MY JOURNEY INTO THE WORLD OF JOINT REPLACEMENT

I did post graduation in GSVM Medical college out of which I worked as Registrar in the department of  orthopedics for one and half years.My experience of joint replacement was only three cases of Austin Moor Head Replacement for fracture neck femur. All these three replacements developed infections and subsequently failed but these old people could walk well despite infection. The usual treatment in those days in the department for hip fractures was Osteotomy (Making another Fracture below) followed by Plaster or Traction till pain becomes less & physiotherapy. 50% of these couldn’t survive & rest walked with support, Limp& shortening of the leg as much as 2 inches. So AM Ball Replacement was functionally much superior.

For the Patients of the Knee Osteoarthritis who came to our OPD, the advice was Knee cap/ crepe bandage, exercise calcium & pain medicines. We used to tell them to accept this painful life & unfortunately 40% of OPD was only such patients, the other dominant diagnosis being backache.

We used to read about Knee Replacements and the good results changing the life of the patients. In India already Dr.Dholakia in Mumbai was doing Joint Replacements the Other name being Dr.Maini in Delhi.

So I was convinced that Joint Replacement is a surgery, which I have to learn reinforced by the result of three infected half Hip replacements done in my department where Patients could walk easily after surgery in spite of infection.

Once out of College I started attending every seminar on Joint Replacement & there were not many. Two Workshops were held in Delhi where I met Dr. Laad of Mumbai. I showed him an X-ray for which I was thinking of getting Hip Replacements done& he gave me some useful tips. In another such workshop I met Dr. Sanjay Agarwala of Hinduja Mumbai & his positive attitude also reinforced my beliefs in this Surgery.

In 1990 I did my First Total Hip Replacement in a lady 57 years old who was on bed for last 7 months for hip fracture with treated by traction previously. It was a Cemented Joint (THR)& cheapest available in the market. There were only two choices and had to be arranged from Delhi or Mumbai. I did not charge at all & arranged medicines as well, after all the family had agreed for the surgery knowing fully well that it was my first surgery of this kind. This lady could walk so well that it became a media story as well getting me more such patients. This first patient of mine with Cemented Cheap Indian THR walked gracefully for 21 years till she died in 2011 at the ripe age of 78. The amount of satisfaction for me is definitely immense & also the driving force to perform well. Now I had a strong tool to change the life of my patients for better.

I kept on doing Hip Replacements & kept on attending various courses on joint Replacements but could not muster enough courage to start Knee Replacements. I was in search of an opportunity to assist such surgeries with some good Surgeon & my patience paid off ultimately. In 1995 in Indo German Work shop in Kolkata Prof Neugebauer of Germany noticed that I am ambidextrous (can use my both hands equally) he got me the IGOF fellowship to Germany under him& took real pains to teach me the fine points of Joint Replacement. He had immense faith in my ability and was instrumental in changing my approach towards surgeries& attitude towards life.
He was one of the top surgeons of the Europe and got me different Fellowships in Germany providing opportunity to learn. His influence even got a fellowship in surgical Pathology for my wife.

Now I started doing Total Knee Replacements & in 1996 did only three surgeries all FS knees of Germany as I was trained on them though it was little bulky. One of them is still alive and doing very fine going for her morning walks at the age of 77.
In 1997 I started using Apollo Knee design, which was less bulky,& the AMK knees of Depue with equally excellent results. One such patient is a successful lawyer of the city going up & down three flight of stairs of the court building many times in a day in 16th year of her Joint Replacement& that is why the Knee Replacement Surgery is known as the Success story of the century.

I was doing now 50 knee replacements & 75 hip replacements all cemented in a year when I got a fellowship to work with Prof Dorr of Arthritis Institute in Los Angels USA, very reputed, popular & designer Surgeon of the west coast. He showed me to look at the surgeries in a conceptual way. My surgical technique or craftsmanship was now based on the understanding of the concept of biomechanics & the alterations, which the procedure can make. Now I could do procedures designing my own tools. I also learnt the art of Press fit or Uncemented Joint Replacements both Hip & Knee. He was Master of Minimal Access Surgery (SmallIncision), which I also learned.

I got the opportunity to visit Australia in 2001on a fellowship in Joint Replacement. I learned the Muscle Sparing Technique and the mini incision approach. I could attend a workshop on Birmingham Hip, a hip surgery that had created revolution in the field ofHip Replacements. These patients could do every thing like normal people after surgery like jogging and playing football. Till now hip replacement was supposed to give painless walk but with many restrictions like not sitting on floor. No crossed leg posture etc..Still I never thought to get this costly joint in India.

