Joint Replacement for Arthritis: Hip, Knee, Shoulder, Elbow

Joint replacement for arthritis is the definitive treatment once medicines, injections and physiotherapy have failed and the patient's daily life is affected. The damaged surfaces of the hip, knee, shoulder or elbow are replaced with implants. Results depend as much on rehabilitation after surgery as on the operation, and complex cases, including failed earlier surgery, can still be reconstructed.

Dr. Mannu Bhatia, Associate Director - Centre for Orthopaedics, BLK-Max Super Speciality Hospital, New Delhi, India, devoted the second half of his masterclass to this stage and to the patients who reach it. Many of the cases he presented were patients who had travelled from Africa and the Middle East, two of them after unsuccessful surgery elsewhere. The earlier steps, from diagnosis to conservative care, are set out in the complete guide to joint arthritis diagnosis and management and the article on non-surgical arthritis treatment.

When arthritis needs joint replacement

Dr. Bhatia's threshold for surgery is functional. Surgery is the definitive step in cases where conservative treatment has failed, whether medicines, injections or physiotherapy, and the arthritis is affecting the patient's life. The X-ray confirms the decision: it shows whether the joint space has gone, and whether the patient needs surgery or can continue with medicines and physiotherapy.

The indications he gave are pain, disability and loss of mobility, in a patient whose joint no longer responds to the earlier rungs of treatment. Rest pain, the pain that persists when the patient is lying down, is the symptom that tells a referring doctor the patient now needs a specialist.

Hip replacement (total hip arthroplasty)

In a total hip replacement, the worn ball of the thigh bone is replaced with an implant fixed into the femur, and the worn socket is lined with a new cup, restoring a smooth bearing surface. The indications are pain, disability and inability to move. Dr. Bhatia's assessment of the outcome was simple: it is a very successful operation when it is done properly.

Hip arthritis is the commonest presentation among his African patients: of every ten patients from Africa he sees with arthritis, roughly eight have arthritis of the hip.

Knee replacement: a resurfacing operation

Dr. Bhatia was precise about terminology. A knee replacement is properly called a knee arthroplasty, and it is a resurfacing operation. As he put it to the audience, the surgeon does not change the patient's knee. The knee remains the patient's own; only the damaged surfaces of the bone ends are resurfaced with metal components, with a plastic insert between them acting as the new gliding surface.

The indication is a severely disabled patient, whether the cause is osteoarthritis or rheumatoid arthritis. He describes the results as excellent: the aim is a patient whose walking gives no sign that the knee or hip has ever been operated on. The robotic approach to the same operation is covered in Dr. Rakesh Mahajan's robotic knee replacement guide.

Shoulder and elbow replacement

The same principle extends to the upper limb: shoulder replacement when the shoulder is destroyed, elbow replacement when the elbow is. These operations are performed far less often than hip and knee replacement, but two of the cases Dr. Bhatia presented, described below, show what elbow surgery can achieve for a patient left with a useless arm. The cost of the procedure for international patients is summarised on the elbow replacement cost page.

Who should not have joint replacement

Asked about the absolute contraindications, Dr. Bhatia named a patient whose general medical condition is poor, for example a patient with cardiac disease in whom the operation itself would carry a serious risk. Active infection, in the joint or elsewhere in the body, is also an absolute contraindication, because it seeds the new implant.

He also set out the conditions the hospital must meet. As the techniques spread and more countries attempt these operations, two things are essential:

1. A genuinely sterile operating theatre. Infection of a joint replacement is among the most serious complications in orthopaedics, and theatre sterility is the first defence.
2. Excellent post-operative facilities. These are what actually deliver the result of the surgery to the patient.

For a referring doctor deciding where to send a patient, this is the practical test: the operation is only as good as the theatre it is done in and the rehabilitation that follows it.

Bilateral hip replacement: same sitting or staged

A question during the session asked whether both hips can be replaced in the same patient. Dr. Bhatia's answer was that bilateral hip replacement can always be done, either in the same sitting or with a gap between the two sides, depending on the patient's condition. If the patient's body can tolerate it, both hips can be replaced at once. If the body, or the finances, do not allow that, the operations can be separated by an interval. Either way, rehabilitation and the expected result have to be planned accordingly. Costs for both approaches are listed on the bilateral total hip replacement cost page and the unilateral total hip replacement cost page.

