Joint Replacement Surgery In India- Common Misconceptions

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Orthopedic surgery for trauma and elective problems like joint replacement is popular amongst the urban and rural population. However due to supply & demand discrepancies, advertising has a big role. The gullible public often is at risk of misinterpreting the reams of information brought out by hospitals. They may land up with their expectations falling short of what was promised. In this article I shall attempt to clarify some commonly heard terms and discuss the possibilities and limitations of the procedure and thereby remove some misconceptions.

Key Hole surgery- is another term for Arthroscopic surgery. The arthroscope is a device introduced into joints through key-hole incisions about 5 mm wide to inspect the internal structures. The orthopedic surgeon often makes 1- 4 key holes during performance of diagnostic and therapeutic procedures all of the same size. Through these other holes or portals, similar sized instruments of 5 mm width are inserted to smoothen, cut, trim or suture damage structures. Arthroscopic surgery is commonly done in the Knee, Shoulder joints and rarely for the elbow, ankle and hip in our country. Arthroscopic ACL and other ligament reconstruction are possible in the knee. However a knee or any other joint replacement cannot be done by Arthroscopic or key hole surgery. An artificial joint is made of metallic alloy and High density poly ethylene. In a Joint replacement the surgeon sculpts the surfaces of the joint to prepare it for implantation. These prostheses should match the dimensions of the original joint. It requires common sense to understand that an artificial joint cannot be introduced and implanted into a joint through a tiny hole,

5 mm wide. Yet large hoardings, banners and radio and newspaper ads would want the public to believe so.

Minimally invasive surgery- This differs totally from Key hole surgery. This is traditional open surgery done through full length incisions and not just punctures holes. The size of the incision is down sized from the traditional sized large incisions. It is not “Arthroscopic surgery”
Joint replacements can be done through minimally invasive incisions. The advantages of minimally invasive surgery are smaller sized scars, less bleeding, less post operative pain, and faster recovery. Hospital stays are shortened even for Joint replacements. Discharge from hospital requires that the patient has minimal or no pain is ambulant independently with or without aids and the wound is showing signs of settling down. It is therefore not the size of the skin incision alone that matters but what happens inside. Minimally invasive surgery is applicable to Joint replacements, Spine surgery trauma and post trauma reconstruction. Image intensification, computer assistance, innovative surgical approaches, skilled surgical assistants and newer equipment are helpful to perform this difficult form of surgery. The whole purpose of this approach is to make the operation patient friendly without compromising the results of the traditional operation. It should not be a mere marketing Gimmick.

Computer assisted surgery- This is an area where the misconceptions fall under two categories. A section of ill informed people think that the computer just performs the surgery like an auto pilot and the surgeon sits back. Another section is given to understand that it is the Gold standard in surgery and that surgery done without computers is bound to fail. Both these perceptions are false. Computer assisted surgery is not robotic surgery, nor are the long term results proved. A Knee replacement done by a well trained and qualified surgeon in the right operating theatre environment has a chance of lasting for 10 -15 years in 95 percent of the people in whom it is implanted. What computer assisted or navigational surgery is capable of doing is perhaps to raise the survivorship rate at 15 years by one to two percent to say 96- 97 percent. Under no circumstances can the prosthesis last for ever as one of the component polyethylenes is bound to wear. If the prosthesis is fitted correctly, then the incidence of loosening is reduced. Due to its inherent wear over a period of time, it cannot be everlasting as claimed in some quarters.
An auto pilot in a modern aircraft makes calculations about altitude, atmospheric turbulence etc and adjusts the elevation and speed of the aircraft without the pilot’s intervention during flight. This does not happen in Orthopaedic surgery. The surgeon cannot stand back and let the computer make the surgical incisions, cut the tissues and bones. Computer assisted surgery is not Robotic surgery where a Machine performs the operation without human assistance.

Computer assisted surgery is traditional open surgery performed by human beings and not Robots. The surgeons makes the incisions and during the operation gets information about remote inaccessible areas like the Hip and ankle joints from “Sensors” or arrays implanted into the leg and thigh bones. This information is processed by the computer to give intra operative information on the correct alignment and positioning of the instruments for making the bony cuts to get the alignment correct. The surgeon makes the cuts and not the computer. The accuracy of the cuts could be marginally improved with this procedure as compared to standard instrumentation. However there are no long term studies to show that more accurate cuts produce improve results. A surgical operation consists of attention to the soft tissues like the ligaments and muscles which the computer cannot see. Nor can it give any information on the size of the implants. These two criteria are paramount to the success of a Total knee replacement, i.e., “Soft tissue balancing’ and “Sizing” of the implant. The computer plays no role in these two steps.

Computer assisted surgery adds on extra operating time to the tune of fifteen minutes to a total knee replacement. This translates into increased cost to the patient. The amortization of the equipment per case works out to nearly fifteen to twenty thousand rupees. Thirdly, some of these navigational aids supplied by a particular company are compatible only with implants supplied by that company alone. So if better implants from another rival company are introduced into the market, the navigational system and the instrumentation won’t work together. So these hospitals are forced to make false propaganda about their function provided by the implants used in their hospital despite the contrary evidence in the literature. For example it has been claimed that a “Rotating platform Knee” provides High flexion to the tune of 155 degrees. If one were to only do an internet search, then this claim would fall flat on its face.
Another term that is misunderstood by patients is “Knee transplant” A knee or other joint replacement is not a transplant. It only resurfaces the worn out portion of the joint and leaves behind the normal bone. The worn out surfaces are sculpted to receive the implant.

Marketing of health services is now an aggressive business with complete control of the media like TV, Radio, print and banners by large corporate hospitals with huge investment on advertising. Misinformation is spread easily by subtle innuendoes and inferences in banner ads. Advertising is ethical and permissible if it doesn’t propagate misinformation. Spreading misinformation by advertisements is unethical as the innocent patient reposes his trust in a Doctor and his trust is betrayed with incorrect information. With nobody to bell the cat, except for some agencies like the advertising standards council of India, the unwary patient is at great risk of being misled. So how do they protect themselves? What are the safeguards from false advertisements? They need to do more deep digging and research by referring to the manufacturer’s information booklet, consulting other specialists, and search the internet. Only then will they perhaps avoid falling into a trap of misinformation and gain full value for their hard earned money.

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