Question 1

What are the commonest indications for knee and hip replacement surgeries?

Dr. Ishwar Bohra · Accepted Answer

The most common indication is age-related osteoarthritis at stage three and above, an absolute indication for joint replacement in both hip and knee. Rheumatoid arthritis and post-traumatic malalignment of the hip or knee are also common. Other indications include autoimmune arthritis, gout and other systemic illness or coagulopathies, and avascular necrosis of the hip, which has become a bigger reason for hip replacement post-COVID.

Question 2

How is AI applicable to orthopaedics?

Dr. Ishwar Bohra · Accepted Answer

AI is imageless: it gives real-time information on the patient's joint alignment, the rotation needed, and the gap balancing required in arthroplasty. The history moved from patient-specific instrumentation (which only allowed a fixed cut), to computer navigation, to robotics, and now AI combined with robots. AI needs no pre-operative CT or MRI and no extra-articular pin placement - it is a pinless, imageless modern technique.

Question 3

Is there much preparation before any joint replacement surgery?

Dr. Ishwar Bohra · Accepted Answer

Yes. We first screen and optimise the patient: ruling out uncontrolled medical illness (diabetes, hypertension, coronary artery disease), any potential infection source, checking haemoglobin is adequate, and ruling out autoimmune or systemic disease. After that, you need good imaging where required, trained OT staff, a clean theatre, good ICU and anaesthetic support, a standby cardiologist, and blood bank access since most cases need transfusion.

Question 4

Is joint replacement possible for patients who cannot accept blood transfusion for religious reasons, such as Jehovah's Witnesses?

Dr. Ishwar Bohra · Accepted Answer

Yes. We optimise the patient's haemoglobin before surgery with hematinics or iron injections and diet, waiting a couple of weeks for it to improve. If that isn't sufficient, we use autologous transfusion: the patient's own blood is drawn and stored in advance, with no cross-matching needed, and given back to the same patient during surgery.

Question 5

Which type of pre-operative templating do you use to achieve accuracy for joint replacement?

Dr. Ishwar Bohra · Accepted Answer

Templating started as physical templating, then moved to digital templating software. But since we have now shifted to more advanced techniques, we don't rely on templating anymore - intraoperative robotic-assisted guidance gives more accurate implant sizing and positioning directly.

Question 6

What is the new advancement in total hip replacement, and are there any alternatives to total hip replacement?

Dr. Ishwar Bohra · Accepted Answer

Beyond computer navigation, robotics and AI, there has also been advancement in surgical approach. Older approaches like the posterior and direct lateral approach cut through muscle to enter the hip. The direct anterior approach (also called direct superior approach) avoids any muscle cut or nerve violation, with very minimal blood loss and a minimally invasive incision - patients can often go home after one day, or even as daycare.

Question 7

What is the risk of infection from joint replacement surgery?

Dr. Ishwar Bohra · Accepted Answer

In our setup, infection risk is under 0.3%. The two main factors are patient factors (immunocompromise, uncontrolled diabetes, hepatitis B, HIV or other viral disease) and surgeon/facility factors (poor surgical technique, poor OT culture, inadequate medication availability, or poor post-operative care).

Question 8

What is the recent evidence on nutrition care for joint replacement patients, and what is the relationship between dieticians and doctors in this care?

Dr. Ishwar Bohra · Accepted Answer

There is a gut-joint axis theory: poor absorption of micronutrients, from conditions like coeliac disease, gluten allergy, Crohn's disease, ulcerative colitis or chronic acid-peptic disease, is linked to an increased chance of arthritis, whether autoimmune or degenerative. Post-operatively, any surgery causes a drop in general immunity for 12 to 20 weeks, since the patient is in a hyper-catabolic state, so we need to give a good protein diet (milk and milk products, protein powder, vegetarian protein) and increase total calories so the patient regains immunity as soon as possible.

Question 9

What is the definitive management for recurrent shoulder joint dislocation?

