Total Knee Replacement: India What we know and our Experience at KMC Hospitals Group

Total Knee Replacement: What we know and our Experience at KMC Hospitals Group
Dr S ChockalingamD.Ortho, FRCS [UK],FRCS [Tr & Ortho], Dr P R Ramasamy MS [Ortho], FRCS [UK]

This is an article I wrote for KMC News which is distributed to Referring and primary care doctors in Trichy Region on 14th December 2009

Total Knee Replacement is one of very successful and common Orthopaedic Operations we do at KMC Hospitals. The incidence of this surgery increasing in number reflects what is happening around the world.[Ref 1] The reason is why it is not more popular than it is at the moment is the cost of the surgery. This is obviously the point I would like to start of this brief about this surgery. The reason it is expensive at present to the reach of the common man is the technology that goes behind in the implant that is used.[ref 2]

The implant often made of strong Cobalt Chrome alloy, though titanium and ceramic are used in some designs. Any metal however polished, will have surface irregularities if one looks under the electron microscope. The surface finish and the material then become very important in reducing this irregularity and thus help in reducing the wear of the material with which this articulates.[Ref 3 and 4]

The material with this metal articulates is a specialized plastic called Ultra High Molecular Weight Polyethylene. Newer highly cross linked Polyethylene has come into use in hip replacement surgery.[ ref 5] However the quality of the Plastic used is controlled in the way this plastic insert is manufactured. This helps in the long term success of the knee replacement surgery.

The long term success of the knee replacement surgery is more important that looking at short term benefits of this surgery.[Ref 6] Any material placed between the end of the femur and tibia will relieve the arthritic pain. What is more important however is the durability of the material in staying without damaging the underlying bone!

The damage to the underlying bone is the worst scenario when faced with the failed knee replacement surgery. One fears this as the damage often starts without any warning such as pain. When one faces a failed knee replacement, the surgical challenges becomes daunting and more importantly becomes very expensive.
This brings me back to the opening paragraph of this brief, the cost of this joint replacement surgery.

A little bit more cost at the initial replacement surgery has been shown to reduce the chances of revision surgery in the long run. Revision surgery after total knee replacement is not something an ordinary individual can tackle not only as a patient but also financially. One cannot expect the Government to subsidize that cost as well as it will be impossible.

What we do at KMC Hospitals to ensure the long term success of this surgery are as follows.
We have a dedicated team involved in this surgery. The chances of infection developing after such surgery should be kept to absolute minimum and we do this by controlling the theatre environment and the personnel involved. We have only used prosthesis which has follow up data in the long run. Post operative protocols have now been developed to suit our working conditions. There are specific appropriate pain control and rehabilitation in place for these patients, both of which go hand in hand.

I have shown some examples of patients we have operated and what they look like and what they can do after such major surgery!

After total knee replacement this patient is able to sit cross legged! and riding a two wheeler at four weeks!, a patient works as a security at the age of 70 going to work by bicycle|!




Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005 Jul;87(7):1487-97.

Kester MA, Herrera L, Wang A, Essner A. Knee bearing technology: where is technology taking us? J Arthroplasty. 2007 Oct;22(7 Suppl 3):16-20

McEwen HM, Barnett PI, Bell CJ, Farrar R, Auger DD, Stone MH, Fisher J. The influence of design, materials and kinematics on the in vitro wear of total knee replacements. J Biomech. 2005 Feb;38(2):357-65.

Lancaster JG, Dowson D, Isaac GH, Fisher J The wear of ultra-high molecular weight polyethylene sliding on metallic and ceramic counterfaces representative of current femoral surfaces in joint replacement. Proc Inst Mech Eng H. 1997;211(1):17-24.

Wang A, Yau SS, Essner A, Herrera L, Manley M, Dumbleton J. A highly crosslinked UHMWPE for CR and PS total knee arthroplasties. J Arthroplasty. 2008 Jun;23(4):559-66. Epub 2008 Feb 13.

Ritter MA. The Anatomical Graduated Component total knee replacement: a long-term evaluation with 20-year survival analysis J Bone Joint Surg Br. 2009 Jun;91(6):745-9.
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The Proof is in the pudding: Awareness strategy adopted for Total Knee Replacement

10th June 2010
Total Knee Replacement is one of the successful surgeries, in Orthopaedics and Surgery in General. The surgery has the benefit of relieving one's pain and improving the quality of life for an individual. This can be proved by various quantification methods such as Joint Specific Scoring Systems, and Quality of Life improvement tools.

