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 : dr_sagarwala@hindujahospital.com

Website : www.drsanjayagarwala.com