This article describes the evolution of replacement surgery to joint conservation in the West and its implications for India

There is a feverish spread of joint replacement surgery in the country. Everyone who is anyone is now talking about joint replacements as the panacea for pain.

Joint replacements have been around since before the second world war when English surgeons first attempted replacement surgery with metal on metal articulations at the hip. But it was in the early sixties that John Charnley first showed that hip replacements can be durable with his metal on plastic articulation and can be done by others other than the inventor (Sir John had this strict condition that nobody did his hip unless they were trained by him in his centre and the manufacturer would not sell the implants). He thereby ensured that well meaning enthusiastic adopters of his technology did not bring his hip into disrepute with failures.

Since then there has been a veritable explosion of developments in other joints. The Americans came out with knee replacements and then came replacements for shoulders/elbows/ankles/fingers and toes. Not all joint replacements are created equal. Hips and knees have been around the longest and hence we have enormous data demonstrating their success. Next came the shoulder and the elbow. Ankle replacements have been moderately successful but still cannot match the durability of their counterparts in the hip and knee.

Various series published by American and European surgeons have shown 95-97% survival at 10 years among knee and hip replacements. Put another way, the patient will know 15 years hence that his surgeon was good.

This frenzy of developments led to a geometric increase in replacement surgery in the West. With the enthusiastic adoption of joint replacements, inevitably there were instances of inappropriate selection of patients, done poorly by inexperienced surgeons which led to disaster. India has probably entered this phase.

In the West, Revision surgery is now a major percentage of knee and hip surgical practice. It is more expensive- requiring resources like bone banks to replace lost bone and experienced surgeons. Revision joint replacements are more extensive and done in much older patients and do not have similar survival statistics as the first primary replacement.

Hence the renewed interest in joint conservation surgery to prolong the life of the native joint for as long as possible until it is replaced.

Cartilage regeneration techniques like microfracture, cartilage cell transplantation, or cartilage-bone transplants either from the same knee or from a donor knee when done appropriately can prolong the native joint’s life sufficiently enough for at least a few years. This is especially good news for younger patients in their 40s and early 50s for whom a knee replacement at that stage will condemn them to at least one if not two revision surgeries in their lifetime, given the longevity of people with modern medicine.

Knees have three compartments –inner, outer and knee cap. Arthritis when localised to one compartment can either be treated by bone realignment to prevent arthritis in the other compartment or that compartment can be replaced in isolation. This kind of Unicondylar Knee Replacement(UKR) is an elegant solution which preserves the patient’s bone stock for a later Total Knee Replacement(TKR).

There are several types of UKRs. Oxford and St.Georg Sled from Europe have been around the longest with excellent survival rates of nearly 98% at 10 years for the Oxford knee, which was first developed in the University of Oxford-hence the name.

Such excellent results can only be obtained by careful selection of patients, meticulous technique and good long term follow up by the same surgeon. This gives the patient an extra decade of life without a major joint replacement.

Isolated knee cap replacements (Patello-Femoral joint arthroplasty – PFJA) are also a good answer to the sometimes vexing problem of knee cap arthritis with an otherwise pristine knee – in which case performing a TKR is unnecessary and unwarranted.

Again European joints like the Avon and Cartier have shown good results. A newer development is the Deuce from the USA which replaces two compartments including the patellofemoral joint.

When you consider the hip, resurfacing hip arthroplasty has the same advantage as the UKR in preserving bone. Prof Ganz in Bern, Switzerland has shown the importance of treating impingement at the hip early on to delay arthritis from developing.

In the shoulder, resurfacing implants like the Copeland or the shoulder cap developed by Miniaci from Cleveland USA again preserve bone for later total replacements.

Such developments show the importance that the orthopaedic community in the developed nations gives to the preservation of the natural joint. This has evolved from the earlier propensity of joint replacements at the drop of a proverbial hat.

However in a developing country like India, such options are expensive. The joint preservation options are not cheap by any means and are available only to those who understand the balance between quality of life issues and money. Furthermore, people who consider joint preservation should understand that these techniques can sometimes slow down arthritis and even give them the option of one primary replacement in their entire lifetime without the possibility of revision surgery. Like all operations, they come with complications like infection which if it happens can always be revised to a full joint replacement unlike an infected primary replacement which will require a full fledged Revision surgery with its attendant problems.