I use these tools in my practice to the standards followed in the UK Joint Replacement Units. The quality of improvement can be quantified in other methods such as QALY. This method shows that the qualtiy of life improvement for the years ahead is comparable to Cardiac Bypass Surgery and better than cataract surgery.

Remember these two surgeries compared are done more frequently than the Knee Replacement surgery. Hence when I started my practice, we sat down with the marketing department at KMC Speciality hospital and worked on a strategy to improve the awareness.

I decided one of the ways would be to take the outcome improvement to the public directly and orgnaised the meeting called Meet Our Patients. We called on the press to interact with my patients who had knee replacement directly with no preconditions.

Patients were more than happy to narrate their quality of life improvement directly to the press who in turn took to the public through their media.

Proof is in the pudding,Right!. We are now in the process of orangising the awareness of arthroscopy in joint problems. I am calling more than 100 of my patients who had arthroscopy of knees, shoulders,ankles, elbow at KMC Speciality to come and narrate their experiences directly to the press.

We are calling this Sports Injuries and Arthroscopy Awareness meeting and organised this sunday.

I will post more on this later.

Regards

Chockalingam

Health Awareness among men over forty years of age, meet by Sugam Charity

Sugam Charity Health Awareness meeting 2 on 11th of April 2010

Following the successful meet organized for women over forty on the 13th feb 2010, Sugam Charity organized the second meet for gents over the age of forty years. The aim of the meeting was to spread the awareness of life style diseases which are rife in this age group.

The format of the meet is to give awareness talk to spread the knowledge and to provide an individual assessment of these people. This is different to the master health check up though one part of it is based on the master health check up as described below.

Master Health Check up is now given as a standard to most corporate employees as part of their corporate social responsibility. The corporate bodies also take up this role to ensure they have healthy employees who in turn will take less sick leave and increase their productivity.

However this type of check up is not given to the people in the villages, one due to the lack of model of someone giving them the option of health check up as corporate bodies. but it is mainly due to the lack of awareness. sporadically the Sons and Daughters who are working in cities bring their kith and kin for these health check up, however the common man misses out.

This type of health check up can bring up the problems, hopefully at an earlier stage so that the treatment can be effective. It would also ensure people with risk factors are advised accordingly so that life style diseases do not affect them in the future.

The second part of this activity is where the charity wants to concentrate. Spreading the awareness by giving them not only their health information but also with an interactive forum at their doorstep.

This has been made very much possible by the talks given by the doctors and more importantly by the Nursing School Principal of KMC, Trichy and her Team. We at Sugam Charity cannot thank them enough as they do this on a sunday when most of us would rather spend relaxing at home. We also thank the Management of the KMC and KMC speciality hospitals for allowing us to use their team the education materials for this public exercise activity.

We at Sugam Charity hope that we have done some good to these people, only time can tell us so.

Regards

Chockalingam

Sugam Charity and health awareness camp at Thatchankurichi, a village in South India

27th of February 2011

As part of our health awareness campaign from the charity we conducted this camp at Thatchankurichi a village in Tamil Nadu, South India. At the outset, i would like to thank the volunteers from the village without their help this would not have materialised. We would also like to thank the School Headmaster, The District Educational Officer and the Collector who have agreed for this camp to be conducted.

KMC and KMC Speciality Hospital provided their technical expertise of the Nursing School Prinicipal and the senior Nurses and their team. they worked hard over the entire session without any break. The doctors were again Dr Rajarathinam, Dr Mathimaraiselvan, Dr Geetha Ravi who worked for nothing at the end of the day, and in fact leaving their work commitments for the charitable work.

There was no treatment given at this site of the camp and no free medication were distributed. The aim of the camp to identify the problems and give free advice.

i am attaching couple of photos

with regards

Chockalingam

health awareness activities at Trichy

I am adding some of the articles written in press and some of the photos of the health awareness activities done at Trichy with KMC speciality and KMC hospitals.

Orthopaedic problems of bones and joints are many and we took on only four issues last year at KMC Speciality Hospital named by WHO bone and Joint Decade. they are 1. osteoporosis 2. arthritis 3. road traffic accidents 4. back and neck problems.

We have done Meet our Patients Meet where the press and the public could freely interact with our patients benefited from advanced ortho care treatment at KMC and KMC speciality hospitals.

We have done Bone and Joint Walk to raise awareness on Bone and joint problems as listed above.

We have given awareness talks to senior citizens who are pensioners in a standard format.

