Question 1

What is the treatment of knee osteoarthritis?

Dr. Ramkinkar Jha · Accepted Answer

Treatment depends on the stage of arthritis and runs from non-invasive to minimally invasive to invasive: non-pharmacological measures, pharmacological therapy, physiotherapy, injections and, finally, surgery. Individual cases can be sent through Jivo for advice.

Question 2

What is the approach to assessing late-life disability?

Dr. Ramkinkar Jha · Accepted Answer

Disability can be assessed with the various scoring systems available, and clinically through a detailed evaluation focused on how much pain the patient has and how much their activities are restricted. A patient with very high disability is a candidate for total joint replacement.

Question 3

What is the durability of a replaced joint, and what is the approximate price range, for comparison with other countries?

Dr. Ramkinkar Jha · Accepted Answer

Durability depends on the patient's condition. In simple cases durability today is very good, more than 20 to 25 years on average, within a range: some joints last 40 to 45 years, some 15. In revision or complex cases, durability is reduced. On price, the rates are very competitive because implants and surgery cost less in the Indian market, at almost one third of the price in developed nations.

Question 4

What are the complications for a patient wearing an external fixator?

Dr. Ramkinkar Jha · Accepted Answer

An external fixator is usually a temporary measure and only very rarely definitive treatment. Fracture-related complications include non-union, the most commonly seen, and malunion, where the fracture heals in a poor position. The most common complication overall is pin tract infection, because the pins communicate with the exterior: infection, and osteomyelitis, develops at the junction of the fixator and the skin.

Question 5

What orthopaedic treatment is suggested for a long-standing, untreated left ankle fracture sustained in adolescence?

Dr. Ramkinkar Jha · Accepted Answer

This is presumably post-traumatic ankle arthritis. The case can be shared for review. The simplest and most durable treatment in this situation is ankle arthrodesis, which relieves the pain and makes the joint stable.

Question 6

In which cases can we proceed with joint infiltration, and what are the consequences of joint infiltration with corticosteroids?

Dr. Ramkinkar Jha · Accepted Answer

All joints are amenable to infiltration; what matters is the purpose. In severe osteoarthritis in a patient unfit for surgery, it provides pain relief. In patients not willing to be operated on for some months or years, it gives temporary relief and buys time until a future replacement. Every option has a cost. Of the injectable classes, platelet-rich plasma and stem cells are intended to promote healing and give late pain relief; viscosupplementation with hyaluronic acid gives early but temporary relief, perhaps six months to a year; corticosteroid is anti-inflammatory, effectively a substitute for oral medication delivered into the joint, and gives excellent pain relief. The problem is that patients do not understand what to do in the pain-free period: they think they are cured, resume rebound activity, the joint deteriorates, and the steroid gets the blame. So make it very clear that the injection is for pain relief. The most serious complication of steroid infiltration is infection, which can worsen the condition to the point that the patient may no longer be a candidate for joint replacement; repeated injections may also hasten cartilage loss, and a joint replacement is best deferred for about three months after a steroid injection.

Question 7

How can we check the compatibility of implant materials?

Dr. Ramkinkar Jha · Accepted Answer

We usually regard the implant as inert. We take an allergy history, looking specifically for allergy to metals such as nickel, cobalt, chromium and molybdenum, to artificial jewellery or to rings. If the patient is allergic to these, we presume sensitivity to the implant alloy metals and suggest a hypoallergenic, gold-coated total knee replacement, known as a gold TKR.

Question 8

A patient complains of excessive discomfort from an implant. How can we determine whether the implant material is incompatible, and what should we do next?

Dr. Ramkinkar Jha · Accepted Answer

First assume the implant is inert and look for the known complications, the most common being infection and aseptic loosening, before blaming the material. Allergy is very rare and should not be the first differential diagnosis when a patient has discomfort after surgery. The cause could be malpositioning from incorrect implantation or a subclinical infection. Rule those out first before attributing the problem to compatibility.

Question 9

Under the Kellgren-Lawrence (KL) grading system, what is the gold standard for diagnosing osteoarthritis? On X-ray, is it the presence of osteophytes, the absence of joint space, or both?

