Dr. Sanjay Agarwala M. S. Orth, MCh.Orth
Specialist in Joint Replacement
and Trauma Surgery
P R E - O P E R A T I V E X - R A Y S
P O S T - O P E R A T I V E X - R A Y S
I N T R O D U C T I O N
NORMAL KNEE
OSTEOARTHRITIS KNEE
TKR
The knee and the hip joints are important
weight bearing joints in the human body.
Whenever we sit, stand, walk, run, drive or
perform any simple, day-to-day task, we
depend on the function of our joints to
support our body during its movements. Any
disease which affects these joints causes
tremendous disability and pain to the
patient.
What is
Arthritis?
Arthritis ('arth' meaning joint, 'itis' meaning
inflammation) is the name given to a group
of disorders affecting joints, in which the
surface of the joint gets worn out. The knee
and hip joints are most commonly affected
by arthritis.
Types of Arthritis
There are many types of arthritis. Common
ones are:
Osteoarthritis (OA): OA is caused by the
breakdown of cartilage which is thought to
occur as an inevitable result of “wear and
tear” on the joints, expedited by several
factors. Bits of cartilage may break off and
cause pain and swelling in the joint between
bones. Over time the cartilage may wear
away entirely, and the bones against rub
each other causing pain.
Rheumatoid Arthritis (RA): RA is an
autoimmune disease. The body's immune
system attacks healthy joints. This causes
inflammation in the lining of the joints
leading to permanent damage.
Gouty Arthritis
:
There is excessive uric acid, which
precipitates and damages the articular
cartilage leading to painful arthritis.
What are the symptoms?
Arthritis is characterized by pain, stiffness,
swelling and reduced function of the joint.
The patient has to curb his/her normal
activity levels and restrict routine activities
like walking, climbing stairs, etc.
How is it diagnosed?
A basic clinical examination coupled with a
plain X-Ray of the affected part will confirm
the presence of arthritis. Special blood tests
may be required to know the specific cause
of arthritis.
T R E A T M E N T
NORMAL HIP JOINT
Once you have been diagnosed with
arthritis, it is a matter of finding the right
treatment for you depending on the kind of
arthritis you have, how bad it is and how it is
affects you. Temporary treatment solutions
are Medications, Physiotherapy, Injections
into the joint, Arthroscopy and joint wash
and Osteotomy. The result varies depending
on factors such as age, severity of disease,
obesity and osteoporosis. Often, the only
permanent solution for pain relief and return
of function is Total joint replacement.
Benefits from a joint replacement
surgery:
1. Reduced joint pain
2. Increased mobility
3. Increased strength
4. Correction of deformity
5. Restoration of limb-length
6. Improved quality of life
Total joint replacement essentially replaces
the old, worn-out surfaces of the joint, with
an artificial joint, which is made of metal
alloys, ceramics and plastics. These high-
quality joints resemble the normal joint
closely and are durable, lasting for almost 15
to 20 years.
High Flexion Knees
There are various types of knee implants
available in the market today. Their cost
varies depending on the amount of flexion
(bending) they provide, and other design
perspectives.
Why do I need high flexion knees ?
Many daily activities in the Asian sub
continent require the ability to flex the
knee beyond
125 degrees. Consider climbing stairs (75-
140 degrees), sitting in a chair and standing
up again (90-130 degrees), or squatting
(130- 150 degrees). For patients with the
ability and desire to perform high-flexion
activities, implant design should not limit
postoperative range of motion.
What is the latest in knee replacement?
Joint replacement has been fine-tuned,
standardized and perfected over the last
three decades. Recent innovation of knee
design is a breakthrough where complete
flexion can be achieved. Earlier implants
provided only pain relief while newer ones
offer the additional advantage of full
functional recovery.(make this bold)
T R E A T M E N T
Some people may think it's better to delay
surgery until they're older because they
believe that knee implants don't last long.
These newer knees are designed for
patients who want their knee replacement
to accommodate normal movements
while significantly minimizing implant
wear as compared to traditional knees.
Minimizing implant wear can in turn help
your knee replacement last longer.
What are the types of High Flex knees?
