This was an informative and interactive session between Guneet Bhatia, Co-Founder, and Director of Patient Relations of MediGence and Dr. Ravi Nayak, Specialist Orthopedic Surgeon of NMC Hospital, Dubai. They discussed in length about advances in joint replacement surgeries and treatment of sports injuries. They further explored the reason why hip resurfacing was discontinued and the common orthopedic disorders in children. You can find the transcript of the session below:
Guneet Bhatia, Co-Founder: Hi Everyone, I have with me Dr. Ravi Nayak of NMC Hospital, Dubai. He is an orthopedic surgeon who specializes in sports injuries, joint replacements, keyhole surgery, and arthroscopic surgery. He is also a member of the Medical Academy of Orthopedic Surgeons. Thank you, Dr. Ravi, for taking the time to discuss some of the questions usually have for orthopedic surgeries. So we will start up with the most basic questions that people usually have about orthopedic surgery. We will also discuss how progressively has orthopedic specialty evolved over the last 10 years. What changes have been there in the quality of the implant, the success rate of such surgeries, specifically when it comes to joint replacement such as knee replacement and hip replacement surgeries.
Dr. Ravi Nayak, Orthopedic Surgeon, NMC Hospital, Dubai: For joint replacement surgeries such as hip replacement and knee replacement, there has been considerable advancement in the last 10-15 years. Especially, with regards to the quality of polyethylene used, the metals that are used in the knee implants. We also use much better techniques now. Earlier, we used to make the patients walk after 2-3 days. Nowadays, with the help of good anesthesia, better implants, we can make the patient walk the same day or the evening after surgery. The implants are also more patient-friendly. We have implants that can fit the size of the patient’s bones. This helps in better recovery and much better rehabilitation. Most of the surgeries we do nowadays have smaller incisions as compared to what we were using before. So I would say that there has been a vast amount of change over the last few years.
Guneet Bhatia: When it comes to key-hole surgery or robotic surgery, is it considered to be more successful as compared to open surgery, or the success rate remains the same and does it just enables fast recovery. Comparatively speaking which is more successful, the open surgery or the arthroscopic/robotic surgery?
Dr. Ravi Nayak: So robotic surgery is used more for hip replacement and knee replacement. And the arthroscopic surgeries are used more for ligament based surgeries. Now we customize the treatment of every patient. Robotic Surgeries or Computer-navigated surgeries are used for those patients who have very severe deformities outside of the knees. Like somebody who has a bow in the thighs, or a bow in the legs. In addition to that, they have knee arthritis, for those surgeries, robotic surgeries or computer navigated surgeries works out very well for them. For those patients who are suffering just from Knee Arthritis, open surgery works equally well. We still have to go a long way for robotic surgery before we can definitely say that there is a definite advantage to using robotic surgery in cases of regular arthritis. As for key-hole surgery which is arthroscopic surgery it is especially useful for those that have an ACL or an Anterior Cruciate Ligament Tear or a posterior cruciate ligament tear. It also helps to treat the early stages of arthritis. So we have to see at what stage of arthritis the patient is in, and accordingly, we offer him arthroscopic or keyhole surgery or an open surgery versus robotic surgery. So it is something called a customized treatment that we give to patients depending on their pain, their deformity of the legs and their future needs.
Guneet Bhatia: So talking about ACL Surgery, supposing that there is a patient having a complete tear in the ACL, and partial tear of the meniscus, does surgery become the only possible option or are there options for rehabilitation for a period of 6 months, and then go for surgical management?
Dr. Ravi Nayak: The ACL or Anterior Cruciate Ligament is a structure inside the joint we call it as is intra-articular. Now the intraarticular structures do not heal on their own, because there is no clot formation. This happens because inside the knee joint there is around 10-15 ml of joint fluid, which acts as a lubricant, and this fluid does not allow clot formation. For example, if there is a cut on the skin, we get a clot first, over that the skins grow. However, in the knee, due to this lubricant, there is no clot formation so the ACL almost never heals. However, not everybody needs surgery. Surgery depends upon what are the expectations, like whether they want to have an active lifestyle or whether they have a sedentary lifestyle. For those who want to have an active lifestyle, for eg those who want to play sports on a regular basis like football, other contact sports, or even cricket, they may need to undergo surgery. But in all cases, we give a course of rehabilitation for around 3-4 weeks. This helps reduce inflammation inside the knee joint, it allows the knee joint to settle down, so that we know where it is going. Those who get instability even after a session of rehabilitation, like for 3-4 weeks of rehabilitation or physiotherapy. If the knee still feels unstable, it is usually called a giveaway. When somebody is going downstairs or getting up from a sitting position. If the knee still feels unstable, then in those cases it is recommended to go for the reconstruction of the anterior cruciate ligament.