We have done first aid program to traffic personnel twice in the last two year to raise awareness on road traffic accidents 2. we have done many free orthopaedic consultations starting in march 2009 at KMC Speciality hospital both as camps and regular free clinics on Fridays for patients who cannot afford to attend a hospital such as ours. These have mainly targeted arthritic patients though osteoporosis and back problems have been covered.

We have done two ATLS type courses named Essentials of Initial Trauma Management at KMC Hospital for doctors sponsored entirely by KMC Hospital and all the consultants have gifted their time and efforts to teach the fundamental principles in trauma management.

I will elaborate all our activities in the next blog and list them and post more articles.

Regards

Chockalingam

Awareness article written on joint replacements

Article written on 24th December 2008

Advanced Ortho Treatment facilities at KMC Speciality Hospitals

Joint Replacements and Key Hole Surgery



What are joints and why do I get pain in my joints?

Joints are present when two bones meet allowing movement to occur.

The ends of bones are lined with a tissue called cartilage. This tissue is strong and smooth. This is lubricated with fluid in the joint.

Ligaments are tissues which hold the bones and allow movement in a certain direction.

Joints are damaged by commonly by diseases, injury, ageing or infection.

Problems with the joints are major causes of immobility and disability. We often see people who can only walk slowly, or for short distances due to pain due to the joint problems. Knee arthritis is very common as one gets old.







What is arthritis?

Arthritis means inflammation of joints. It can be due to many causes.

Your Orthopaedic Surgeon would be able to diagnose the cause of arthritis by taking a history from yourselves and examination. He would need to request specific tests if the cause is not clear by examination alone.






Is there a cure for my arthritis?

It depends on the cause of arthritis. The most common cause of arthritis is Osteoarthritis, which is wear and tear of the joint lining called cartilage with age alone. This can come earlier if there had been previous injury.

The treatment of joint disorders has greatly improved in the last thirty years in other countries and over the past ten years in India. This is partly due to the option of treatment with artificial joint replacements.

What are artificial joint replacements?

Artificial joints replace worn out [arthritic] joints. They are very commonly performed for pain and are very successful in relieving pain. Knees and hips are very commonly replaced, though artificial joint replacements are done for shoulder, elbow, hand and ankle as well.












How do they actually look like?

The picture shows some of the actual prostheses in joint replacements. These are not all inclusive as advanced designs are available for patients



What are current advances in joint replacements?

Only part of the knee replaced as shown in the picture below. Advances in metallurgy and materials in the prosthetic design are available to a patient in Trichy. Management before and after surgery has changed over the past few years. The surgeon at KMC Speciality would use the up to date management practised in UK due to his recent return from England.






Are these new or experimental?

No. These have been successfully performed for over thirty years. The joints are manufactured by advanced engineering methods. They are made of very high quality metal, ceramic and polyethylene. Over 60000 patients are receiving these prostheses by surgery in one year in Australia alone [2003-2004 figures]

Who will perform this at KMC and what is his experience

The surgery would be performed by a senior surgeon who has returned to Trichy after more than fifteen years of experience in UK. He has performed surgeries routinely for the past seven years as a senior surgeon. He had been practising in the largest centre for joint Replacements in UK where more than 4200 patients are treated per year alone [2007 figures]



He has performed research in this field in UK. This has been published and his article which is commonly quoted in the international literature.


“ Outcome of cemented-v-cementless fixation of femoral component in TKR with the identification of radiological signs for the prediction of failure
THE KNEE Dec 1; 7(4): 233-238 2000”

Is this treatment without any problems?

This treatment is very successful in relieving pain. However some patients can have complications. The surgery performed by an experienced surgeon can reduce the complications. Hence it is essential to know your Doctor and his experience who performs this surgery.


Will I be able to walk without limp and will my joint move normally after surgery?

As pain goes your walking will actually improve than before surgery. Hip replacement patients return to normality sooner even though it is a deeper joint. Knee replacement patients will return comparatively slower, however there would be no difference in the success of this surgery.

Treatment after surgery improves the success greatly and your Surgeon would advise you accordingly.

What Should I do?

If you or someone you know suffers from joint pain, please understand that one should not have to live with pain.

Not all patients with joint pain will need joint replacements.

Other causes of joint pain can be treatable completely by medication such as gouty arthritis. Some of the patients’ joint pain can be treated by medication such as Rheumatoid arthritis, though surgery can remarkably change one’s life with surgery.
Other patients can be treated by key hole surgery to the joints.

