Principal Director & Unit Head, Orthopaedics, Fortis Memorial Research Institute, Gurgaon
Part 6 of 9 in Recent Advances in Joint Replacement
When Joint Replacement Surgery Should Be Delayed or Avoided
April 13, 2025
Joint replacement is not automatically the right answer once a joint is damaged. Dr. Jangid set out several situations in his masterclass where surgery has to be delayed, modified, or, in a narrow set of cases, avoided altogether.
Active infection must be cleared first
A common referral his team receives is a patient with an active joint infection who has already been told they need a replacement. Dr. Jangid was clear that infection does not rule out surgery, but it must be controlled first: the standard approach is an antibiotic spacer placed for around six weeks to clear the infection, after which the patient can proceed to replacement.
When surgery is not the right option
Some patients are genuinely poor candidates for joint replacement. Patients with neurological conditions that affect balance and neuromuscular control cannot reliably stabilise a new joint and are not good surgical candidates. Patients whose joint is already covered by a skin flap or graft from earlier trauma are also excluded. A further group Dr. Jangid described are patients with neuropathic joints, severely damaged joints where nerve involvement means the patient does not feel pain. Surgery is generally avoided here unless the joint has become so unstable that the patient cannot walk, in which case a stable, revision-type implant is used cautiously.
How disease progression should guide timing
Dr. Jangid walked through how joint damage typically progresses: the joint space narrows, then the joint reaches bone-on-bone contact, then advanced disease brings extra bone formation from rubbing and visible misalignment, and in the most advanced cases the joint's normal anatomy becomes difficult to recognise on imaging. His guidance was straightforward: patients get better results the sooner they come in, but even the most advanced, longest-neglected cases can still be treated successfully with surgery.
This article is based on a Jivo Masterclass session conducted by Dr. Subhash Jangid, Senior Director, Orthopaedics & Joint Reconstruction, Fortis Memorial Research Institute, Gurgaon. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Subhash Jangid taught doctors across Africa on April 13, 2025.
FROM THE LIVE Q&A
Doctor on the call (name unclear from transcript)
Most post-operative painkillers are known to affect the liver. What pain medication is recommended after joint replacement that avoids this?
Dr. Subhash Jangid
Opioids are used at a very low dose, delivered through a transdermal skin patch or a nasal spray rather than as tablets or injections, giving good pain control without sedation, headache or nausea. Alongside this, the only oral tablet used is paracetamol, which does not affect the stomach or the kidneys.
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Frequently Asked Questions
Sharing an update: how valuable has attending these weekly sessions been?▼
The attendee said he joins every Sunday and is never disappointed, describing the sessions as consistently insightful and helpful for improving his own practice. He mentioned he had further questions and would send them on separately to be passed along to Dr. Jangid.
Could the presentation be shared as a PDF in French as well as English, and was a translator available for the French-speaking doctors on the call?▼
Yes to both. The English PDF was shared with the group, the French version had already been sent separately, and a dedicated French translator was present throughout the session to help the doctors from Congo follow along.
Could the presentation be shared as an English-language PDF?▼
Yes, the English PDF was shared again on request.
One attendee thanked Dr. Jangid for the presentation and asked about opportunities to train under him.▼
Doctors from Africa can apply for a one-year fellowship programme in India to learn joint replacement surgery. Interested doctors need to email the team and register with India's National Medical Council before joining for the year-long training.
Is there an age limit for hip or knee replacement surgery?▼
There is no fixed age limit at either end. Hip replacement is generally offered from skeletal maturity onward if the joint is badly damaged, and partial knee replacement is usually done from around age 40, occasionally as early as 30, though most patients present between 45 and 50. Modern implants can last more than 30 years, so age by itself is not the deciding factor.
Does having an infection permanently rule out joint replacement surgery?▼
No. The infection needs to be controlled first, typically with an antibiotic spacer placed for around six weeks, after which the patient can proceed to replacement surgery.
Why are joint replacements generally avoided in neuropathic joints?▼
Because nerve involvement means the patient cannot feel pain, so surgery is reserved for cases where the joint has become too unstable to walk on, and even then a stable, revision-type implant is used cautiously.
In This Series: Recent Advances in Joint Replacement
- 1.Recent Advances in Joint Replacement
- 2.Who Needs a Knee or Hip Replacement: Symptoms and Warning Signs
- 3.Partial or Total Knee Replacement: Matching the Procedure to the Patient
- 4.How Robotic Surgery Is Changing Joint Replacement
- 5.Hip Replacement Surgery: Implant Design, Materials and Durability
- 6.When Joint Replacement Surgery Should Be Delayed or Avoided
- 7.Correcting Severe and Bilateral Knee Deformities
- 8.Recovery, Pain Management and Rehabilitation After Joint Replacement
- 9.Joint Replacement Surgery in India: What International Patients Should Know