Rotating Platform (Mobile Bearing) and
Posterior Stabilized High Flex knee system
are the two types of high flex knees. They
are designed to provide high knee flexion
(bending) up to 155 degrees. This means
that with appropriate rehabilitation a
patient can resume an active life style after
total knee replacement prolonged
kneeling, squatting and cross legged
sitting.
Complete knee bending is a prerequisite
for patients of Asia, more so in the Indian
c o n t i n e n t d u e t o s o c i o - c u l t u r a l
requirements. For this very reason,
Dr.Agarwala has been offering this
procedure to all his patients.
What's new in hip replacement?
Surface Replacement (Resurfacing)-
Compared to traditional hip replacement,
removes less bone but has metal on metal
articulation which is controversial in the
current scenario due to release of metal
ions.
Hard on hard bearing surface like large
head ceramic on ceramic is the current
replacement option available which offers
normal functional activities, less wear rate
and reduced chances of dislocation and
last longer for almost 20-25 years.
What are the advantages of large head
ceramic on ceramic THR?
Ÿ Increased range of motion. Patients can
squat, sit crosslegged and even use the
Indian toilet !
Ÿ Reduced chance for impingement and
subsequent dislocation. A larger femoral
head travel a greater distance before
subluxating or dislocating, hence safer.
Ÿ Greater longevity due to reduced
wear.
T R E A T M E N T
What implant should I choose?
Whether a total hip replacement or a total hip resurfacing is the procedure of choice
for a specific patient is dependent on a variety of factors. Dr. Agarwala offers large
head ceramic on ceramic arthroplasty. In certain cases, cup with screw or cemented
option has to be used .
The femoral head size varies from 28 to 44 based on kind of particular joint being
selected for the patient.
P R E - O P E R A T I V E X - R A Y P O S T - O P E R A T I V E X - R A Y
C A S
Benefits of Computer-
Assisted Surgery
• Precise implant
positioning
Computer Navigated Joint
Replacement Surgery
(CAS)
This is not necessary in most routine
cases. Dr. Agarwala uses CAS only
(make bold) in selected cases.
Joint replacement surgery makes unique
demands regarding implant alignment,
positioning, and tissue balance. Even the
slightest deviation from the desired
placement can produce poor long-term
results. Dr. Agarwala uses the computer
navigation to view a patient's anatomy in
three dimensions and to track instruments
in relation to a patient's anatomy during a
surgical procedure much as the driver of
a car uses the GPS system to find the way
on a road.
The computer-navigation system uses
trackers and an image-guided surgery
(IGS) camera attached to the computer.
Using the trackers the camera can
precisely follow the position of the
transmitters that are firmly affixed to the
patient's operative leg and transmit the
data to the computer which is then
displayed on the monitor in relation to
the patients' unique anatomy.
• Less tissue trauma
• Smaller scars
• Reduced blood loss
• Shorter hospital stay
• Faster and less painful
rehabilitation
• The possibility of a
quicker return to work
and daily activities
F A Q S
Joint replacement surgery has given
years of pain-free living to millions of
arthritics all over the world. With
advanced materials and surgical
t e c h n i q u e s , a n d t h e e f f o r t s o f
orthopaedic surgeons working with
bio-engineers, the future is promising
for those who choose to have a total
joint replacement.
Who needs a joint replacement?
Patients with severe joint pains,
affecting their bodily functions and
causing restriction of movement, and
who are well motivated, are candidates
for surgery.
Initially ,patients with arthritis are
treated with non-surgical modalities,
like medications, physiotherapy and
orthoses (like knee-caps ,walking
sticks ,etc). It is only when these
m o d a l i t i e s t o o c a n n o t c o n t r o l
symptoms, that Dr. Agarwala advises
surgery.
A r e t h e r e m a n y c o m p l i c a t i o n s
involved ?
As with all major surgical procedures ,
complications can occur. The most
common complications following joint
replacement are :
Deep Vein Thrombosis
Infection in the joint
Stiff ness of the joint
Loosening of the joint
This is not intended to be a complete
list of the possible complications, but
these are the most common. The rate is
less than 1% for major complications
(like infection), and less than 5% for
minor complications (like delayed
h e a l i n g ) . T h i s i s e q u a l t o t h e
complication rate worldwide.
