On a knee high: All about joint replacement surgery

Joint replacement surgery is becoming rather common among the elderly these days. One of the causes is osteoarthritis which results in knee pain and difficulty in movement. The surgery, if done under the right conditions and followed through with proper post-operative care, can make a huge difference to the patient’s life. Dr. Raviraj. A, Orthopaedic and Joint Replacement Surgeon, Apollo hospitals Bangalore, tells us more about Joint replacement surgery among the elderly in this interview.

1)   What is a joint replacement surgery and what does it entail?

A joint replacement is a surgical treatment performed for severe wear and tear in the joint (arthritis). This involves surgically trimming the two opposing surfaces of the bones forming the affected joint and replacing them with artificial materials, such as a metal to alleviate the pain and to increase the function of the joint and overall mobility of the person. The common joints involved are knee and the hip joints. The arthritis of the knee causing deformity and pain are common symptoms in elderly patients due to osteoarthritis (age related wear and tear) of the knee.

Joint replacement requires a well trained surgeon, a well equipped centre that can handle medical problems such as diabetes, hypertension, heart disease etc., which are very common in elderly patients undergoing joint replacement. An expert pain management team and a physical therapy team are essential to the set up.

2)   Why and when is it considered?

It’s considered in elderly patients with degenerative joint disease when the arthritis is advanced, when the problem affects the activities of daily living (ADL) and when the pain is severe. The most common joint replacement surgery is performed for the knee, with the next common one being for the hip joints.

Similarly in a younger patient the surgery is performed in a diseased joint due to arthritis such as rheumatoid arthritis or after a fracture.

3)   How old is this line of treatment and how safe is it?

This treatment is not a new treatment. This is more than 50 years old when it was first started in the West. But it has become more popular in India in the last 20 years. There has been a paradigm shift in the perspective in the last few years with emphasis on the use of cutting edge technology, longevity of the implant and the outcome of the surgery.

It’s quite a safe treatment and can be performed in elderly patients with associated medical issues such as diabetes, hypertension and or heart disease. With the advances in the medical technology and anaesthesia techniques and experience of the medical and surgical teams, this surgery is becoming very safe and popular. However, a medical, cardiology and anaesthetic evaluation is done to quantify the risk if any. This way the medical and the surgical team can handle it better during and after the surgery. Some of the medical conditions might have to be optimised before the knee or hip replacement surgery.

4)   It seems to have become a common form of treatment. Why?

It’s becoming a common form of treatment because:

a ) Elderly population is increasing due to increase in the average life span and hence increasing the load of arthritic patients.

b) There is increased awareness in the general public about the disease process and treatment modalities available.

c) Availability of the centers which have the infrastructure, equipment and skilled and trained surgeons.

5)   What are the benefits of this surgery?

The major benefit of a joint replacement surgery is alleviation of the severe pain caused by joint destruction. The surgery apart from correcting the deformity (bent or bowed legs) also improves the joint mobility without pain. The overall walking of the patient is restored to normalcy after the surgery. This helps the elderly patients with associated medical issues such as diabetes to get back to their walking and exercise programme.

This also makes this group of patients more independent for their daily routine, whereas otherwise they would have to depend on helpers or a stick or walker’s assistance in severe cases.

6)   What can be the associated risks and complications?

In general the risk is very less when performed in a centre dedicated to handling this kind of patients and surgeries. The benefits outweigh the risk. The overall risk is less and is close to 1%.

7)   Which are the body parts that can be replaced and of these which are the more commonly replaced?

The most common joint replacement surgery is performed for the knee, with hip joints coming next. However even shoulder, elbow and ankle joint replacements can be performed when the arthritis involving these joints is very severe. In a younger patient the surgery is performed in a diseased joint due to arthritis such as rheumatoid arthritis or after a fracture.

8)   Is there a suitable age by when a patient should get it done?

Elderly patients and patients above 50 years of age with severe arthritis of the knee interfering with activities of daily living are the ideal candidates for surgery. Disabling hip pain even in younger patients calls for surgery. Age alone is not the criteria for surgery. The requirement for surgery is best considered on the merit of individual patient and his symptoms.

9)   What are the indicators/ signs that may suggest that a patient needs surgery?

Signs that predict the need for surgery are:

Increasing pain, interference with activities of daily living, disabling pain in knee or hip decreasing the walking distance progressively, inability to sit on the floor, squat, use Indian style of toilet, stair climbing, etc. Further indicators are when the initial treatments such as medication and physiotherapy no longer yield sustained benefits or when the requirement for pain killers increase.

10)   Any pre-existing physical conditions that may make the surgery tricky?

