is complete with all the pieces in right place with precision.

in trauma the term "golden hour" is very important. the first hour after injury if well managed saves lives. well trained ambulance staff and attending paramedics are vital.

once stabilised patient is transferred to "accident and emergency" department the trauma team consisting of orthopaedic surgeon, general surgeon, casualty specialist and anaesthetist awaits. the equipment in A&E department and trained nurses make world of a difference.

readiness of emergency operating theatres with appropriate life and limb saving equipment is paramount.

when i returned from england to fortis hospitals this is one of the first things i checked out.

I had been an "advanced trauma life support" provider in England and i adhere to the principles here.

we can quote lots of examples how we made a difference to many lives at fortis.

1. 15 year old girl lost her balance and fell down 9 storeys. i received a call from her doctor. it was sunday morning and i could just drive down to fortis in minutes. this beautiful girl was brought to A&E in a state of shock with multiple limb fractures.

advanced trauma life support protocol was followed. her airway (A) was secured first. Breathing (B) was ensures normal. Circulation (C) i.e blood pressure stabilized with adequate fluid resuscitation.

After above A,B,C were stabilized she was moved to CT scan where the whole body was scanned to check internal organ damage.

When she was shifted back she was reexamined.

this girl was taken to operating theatre after fully stabilizing and she went home smiling in just over a week since this horrendous fall.

2. 23 year old factory worker got his right hand cut off in a machine. he went from pillar to post so seek help. he did not succeed in finding anyone who would agree to repair his hand back to his body.

by the time he arrived in fortis it was almost ten hours since the injury.

i was not very hopeful about the prospects especially because so much time had lapsed. the had tissues may well have started to decompose.

in any case i decided to go by the book and put the machinery into motion.

i requested my esteemed plastic surgeon colleague to come over to do microvascular work to repair his blood vessels.

in the meanwhile i cleaned up all the dirt and provided stabilization to the bones.

this created a stable bed for repair of blood vessels. 

after the repair the blood gushed back into his hand after eleven hours.

in a couple of days it was heartening to see that his hand had survived.

we reconstructed his nerves in subsequent weeks and freed up his tendons.

today he can move and feels his fingers and is back to work.

3. 18 years old student was riding pillion on a motorcycle. the bike had an accident and he was ejected off the eastern experss  highway mulund flyover.

this boy fell 25 or 30 feet on hard road. he was rushed to fortis hospital where we followed ATLS protocol and resuscitated and stabilized him.

he underwent several surgeries and was finally restored to a completely normal young man.

4. 25 years old junior doctor working as a houseman was knocked down and run over by a truck.

he was taken to a local hospital where he was given initial treatment for a massive soft tissue swelling of his shoulder.

actually the wheel had passed over his shoulder causing rupture of main artery to his arm.

to make the matters worse muscles and nerves in that area had got bruised and stretched out too.

it was five hours since the accident when he was shifted to fortis.

initial stabilization in casualty was really fast tracked. I had to take him to theatre to restore circulation of his limb but he had to be stabilized too. luckily the young man was strong like a bull and stabilized fast.

we operated on him within three hours of him arriving in hospital. his artery was repaired.

he required further reconstructive surgeries to treat shoulder dislocation and nerve injuries. today the young doctor has fully functioning hand and wants to be a surgeon.