Dr. Ishwar Bohra · Accepted Answer

There are two types of surgery: arthroscopic and open. For most patients without too many dislocations, arthroscopic Bankart repair plus a Remplissage procedure is the gold standard. For patients with more than 10 dislocations, open surgery is usually better. Bone defects on the socket side get bony augmentation; larger defects on the humeral head side may need grafting, or the tissue can be managed by moving the teres minor muscle into the defect - the traditionally open Latarjet procedure for this is now increasingly done arthroscopically.

Question 10

Is there an estimated age cutoff for knee or hip replacement - can a patient be too young or too old?

Dr. Ishwar Bohra · Accepted Answer

There is no strict age criterion. Implant durability was initially only around 10 years; we are now in the third generation of implants with a longevity of almost 30 years. Hip replacement can be done from age 18 once bone growth is complete, with no upper limit based on physiological rather than chronological age - we have done hip replacement at age 104. Younger patients, even under 20, may need replacement for traumatic arthritis, sickle cell disease or haemophilic arthropathy.

Question 11

Is it possible to arrange club foot treatment for a 3-month-old child?

Dr. Ishwar Bohra · Accepted Answer

Club foot treatment should start as early as possible, even from day one of life, since it can now be diagnosed prenatally via a level-2 ultrasound. On day one or two the skin is very fragile, so casting is difficult immediately; manipulation and serial casting typically start after 2-3 days. Age is not a barrier - treatment can be started even in a one-day-old child.

Question 12

What is the post-operative prognosis of spinal cord injury?

Dr. Ishwar Bohra · Accepted Answer

If there is a complete spinal cord transection, nothing currently works to regenerate it, including stem cells - the future is not good in these cases. If there is partial injury with some viable nerve roots, the patient can have some movement with a wheelchair or braces; assistive devices and specialised training exist for bladder and bowel management in patients who remain paralysed, but overall progress is not good once there is a spinal cord injury.

Question 13

Is electromyography (EMG) and nerve conduction study a required diagnostic procedure in orthopaedic treatment?

Dr. Ishwar Bohra · Accepted Answer

It depends on the patient - when there is a suspected nerve injury, EMG and nerve conduction velocity (NCV) studies are used by neurosurgeons, neurologists, orthopaedic and plastic surgeons to assess muscle power and nerve conduction. For example, with a humerus fracture and a dropping wrist, these tests help diagnose which nerve is involved and how completely.

Question 14

How should a doctor proceed in a local setup with limited resources when a procedure is complicated?

Dr. Ishwar Bohra · Accepted Answer

It would be unfair to the patient to attempt a procedure without confidence in the outcome. Even at the highest level of care, some procedures are not attempted if resources are limited or the outcome is uncertain - the patient and family should be counselled honestly about limitations and realistic benefit before deciding whether to proceed.

Question 15

How long can a hip or knee replacement last, is it permanent, and what is the typical pricing in India?

Dr. Ishwar Bohra · Accepted Answer

Implant life is now more than 30 years, and outcomes have improved so much that patients can do high-flexion activities like kneeling and squatting again within a few months. Pricing for joint replacement broadly ranges between $5,000 and $10,000 depending on the specifics of the surgery, with competitive package pricing available for common procedures like unilateral or bilateral knee and hip replacement.

Question 16

Is there any alternative to joint replacement?

Dr. Ishwar Bohra · Accepted Answer

Yes - for patients who are afraid of or want to avoid replacement, options include braces, lifestyle modification, analgesics, and supplements like calcium, vitamin D, glucosamine and collagen peptides, along with other conservative therapies.

Question 17

What is the experience of joint replacement in children?

Dr. Ishwar Bohra · Accepted Answer

Joint replacement is sometimes needed in children too - for hip pathology like SCFE or Perthes disease, traumatic hip fracture, or septic arthritis, since there is no growth potential left in a badly damaged joint. Replacement gives the child a painless life, while the opposite joint can have its growth arrested (hemiepiphysiodesis) to avoid limb-length discrepancy. Similarly for knees destroyed by haemophilia, sickle cell disease, viral arthropathy or infection.

Question 18

What is your preferred mode of anaesthesia, and do you use it for upper extremity procedures too?

Dr. Ishwar Bohra · Accepted Answer

General anaesthesia and regional nerve blocks, including for upper extremity procedures.

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