For those who have a meniscus tear, again it will depend on whether they have any mechanical symptoms. Mechanical symptoms involve the locking of the joint. Those who have a big meniscus tear, their knee sometimes get locked up in one particular position. Those symptoms would require surgery to be healed. Otherwise, most patients can be treated with good rehabilitation, good physiotherapy, and some activity modification.
Guneet Bhatia: What is the recovery process like for professional football players post ACL Reconstruction Surgery. How soon can they back to playing on the field?
Dr. Ravi Nayak: So after the ACL Reconstruction Surgery, we mobilize them from the second day onwards. We make them stand up and walk with the help of a walker. The walker is used for the first 2 weeks. During these two weeks, we start off with some exercises to strengthen the hamstring and quadriceps muscles to stretch out the hamstring. Gradually, after 2-6 weeks we take them off the walker and start doing some other exercises to strengthen the hip and the knee muscles. Usually, those who are football players, they can go back to playing sports, regular football after around 9 months. That is what we usually recommend. They can start doing some regular activities like cycling and swimming after around 2-6 months from the surgery. They can start doing some running based exercises 3-6 months. They can start training professionally after around 6 months, but they should not play a game until they feel the operated knee is as good as the non-operated knee. So there is usually a timeline but varies anywhere from 6 months to 12 months.
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Guneet Bhatia: Coming back to hip replacement, we receive a lot of queries for hip resurfacing surgery, which is unfortunately not done in a majority of the countries. And the response that we receive is that it is not very successful, but there are patients who request in particular for hip resurfacing surgery. So why is it not considered as successful as the hip replacement surgery? Are there issues with the implant or its longevity is not very long. What is the actual reason/cause why one is recommended over the other?
Dr. Ravi Nayak: We have to understand what are the Indications for using hip resurfacing versus the indications for using a hip replacement surgery. Hip Resurfacing surgery was very popular when it was first introduced. It involved with only changing the worn off surfaces of the hip joint. In the hip, there is a cup and a ball. That is called the ball-and-socket joint. The hip resurfacing involved preserving as much as the bone as possible. And changing only the surface of the femoral head that is a ball and the acetabulum, which is the socket. What happened was that this surgery was accepted and used very widely, but over a period of time, it was found that the rate of complications was higher. It was not that the procedure was not good. It was a revolution in hip surgery. But a number of complications were found, especially in ladies of childbearing age. So this age group of ladies had a particularly high rate of incidence of cobalt ions in their blood. The men also had similar symptoms, but it did not affect their procreation. In ladies, it was suspected that it can affect their fertility. Also, there are other complications associated with hip resurfacing such as ALVAL syndrome, where ions eat into the surrounding muscles and surrounding bones become progressively weaker. After finding this, it as decided to take back the implants, and that is why you would find many hip surgeons who are not offering hip resurfacing surgery.
The long-term prognosis is not good in a majority of cases. It can be offered in very rare cases to very few patients- those who are men, and they have good bone quality in the femoral head, and its just the surface which is worn out. Only in those cases will it give very good results, but there are very high chances that the cobalt-ions in the body can go higher. Hence we don’t offer that surgery to most patients. A Hip replacement does not have this issue. Even the hip replacement which was done 33 years ago has shown a 67% survival. Hence the hip replacement is a time tested procedure. Especially a metal on polyethylene component implant is a time tested procedure, and we don’t find it difficult to offer it to patients especially since it is going to last for such a long time. And with changes in the metal alloy composition, with changes in polyethylene ( good availability of highly cross-linked polyethylene which does not wear off as much as did it in earlier versions). Hence we are more confident to offer a hip replacement to those who need it especially with hip arthritis or avascular necrosis or any post-traumatic arthritis.
Guneet Bhatia: And since you mentioned necrosis Is Hip the most commonly affected joint, or can it also start from other joints in the body?
Dr. Ravi Nayak: Avascular necrosis is common in those joints which have poor blood supply. Now there are 2-3 joints that have very poor blood joints. The most common is obviously the hip. Its nature is not that it will spread from one place to another. It usually occurs in those areas where there has been some kind of injury. So the most common joint is the hip, the 2nd most common area is the wrist, which is called the scaphoid bone, and the third most important bone is the talus bone which is in the ankle. So these 3 areas are affected by avascular necrosis, but it does not spread from one joint to the other. If it happens because of an ankle injury it will happen only in the talus bone, if it happens because of the wrist injury then it will happen in the scaphoid bone, so it does not mean that every wrist injury or every ankle injury will give rise to avascular necrosis. There are very few patients especially who develop fractures of these bones who may develop avascular necrosis, the hip is a specially a site of avascular necrosis. because it is a very big joint and it bears a lot of pressure of the body so it degenerates rapidly that is why you find more cases of hip avascular necrosis also there are some developmental congenital changes in the hip which can give rise to avascular necrosis, so that is why we see more often in the hip but it does not shift from one joint to another.