What is key hole surgery of knee?

I am sure you are aware of sportsmen twisting their knee and disappear from the sports scene for couple of months before returning to normality. They often sustain cartilage injuries which are treatable by key hole surgery. Surprisingly quite a lot of general population have cartilage problems, but choose to live with pain. They can also be treated by key hole surgery.

Advanced Ortho Care at KMC Speciality Hospital

Sports Injury Service and Advanced Arthorscopic Surgery Service At KMC Speciality Hospital

Sports is becoming more of a passion as much as a hobby in our Country. Winning World level events has attracted more of our young boys and girls to partake in sports and even take this as their profession. As each profession carries its risks, sports poses us the biggest risk to these young generation in the form of injuries.

Injuries in sports mostly affect the musculoskeletal system. The muscles, tendons, bones and the joints are the components of this system. The joints are complex structures having cartilage, ligaments attached to the bone through soft tissues.

Most sports injuries are managed initially with the following fundamental principles. Remember the mnemonic RICE whenever one gets injured. Rest the injured part, apply Ice, apply Compression and Elevate the injured part. The practice of applying warmth in the form of hot water pack/bottle to the injured part is not recommended.

Physiotherapists either at the sports arena or at the hospital can treat majority of minor injuries to the muscles and tendons. The spasm associated with the muscle and tendon injuries can be treated with stretching and local treatment as described above. Some of these injuries especially the minor ligament injuries need rehabilitation by attending a dedicated physiotherapy department.

KMC Speciality Hospital has a dedicated Physiotherapy department to treat these injuries. The devices available in the department cover all areas of the body. They are designed to treat with mobilisation, stabilisation and retraining.
Though the initial pain and suffering improve with these simple measures and physiotherapy treatment, the long term recovery depends on detection and treatment of major injuries. These major injuries often feel like minor injuries after rehabilitation. However the key to return to sports and normality relies on recognising these as needing further treatment.

Hence we need experts who can diagnose and be able to treat them with the modern treatment methods. At KMC Speciality Hospital, we have surgeons trained and practiced abroad in treating these injuries. Treating them with modern treatment methods practiced in western countries is the key for getting back to normality.

Modern methods of treatment of the sports injuries often involve keyhole surgery to the joints. This is called Arthroscopic Surgery. Arthroscopy started as far as back in 1910s, though the treatment with this technique was possible after 1970s in Japan.

The Advanced Ortho Care at KMC Speciality Hospital has a dedicated state of the art High Definition Arthroscope with HD monitor for excellent visualisation and treatment of the injured part. The supportive power instruments, electronically controlled pump system and Radiofrequency Ablation techniques are at par with the most advanced hospitals in the world.

The problems, which can be treated with these Arthroscopic techniques, are many and can only be listed as a guide as follows.
1. Cartilage injuries of the knee: Meniscus Injuries in the knee and Wrist cartilage injuries
2. Ligament Injuries: Anterior and Posterior Cruciate Ligament Injuries in the knee
3. Tendon injuries of the muscles in the shoulder: Rotator Cuff Injuries and SLAP lesions
4. Recurrent Dislocations: Dislocations of the shoulder and kneecap, which often recur in young sports people
5. Recurrent and persistent pain in joints: Impingement of the joints, which affect mostly shoulders, ankles and elbow
6. Post trauma stiffness of the joints
7. Instabilities of the joints: shoulders and ankles
8. Infections of joints
9. Arthroscopic fusions of joints especially ankle

The technical expertise in delivering the treatment methods listed above is as important as the facility available in our Hospital. The surgeons who deliver this World Class treatment have not only acquired these skills in countries around the world, but also have been practising surgeons in UK before their return to their homeland Trichy.


Some of the other Advanced Ortho treatment Methods provided at KMC Speciality Hospital are as follows
1. Joint Replacements of Knee, Hip, Shoulder, Elbow and Ankle using imported implants with international standards [Swedish, UK and Australian Standard]
2. Partial joint replacements with implants originating from Oxford,UK.
3. World Class treatment methods of simple and major Trauma using principles of international Swiss [AO] and American Standards [ATLS]
4. Treatment of Pelvic, Acetabular and Spinal Injuries
5. Treatment of deformities in Children with Ponseti Method [Canada]
6. Treatment of complex trauma and deformities using Russian Technique [Ilizarov technique]
7. Treatment of Fractures in Children using French Technique [Nancy]

Warm Regards

Chockalingam