Arthritis & Joint Replacement

HOSMAT Joint Replacement Centre is headed by Dr. Thomas A Chandy - Chief of Orthopaedics and Joint Replacement Centre who has had a rich experience, with over 18 years in the U.S. He has successfully done 8000 Joint Replacement surgeries in the U.S. and at HOSMAT, an average rate of 600 replacements per year. HOSMAT is one of the first hospitals in India in 1992 to have 2 dedicated operation theatres, out of 12, exclusively for joint replacement. HOSMAT Joint Replacement Centre has been recognized by three U.S. Multinational companies for 3 fellowship programs, with one fellow every year, after being qualified as an Orthopaedic surgeon (M.S. or DNB). HOSMAT Joint Replacement Centre has all the facilities which are mandatory for Joint Replacement surgeries to be undertaken. It is supported by excellent physiotherapy and occupational therapy staff.

Dr. Thomas A Chandy is a US Board certified Orthopaedic specialist who returned to Bangalore in 1993, after 20 years in the US with vast experience in Joint Replacement and Orthopaedic Surgery.

doctor thomas

Dr. Thomas A Chandy

Director & Chief of Joint Replacement Centre

Foreword

There was a misconception that it is a new surgery. However, Dr. Smith Peterson in the US in 1940 and Sr. John Charnley in England, 1962 were pioneers of joint replacement. In the last 40 to 50 years, tremendous progress has been made. Some of the hips that Sr. John Charnley inserted in the 60s and 70s, are still going strong. At Hosmat Joint Replacement has been performed, since its inception in 1993, but the Director of the Hosmat Joint Replacement center has been doing Joint Replacements since 1978 to 1993 in the US, and since 1993 at Hosmat Joint Replacement center.

Tremendous progress has been made in the last 40 years in the implant design, materials used, and the method of fixation. A knowledge of the, structure and function of a joint is necessary, to understand about joint replacement. Articular or smooth cartilage, covers the moving surfaces of the bones, inside the joint and there is extremely low friction. It has limited potential for growth and repair in an adult. There is excessive load on the hip due to obesity or improper alignment (due to knock knees or bowlegs) and the cartilage wears out. In a knee replacement, the worn out surfaces are replaced with a new surface of low friction, whereas in the hip and shoulder, the ball and socket is replaced. The present surgical steel alloys using cobalt-chrome-titanium and others including cement are biocompatible, which means that the patient's reaction to the materials are quite rare.

Over 2,00,000 joint replacements are done every year in the US. In India the numbers are smaller but growing. There are a handful of well-established centres around the country, that have been doing joint replacements effectively. There are few requirements to have a successful joint replacement centre:

  • The surgeon and the staff should be adequately trained and experienced.
  • The operation theatre should be well equipped for doing Orthopaedic surgery.
  • Environmental factors are important which requires very clean air, like central air conditioning, and laminar air flow, special HEPA filters that can filter 0.2 - 0.3 microns.
  • The traffic should be restricted, a good anaesthesia department, ICU, good Physiotherapy department and a blood bank are important. As well as a bone bank for revision joint replacement tumour surgery.

In the last 10-15 years AUTO TRANSFUSION has been popular in the US and some centres in India, where the patient donates his own blood 3 weeks before the proposed surgery, and his own blood is given back to him at the time of surgery.

Our implants are only US made ones, currently being used in the US. The Indian and Chinese implants have not been able to match the quality of the US ones.

The previous generation has accepted living with the pain as there were no alternatives. Nowadays with longer life expectancy, and active life style, and without a joint family, one has to remain independent. Therefore, joint replacement is being demanded by this active group of patients who are living into the 70s, 80s, and 90s.

Physiotherapy in various forms of heat, electrotherapy and, exercises may be helpful on temporary basis, but has side effects. Injections into the knee claiming to improve the lubrications, cause more harm. Cyclotron or RFQMR(QMR) magnetotherapy claims a cure, but is not proven to work and is very expensive. Arthroscopy for arthritis using a small telescope, can be helpful to decrease the pain, in varying degrees, temporarily for a short period of time. A walking stick or crutch can be useful, as well as knee caps and braces.