Pre-operative assessment - All patients
need to undergo blood tests ,X-
rays,ECG etc. prior to the surgery
anesthesia and medical fitness needs to
be obtained in patients with medical
problems before admission.
Anesthesia for Surgery - There are two
types of anesthesia 1) General
Anesthesia and 2) Spinal / Epidural
Anesthesia.
Pain Management - After surgery pain
may be there for first 3 to 5 days but,
we have different modalities to
control the pain.
a) PCA (Patient Controlled Analgesia) -
This is a machine which allows
p a t i e n t t o t a k e c o n t i n u o u s
i n t r a v e n o u s a n a l g e s i c s l i k e
morphine derivatives and there is a
provision of taking extra dose , if
required.
b) Epidural Anesthesia - A catheter is
kept in the back (spine) at the time of
spinal anesthesia through which
a n a l g e s i c s a r e g i v e n p o s t -
operatively.
c) Regional blocks.
d) Suppositories.
e) Intravenous and Oral Analgesics
(large amount of Paracetamol, anti-
inflammatory drugs).
f) Skin patches which give off drugs to
the blood stream.
How many days do I have to spend in
the hospital?
F A Q S
Normally, you will be in the hospital
for 5 to 7 days, including a day or two
before surgery (depending on your
general health) and 4 to 5 days after
surgery.
When will I be able to walk after
surgery?
The next day of surgery you will be
made to stand and often you may be
able to take a few steps. A walker will
be required initially, followed by a
walking stick for a few weeks, to
support you , but normally , you will be
climbing stairs by the 3rd to 5th day of
surgery.
Will I require blood transfusion?
Most patient with normal hemoglobin
levels do not need transfusion, but
blood is - - - - kept available as a
precautionary measure. We ma y give
drugs like tranexamic acid prior to and
after surgery to prevent blood loss.
Are there other options to blood
transfusion?
Yes there are . you can have your own
blood donated 2 to 3 weeks before
surgery , for use after surgery ( auto-
transfusion). Alternatively , you can
h a v e i n j e c t i o n s o f H u m a n
Erthropoietin (EPREX) to build to build
up your haemoglobin level to normal.
What is
Erythropoietin?
It is a normally occurring hormone in
the body , which stimulates blood
production . On an average you may
require upto 5 injections.
“The use of recombinant human
erythropoietin in Indian patients
undergoing major orthopaedic
surgeries to reduce pre operative
transfusion requirement”. Paper
published by Dr. Sanjay Agarwala in
Indian Journal of surgery . Vol. 64 No.
1,2002.
When can I resume my routine , day-
to-day activities after surgery?
Walking around the house, bathing
and maybe sitting in the car, will all
start as soon as you go home by the 5th
to 7th day. Other activities, like going
for walks, swimming etc. will be
permitted by the end of the 1st month
after surgery. You may need to use a
walking stick for 6to 8 weeks after
surgery.
After surgery, won't many of my
activities be restricted?
Patients who have undergone total
knee replacement will have no
restriction of activities with the
prosthesis we propose to implant.
Within few weeks you should be able
to squat and sit cross-legged, with the
new high flexion knees.
Those patients who are scheduled to
undergo total hip replacement will
be advised regarding restrictions
depending on the implant type. With
the standard hip prosthesis(which have
stood the test of time) you will not be
permitted to squat, sit cross legged on
the floor or use Indian toilet. However,
with the advanced prosthesis (newer,
but more expensive)such as ceramic on
ceramic large head arthroplasty, none
of your activities need to be restricted.
P O S T - O P E R A T I V E P R O T O C O L
Will I need prolonged physiotherapy
after this surgery?
All the exercises that you need to do
are taught to you in the hospital itself
before you are discharged. There is
generally no need for a physiotherapist
to visit you at home after surgery. You
will be your own physiotherapist, but if
you feel more confident with a
physiotherapist, do go ahead.
I s J o i n t R e p l a c e m e n t S u r g e r y
Permanent?
Most older persons can expect their
new joints to last a lifetime.Some
younger persons, With a total joint
replacement, who are guite active,may
need a second replacement after
15 to 25
years.
