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 four, which is the absolute indication for joint replacement in both the hip and the knee. Other common indications are rheumatoid arthritis and trauma, since post-traumatic malalignment of the hip or knee can lead to arthritis. Less common indications include autoimmune arthritis, gout, other systemic illness and coagulopathies. Nowadays we also see a lot of post-COVID avascular necrosis of the hip, which is another big reason for hip replacement.

Question 2

How is AI applicable to orthopaedics?

Dr. Ishwar Bohra · Accepted Answer

AI is a game changer, and even more so in the future. It is imageless, so no extra investigation is needed, and it gives real-time information about the patient's joint alignment, the rotation required and the gap balancing required in arthroplasty. Historically, patient-specific instrumentation came first, which was limited because it only guided the bone cuts, then computer navigation, then robotics, and now AI with the robot. AI provides 3D alignment of the joint using a virtual camera and a very small laptop. In that respect it is better than the robot, because it needs no pre-operative CT or MRI of the joint and no extra-articular pin placement: it is a pinless, imageless technique.

Question 3

Is there much preparation before any joint replacement surgery?

Dr. Ishwar Bohra · Accepted Answer

Yes. For any major joint replacement, hip, knee or shoulder, we first screen and optimise the patient. Screening means ruling out medical and systemic illness such as diabetes, uncontrolled hypertension or coronary artery disease, any autoimmune or systemic disease, and any potential source of infection, such as an existing pneumonia or a skin or fungal infection. Haemoglobin should be more than 10, although the parameters differ between countries and populations. After that come the investigations, including CT or MRI if you want to use the newer technology. You then need good, trained theatre staff and a clean theatre, good post-operative care with a good ICU and anaesthetist, and a cardiologist on standby in case something happens. A blood bank, or some arrangement for blood transfusion, is desirable.

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. In these cases we first optimise the patient before surgery: if haemoglobin is not adequate, we give haematinics or iron injections and dietary support, and wait a couple of weeks for a good haemoglobin level. During surgery, blood loss is kept to a minimum with tranexamic acid and careful technique. There is also the option of autologous transfusion: the patient's own blood is removed beforehand and stored in the blood bank, and given back during surgery, with no cross-matching needed. What each patient will accept must be discussed and documented before surgery.

Question 5

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

Dr. Ishwar Bohra · Accepted Answer

Templating is now an old practice. It began as physical templating and then moved to digital templating, and there is still software that gives an accurate size for the acetabular cup and femoral stem, or the femoral component in the knee. But because we have shifted to more advanced techniques, we no longer template: intraoperative, robotic-assisted guidance gives a more accurate size and dimension of the implant.

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

There are many advances: computer navigation, robotics and AI, and also the surgical approach. Most surgeons enter the hip from behind, through the posterior approach, and the posterior and direct lateral approaches involve a lot of muscle cutting to reach the joint. Nowadays we use the direct anterior approach, going to the hip directly from the front, or muscle-sparing approaches such as the direct superior approach. The anterior approach works between muscles rather than cutting them, with no muscle cut and no nerve violation; blood loss is very minimal, and the minimally invasive incision is very small. Patients can go home after one day, and sometimes it can be done as daycare surgery.

Question 7

What is the risk of infection from joint replacement surgery?

Dr. Ishwar Bohra · Accepted Answer

In our setup the risk of infection is practically very low. Two main factors can lead to infection. Patient factors: the patient is immunocompromised or has comorbidities such as uncontrolled diabetes, or associated hepatitis B, HIV or another viral disease, and the surgery still has to be performed; these patients are at high risk. Surgeon factors: the surgery is not well done, the operating theatre conditions and theatre culture are poor, adequate medication is not available, or post-operative care is poor.

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 recent gut-joint axis theory: the gut is very important in managing the whole body, even in people not having a joint replacement. Poor absorption of micronutrients, coeliac disease, gluten allergy, or chronic illness such as Crohn's disease, ulcerative colitis or chronic acid-peptic disease are all linked with an increased chance of arthritis, whether autoimmune or degenerative. Post-operative nutrition is very important, because any surgery decreases the patient's general immunity for 12 to 20 weeks. During that time the patient is in a hypercatabolic state, so we need to give a good protein diet to compensate: milk and milk products, protein powder and vegetarian protein, with increased total calories, so the patient regains immunity as soon as possible after surgery.

Question 9

What is the definitive management for recurrent shoulder joint dislocation?

Dr. Ishwar Bohra · Accepted Answer

There are two types of surgery for recurrent shoulder dislocation: arthroscopic and open. For most patients without significant bone loss, arthroscopic Bankart repair plus remplissage is the gold standard. A patient who has dislocated more than 10 times is probably better served by open surgery. Frequent dislocators may have a bone defect on the socket side, the head side or both. If the glenoid defect is more than 30 percent, a bony augmentation of the glenoid such as the Latarjet is done, and a large Hill-Sachs lesion on the humeral side sometimes needs grafting. The Latarjet operation, which used to be done open, is now being done arthroscopically. It takes a little more time and is a difficult procedure, but because it is fully arthroscopic, recovery is fast and there is no open incision. Any associated pathology, such as a rotator cuff or biceps lesion, is addressed at the same time.