Associated medical issues such as diabetes, hypertension and or heart disease are common at this age. However the presence of any of these is no contraindication for the surgical procedure. With the advances in the medical technology and anaesthesia techniques and experience of the medical and surgical teams, joint replacement surgery is becoming safe. Some of the medical conditions might have to be optimized before the knee or hip replacement surgey. The presence of severe deformities and severe osteoporosis can be little tricky but can be efficiently handled with proper pre-surgery planning.

11)   What are the pre-operative procedures that are involved?

Preoperative procedures involve any check for presence of infections in other regions in the body. A medical and cardiology and anesthesia consultation is done as routine prior to surgery and can be obtained after admission to the hospital.

12)   How long can the hospitalization be for?

Hospitalization for a single joint surgery or when two joint replacement surgeries are performed on the same day ranges between three to five days post surgery.

13)   What does post-operative care involve?

The post operative care involves pain management by various modalities to make the patient comfortable in the post surgery period so as to participate in the rehabilitation programme. The physical rehabilitation involves making the patient walk with the help of support, this usually happens on the next morning after surgery. The patient is taught to do a range of movement exercises of the replaced joints and to strengthen the muscles around the joint. Usually patients are able to walk with support independently and use the rest room without support at the end of three to four days after the surgery.

14)   How long can the rehabilitation take?

The rehabilitation can take anything between one to three months. Most patients are able to be independent by three to six weeks. The rehabilitation involves walking and muscle strengthening exercises which most of the time can be performed by the patient herself/himself without requiring a formal rehabilitation specialist.

15)   What does rehabilitation entail?

The physical rehabilitation involves making the patient walk with the help of support, this usually happens on the next morning after surgery. The patient is taught to do a range of movement exercises of the replaced joints and to strengthen the muscles around the joint. Usually most patients are able to walk with support independently and use the rest room without support, at the end of three to four days after the surgery.

16)   Which are the medical aids that can assist in the recovery process and how long can a person be dependent on them? 

A walking stick, walker and brace are some of the medical aids that can assist in the recovery process. The dependency on these aids ranges between one to three months. Most patients are able to be independent by three to six weeks. Most patients can walk without any aid at the end of their rehabilitation programme.

17)   Is nursing care needed during recovery process?

Nursing care is crucial to prevent the complications of surgery such as bed sore and pneumonia. Good nursing care is vital and delivered at the hospital. At home the patient can mostly take care of this with a relative or a care taker. Very elderly and fragile patients might require post discharge nursing care at home.

18)   How important is diet during all this?

There are no strict recommendations for these patients. In the immediate post operative period, fibre rich diet is recommended to avoid constipation which is common in these elderly patients. The diabetic and hypertensive (increased blood pressure) patients have to have strict diet as per the dietician’s recommendations. Good sugar control is of paramount importance during the post operative period.

19) How critical can body weight be?

Body weight is not very critical. Joint replacement surgery can be performed in obese individuals with great success. Morbid obesity may call for a bariatric consultation or a procedure. This is decided on an individual case scenario.

20)   What can go wrong during recovery process?

Major complications are less common and early recognition and prompt treatment is important. The common complications are electrolyte imbalance, decreased hemoglobin due to blood loss, urinary retention requiring catheterization. Inadequate exercises during the recovery period can give rise to stiff joints with lesser range of motion and suboptimal outcome. Most complications that can happen during the recovery phase are avoidable or treatable.

21)   What are the things that family members of the patient should keep in mind both before and after surgery?

The family members play a crucial role in supporting the patient psychologically, socially and emotionally during and in the post surgery period. They should be a constant source of motivation during this period.

22)   Last but not the least any ball park figure for the cost of surgery?

The cost of surgery is highly variable with the type of the implant used, cost of implants, the hospital, the surgeon, primary or revision joint replacement, etc. However the cost can range from Rs one lakh to Rs three or four lakhs. However this is best decided by the surgeon on individual case basis. These days most corporate employees, health insurance companies, government sectors, semi-government and some private sector employees or their parents can claim the expenses for the surgery.

— Interviewed by Nidhi Chawla

Pic courtesy: Wikimedia Commons

About the expert: Dr. Raviraj A is a Joint Replacement and Arthroscopic Surgeon at Apollo Hospitals, Bangalore. Dr.Raviraj’s expertise consists of Joint replacements, sports medicine, arthroscopy, and complex trauma. He has trained and worked in many orthopaedic institutions and has gained in depth experience in Orthopaedics; especially in joint replacement and arthroscopic surgeries. With a fellowship in joint replacement surgery to his credit, he has performed several joint replacement surgeries of the knee – total knee replacement (TKR), both primary TKR and revision TKR, hip – Total hip replacement (THR) both primary THR and revision THR, and Total shoulder and elbow replacement. He also was trained in joint replacement by visiting fellowship at the Chula Longkorn university, Bangkok, Thailand.