Question 1

Will regenerative treatments such as PRP replace the need for surgery, given that patients are often afraid of surgery?

Dr. Vipin Maheshwari · Accepted Answer

This is the future, even if it takes a few more years to be accepted. For small cartilage defects, partial ACL tears and small meniscal tears that are mildly symptomatic in patients not interested in surgery, we now offer orthobiologics, and these patients do symptomatically very well. The key is personalisation: a young, very active patient in contact sport who wants to return quickly may not suit it, because orthobiologics take time and the field is still at a nascent stage. If a patient is scared of surgery and is low-demand, I tell them to try it. We have had very good results with PRP and BMAC, even in avascular necrosis of the hip. The main hurdles are availability and acceptability: PRP takes at least three to four injections spaced over about two months, and patients sometimes lose patience. Once they understand they can avoid surgery, many surgeries will be avoided, and in two to three years a lot will change.

Question 2

Why do peripheral meniscus tears have better healing potential?

Dr. Vipin Maheshwari · Accepted Answer

The meniscus is not a very vascular structure, and its blood supply runs from the outside in. It is divided into three zones. The outer zone, near the capsule, is the red-red zone: it has a decent blood supply, which is one of the reasons peripheral tears heal better. Towards the centre is the red-white zone, where the blood supply is moderate; a meniscal repair can still be attempted there, but it must be augmented. On the inner side of the joint is the white-white zone, where the blood supply is extremely poor and tears do not heal well. Peripheral tears heal much better; tears that run into the inner zone, such as radial tears, heal less predictably, although modern repair techniques have improved their results.

Question 3

Why does modern practice try to preserve meniscal tissue whenever possible?

Dr. Vipin Maheshwari · Accepted Answer

The meniscus is not something that can be cut and thrown away; it is one of the most important structures in the knee. It is the only shock absorber, the cushion, between the thigh bone and the shin bone, and it takes all the stress of walking, moving and playing, so the cartilage of the femur does not transmit stress directly onto the cartilage of the tibia. Once a torn meniscus is cut out, nothing is left in between: the cartilage of the femur rubs on the tibia, the cartilage wears away and the patient develops arthritis within a few years. So whenever possible, always preserve the meniscus. A patient can do well without an ACL, but without a meniscus, arthritis cannot be stopped.

Question 4

With minimally invasive surgeries there is a risk of conversion to open surgery. Does that apply to arthroscopy?

Dr. Vipin Maheshwari · Accepted Answer

Not at all. Minimally invasive spine or brain surgery is a different situation, but in arthroscopy the concept is the opposite: the joint is seen much better through the arthroscope than through an open approach. Even if you open the knee completely, you cannot see an ACL reconstruction as well, or attempt a repair of the posterior horn of the medial meniscus. I do not remember any time in the last 20 years that I went in for an arthroscopy and had to open it; if I have planned an arthroscopy, I have never converted it. In gynaecological surgery a tumour may be stuck to the omentum or intestines with no plane between them. In arthroscopy there is no tumour: we are dealing with a knee or shoulder that was normal a few months ago, was injured, and has something torn that we are recreating.

Question 5

How safe are arthroscopic surgeries? Will the patient's condition worsen?

Dr. Vipin Maheshwari · Accepted Answer

The aim of any surgery should be to make the patient better, not worse, and there is risk in every surgery. When patients ask me about risk, I compare it to buying a car: we look at comfort, air conditioning and mileage, and rarely think about the fact that cars can have accidents. Arthroscopy carries that kind of risk. The good thing about the knee and shoulder joints is that all the important structures lie outside the joint; there is no major blood vessel or nerve inside it. So as long as the anatomy is well known and the surgery well planned, it is one of the safest operations. Most arthroscopies are done as day-care procedures: patients come in the morning and go home by evening or night.

Question 6

Does the same safety apply to hip arthroscopy?

Dr. Vipin Maheshwari · Accepted Answer

Hip arthroscopy is a little different because the hip is not a subcutaneous joint; it is very deep. But there are designated portals, designed by surgeons who studied the anatomy for years before putting in a scope, and as long as you stick to the anatomy and know your landmarks, hip arthroscopy is very safe. We do many labral repairs, loose body removals and cartilage procedures through the hip arthroscope. For surgeons who feel the hip is too deep to reach, a mini-open approach is safer when starting out: a small skin incision, going a little deeper, and introducing the scope once near the hip.

Question 7

What can patients expect in terms of recovery timelines after, say, an ACL reconstruction?

Dr. Vipin Maheshwari · Accepted Answer

Every surgery demands respect: respect the surgery and it will respect the anatomy. Taking the most common example, an ACL reconstruction: with newer techniques such as all-inside reconstruction with fibre tape augmentation, patients can bear weight and walk from day one, using a stick for three to four days until the pain settles. That does not mean the treatment is over; they still need to rehabilitate with physiotherapy, and each case differs. It takes around six weeks for the graft to become solidly incorporated into the bone. I do not advise any running or jogging before three months, and return to sport, particularly pivoting sport, is usually at around nine months, once strength and functional tests are passed.