Guneet Bhatia: We also receive a lot of requests from patients specifically from the African subcontinent for Osteomyelitis, so I just want to know how treatable it is? What are some of the warning signs of Osteomyelitis and up to what extent can actually it be treated?
Dr. Ravi Nayak: Osteomyelitis in simple terms means infection of the bones. Osteomyelitis can be either acute, acute means happening over a period of maybe a week or maximum up to 3 weeks and chronic, chronic means it has been long-standing, it has been there for a very long time. So acute Osteomyelitis happens more commonly in young children those who have not completed their growth, so you can say somewhere 16 to 18 years of age and it is just like any other infection and it spreads very rapidly and hence it needs to be detected early. The signs of acute Osteomyelitis are there is swelling around the joints especially around the knee. The knee is most commonly involved in children and there is swelling, there is fever, there is increase in thigh girth, the thighs suddenly starts becoming more thicker and there are painful movements, so these are and there is definitely signs of infection like nausea, vomiting, fever so acute Osteomyelitis needs to be treated as early as possible. Now, chronic Osteomyelitis happens because of some previous procedures like if there has been a previous surgery or if there has been an implant which has been placed inside the bone, so then in those cases chronic Osteomyelitis can happen because of various reasons, maybe because the patient has some co-morbid conditions some other diseases like diabetes or immunocompromised status so in those cases there is chance that there may be infection of the bone leading to chronic Osteomyelitis, now chronic Osteomyelitis extends over a long period of time and there is a sufficient amount of time before it comes to the surface, so it can manifest just as pain and some activity restriction, painful movements it may need x-rays, it can be detected by MRI, but if it is detected early then treatment can be done only with antibiotics. However if the infection comes all the way to the skin and there is a sinus formation then it may need to be treated by surgery by removing the sinus and by removing the dead bone, so depending on the stage of Osteomyelitis the treatment varies also it varies whether it is in the lower limbs, whether it is in the arms because in the lower limbs then we can offer bone grafting depending upon whether there is bone loss we offer bone grafting, we offer bone transport. So there are different options depending on levels of Osteomyelitis.
Guneet Bhatia: What about children who are you know born with bow legs or Blount disease. How possible is it to treat them? Can they be treated perfectly with good success rate?
Dr. Ravi Nayak: So those children who have bow legs, now usually bow legs is common during the early years of life may be less than 7 years of age, initially they have the knees pointing outwards, then sometimes they have knees pointing inwards which is called Varus and Valgus, so they are different stages of the development and at different stages you can see a different kind of bow legs but if the bow legs persists after 7 years of age then something needs to be done about it. For those who have Blount’s disease what we can offer is depending on whether their height is completed or not completed. If the height is not completed there is a simple procedure called as hemiepiphysiodesis where we put pins on the outer side, now what happens in Blount’s disease is that the growing end of the bone especially around the knee there is the bone called as Tibia, the inner side of the bone grows slower than the outer side of the bone so that is why the outer side grows much faster and there is gradually bowing of the legs with the knees facing outwards. So what we do in this case if the child presents to us at the right time around before 12 years, 9 to 12 years is a good time to do a kind of surgery called hemiepiphysiodesis, then we reduce the growth of the bone on the outer side so the inner side of the bone gets adequate time to catch up with the outer side and gradually the leg straightens out. But this is best done before 12 years of age when the growth spot because there are different levels of growth spots. The child starts growing. The first growth spot is around 9 years the second spot is around 12 years so we use the body’s natural growth to correct the deformity, however, if the deformity has been persistence since a long time and the growth is completed like somebody who comes to us at around 16 to 18 years of age then the treatment changes. We offer a different surgery called as Osteotomy, where we need to cut the bone, correct the deformity and then fix it back either with plates or with some bone graft, so depending on the age of the child we offer different treatments but yes definitely it can be corrected we need to monitor the child regularly as he/she grows and we need to take out the pins at just the right time to see that it does not.
Guneet Bhatia: Ok, I think this would be more relevant to the question that I just asked. What about external fixators ? How popular are they ? How successful are they ? Are they being used to correct only unequal leg length or for bow legs as well or for any other purpose. Are they basically successful, external fixators because the process is quite long and there has been an increase in demand as well from a patient asking specifically for this procedure?