TOTAL JOINT REPLACEMENT
POST-OPERATIVE
PROTOCOL
What follows are a set of instructions
given to our patients after surgery. This
will help you gauge what is required in
the recovery period.
DAY O (DAY OF OPERATION)
Ÿ Pain is natural after such a major
operation. So, do not let it worry
you. To make you as comfortable
as possible, we often use a PCA (a
Patient Controlled Analgesic). As
a n d w h e n y o u f e e l p a i n ,
medication is given to you at the
press of a button. In addition, you
may also ask for an injection from
the ward sister. The pain gradually
reduces over the first 24 hours.
Ÿ A f t e r t h e i n i t i a l p e r i o d o f
drowsiness, you can start taking
sips of water, or suck on an ice or a
peppermint. You may feel some
nausea. Some patients tend to
v o m i t a f e w t i m e s a f t e r
anaesthesia. If you do, ask for
medication to control it.
Ÿ There may be a couple of tubes
coming out of the operation site.
These are to drain away the excess
'unwanted' blood. These tubes
are normally removed on the 2nd
day. There will also be a tube for
draining urine, which will be
r e m o v e d w h e n y o u f e e l
comfortable about passing urine
on your own, generally in 2 days.
Ÿ You may turn sides if you need to,
but make sure to keep a pillow
between your legs when you do.
Ÿ You may sit up with support.
Alternatively you may ask for your
bed to be propped up.
Ÿ You should wriggle your toes as
much as possible and move your
feet at the ankles, to help reduce
the swelling of your legs. This will
reduce pain and prevent
swelling or DVT of the legs. If
you have undergone hip
replacement, you may have a
“triangular pillow” between your
legs to avoid scissoring (crossing
over of the leg-to prevent
dislocation)
P O S T - O P E R A T I V E P R O T O C O L
DAY 1
Ÿ You are permitted to sit up or sit
with your legs dangling by the
b e d s i d e . I n c a s e o f K n e e
Replacement, support your leg on
a chair or a stool.
Ÿ Push your ankle up and down
alternately.
Ÿ Press your knee down on the bed (
to pull your knee cap up) and then
a relax.
Ÿ Perform the above exercises as
many times in a day as you can .
They will help in reducing pain
and swelling.
Ÿ You will be given elastic stockings
to be worn on both legs to prevent
swelling and DVT.
Calf pumps – Sequential calf
compression devices
Ÿ Post –operative blood tests will be
done today.
Ÿ Your dressing may have a little
blood stains, which is normal.
Ÿ if pain is reasonably under
control, you will be made to stand
and walk.
Day 2
Ÿ The tubes from your operation site
will be removed.
Ÿ The physiotherapists will help you
start standing with the help of a
walker and you may even take a
few steps.
Ÿ The urine tube may also be
removed today, and you will be
permitted to use the toilet ,
depending on your comfort level.
Ÿ Most injectable medicines will be
stopped.
Ÿ The dressing will be checked and
a light comfortable dressing will
be done.
DAY 3 to 6
Ÿ Physiotherapist will come by to
start knee bending exercises in
case of a knee replacement, on a
special machine (CPM). You may
also bend the knee by yourself
depending on your comfort level.
Ÿ During these days, you will need
to work hard on your walking
and the exercises shown to you.
Ÿ You will also start climbing stairs.
Ÿ In case of knee replacement
practice knee bending and
straightening. On your own,
sitting by the bedside.
Ÿ Also learn to tighten and
loosen the knee cap .as many
times in t he day as possible
(Quardriceps tightening).
Ÿ You will graduate from a
walker to a single stick,
depending on your comfort
level.
Ÿ You will be discharged, with a
full report of your
treatment and medicines to be
taken.
Ÿ We often use concealed sutures.
(All this part has not got printed)
D V T P R O P H Y L A X I S
What is Deep Vein Thrombosis?
Deep Vein Thrombosis (DVT) is a
condition resulting from the formation
of blood clots inside a deep vein,
commonly located in the calf or thigh.
DVT occurs when the blood clots
either partially or completely blocks
the flow of the blood in the vein .This
can happen when the rhythm of
circulation of the blood slows down
due to illness, injury, or immobility
after surgery, leading to a tendency for
blood to accumulate or “pool”. A static
p o o l o f b l o o d o f f e r s a n i d e a l
environment for clot formation and
poses a potential risk for DVT.