Joint replacement came to stay in the 60's and 70's and it is now a common operation. It is safe, effective and changes one's life style so that one can lead a fruitful, active independent, and pain-free life.

What is arthritis?

"Arth"- Joint "itis" - inflammation. The word therefore, means inflammation of the joint. The end of the bone is covered by a tough elastic tissue called cartilage, which keeps the bones from rubbing against each other. The joint is enclosed by a synovial membrane which releases synovial fluid into the small space between the two bones. This fluid lubricates the joints, allowing movement. Tendons and ligaments attached to the bones, provide support and direction to the bones.

Arthritis is malfunction of the body's immune system, which attacks the tissues mentioned above, causing them to deteriorate and finally leads to wear and tear of the bones as they rub against each other, causing acute pain. Arthritis manifests itself in more than 100 diseases belonging to the classification " Rheumatic Diseases." Arthritis can affect any one, including children and because the cause of it has still not been established, it is also called an autoimmune disease.

Inflammation of the joints is a major manifestation in arthritis that causes swelling, redness, pain stiffness and loss of motion in affected areas. Osteoarthritis and Rheumatoid arthritis are the two most well-known forms of arthritis. The former which usually afflicts aged people is caused by the wearing out of the cartilage and manifests itself through pain mainly in the principal joints such as knees and hips, fingers and toes. Rheumatoid arthritis is more systemic as it usually involves the whole system by showing up in several joints through acute inflammation and pain.

What is the treatment for arthritis?

There are many different drugs used to treat arthritis. These include aspirin, non-steroids anti-inflammatory drugs (NSAIDS), gold salts, antimalarial drugs, cortico steroid and anticancer drugs in a very low dose. Each drug tries to contain the effect of attack of the immune system, but may work on some and not on others. Each drug has its own side effects and care must be taken to consult a doctor and take the drugs recommended by him under his supervision and follow up.

In addition to medication which helps to ease the pain, regular exercise is very important. Proper exercises help keep joints flexible, build and preserve muscle strength and help protect the joint from further deterioration. Physiotherapy can help. Though many persons who suffer from arthritis, feel better in a warmer climate, it does not necessarily cure or improve the disease itself.

People with arthritis, like everyone else need well balanced diets, to stay as healthy as

Surgical Treatment

Hospital Visit

During the hospital visit, your doctor will take a careful history, examine you and review x-rays of your knees. He will discuss your general condition, allergies and the medications you are taking. Our surgical assistant will schedule a date for your operation.

Medical Clearance

Before proceeding with surgery we want to be sure that any medical problems you have, are under control. Please be sure to bring any medical problems you have, to our attention. This includes medications you may have checked online for any of the allergies that you may have. Prior to surgery you should correct any dental problems. You should continue to take blood pressure, heart and other medication right up to the time of your surgery. Take any heart or blood pressure medication with a small sip of water on the morning of surgery before coming to the hospital. If you are taking arthritis medications or any blood thinning medications such as Coumadin, please ask your doctor for guidance about when to stop taking these medicines. If you are diabetic and take insulin every morning, you must discuss this with your physician. also.

Approximately two weeks prior to surgery, all of your laboratory studies should have been completed and the results returned to your doctor. This allows time for any problems, such as a bladder infection, to be evaluated and treated. It is important that this laboratory evaluation be completed on time so that your surgery will not be delayed or postponed.

Donating Blood

In the last 10-15 years AUTO TRANSFUSION has been popular in the US and in some centres in India, where the patient donates his own blood 3 weeks before the proposed surgery, and his or her own blood is given back to him at the time of the surgery.