Rehabilitation after joint replacement decides the result

Dr. Bhatia was unequivocal: the success of any joint replacement, whether knee, hip or any other, depends on how well the patient does physiotherapy and physical exercise after the operation. A patient who does it properly can return to virtually any normal activity.

Activity limits after surgery

Patients ask him whether they can return to sport. His exchange with a football player asking about football after hip replacement captures the principle. He tells him he can, and then asks what will happen if he falls and fractures around the new hip. High-impact activities should always be avoided after joint replacement. Walking, daily activity and low-impact exercise are the goal; contact sport is not.

Follow-up

Patients should continue to see their surgeon regularly after the operation, to confirm that everything is going well. For international patients, that means planning follow-up before travelling home. The recovery timeline after knee replacement is covered in detail in Dr. Rakesh Mahajan's article on knee replacement recovery, infection risk and implant life.

Customised 3D-printed implants

Joint replacement is also moving towards implants made for one patient. Dr. Bhatia has operated on patients using 3D-printed implants customised to the individual patient's body, and he described the subject as large enough for a session of its own. Stem cell therapy, the other emerging option he mentioned, is discussed in the article on non-surgical arthritis treatment.

Joint replacement cases: patients from Africa and the Middle East

Dr. Bhatia presented a series of patients, with X-rays before and after surgery and videos of their recovery. Details below are generalised to protect patient privacy.

A woman in her seventies with severe knee arthritis

A woman in her seventies from Central Africa came with advanced knee arthritis: her X-ray showed a reduced joint space and the bones becoming curved into deformity. She underwent total knee replacement. Eight to nine days after the operation, with her dressings still on and her sutures not yet removed, she was dancing. A month after surgery, having continued physiotherapy, she sent Dr. Bhatia a video of herself exercising outdoors.

A man in his thirties with both hips destroyed after steroid treatment

A man in his thirties from East Africa had received large doses of steroids for a chest illness during the COVID-19 pandemic, as many patients did. He then developed arthritis in both hips, was confined to a wheelchair and could not walk. Dr. Bhatia replaced both hips. Around 12 days after surgery he was rehabilitating, walking within two weeks of the operation, and at one month he was walking normally. High-dose corticosteroid treatment is a recognised cause of avascular necrosis of the femoral head, in which the bone of the hip ball loses its blood supply and collapses, leading to secondary arthritis; it can occur in young adults and often affects both hips.

A young woman with a fused elbow

A young woman from West Africa who also had anaemia came with an elbow that was fused solid (ankylosed), with one of the bones of the joint missing on X-ray. She wanted a mobile elbow. Dr. Bhatia described it as a very tough case. Before surgery she could not use the arm; after surgery she could use it fully for daily activities.

A woman whose hip had failed twice elsewhere

A woman from the Middle East had undergone hip surgery that failed, and then failed again. She was confined to a wheelchair, had also had spinal surgery, and her bone was highly osteoporotic and deficient. Her family asked Dr. Bhatia to help her walk again. He performed a complex hip replacement designed for the bone loss, and she is now walking well. Complex reconstruction of this kind is the subject of Dr. Rakesh Mahajan's guide to complex total hip arthroplasty.

A man in his thirties with a fused, shortened elbow

A man in his thirties from Central Africa had a fractured elbow operated on six to seven times in his home country. He contacted Dr. Bhatia wanting a working elbow, but because of a language misunderstanding he went to another centre, where the elbow was fused (an elbow arthrodesis) after the bone was cut. He was left with a shortened, stiff arm. He then came to Dr. Bhatia, who performed an elbow replacement. In a video testimonial recorded afterwards, he demonstrated how he now uses the arm.

The case carries a lesson beyond surgery: for international patients, clear communication in the patient's own language is part of getting the right operation.

Dr. Bhatia also operates on the spine, and he showed testimonials from patients from Central Africa who had undergone spinal surgery with him, including an older woman who had had three previous operations. He later met several of these patients when he visited the region.

Cost of joint replacement for international patients

Asked how affordable these operations are, Dr. Bhatia said they are very affordable in India: around half the price of the same surgery in Nigeria, and much less than in Europe or the United States. He gave no specific figures in the session. Indicative package costs are published on the total knee replacement cost page, the bilateral total knee replacement cost page and the hip pages linked above.

The questions doctors raised on the call, including contraindications and staged bilateral surgery, are collected on the masterclass Live Discussion page. Dr. Ramkinkar Jha's guide to hip and knee replacement surgery covers the operations from a surgeon's technical perspective, and more joint content is on the orthopaedics specialty page.