Dr. Ramkinkar Jha · Accepted Answer

The KL system is only a classification of osteoarthritis, and not a very good one. Diagnosis is clinical: a patient with typical pain (pain while walking, climbing stairs or sitting cross-legged) and definite joint-line tenderness is almost confirmatory for osteoarthritis. That is the gold standard. X-ray serves as the baseline test, and several classification systems are based on it, but X-ray is not the criterion for deciding who should undergo surgery. A KL grade 4 patient with minimal pain who is managed well with physical therapy may not be a candidate for knee replacement, while a grade 3 patient whose pain persists despite all conservative measures is a candidate for joint replacement. That paradox is why X-ray grading is not the gold standard. On osteophytes, their location matters more: around the weight-bearing area, or kissing lesions, they are very relevant and may be amenable to minimally invasive surgery such as arthroscopy. For me, though, joint space reduction matters most, because it indirectly shows that the articular cartilage is gone, and that is irreversible.

Question 10

How effective is medical therapy, and what is the role of steroids in early-stage osteoarthritis?

Dr. Ramkinkar Jha · Accepted Answer

Medical therapy is the first line of treatment and should be tried first. Once pain is not relieved with medical therapy and physical therapy, and the patient has difficulty with activities of daily living, the patient becomes a candidate for surgery.

Question 11

What is the success rate of replacement therapy in terms of biocompatibility and durability?

Dr. Ramkinkar Jha · Accepted Answer

Taking an average value, the survivorship of newer implants is more than 20 to 25 years, though there is a range. Measuring success has a prerequisite: we presume the patient has taken care of the joint and followed the precautions, physical therapy and exercises advised. The average I have given assumes that has been done.

Question 12

How often is the implant reviewed, and will it need to be removed, or is it permanent?

Dr. Ramkinkar Jha · Accepted Answer

It is a permanent procedure; the implant does not need to be removed. The first follow-up milestone is at two weeks, to remove the stitches, then six weeks after surgery, then three months, six months, and annually after that.

Question 13

What special care must a patient who is an athlete take after a hip replacement?

Dr. Ramkinkar Jha · Accepted Answer

In athletes the activity demand, such as jumping and contact sports, is much higher than in the normal population, and an artificial joint undergoes wear over time. As a general rule we tell patients not to jump or run, for the sake of implant longevity: the more activity, the more wear and the greater the chance of revision surgery. For an athlete, we first advise changing the activity level if possible. If that is not possible, certain implant variations are available that can be offered when it is mandatory for the athlete to continue sport, such as hip resurfacing, which is more favoured in athletes. A ceramic implant is not a good choice for them, because of a higher chance of breakage.

Question 14

If a patient develops an infection around the implant, should the implant be removed or treated with antibiotics? And are there implants that are MRI-compatible?

Dr. Ramkinkar Jha · Accepted Answer

For infection, first understand its type and duration. If it is acute, be very aggressive: antibiotics alone will not suffice. Do not hesitate to go in and clean the joint, with multiple debridements until it is clean inside; antibiotics are an adjuvant, not the primary therapy. In the knee you can also change the polyethylene component, place a drain for three to five days and give antibiotics. If the infection is longstanding, presenting after more than one month, a staged revision may be needed: in stage one, remove the implant and place an antibiotic spacer, then monitor for six weeks with ESR, CRP and CBC. Once the infection markers are within normal limits and the skin has healed, proceed to stage two, the revision total replacement. On MRI: MRI can be done with any joint replacement, at that site or elsewhere, provided the implant is well fixed. If the implant is unstable, for example after a periprosthetic fracture or with nearby loose screws, MRI may not be a good idea. To image the replaced joint itself, special metal artefact reduction sequences (MARS MRI) are used, in which the implant artefact is minimised.

Question 15

Can you explain the '90 degree rule' for hip replacement surgery?

Dr. Ramkinkar Jha · Accepted Answer

It is not in the textbooks, but it is a common practice: in the first six to eight weeks after a hip replacement we do not want the patient to bend beyond 90 degrees. This reduces the chance of dislocation and allows the capsule to heal well. That is the 90 degree rule for hip replacement.

Question 16

Can a knee joint with limited movement after earlier trauma be replaced?

Dr. Ramkinkar Jha · Accepted Answer

Certainly it can. The difference is that the implant changes from a simple design to a more complex, possibly constrained, type. Constrained joint replacement is usually recommended in post-traumatic conditions.

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