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 recognised by three U.S. Multinational companies for 3 fellowship programmes, 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.
Dr. Thomas A Chandy
Director & Chief of Joint Replacement Centre
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 excpectancy, 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 affect of attack of the immune system, but may work on some and not on others. Each drug has its own side affects 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 possible. Overeating and overweight will put an unnecessary burden on the system and joints and therefore should be controlled.
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.
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 ONLINEd any allergies 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.
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.
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.
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.
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.
Physiotherapy And Recovery
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 patients.
Range Of Motion Excercise
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 utilise the service of a homecare physiotherapist for the exercise programme 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 thee latest and most modern advancement in the field of knee replacement surgery. The various types of knee replacement implants 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 erhead, 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.
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 patients 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.
Commonly Asked Questions On Joint Replacement
01. What are the commonly used materials for joint replacement ?
Commonly used materials for joint replacement are a stainless steel alloy called Cobalt Chrome Alloy and plastic called ultra high molecular Weight High Density Polyethylene - Cross Linked Type.
02. At what age can joint replacement be done? Can it be done for children?
Joint replacement is commonly done for patients above the age of 55 years. It may be done between ages of 40 and 60. It is occasionally done between ages of 20 and 40. It is never done in children.
03. What is the average hospital stay recommended after joint replacement?
The hospital stay is for seven days after joint replacement.
04. What is the average time taken for joint replacement surgery?
The average time taken for joint replacement surgery is 1-1.1/2 hrs.
05.Can a person with diabetes, high blood pressure, or heart trouble undergo joint replacement?
Even a person with diabetes, high blood pressure, cardiac disorders can undergo joint replacement surgery under medical supervision. The diabetes or BP must be under control.
06. What are the common complications after joint replacement?
The possible complications after joint replacement are general as in other operations and Deep Vein Thrombosis, dislocation for hips and infection. Long term complications are loosening and wear. These are easily preventable and in all cases preventive measures are taken. The infection rate in India averages 5 to 8 per cent. In the US it is 1 to 2 per cent. At Hosmat our infection is the lowest in India at 0.8 per cent.
07. What is the role of physiotherapy and exercises after joint replacement?
Exercises called CPM - Continuous Passive Motion machine start within 1-2 days after joint replacement, while walking is started 2-3 days after joint replacement with full weight bearing, as tolerated.
08. Does one need some support of a walker or a stick after joint replacement?
Yes, if only the knee is involved, then a walker for one week and a walking stick for 3 weeks. If both knees are replaced, then it takes twice the time. The same protocol for hip replacement with cement. Non cemented hips - walking after 2-3 months with a walking stick and weight bearing.
09. What precautions are taken to prevent these complications?
To prevent deep vein thrombosis, early exercises are started, and in some patients specialized medication, is administered. To prevent infection, surgery is carried out in a specialized operation theatre and antibiotics are given pre-operatively. Long term loosening is prevented by keeping the weight down and avoiding excessive activity and squatting.
10. Can a patient be operated for two joint replacements at the same time?
Usually one joint is resurfaced at a time, but if the patient is fit, occasionally both knees or both hips may be resurfaced in one sitting. The blood loss and infection risk may be slightly higher. Hosmat has an excellent anaesthesia team and higly qualified cardiologists, physicians and pulmonary specialists. We do bilateral knee in the same day, every day.
11. Can these operations be done in any Nursing home or hospital?
No. This is a specialized surgery which requires a special set up, including proper operation theatre, post-operative intensive care unit, trained nurses and technicians and expert physiotherapists to achieve desired results. If needs a special air conditioning with special dust filters (HEPA 0.3 micros) and multiple air changes and also a blood bank. It also requires well-trained doctors and nurses.
12. What are the precautions to be used after joint replacement?
It is advisable to use a bedside commode for 3 to 4 weeks and a normal toilet after that, Avoid sitting on floor, jogging, running and fast sports after joint replacement surgery. Moderate speed walking, climbing stairs and swimming are permitted.
13. Is it covered under Insurance?
That will depend on your mediclaim policy and other insurance. More insurance companies are operating now and all cover these surgeries. The discharge summary will state the diagnosis and operation.
14. After the knee replacement will the patient be able to squat?
It is difficulty to do the traditional squatting. However, one can sit cross legged for a special occasions and can also sit in the sideways sitting position of the ground. For a hip replacement also, one should not squat on the floor, one can sit cross legged without full bending for special occasions, only and that also after 6 months to 1 year.
15. Does one need plaster of Paris cast after surgery?
No, your knee is free, a brace is used for few days for comfort and support and, usually hinged knee cap is used for walking for a few weeks.
16. Is the knee replacement a transplant?
It is not a transplant for the knee, the lower end of the thigh bone and upper end of leg bone and the knee cap of patella have a new surface. However, for the shoulder and hip the ball is replaced with a new socket or cup is lined with a new cup.
17. Does one play golf after a knee replacement?
Yes, one can play golf quite easily with 9 holes after 2 months. In a reasonably healthy person after a knee replacement, 18 holes can also be done after 4 months.
18. Does one can play Tennis and other Sports?
Tennis and running is too vigorous including jogging, and it is not advised because it will cause additional wear and tear.