Am I at risk for developing DVT?
DVT remains a serious preventable
cause of postoperative morbidity in
patients undergoing arthroplasty.
Undiagnosed and untreated Deep Vein
Thrombosis (DVT) will lead to
pulmonary embolism which is a
serious complication. We were the first
to highlight the true incidence of
postoperative DVT and its pattern of
distribution in Indian patients. We have
set protocols to address DVT based on
our research and experience.
How is DVT prevented?
All patients receive either LMWH or
oral drugs for 3 to 7 days following
a r t h r o p l a s t y . P a t i e n t s a r e a l s o
instructed to wear compression
stockings to prevent pooling and aid
blood flow. We also give sequential
compression devices to prevent DVT in
the initial post-operative period.
Please inform us if you a r e
already on blood thinning drugs such
as aspirin, warfarin or clopidegrol.
Papers published by Dr. Sanjay
Agarwala on Deep Vein Thrombosis:
1. “Screening for DVT in postoperative
orthopaedic patients “. Indian Journal
of Orthopeadics, 2002.
2. “DVT in India Patients undergoing
major lower limb surgery”. Indian
Journal of Surgery, 2003.
3. “Incidence of DVT in Indian
P a t i e n t s ” . I n d i a n J o u r n a l o f
Orthopaedic, 2003.
4. “Pre and Post-operative DVT in
Indian patients Efficacy of LMWH as a
prophylaxis agent”. Indian Journal of
Orthopaedic, 2005.
I M P O R T A N T T I P S
MUGA
Patients who have flexion deformities
and restricted range of motion prior to
surgery as well as those who lack
motivation to perform physiotherapy
after surgery may need manipulation
under anesthesia to help
overcome the stiffness. The primary
aim of MUGA is to overcome tissue
adhesions in and around the knee.
Studies have shown that manipulation
performed within a week of surgery
will greatly improve range of motion.
Based on range of motion after
surgery we may decide to perform
MUGA which is a minor
procedure done in the operation
theatre. Under anaesthesia the knee
will be bent & straightened to the
maximum extent possible to help the
patients recovery.
Please note that we often make use of
the CPM machine which lowers the
need for MUGA.
A FEW TIPS THAT YOU SHOULD
FOLLOW AT HOME ARE:
· Perform your exercises regularly
· Walk climb stairs, according to
your comfort level
· Use a walking stick in the opposite
hand
· Watch your weight
· Consult your doctor in case of any
new symptoms
· Be extra cautious of carpets, wires
at home and on wet bathroom floors
Some degree of swelling in the foot
and lower leg is normal after this
surgery, and need not worry you. Such
a swelling may remain up to 9 to12
months.
We would like to see you in month , 3
month , 6 month and then on a annual
basis. Kindly make sure to bring along a
new set of X-rays of your operated joint,
along with your previous x-ray.
NOTE:
Ÿ Patients are often worried about
fever following joint replacement
surgeries. Intermittent fever is not
a cause for worry and can be
treated with just paracetamol.
Ÿ O n l y i f c o n s t a n t h i g h
temperature, increasing pain.
Tenderness or raised white blood
counts persist for more than five
days after surgery, infection may
b e s u s p e c t e d . F o l l o w i n g
investigations a p p r o p r i a t e
treatment is instituted.
Normally antibiotic prophylaxis
for a single day after surgery is
adequate, “Postoperative
pyrexia after arthroplasty
when to panic” ? Paper by
Dr. Sanjay Agarwala- published
in Indian journal of
Orthopaedics. April 2005 pg 7.
Ÿ Make sure to inform your doctor
about your joint replacement
surgery, if you are to undergo any
other minor or major surgery,
including a dental extraction. You
should receive some antibiotic
c o v e r s t a r t i n g b e f o r e t h e
procedure and continued to
avoid seeding of the artificial joint
with bacteria.
Ÿ In case of pus pocket anywhere in
t h e b o d y , a n t i b i o t i c s a r e
mandatory.
