Knee Replacements: Are We Overdoing?

Some vouch that the problem of unwarranted knee replacement surgeries in India is worse than abroad. To add to this, most patients assume that imported implants are better and end up paying a whopping Rs 2 lakhs for the implant, plus additional fees for the surgery and hospitalization. Critics aver that surgeons earn a lot from commission on each surgery and that's why many of them promote it as a permanent solution even to patients not requiring them.

---

The knee joint is the largest, the most complex, and the most stressed joint in the body. It is this complexity and stress which can cause osteoarthritis. Osteoarthritis, commonly known as “wear-and-tear arthritis”, is a condition in which the natural cushioning between joints – the cartilage - wears away. When this happens, the bones of the joints rub more closely against one another with less of the shock-absorbing benefits of cartilage. The rubbing results in pain, swelling, stiffness, decreased ability to move and, sometimes, the formation of bone spurs.

John, my colleague, had been an athlete in his youth. Just before his sixtieth birthday he started experiencing pain in both the knees after activity. The pain would ease after rest. Gradually, there was swelling and a feeling of warmth in the joints. Months later, nagging stiffness occurred, worse in the morning, or, after sitting for a while. A year later there was marked decreased of mobility, which made it difficult for him to get in and out of chairs or cars, use the stairs, or walk. His symptoms went on worsening. His sleep was often disturbed because of the pain.

He consulted many doctors. They advised weight loss, pain relievers, intra-articular injections, acupuncture, and chondroitin/glucosamine supplements. Nothing seemed to work. John began to lose his patience and often gave in to despair. Braces and physiotherapy proved futile. At last, he decided to go for something he had been putting off all along: total knee replacement (TKR).

TKR is an orthopaedic procedure that is used to replace the damaged or worn surfaces of the knee. Replacing these surfaces with an implant (called "prosthesis") will relieve pain and increase mobility, allowing you to return to your normal, everyday activities. The surgery can be performed with a long incision or through a minimally invasive approach. John opted for the latter, because he was told of the fewer chances of postoperative pain, a shorter hospital stay, and quick recovery. At last he went under the knife and after flawless surgery, John felt like he had not for so many years.

TKR, however, may provide incomplete relief and require a “re-do”. It can also have its share of problems. However, orthopaedic surgeons use newer technologies for better outcomes. In some centers, computer assisted TKR is used to guide the surgeon to precisely plan the exact amount and angle of the bone to be removed during surgery.

What is a matter of concern, however (and we face this all over the world), is an exponential increase in the number of TKRs. Experts themselves question the unwarranted sense of urgency in rushing for a replacement. Surely, they say, in many arthritis patients, lifestyle modifications, weight loss and exercise could avert the need for traumatic surgery. The Indian Society of Hip and Knee Surgeons reports 66,352 total knee replacements in the country in 2013, compared to merely 9,951 cases reported by it in year 2008. While there is no study to assess how many of these total knee replacements were uncalled for, a new study published in Arthritis & Rheumatology, a journal of American College of Rheumatology, has revealed that over one-third of such surgeries conducted in the US were "inappropriate".

 

Some vouch that the problem (of unwarranted TKR surgeries) in India is worse than abroad. To add to this, most patients assume that imported implants are better and end up paying a whopping Rs 2 lakhs for the implant, plus additional fees for the surgery and hospitalization. Critics aver that surgeons earn a lot from commission on each surgery and that's why many of them promote it as a permanent solution even to patients not requiring them.

Dr C S Yadav, professor, department of orthopedics at AIIMS, said, "Nearly 30-35% of knee replacements conducted in India are unnecessary. At AIIMS, we have been holding awareness programmes to educate patients about the need to focus more on lifestyle modification than be lured by the idea of a replacement surgery pushed by private practitioners."

But private practitioners insist that unnecessary total knee replacements are a myth. "In Western countries, people are indeed pushing doctors for procedures to seek immediate relief from arthritis pain. But here in India most often we get patients who prefer to wait until the joints are damaged beyond repair before opting for surgery", says one private consultant.

While there are black sheep in every profession, it is my experience that at least some orthopaedic surgeons practicing in Goa do their best to dissuade patients from undergoing the procedure until all non-surgical measures are exhausted, and that is highly creditable. Elsewhere the scenario may be different.