Thursday, August 23, 2012


Knee replacement is one of the most successful surgeries in all of medicine. Pioneering work in knee replacement was done in the early 70's by prominent scientists and surgeons in the US and UK. Since then knee replacement has come a long way. 
Surgeon experience has grown. Surgery is faster, more precise and with minimum errors. Anaesthesia is better. Pain management is better. All this has resulted in faster recuperation for the patient. The patient walks independently on the second day after surgery. The patient is discharged in 5 or 6 days. Replacing both the knees in one sitting is now possible and the advantages are obvious. The knee replacement prosthesis’ have undergone a tremendous evolution as well. Better prosthesis translates into better function and a longer life for the joint. Most patients enjoy a near normal knee function postoperatively with the knee bending completely. In fact for patients needing knee replacement, things have never looked as promising as they are now! 

Fear to do undergo surgery is common and well justified. Any normal person would not want to undergo knee replacement by choice and would look for ways and means to avoid surgery. While this is a sensible approach, I see many patients taking it too far. They will avoid surgery at all costs, no matter how much pain they have to suffer. Fear instilled by friends and family adds to the problem. If feel this kind of attitude is unwarranted. 
Unqualified people classically will see a result as black or white. This person selling fruit is good, that petrol pump is bad, this school is terrible, etc. There may be some truth in the statement but it can never be a whole truth. This is because life is never black or white, but many shades of grey! Let me try and explain with an example. If a surgeon did one thousand knee replacements in a year, and one surgery went wrong, he would have a success rate of 99.9%, right? Sounds good? Now let's consider the surgery that went bad. What would that patient’s relative say? He would obviously tell you that knee replacement is a bad surgery and no one should get it done (black or white response) Is he justified in making such a statement? May be. But is he saying the truth? No! 
Are we as doctors justified in denying 999 people an excellent result because of the possibility of one case going wrong? No! 
I urge everyone to take any decision rationally and sensibly. It is unwise to base your decision on one particular example. There are too many variables. Some hospitals have better infrastructure than others, some joint replacement prosthesis are better than others, some surgeons are better than others and some patients are more suitable for this surgery than others!! Do your homework well and you will be rewarded with an excellent result. 

Progress in any field is welcome and inevitable. Even though knee replacement has progressed tremendously, more progress continues. 

Computer assisted surgery (CAS) is one such recent advance. Computers have brought accuracy in all fields. May it be computerised matching of colours or computerised cut out of designs. Humans cannot match computers in accuracy. CAS improves the accuracy of knee replacement. This results in better restoration of alignment of the leg and better fitting of the components. 

Another advance is custom knee replacement or knee replacement using custom made instruments and implants. Knee replacement is about fitting components of the right size into patients. Just as a custom made suit fits far better than a readymade one… similarly custom made instruments increase the accuracy of knee replacement. For this an MRI of the patients knee is done before surgery and sent to the company (mostly abroad) The company then manufactures instruments tailor made to that knee based on MRI and ships them to us. We then use these instruments to do knee replacement with perfect accuracy and therefore better results. 

The knee has three compartments and all are involved in a typical case of advanced osteoarthritis. However in a few patients, only one or two compartments are involved. Nowadays it is possible to do partial knee replacement in these patients (uni-condylar knee replacement and bi-condylar knee replacement). These surgeries are more bone and ligament saving. Because we remove less, patients feel the knee is more natural after surgery. Also revising these implants to a total knee replacement is easier later. 

And lastly I'll just mention Robotic Surgery. Yes robots have arrived in the field of knee replacement. In knee replacement we have to cut the bone accurately to allow accurate replacement with implants. In robotic knee replacement, the bone is cut by a robotic arm. This ensures extreme accuracy and therefore superior results. Robotic surgery is still in its infancy in India. 

To conclude, knee replacement is a fantastic surgery. It is getting better every day. With recent advances, success is almost guaranteed. But every surgeon cannot do it and every hospital is not equipped for it and every patient is not ideal for it! Do your homework!