Approximately half of the patients receiving knee replacement surgery, require blood transfusions afterwards. In order to prevent possible complications from blood transfusions such as fever, hepatitis or HIV infection, we recommend all patients be evaluated for donating their own blood. An alternate program called "directed donor" in which family and friends with your blood type can donate blood for you, may also be considered.

Exercising Before Surgery

It is important for you to improve your general medical condition prior to surgery. With this in mind you should continue to eat nutritious well-balanced meals. Make every effort to stop smoking one week prior to surgery. While your knee pain will make it difficult, we would like you to work on those muscles which will be used right after surgery to stand and walk.

Hospital Orientation

HOSMAT Joint Replacement Center offers orientation classes. We strongly urge your participation in these programs. If you still have questions after these orientations, you may wish to speak to another patient who has had a knee replacement procedure. This can be arranged by calling the hospital and we can put you in touch with one of our patients who has volunteered to speak with patients like yourself.

Admission

You will be admitted to the hospital the morning of surgery. It is important to remember not to eat or drink anything after midnight the evening before surgery. You should take any heart or blood pressure medicine with a small sip of water the morning of surgery before coming to the hospital. Your consultant doctor will visit you with the In-house Anaesthetist and explain to you the hospital stay and procedure to be followed from day one. An IV (intravenous) line will be started in your arm and you will receive a dose of antibiotic. This antibiotic is administered for one to two days after surgery to help prevent infection. A preliminary antiseptic scrub of your knee will be performed which is repeated again in the operating room after anesthesia has been induced.

Surgery

Most patients are given a general anesthetic but a spinal or epidural anesthetic technique is also very satisfactory. During surgery, the joint surfaces are resurfaced and the joint is realigned. The decision whether to resurface the kneecap, is made during surgery. The entire operation lasts about an hour and a half after which you are taken to the recovery room to be monitored while coming out of anesthesia. After about an hour, you will be taken to your room.

Most knee replacement patients will have a tube similar to an IV line coming from their knee to drain excess blood. If used, this drain is generally discontinued the day after surgery.

You and your surgeon may decide that a catheter should be placed in your bladder to assist in monitoring urine flow. If this catheter has been placed, it is usually removed in a couple of days when you become more active.

What is the treatment for arthritis?

The day after surgery, physical therapists will begin to help you get up and move around. Exercises will begin to help you bend your knee. To help bend the knee, most patients use a continuous passive motion (CPM) machine which gradually and slowly increases the flexibility of the joint. HOSMAT has a homecare physio programme for 3-4 weeks for all

Physiotherapy and Recovery

You will be continually reminded to perform exercises with your ankles to help keep the blood flowing in your leg to help prevent phlebitis and swelling.

Almost every patient develops an area of numbness on the outer side of the knee following knee replacement. This is due to the position of the incision and the nerves in the skin. This numbness is permanent but becomes less noticeable with time and causes no disability.

Mild swelling is common in the operated leg after going home. This usually improves with elevation and the ankle exercises.

Living With Your New Knee

After discharge from the hospital, you will be encouraged to perform your exercises and to walk at home. It is common for patients to utilize the service of a homecare physiotherapist for the exercise program for 1 or 2 weeks. Your sutures will still be in place and this area should be kept clean and dry. If there are any problems with your incision such as redness or drainage, please notify the hospital. You should take your temperature twice a day and for any temperature elevation above 100.5 degrees F, contact the hospital. When you come to the hospital two weeks after surgery, sutures will be removed and new x-rays of the knee obtained. We will monitor your progress on a regular basis until you have resumed normal activities. Most patients usually walk on crutches for about four weeks after surgery and are able to resume most normal activities such as driving a car by about six weeks after surgery.

Who needs surgery?

A joint replacement is essential in individuals suffering from a painful disabling arthritis pain which persists in spite of medical treatment. The procedure is, therefore, indicated for painful arthritic joints with or without deformity - in-patients suffering from rheumatoid arthritis, osteoarthritis, traumatic arthritis and certain other non-septic arthritis.