Dr. Ravi Nayak: So external fixation is used as we discussed earlier for Osteomyelitis, so external fixation can be used for the different kinds of external fixations that are rail fixator, there is Ilizarov fixator. So there are different kinds depending on what we are offering to the patients, whether we are offering limb length, whether we are taking care of any bone defects of any bone transport is called as bone transport. So depending on the pathology external fixator is usually offered for those who want limb lengthening for those who have bone defects and for the temporary management of wounds. It is not definitive management for most cases a temporary management but in those who want bone transport and limb lengthening it is definitive management. I do agree it takes a very long time to achieve the required results and it requires a lot of patience both from the doctor and from the patient and it requires a lot of maintenance, like the patient, need to clean the pins regularly so that they don’t get infected but it is a good option for many cases, however we now have different options like nail inside nail technique where some bone transport can be done over a nail its not just the external fixator, so depending on what pathology, what is the age of the patient, how patience the patient is, what are the patience levels so depending on that we can offer the treatment accordingly.
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Guneet Bhatia: What about sports injuries ? From your perspective what are some of the most common sports injuries for which you receive patients from around the world.
Dr. Ravi Nayak: So sports injuries, the most common sports injuries that we see are ACL injuries, we also see those who have collateral ligament injuries like the LCL or the MCL or even the medial patella of femoral ligament that is called as the MPFL ligament and meniscus injuries so these are very common sport injuries in the knees that we see. We also see local patients who have ankle injuries they have ankle ligament injuries, ankle fractures and most of the sportsperson we give them good rehabilitation initially so they are optimized for surgery and depending on whether they want to continue with the sport we then offer them the surgery which is best for them.
Guneet Bhatia: Ok, I will just wrap up this session with the last question. What are some of the tips that you would give our Audience to maintain bone health?
Dr. Ravi Nayak: The best time to develop bone health, we may not realize it but the best time to develop bone health is in our teenage so most people develop maximal bone mass by around 25 years of age that is the time till when the body keeps depositing calcium in the bones and you can actually develop bone mass very well. After 25 it plateaus till around 45 to 50 years of age and especially in ladies after menopause the bone mass goes down by almost 2% to 3% every year so at the end of ten years they lose around 30% of their body weight of calcium of bone. Why this is important is because if at around 25 years of age normally in a 60-kilo person, the person who weighs 60 kilos the calcium in the body is around 5 kilos, the calcium in the bones. So if you have 5 kilos to start off with at 25 years of age by 50-55 you will be left with around you know 3 or 4 kilos so that is a good number which can be maintained, so you need to start building up bone mass in the early years of life however if you have not done that earlier it would be better to start off at any age. You need to have lots of calcium-rich foods especially like dairy foods, milk, yogurt, low-fat cheese, now we have low-fat options in all the dairy products so people can go for those. For those who do not like dairy like you have somebody with lactose intolerance we have different foods like broccoli, bananas we have figs (anjeer) which has lots of calcium. There are different foods for those non-vegetarians like egg whites you have sea fish like sardines and salmon which contains lots of calcium. So the food should be adequate the diet should be adequate in calcium.
The daily requirement for somebody who is from 19 to 50 years of age is around 1000 milligrams of calcium daily in the diet. In addition, you need to have adequate amounts of Vitamin D, so Vitamin D we usually get from exposure to sunlight. Daily between around 10 O’clock to 3 O’Clock for around half n hour and that exposure for 3 days in a week generates vitamin D for that whole week and there are very few vegetarian products which contain vitamin D. Non vegetarian products lot of non-vegetarian foods contains vitamin D like egg yolk and milk also contains vitamin D. So maintaining proper calcium, maintaining proper vitamin D and doing regular exercise. Nowadays what we see many people have a sedentary lifestyle once they start working. They are active till they are around in school or college but after college once they join work everybody becomes sedentary, the most they can do is the, the most stressful thing in their life is going to work and coming back, that is the only exercise in their life, so what I would suggest is people can make minor modifications, if we don’t have any kind of knee pain, ankle pain, or hip pain then you can use stairs may be instead of the lift, but do not climb more than 3 flight of stairs some people we see climbing more than 8 to 10 flights of stairs that will be more detrimental that will be more harmful so climbing just you know up to 2 or 3 flights of stairs is good enough instead of taking the lift, then you can walk short distances for around 15 to 20 minutes instead of taking a bus you can walk a short distance and by making minor modifications in your regular routine it would me good to maintain proper bone mass that is the time that the calcium will get deposited in the bones especially if you exercise. So if you can include some minor exercise routines as part of your daily activities, lift some low weights then it will be very good for the bones and for the joints
Guneet Bhatia: Thank you so much it was very useful and hopefully we will be collaborating again with you with few more questions regarding orthopedic surgery and some of the issues related to bone health.
Thank you for taking out time and sharing your thoughts on the questions that we directly had from people who share their queries with us.