A L T E R N A T I V E S
KNEE
Visco supplementation
Intra-articular hyaluronic acid injection
can give short term relief and is usually
helpful only in early stage of arthritis.
Arthroscopy :
It is a surgical procedure involving a
small incision in your skin around the
knee joint, through which special
scopes attached to a camera are
inserted into the joint. This allows the
surgeon to visualize the insides of the
joint and trim and repair torn tissues.
High Tibial Box Osteotomy:
In this surgery , the leg bone is cut near
the knee to restore alignment. It can be
performed in a selected number of
patients in whom only the inner half of
the knee joint is worn out or in younger
patients with early arthritis. The
procedure does buy time till a Total
K n e e R e p l a c e m e n t b e c o m e s
mandatory.
“ Box Osteotomy .A new technique of
p r o x i m a l t i b i a l O s t e o t o m y f o r
osteoarthritis of the knee”. Paper
published by Dr. Sanjay Agarwala in
j o u r n a l o f o r t h o p a e d i c s a n d
Traumatology, 2001. no.3, pg218 and
another paper, " Staple V/s locking
compression plate fixation after lateral
closing wedge high tibial osteotomy in
j o u r n a l o f o r t h o p a e d i c s u r g e r y
2008;16(3)(303-7).
Now we also offer medial opening
wedge osteotomy in selected group of
cases, yet another technique.
Unicondylar knees
Depending on the severity of OA , a
grey zone exists when a high Tibial
Osteotomy is inadequate and a total
Knee Replacement too drastic a
procedure. It is in these cases there is an
option of the Unicondylar Knee
Replacement (UKR). The advantages of
the Unicondylar Knee Replacement
that it is done through a small incision
and only the damaged part of the knee
affected condyle is replaced. The
patient can use an Indian commode,
squat on the floor. At the time of
surgery it may be necessary to switch to
a total Replacement if the entire joint
has been affected.
A L T E R N A T I V E S
HIP
Avascular necrosis of the femur head
(AVN) leads to osteoarthritis of the hip
till a few years back there was no non
surgical option for treating early stages.
Before arthritis sets in, the disease
process can be controlled by certain
a n t i o s t e o p o r o s i s d r u g s l i k e
Alendronate. This innovation was
c o n c e p t u a l i z e d b y D r . S a n j a y
Agarwala which is now a proven
treatment for early AVN. Articles have
been published in world literature by Dr.
Sanjay Agarwala as” Alendronate
treatment of vascular necrosis
(AVN) of hip'an open exploratory
pilot study.
1.E f f i c a c y o f A l e n d r o n a t e – A
Bisphosphonate in the treatment of
AVN of the hip – A prospective open
label study published in the Journal of
Association of Physicians of India, Vol-
491, September 2001.
2. “Alendronate in the treatment of
Avascular necrosis (AVN) of hip”
British Society for Rheumatology 2002;
41:346-347.
3. “ E f f i c a c y o f a l e n d r o n a t e , a
bisphosponate in the treatment of AVN
of the hip. A prospective open-label
study published in Rheumatology,
April 2005 : Vol. 44 pgs 352 – 359.
4. The use of Alendronate in the
treatment of Avascular Necrosis of the
femoral head. (Follow-up to 8 years)
published in the Journal of Bone and
Joint Surgery (Br). Vol 91-B, No.8,
August 2009.
5. Ten Year Follow-up of Avascular
Necrosis of the femoral head treated
with Alendronate for 3 years published
in the Journal of Arthroplasty, Vol. 26,
No.7, 2011.
Consultant Orthopedic Surgeon
Specialist in Joint Replacement & Trauma Surgery
At P.D. Hinduja National Hospital : Assistance for Appointments – 91 22 24447173.,
Surgical attachments at P.D.Hinduja National Hospital,
Call Centre No. for Appointments – 91 22 39818181 / 91 22 67668181,
Secretary - 91 22 24447185 O Emergency : 9869446644.
Breach Candy Hospital.
Private Clinic -104/B, Sukh Sagar Building , 1st floor, Above Kobe Sizzlers ,
N.S.Patkar Marg (Hughes Road), Opera House, Mumbai - 400007.
Tel No. 9869480707,23610707.
Email : [email protected]
Website : www.drsanjayagarwala.com
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