Question 1

What is the financial implication of hip replacement surgeries, as most African countries, like India, are also developing and most patients don't have insurance?

Dr. Rakesh Mahajan · Accepted Answer

Earlier, the international companies Johnson, Stryker and Zimmer supplied us with all the revision and complex hip replacement implants, but they have since withdrawn most of their hardware because of duties and government policies. Fortunately, two or three Indian companies have come up very well; they have collaborated with these companies and produced cost-effective options. A hip replacement used to cost around 10,000 to 12,000 US dollars; that has now come down to between 7,000 and 8,000 US dollars. Where there are problems, we try to reduce our surgical fees: I always try to help the patient to the maximum, and I tell them I will reduce my fee.

Question 2

Healthcare infrastructure differs across African countries. What should prompt a doctor in Africa to consider that a patient may need care abroad, and to share the case for a possible international referral?

Dr. Rakesh Mahajan · Accepted Answer

My WhatsApp number is always available, and I try to work up cases as early as possible. Doctors can send the patient's brief history and minimum X-rays, and I can guide them on the best option, with the approximate length of stay and approximate expenses. The other route is through Jivo. We can also discuss X-rays and indications on this platform, whether surgery will help, and the total expenses and stay, perhaps once a month or once in two months, with doctors sharing the X-rays or reports of their patients.

Question 3

What is the success rate when athletes undergo hip replacement and resume their profession, and how early can they return to training and sport?

Dr. Rakesh Mahajan · Accepted Answer

It depends on the pathology and on the athlete's activity. For a long-distance runner, for example, a different type of hip replacement is needed. One cannot be 100% certain, but an athlete can carry on with most of his activities.

Question 4

What about physically demanding sports such as football or basketball, with a lot of jumping: can those athletes continue their careers?

Dr. Rakesh Mahajan · Accepted Answer

If they have had a total hip replacement, these are not sports one can carry on with, but they can change their sport, which is the best way. If the condition is femoroacetabular impingement (FAI), that is a different option: we do hip arthroscopy, remove the impingement, clean the cartilage and put in stem cell therapy, let the hip regenerate for about 6 months, then repeat the MRI, and we see wonderful results there as well.

Question 5

Fast bowlers in cricket undergo very demanding surgery after injuries. How do they return to international sport?

Dr. Rakesh Mahajan · Accepted Answer

Most sports damage is to ligaments or osteochondral defects; these athletes do not have arthritis. Hip arthritis is a different issue: in hip replacement, arthritis is the culprit, there is no cartilage, the anatomy is deformed and the patient cannot carry out daily routine activities. After hip replacement, patients carry out their daily routine and a pain-free hip gives them great satisfaction. Sports injuries mainly damage part of the cartilage or a ligament, and we correct those with PRP injections and stem cell therapy, which are very good, together with arthroscopic procedures to repair the ligament injuries. That is why, after 6 months or so, these athletes are back to high-level sport.

Question 6

In patients with advanced osteoarthritis of the hip joint who present with pain but sufficient mobility, is there a place for conservative management, and when should surgery be recommended?

Dr. Rakesh Mahajan · Accepted Answer

We do the basic investigation and check on the X-ray whether the hip joint space is maintained. If pain has started but mobility is still there because the joint space and cartilage are maintained, we do not straight away advise hip replacement. We have other options, such as the arthroscopic method, where we clean up the osteochondral extra bone formation or the damaged part of the cartilage and repair it with stem cell therapy. That is a good indication instead of hip replacement. Once CT or MRI shows the cartilage is completely damaged, with no blood flow to the femoral head, the only answer is hip replacement.

Question 7

Do you have expertise in hip arthroplasty for children with sickle cell disease?

Dr. Rakesh Mahajan · Accepted Answer

Hip arthroplasty is not recommended below 17 or 18 years of age; we have to wait. Below that age we have the arthroscopic method, where we clean up the damage, or osteotomies, where we change the weight-bearing surface of the hip, such as valgus or varus osteotomy and other geometric corrections. We see on the MRI where the main damage is and shift the weight-bearing area of the femoral head, and the pain is relieved much better.

Question 8

How can patients generally expect their hip implants to last, and what factors influence the longevity of these implants?

Dr. Rakesh Mahajan · Accepted Answer

After hip replacement, certain positions are not recommended: sitting on the floor, sitting cross-legged and squatting. These positions damage and loosen the implant over time. High-energy sports activities should also be avoided. Following these recommendations increases longevity: a well-fitted hip lasts 30 to 35 years.

Question 9

Could you briefly describe how stem cell therapy is used in hip disorders?

Dr. Rakesh Mahajan · Accepted Answer

Stem cells are progenitor cells that can convert into osteoblasts or chondroblasts. In the hip we are dealing with cartilage: where a few islands of hip cartilage are damaged, we clean them up with hip arthroscopy and inject the stem cells. On review MRI we have seen excellent changes over time: just like grass growing, the cartilage starts growing and the damaged areas shrink, and over 6 months or so the patient has fewer symptoms. Stem cell therapy does take time, because these cells must convert into chondroblasts before the cartilage starts growing.

Question 10

How are these stem cells harvested, and how long does it take to harvest them?

Dr. Rakesh Mahajan · Accepted Answer

In orthopaedics we harvest them from the iliac crest. A needle is passed into the bone, posteriorly or anteriorly, and around 120 ml of blood is drawn from the marrow of the iliac bone. This is placed in a centrifuge for around 45 minutes to 1 hour, and the resulting stem cell concentrate is then injected.

Question 11

For an adult with sickle cell disease who is past the age for bone marrow transplant and is a candidate for hip replacement, how do you manage it?

Dr. Rakesh Mahajan · Accepted Answer

In sickle cell disease there is avascular necrosis of the femoral head: the blood supply to the head is damaged, the head starts dying and the hip progresses to arthritis. In most cases, after discussion with Dr. Dharma, once the sickle cell level in the blood is below 20%, the patient is fit for surgery. We then plan the operation, and in most cases a primary hip arthroplasty is done.

Live Discussion with Dr. Rakesh Mahajan