Partial knee surgery, not total, a good option for many patients, say orthopaedic surgeons from Mumbai
Now, roughly 2.5 lakh Indians undergo knee replacement surgery every year. Considering that more Indians — from 23.46 million in 1990 to 62 million now — suffer from degenerative joint disease osteoarthritis, in which the protective cartilage cushioning the ends of bones wears down, the knee replacement numbers can only increase.
In this backdrop, two orthopaedic surgeons from the city, Dr Amyn Rajani and Dr Arun Mullaji, have published separate research papers in indexed medical journals highlighting that total knee replacement, which entails cutting through ligament, cartilage, and bones, may not be the only alternative for patients.
Their research articles highlight that partial knee replacement could be good enough for many Indians.
The knee has three compartments: the medial (34%), lateral (33%), and patellofemoral (33%). Arthritis begins in the medial compartment, meaning 66% of the knee is normal and functional at this stage. "Nearly 50% of patients suffer from arthritis confined only to the medial compartment of the knee, meaning a full knee replacement may be unnecessary for them," said Dr Rajani.
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A total replacement for such patients means "unnecessarily removing the healthy 66% of the knee" and replacing it with an artificial implant.
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His research paper in the Journal of Clinical Orthopaedics and Trauma looks at long-term five to nine years of follow-up of patients who underwent partial knee replacement. "The results are impressive, showing a survivorship rate of 96.85% over five years," said the doctor.
The patients reported minimal pain, quicker return to daily activities, and could squat and sit cross-legged.
Going by global estimates, roughly 70% of patients undergoing knee replacement will need the total option, while the remaining may only need partial replacement. "Only 12.7% of the Indian population is recommended surgical intervention for knee osteoarthritis, with well over 80% of those being total knee replacements.
This shows that the number of medial unicompartmental knee replacements is low in India," said Dr Rajani.
The doctors believe partial knee replacement is safer and, as it involves minimal cuts, recovery is faster. Dr Mullaji spoke about his first patient (now 78) who underwent a partial knee replacement and made it to the Limca Book of Records in 1997. "I followed her progress for 28 years, and she needed a revision last year mainly because of other degenerative diseases she developed in the interim," he said.
Dr Mullaji, who completed over 4,000 partial knee replacements, said the technique is underutilised because few surgeons are trained in it and patients are unaware of it. "There also are some patients who are 'business-minded' and think a total knee replacement is better than partial," he said.
Dr Mullaji's research paper, which was published online in the Journal of Orthopaedics on Saturday, reviewed the progress of 2,500 patients on whom he performed the partial knee replacement.
"This study has established that leg alignment can be achieved with unicompartmental surgery," he said.
Dr Mohan Desai, head of orthopaedics in BMC-run KEM Hospital in Parel, said there are specific criteria laid down for the selection of patients for partial knee replacement. It's recommended for patients who are younger (below 50), those with minimum damage due to disease, and older patients with other comorbidities such as heart disease that makes total replacement a riskier surgery.
"There is a grey zone where some patients may have extended indications and may want total knee replacement," said Dr Desai, who regularly performs partial knee replacement using a robotic arm at KEM Hospital, Parel.
Senior orthopaedic surgeon Dr Sanjay Agarwala said that the decision to do a partial knee replacement depends on the concerned surgeon's ability and belief. "Partial knee replacement doesn't always lead to correct alignment of the leg in many patients as patient selection and surgeon's training are of critical importance," he said.
"Most patients coming to me have extensive disease and would need total knee replacement," said Dr Agarwala, who, incidentally, prefers other techniques such as high tibial osteotomy (a surgical procedure that realigns the knee joint by cutting and reshaping the tibia or the shin bone) to partial knee replacement. "Some patients with single compartment disease would benefit from splints and braces and not need a partial replacement," Dr Agarwala added.
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