After return I started doing Knee Replacement with the muscle sparing technique with wonderful results. Now my Patients could walk in 2 days and move the knee next day.

In 2003 Birmingham Hip was launched in North India, Dr.Vijay Bose was already doing it in Chennai since 2002. In 2003 I did my first BHR & the person was an engineer, son of a very senior physician of the state. They had already researched a lot about the surgery. He had TB Hip when young and had a profound limp, as the hip was not mobile His operation created a wave as this young fellow could do every thing gradually. Gone was the limp and he started jogging gradually. Now I had something very important & worthwhile for my young hip patients. I have a very big series of such Patients now however this was a very selective surgery and all hip patients could not be given this joint. Moreover this was Metal on Metal, which has been a concern for many for Metal toxicity.

Came 2004 & I got trained in the art of High Flexion Knee replacement the RPF Knee of Dr.Ranawat In 2005 this design was launched in India and I was the first in this part of India to start. First time we could say to our patients to sit on the ground or kneel if required. Though still it should be avoided as it creates lot of strain while getting up from the ground and increases the wear. At present I have the biggest series of RPF Knee Patients from this part of India.

Now I was invited in various conferences & Seminars to give talks on different aspects of Joint Replacement.

To keep updated I was going to USA every alternate year to attend Current Concepts Training Programs and American Academy Programs. I also became member of American Academy.

For younger hip patients who could not get Resurfacing because of technical reasons a new Implant was introduced. This Proxima Stem was giving results similar to Resurfacing using a Normal size of the femur head (Large Head). New Ceramic material was also launched for hips.

Now every Hip patient could be operated restoring normal biomechanics. So now my hip patients could do all the activities like normal persons (Running, Sitting on Ground doing Pooja & Namaj)

I went to Australia again for Training into Computer Navigation System for Joint Replacement System. I had already done a course in Computer Navigation system in 2004 from Malaysia. This training program gave me the drive to buy my own system after I realized the advantages. Computer Navigation could give the best Alignment and Ligament tension in Joint Replacement Patients with smaller cuts. So Function was better, the life of the joint was longer and need of Physiotherapy was less. I got my Computer Navigation system in 2007 with the help of my Industrialist friend, Sri Vikram Kothari.

Small changes were made in the design of the knee implant. The best was addition of polished Chrome Cobalt Tray with Semi Cross linked plastic, reducing wear and increasing the life of the joints.

On the hip side small Silent Hip was introduced. I was the first few from India to get training and the first in north India to operate using Silent Hip in a patient, a software Engineer from Lucknow. The training I received was in University of Kiel, Germany in High Performance Joint Replacements including Muscle Sparing Approaches on Cadaver.

I went for a Fellowship in Computer Assisted High Performance Joint Replacement to University of Heidelberg, Germany.
Now I can say with deep satisfaction and conviction that the world of Joint Replacement has changed in Philosophy and Practice both.

In 1990 when I started Joint Replacements the Aim was to give Pain Free Movement. It came with lot of limitations as far as range of movement and daily routine was considered. The complications & the failure rate were high. The life of joint replacement was taken as 15 years so young patients were left to suffer.

Now we are much wiser because of the advances made in the field of Biology, Tissue Response to Different Materials used in Surgery, Metallurgy & Biomechanics.

In High Performance Joint Replacement we are talking about-1) Muscle Sparing Approach. 2) Less Bone to be Cut so better Propriception.3) newer Materials like Ceramic, Cross Linked Plastics, Polished Trays, Surfaces made for better osteointegration like Gription and development of Trabecular Metal where the Bone can grow inside the Metal.

To use all this newer advances the Surgeon has to be adequately trained and should be an excellent craftsman to apply during surgery.

So Now we are talking about giving Functional Freedom to our Patients, The can Run , Play sports, sit on the ground. In short they can do everything, which a normal person of his age is capable of doing. Because of Long Life these can be safely used for younger Patients.

I am doing High Performance Joint Replacement since 2003 & my patients are doing every thing as just described. The Satisfaction & the happiness, which I get watching my Patients leading a High Quality Life are immense & not comparable. We as Doctors are capable of bringing smile to our patients and giving reasons to be Happy many times in the day which no other profession is capable.After doing more than 5000 Joint Replacement Surgeries & looking at the change in my patient’s quality of life I am more motivated to propagate this Surgery to my Colleagues. I already run a Joint Replacement Training Course with the help of my International & National friends every year since 2005. We are proud that we have trained more than 500 Surgeons in field of Joint Replacement from central India who have taken this surgery to small cities now.