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New horizons in joints replacement surgery : Dr. Raju Vaishya

Joint webTotal Joint Replacement (TJR) represents a major advance in the management of severe, crippling arthritis. More than 5,00,000 patients undergo Total Joint Replacement each year, in USA alone. Joint replacement surgery not only relieves the pain & suffering of a crippling arthritic, but give a new lease of life to the joint & improves the quality of life tremendously.
The true credit of bringing focus in India on Osteo-arthritis, an age old disease known to human, must go to our beloved Prime Minister, Shri Atal Bihari Vajpayee. many years ago, he was almost written off from the politics by his opponents & rival competitors due to his disabling arthritis, he then volunteered himself for the surgery of Total Knee Replacement of both knees to relieve the agony of his knee pain. Still, many have had their doubts as to its outcome & wondered weather he would be able to survive his remaining tenure as PM. He has surprised every one & proven wrong, as he is now much more active & strong politically & in fact has volunteered himself for the next tenure of PM! His new knees must get a due credit for this, as they have give a new lease of life to PM’s failing knees.
In recent years there has been some revolutionary advances in joint replacement surgery. Till recently the joints, which were commonly replaced were that of knee joints and hip joints. Now the other parts of body can also be replaced as that of shoulder, elbow, wrist, finger and ankle joints. It has been observed that Asian bones are not only small but also more fragile as compared to European and American bones. This discovery has led to better joints, which are better replicates of original joints and their life span has also increased to 20 to 25 years. The improvement in the designs & materials used in artificial joints have contributed to increase the life span of these joints. Some new bearing surfaces, like metal on metal, ceramic on ceramic & development of cross linked poly ethylene has shown to increase the life of these joints by reducing the wear rate & providing an efficient low friction artificial joint surfaces. Hence, it is now possible to implant these joints even in younger patients with crippling arthritis.
Contemporary Total Knee Replacement (TKR) which is currently one of the most frequently performed orthopaedic surgical procedures, has developed over the past 30 years. Although the goal of TKR is simple, the means of accomplishment are complex as surgeons & engineers strive to design a prosthetic joint that will function like a human knee. Success of the procedure not only is dependent on the skills of the surgeon & his team, but is also coupled with the design of the implant & instrumentation. A scientific sound design must be complemented by easily used instruments & a technique that assumes accuracy & reproducibility.
Although the procedure is among one of the most successful in Orthopaedic Surgery, the debate continues as to the best treatment option regarding TKR- fixed bearing or mobile bearing prostheses. Many of the fixed-bearing prosthetic designs have performed well at 10- to 20-years follow-up, but polyethylene wear, restricted joint mobility & patello-femoral complications have been reported. A newer approach to TKR (Mobile Bearing Knees) has been introduced in an attempt to reduced some of these problems. The Mobile Bearing Knees (MBK) may solve the fundamental mechanical problem of allowing joint mobility while minimising the wear of polyethylene bearings. Hence, MBK not only increases the life span/survival of the artificial joint but allows the patients to fold their knees more to near normal, as compared to the conventional TKR.
Now, newer ‘High flex knees’ have made it possible for the patients to almost fully bend their knees & to do normal activities of daily living like cross leg sitting & using Indian toilet. There are however, strict patient selection criteria for using these type of joints.
The other major development in orthopedic surgery has taken place in knee surgery, which is called uni-compartmental knee replacement. Now the recovery has become more swift and painless due to better cementing techniques. This surgery is more useful for younger generation because now surgery is also done without using binding materials. The screws and other press fit methods ensure further replacements and adjustments with less difficulty and pain.
In case of hip replacement surgery the method called hybrid hip replacement techniques is becoming common with higher success rates. The younger generation is showing higher success rate. Here the hip joint cup is fixed without cement through screws. The femoral component or the part of bone only needs cementing material. This technique has increased the life of joints and reduced post surgery recovery period. Young patients with arthritis (i.e, Rheumatoid Arthritis, Ankylosing Spondylitis, AVN etc) pose challenges for the surgeons, due to limited life span of artificial joints, requiring revision surgery later in life. The newer bearing surfaces like ceramic on ceramic & metal on metal, surface resurfacing etc are proving to be blessing for young arthritics, as they are likely to provide them long lasting solution to their hip problems. Birmingham Hip Resurfacing (BHR) has now made it possible for patients suffering with hip arthritis to fully bend their hips. These artificial joints are made of metal on metal bearing (with a very low wear rates) & involve minimal bone resection during surgery (bone preserving).
There has been phenomenal improvement in cementing methods for joining the joints. The material used for cementing is poly methyl methacrylate. It has been observed that if cementing is done properly then life of joints also increase and can last for life long. These days better quality cement guns are used. For mixing the material, vacuum mixers with pressurization techniques are used.
Not only there have improvements in the materials, designs & instrumentation of joint replacement surgery, but new techniques of replacing joints using small cuts (Minimally Invasive Surgery or MIS), computer assisted navigation surgery, & robot assisted surgery are becoming popular, as they are likely to provide more accurate placement of artificial joints with minimum of discomfort to the patient.
The future of joint replacement surgery is bright in India. The number of total joint replacements being done in India is increasing at a rapid rate in the recent past. Total Joint Replacement surgery has come here to stay forever, as it has proved worldwide over in the last 3 decades, through its excellent results. The two main problems of limited activities & life span of the artificial joints seems to have been addressed by these newer joints. A great amount of research is being carried out to further improve both the materials used in the replacement parts and in their design to make them function smoothly and as ‘normally’ as possible. With more trained personnel available in time to come & lower cost of prosthesis would certainly help in making the TJR to become extremely popular treatment option.

rajuVaishyaDr. (Prof.) Raju Vaishya , a surgeon of international repute, is best known for his swift surgical skills in the field of Orthopedic & Joint Replacement. He has been working at Indraprastha Apollo Hospitals, New Delhi as a Professor and Senior consultant. He is the founder president of Arthritis Care Foundation. Apart from his distinguished clinical work in the field of arthroscopic and joint replace¬ment surgery, he is well known for his academic contributions. He has more than 150 published articles in various International and national peer-reviewed medical journals and has been regularly invited to give lectures, chairing sessions,etc. in Orthopaedic conferences around the world. He has been awarded for the best paper publication on nu¬merous occasions by Delhi Orthopedic Association and Apollo Hospitals. His work was recognized in the Limca book of records in 2012, 2013 & 2015 for do¬ing bilateral Total Knee Replacement in 93 years old gentleman, bilateral Total Knee Replacement in the oldest couple in a single sitting, ACL reconstruction on oldest man.

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