19. How far can one walk after a Joint Replacement?
One can walk as many kilometers as general health will allow. Some patients can walk even 8 k.m at one stretch. But generally one can walk for 2 to 5 km without any problem.
20. How does Joint Replacement affect swimming and cycling?
Swimming and cycling are certain exercise are good exercises. However one must be cautious in climbing out of the pool with other joints involved.
21. What is the result of shoulder replacement?
Shoulder replacement today is comparable to the knee replacement in results and function, and is good.
22. What is result of ankle replacement?
For Ankle replacement worldwide, the result is not as good as knee and hip replacement. (Generally for an ankle with severe disabling i.e. a fusion or arthrodesis works very well joining the end of the leg bone and the upper end of the foot bone).
23. How about joint replacement in cancer?
Cancer involving the end of the bones can be replaced by custom-made prosthesis after removing the cancerous growth based on the circumstances of the patient and type of tumour, and whether a primary bone tumour or spread from elsewhere like from breast, lung or Kidney.
Commonly Asked Questions On Arthritis
01. What are the types of arthritis?
There are two main types of arthritis, Osteoarthritis means wear and tear due to ageing and joint injury and overweight. The other common type of arthritis is called Rheumatoid arthritis, which is almost like as if one is allergic to ones own joints.
02. At what age does arthritis pain start?
Rheumatoid arthritis usually starts at the age of 30, osteoarthritis starts about 40-45 in overweight people, osteoarthritis can start from 30.
03. How common is arthritis?
About 12 per cent of the population worldwide suffer from arthritis.
04. Does spondylitis come under arthritis ?
Yes, it is a form of degenerative arthritis of the spine - Neck (cervical) or lumbar (low back).
05. How is arthritis diagnosed?
The early warning signs are resisting pain and stiffness in the joints especially getting up from the bed or a chair. The clinical examination is necessary as well as to rule out other joint problems like Tuberculosis and blood test like rheumatoid factor though it is positive only about 65% of patients. Erythrocyte sedimentation Rate or ESR is another test which is useful, normal is 0-10. In Rheumatoid arthritis it is high and another test called CRP and antinuclear antibody or ANA is also useful. Uric acid test is useful to rule out gouty arthritis. In osteoarthritis and spondylytis, x-rays and scans will be diagnosed and blood tests are normal.
06. Is there any cure for arthritis?
There is no cure for arthritis, but in about 20% of patients, it may burn itself where there are no symptoms, and gradually if there is no evidence of arthritis, we consider this as a cure. A good percentage of patients get remission which in rheumatoid arthritis means that symptoms signs and ESR subside, but it not always permanent.
07. Are steroids useful?
Oral steroids may be helpful for a very acute case, but it is not recommended routinely because of the severe osteoporosis as well as the side effects affecting the heart and kidney, as well as decreased immune response. Steroid injections are not recommended and should be avoided because it causes more severe degeneration in the knee and improvement is only temporary.
08. What is role of physiotherapy in arthritis?
Physiotherapy is very useful. Electrotherapy produces penetrating heat into the joints. Diathermy also known as short wave diathermy (SWD) the ultrasonic massage, wax, whirlpool and oil massage can be helpful, but not curative. Exercises are important in physiotherapy for maintaining joint mobility and flexibility.
09. Does weight play a role in arthritis?
Yes, since overweight people develop osteoarthritis of wear and tear, quite rapidly. It does not have much bearing an rheumatoid arthritis.
10. Is arthritis hereditary?
Osteoarthritis due to wear and tear is not hereditary, rheumatoid arthritis and primary osteoarthritis in a small percentage (10-15 per cent) of patients is possible.
11. What is spondylitis or spondylosis?
Spondylitis also known as spondylosis effects the neck and spine, mainly and partly the lumbar. It is a form of degenerative or osteoarthritis of the spine.
12. How is it treated?
It is generally treated by physiotherapy and rest. Sometimes with a cervical collar or belt and massage therapy, NSAIDS.
13. What is the role of diet in arthritis?
There is no direct correlations. However, a well nourished diet that does not induce weight gain is important.
14. Can crooked knees cause osteoarthritis ?
Yes, it is commonly seen in India where women are often bowlegged. This causes severe wear and tear arthritis, or osteoarthritis, of inner side of the knee. The excessive knock causes direct arthritis or osteoarthritis from outer or lateral of the knee.
15. What is the treatment for these type of arthritis?
Arthritis due to varus or knock-knees is usually an osteotomy where the bone is cut and straightened and the load transmitted to the other side to receive the load. It takes 2-3 months to recover from this. At HOSMAT, we do a unicondylar partial knee replacement. The patient can walk after 2 days. Relief of pain is better than in osteotomy.
16. At what age is this surgery done?
This is generally done for young people, below 40-45 yrs and after 50 yrs of age, total knee replacement is more reliable.
17. What is role of arthroscopy in arthritis?
Arthroscopic surgery is useful for diagnosis and smoothening the rough areas under the knee cap and the knee, but it does not cure the arthritis. It gives improvement only for a few weeks or months. If there is an associated cartilage tear, then there is good improvement for 1-2 yrs. In those patients where the knee cap or patella is out of alignment causing wear and tear, arthroscopic lateral release is very helpful. Arthroscopic surgery does not cure arthritis and does not replace the knee replacement.