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

The Bone and Joint Decade 2000-2010, Ten years on........

This is an article I am writing for increasing the awareness of bone and joint disorders among the public and the medical community alike.I hope you find it useful

World Health Organisation [WHO] endorsed the launch of “Bone and Joint Decade [BJD]- 2000 to 2010” in Geneva in January 2000. The key goal is “to keep the people moving by prevention and treatment of bone and joint problems. This will in turn reduce the cost and the burden to the individuals, the carers and the society at large”.

BJD-India duly followed with National Action Network launched from Pune by eminent doctors. This was endorsed by the Government of India. As we are on the verge of this decade behind us, it is time for us to reflect and hence this article.

Arthritis affecting a joint such as knee and hips are very common in India. Every other person over the age of 65 in India is affected with arthritis. Unfortunately the treatment is not sought or often delayed.

The road traffic accidents are not only common, but also results in severely injured people. The deaths are frequent and multiple numbers of people are involved in the same accident. This is reflected in the Official statistics of the department of Road Transport and Highways, Government of India.

Unfortunately such affections of the bone and joints leave people with physical disability. The patients become dependent on the family and the society adding to the mental suffering. Some of the patients are left crippled due this pain. The true extent of their suffering is revealed in the limitation of their activities of daily living let alone their limitations in the society.

When one is not able to do even routine activities such as walking, secondary health problems arise. These include sedentary lives, increasing obesity, diabetes, high blood pressure and heart diseases. WHO recognised this growing trend in the society often leaving a financial burden.

Diet and exercise play important role in the health of our bone and joints as much as for our heart. Yet our life style had become sedentary. Increasing incidence of overweight and obesity has aggravated the bone and joint problem such as arthritis. Specific remedies for certain arthritis such as Rheumatoid are not sought. These lead to crippling deformities and disabilities. On the other hand, there is misuse of pain killers leading to other problems such as kidney failure.

Wearing a seat belt is the most effective way to prevent injuries when travelling in a car or a bus. Yet many of us remove the seat belts or consider it a hindrance to wear. Traffic rules and restrictions are rarely followed resulting in serious and disabling injuries.

“A painful advanced arthritic joint can be cured with a joint replacement” is a well known fact to many in a Western country such as UK. However people in our villages are left suffering due to the lack of awareness. This lack of awareness is present even in educated persons living in cosmopolitan cities.

With this launch of Bone and Joint Decade, WHO highlighted the need for the improvement in the diagnosis and treatment of such disorders. WHO encouraged prevention through education campaigns. Ten years on since the Bone and Joint Decade launch by the WHO, the real question had there been an any improvement at all ?

In spite of all being written early in this article, there is certainly more awareness created by this WHO initiative. The government of India through its participation in this Bone and Joint Decade has shown its commitment in prevention and treatment of these disabling conditions.

Government Welfare schemes helping them finance the treatment ensures that poor are not left alone in this treatment reach. One has to mention one such scheme for the people below the poverty line at this juncture which has benefited and continues to a huge number of financially disadvantaged section of our society.

More people are seeking treatment rather than neglecting these ailments. They are asking for the accurate diagnosis as much as the treatment itself. This is especially facilitated when they see others benefited due to the treatment options such as joint replacements. People have started to recognise the fact that “Early and appropriate treatment of injuries prevents long term disability”. Technological advances such as key hole treatment of joint problems with arthroscopy are now known.

Every year many hospitals follow the activity week to focus their year long efforts to the public in October[ 12th to 20th of October of 2010 for this year]. Many hospitals and doctors are conducting free camps to facilitate such an awareness. Their efforts should be lauded with reverence for the public service.

There is certainly a larger section of our public where the awareness has not reached as we still see a significant number of disabled people due to the bone and joint problems. Hence more concerted efforts should be done from the community in general and the medical community in particular.

Education in road traffic accident prevention should reach the “prospective road users” namely our children. Public awareness campaigns should increase in number and reach the inner villages. Medical schools should increase the training given to the doctors in dealing with bone and joint problems. There is a need for the entire community to celebrate this bone and joint week in October.

May I conclude this article saying that “Let the end of the Bone and joint Decade -2000-2010 herald a new beginning in spreading awareness of the increasing number of Bone and Joint problems. These are either preventable and when affected, many of them are certainly curable”

Dr S Chockalingam
Consultant Trauma and Orthopaedic Surgeon
KMC and KMC Speciality Hospitals,
Trichy

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

Open Doors For More Patients:Raising Awareness of Knee replacement in rural India

The Fourth of September 2010

We decided to make a video of one of my patients who had a knee replacement. The video showed the impact this operation can make to a lady in a rural place in India. This video raises awareness significantly of a disability which is silently crippling people in India. With so many other life threatening issues and health hazards, the disability due to arthritis is not well known or written.

Arthritis not only limits one's walking ability, also disables a person in activities of daily living. I quantify my patients' disability tailored to Indian conditions and also use international scoring systems. But seeing is believing and for the public, there could not be any better educational method than a video play back.

please visit the sugam charity web site from the useful links site to view this video.

Warm Regards

Chockalingam

Traffic awareness and Speed awareness

This is a subject quite close to my heart. Trauma is called an accident in India often meaning this was unexpected. this gives a implication that one can feel sorry for the event and the persons involved in the accident. This is quite the opposite to what is true. most trauma incidents and if not all can be predicted and preventable. the western countries have worked on this so well that most accidents are prevented.

the problem in a country like India had always been traffic awareness or the lack of it. however the present scenario of lack of speed awarenss complicates in a significant way. the same lack of traffic awareness with low speed and high speed have different implications with the resultant severity of injury quite high.

this is recognised in a country like UK where the stress on speed awareness is given a huge thrust on public education even when the traffic awareness is high

I will continue in my next blog and elaborate

Sugam Charitable Trust and more health web sites

Dear Everyone, we have now conducted quite a few successful clinics under The Sugam Charitable Trust. We are now advising over twenty five patients per month. Where there is a need for specialist opinion, we are advising them of the need to.

We are keen to do more work on the charitable front. but we need clear directions. we have focused on the health education to the public in the form of newsletters and printed information. i am also in the process of passing on the important health information web links

please find such useful and regulated links

Sugam charitable trust http://www.sugam.org/sugamui/pages/Home.aspx

low back pain exercises http://orthoinfo.aaos.org/topic.cfm?topic=A00302

flexibility exercises http://orthoinfo.aaos.org/topic.cfm?topic=A00310&return_link=0