Question 10

Is there an age range for knee or hip replacement? Patients often ask whether they are too young or too old.

Dr. Ishwar Bohra · Accepted Answer

There are criteria, and they relate to the durability, or survival, of the implant. Initially implants lasted only about 10 years; we are now in the third generation of knee replacement, and implants now last more than 30 years. In younger patients, knee replacement is generally needed for traumatic arthritis, where an accident has completely destroyed cartilage that cannot be reconstructed; the same applies to the hip. Hip problems are more frequent than knee problems at a younger age, for example after congenital dislocation of the hip or Perthes disease, and hip replacement can be done after 18 years of age, once bone growth is complete. In special cases we even do early hip replacement, for example in sickle cell disease or in haemophilic patients with coagulopathy, who can have very bad, painful joints. There is no strict age criterion: even in a patient in their twenties who cannot walk or has severe difficulty, we can go ahead, because modern implants last for decades and a knee or hip replaced at 20 can be revised at the age of 50, while the patient stays walking, productive and pain-free. In old age it depends entirely on the patient's medical condition; we have done a hip replacement in a 104-year-old. Physiological age matters, not numerical age.

Question 11

Is it possible to arrange clubfoot treatment for a three-month-old child with clubfoot of the left foot?

Dr. Ishwar Bohra · Accepted Answer

Clubfoot treatment nowadays starts from day one, as early as possible, because it can be diagnosed before birth on a level-two ultrasound. The paediatrician or the gynaecologist following the pregnancy should be alert and inform the orthopaedic surgeon that the baby is going to have a clubfoot. On day one or two the newborn's skin is very fragile, so putting on a plaster is difficult; after two or three days you can start manipulation and serial casting. Age is no barrier: treatment can begin even in a one-day-old child.

Question 12

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

Dr. Ishwar Bohra · Accepted Answer

Spinal cord injury is a big and debatable topic. If there is a complete transection of the spinal cord, nothing works as of now: no stem cells, nothing regenerates the spinal cord, and the outlook is not good. If the injury is partial and some roots and nerves are viable, some movement is possible, with a wheelchair or braces; with a complete injury the patient usually remains paraplegic or tetraplegic. There are assistive devices for daily life, such as robotic chairs and devices that stimulate the calf and thigh muscles, and these patients need bladder training because of urinary and faecal incontinence. These are very specialised programmes, run in specialised centres that train patients to live with such injuries. But progress is not good once a patient has a complete 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 nerve injury, we need nerve conduction velocity studies and electromyography. They are diagnostic tools used by neurosurgeons, neurologists, orthopaedic surgeons and plastic surgeons to assess nerve conduction and the electrical activity of muscles. For example, if a patient has a fracture of the humerus and the wrist is dropping, these tests are needed to establish whether it is a complete nerve injury and which other nerves are involved.

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 go ahead if you know from the outset that there is a problem in performing or completing the procedure with a good result. There are procedures that even we, at the highest level of care, do not do, for two reasons: either resources are limited or we are not sure of the outcome. If the outcome is not going to be good, you should counsel the patient, meeting the patient, the family and the attendants. If the patient is then willing and aware of everything, you can proceed. You should tell them the best you can deliver, the limitations you cannot overcome, and how much benefit they will get from the procedure.

Question 15

How long does a hip or knee replacement last, what is the prognosis, and is it permanent or does it need to be replaced at a certain age or stage?

Dr. Ishwar Bohra · Accepted Answer

Most knee and hip replacements now last more than 30 years. The prognosis is very good nowadays, because patients can do everything. We now do hip replacement designed for high flexion, and after three months many patients are praying again in the kneeling position and squatting.

Question 16

What is the approximate cost of a knee or hip replacement in India, so that doctors can give patients a directional figure?

Dr. Ishwar Bohra · Accepted Answer

Larger orthopaedic surgeries broadly range between US$5,000 and US$10,000, depending on how serious the surgery is. The exact figure is decided by the hospital's commercial team once we have studied the case and decided which procedures and steps the patient needs, so it varies from case to case. BLK has packages for knee and hip replacement, unilateral and bilateral, which are very competitive and affordable compared with other countries.

Question 17

Is there any alternative to joint replacement?

Dr. Ishwar Bohra · Accepted Answer

Yes. If a patient is afraid of replacement or does not want it, there are many braces available, along with lifestyle modification, exercise and weight loss, which are the core treatment, and medicines such as analgesics. Calcium and vitamin D support bone health, and supplements such as glucosamine, chondroitin and collagen peptides, with exercise, help regain the previous disease state.

Question 18

What is the experience of joint replacement in children?

Dr. Ishwar Bohra · Accepted Answer

Sometimes we do replacements in children as well. In hip pathology such as SCFE, avascular necrosis, Perthes disease, traumatic hip fracture or septic arthritis (Tom Smith arthritis), the joint has no growth potential and the bone will not grow, so replacement at least gives the child a painless life. The growth on the opposite side can then be arrested so that there is no limb-length discrepancy. The same applies to the knee, when it is completely worn out by haemophilia, sickle cell disease, viral arthropathy, other infections or injuries. Sometimes replacement in children is unavoidable, and they do very well.

Question 19

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.

Live Discussion with Dr. Ishwar Bohra