High Flexion Knee Replacement

High flexion rotating platform knee replacement surgery, also called mobile bearing high bending knee is the latest and most modern advancement in the field of knee replacement surgery. The various types of knee replacement implant available in the market do not allow one squat or sit cross-legged, with high flex cross rotation platform knee replacement surgery, one can do this. Rotating Platform High Flexion is one very few implants, at the moment that gives the combination of high knee flexi0on and rotation. The advantage of rotation is that it gives movement in two planes, similar to normal knee, being minimally invasive, and the incision in the skin is much smaller and recovery is faster.

HOSMAT is the first hospital in South India to have a Computer-aided system, ROTATING PLATFORM knee replacement surgery, High Bending and Minimally Invasive system of surgery. The computer navigation system helps in dong a smaller incision with exact precision. The computer identifies shapes and size of the joint along with various angles by degrees. Manually, one can go wrong by a few degrees. The benefits of rotating platform high bending knee replacement surgery are:

  • Deep flexion ranging from 120 to 140 degrees, as a normal knee with reduced wear.
  • Rotational Freedom in deep flexion.
  • Allow kneeling, squatting and sitting cross legged, praying on the floor.
  • Excellent, bending & rotation.
  • Active lifestyle with long implant life.
  • Ideal for younger and middle aged active patient up to 65 yrs.

A knee replacement allows a patient to walk normally without pain, to perform all activities of daily living, work & certain play activities like long walk, dancing, golf, swimming & bicycle riding.

Other Joints Replacement

It is done for patients suffering from arthritis or a result of fracture where the head is split or broken into pieces - hemi-replacement (ball replacement only for fractures).

Shoulder arthritis can make common tasks such as reaching the head, combing one's hair and putting on clothes, a painful experience. Shoulder replacement is an excellent choice for relief of severe arthritis pain. The procedure may improve range of motion but the final result is unpredictable. The shoulder joint resembles a ball and socket and is stabilized by muscles and ligaments. The end of the humerus or arm bone, which forms the ball, is replaced with a metal prosthesis. One corner of the shoulder blade forms the glenoid or socket. Although the glenoid can be resurfaced with a plastic component, it often does not need to be replaced. Shoulder replacement often allows patients to begin a gentle range of motions a few days after surgery.

Elbow Replacement

Arthritis of the elbow can be due to systemic arthritis (arthritis that usually affects many joints) or previous injury. Replacement of the elbow, is an excellent procedure for relieving pain and restoring motion. The prosthesis consists of two stems inserted into the humerus (arm bone) and ulna (one of the two forearm bones) with a hinge in between. The hinge is slightly loose to allow motion similar to the natural elbow. Patients can usually begin to move the new elbow, a few days after surgery.

Revision of the Hip and Knee Replacement

Revision surgery of the hip and knee, is when the surgery has to be done again due to several reasons. The most common reason is loosening of the implant in the bone after many years. It is caused or aggravated by the wear and tear process. Other causes are breakage, joint instability, breakage, joint instability fracture, gradual bone loss, dislocation of the knee cap. However, persisting pain in the hip and knee is the most common reason for a revision, because in many cases of loosening without pain, there is no urgency in doing a revision. Hosmat uses various techniques and special revision instruments and implants in revision surgery to give pain-free and active life.

Life After Surgery

The patient’s life style after Joint Replacement takes a dramatic turn for the better. The patient’s activity is much improved. One can walk a few kilometers which can vary from 2 - 6 kilometers at one stretch, depending on the patient’s general health. He or she can climb stairs without pain. Sitting cross legged can be done for special occasion only. Using an Indian toilet is not advised except in an emergency. A golfer can return to playing 9 to 18 holes of golf.

The debilitating pain you experience with daily activities will be drastically reduced. You can probably reduce or eliminate the anti-inflammatory medication you took before surgery. Your activity level will also increase. Because a total knee replacement has man-made components and cannot continually repair itself, your doctor will probably advise against activities which can cause wear and tear of your new joint.