Question 8

With more people training in gyms and playing sport, how often do you see these injuries, and which body parts are most affected?

Dr. Vipin Maheshwari · Accepted Answer

In the knee, we see many people doing heavy weight training, squatting with 100 kg on their shoulders, and a lot of cartilage degeneration because all the focus is on building the upper body and not the lower limb muscles; we also see ligament injuries. Over the last 10 to 15 years sport has become part of daily life: running, trekking, cycling, and high-impact sports such as tennis, table tennis, cricket and football all stress the knees. The positive side is that people are active and better informed about their injury, the procedure and rehabilitation. Ankle ligament injuries, once treated with a crepe bandage and left to live with, are now diagnosed and operated on. The shoulder is different: rotator cuff tears arise mainly from degeneration, because the tendon has a poor blood supply and tears over the years, while shoulder dislocations are becoming more common with contact sports such as boxing and taekwondo, and recurrent dislocations are fixed according to the patient.

Question 9

Which gym exercises are the most dangerous for the knees and shoulders?

Dr. Vipin Maheshwari · Accepted Answer

Squats are number one, especially with heavy weight on the shoulders. On a treadmill, be careful about speed: inclining it to four or five and running very fast can easily twist the knee. With the twisters people use for their abdomen, a slight slip of the foot can cause a major ligament injury in the knee. On the quadriceps extension machine, constantly adding weight to build bigger quadriceps can rupture the ACL, the quadriceps tendon or the patellar tendon. For the shoulder, do not take the arms too far back in fly exercises, especially with a history of subluxation or shoulder pain. I am not stopping anyone from exercising, but warm up, know your limits and do not compare yourself with others. Most importantly, do not ignore pain or push through it because a trainer or friend says nothing will happen. If a biceps curl at 5 kg hurts, stop, give the tissues a few weeks to heal, then restart with a smaller weight and build up. The answer to pain is never more exercise.

Question 10

In a cross-border setting, what broad indicators, in symptoms or scans, should prompt a doctor partner to seek a specialist opinion?

Dr. Vipin Maheshwari · Accepted Answer

The first thing, as taught in medical practice, is a good history of how the injury happened. A 25-year-old woman who felt mild pain at the front of the knee while simply walking does not need an MRI; treat her conservatively with rest and painkillers. A patient who was playing football, felt the knee pop and fell to the ground in pain has a ligament injury. Ligaments are very strong structures and do not break easily, so understand the impact and the mechanism. If the knee is functioning, has full range of motion and the ligaments seem intact, no investigation is needed. If there is good suspicion, after an accident, heavy sport or a blow from behind with severe pain, never be shy to get an MRI; delaying loses time. Increasingly, ligaments are stitched back rather than replaced: if the patient comes within two to three weeks of injury, an ACL torn close to its thigh-bone attachment can be repaired and the patient keeps their own ACL. Second, if a patient keeps returning with pain, do not assume vitamin deficiency or non-compliance; something is being missed, and clinical examination may not elicit every sign of ligament injury. Get an MRI, and if you are not confident about the report, take a second opinion. We are always happy to help: if it does not need surgery, it can be treated locally, and if it needs surgery or there is doubt, we will give our opinion, and the doctor can decide whether to treat in their own country or send the patient.

Question 11

What are rough cost estimates for these procedures for international patients?

Dr. Vipin Maheshwari · Accepted Answer

A single ligament reconstruction, ACL or PCL, costs approximately $4,000 to $4,500, all-inclusive from admission to discharge. Meniscal debridement alone is $2,500 to $3,000, and meniscal repair ranges from $4,000 to $5,000 depending on the number of suture anchors used, at roughly $500 each. A simple Bankart repair for shoulder instability costs $4,000 to $5,000, with remplissage adding about $1,000. PRP injections without surgery run about $500 per injection, with 3 to 4 injections typically needed over roughly six weeks.

Question 12

Does adding robotics to arthroscopy increase the cost?

Dr. Vipin Maheshwari · Accepted Answer

Robotics has not yet come into arthroscopy; it is still being developed. We use robotics for joint replacements, and robotic arthroscopy should be available in about six months. But arthroscopy does not need robotics much, because the joint is already seen with the camera.

Question 13

What success rates can patients realistically expect from these procedures?

Dr. Vipin Maheshwari · Accepted Answer

To me, success in arthroscopic surgery means getting the patient back to the condition they were in before the injury. Ligament surgery, ACL or PCL, restores a stable knee in about 90 to 95% of patients, and we rarely see failures in our ligament reconstructions. Meniscal repair depends on how much of the meniscus is torn and how soon the patient comes. A large tear left open for a year is not expected to heal back; the meniscus is trimmed and debrided and whatever remnant remains is repaired, and overall around 75 to 85% of meniscal repairs succeed. Surgery for a dislocating shoulder, well planned, should succeed in about 85 to 95% of cases, and rotator cuff repair in 90 to 95%. These high success rates come from recreating the biology and from advances in implants.

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