Case study

“AVN (Avascular OsteoNecrosis) Is a condition where the blood supply to the bone is blocked. This leads to death and necrosis with pain and eventual collapse of the affected bone, most commonly seen in the hip (femoral head) with crippling pain. The incidence of AVN has increased recently after COVID-19 Pandemic. This, if identified early, can be treated medically.” UNDERSTANDING THE DISEASE OF AVASCULAR NECROSIS Avascular Necrosis (AVN) or Osteonecrosis of the femoral head is a pathological process that results from interruption of blood supply to the bone which leads to the death of marrow and osteocytes resulting in collapse of the necrotic segment of the femoral head. In the early stages of the disease, there is severe pain from the dying bone. Later this leads to frank arthritis of the hip, causing stiffness, limitation of movement and adds to the disability of the patient in day to day routine life. This is the most common cause of total hip replacement in young patients in India. ETIOLOGY : Avascular Necrosis (AVN) is often seen in association with a number of different conditions. Trauma with fracture of the femoral neck, especially in the sub-capital region, interrupts the major part of the blood supply to the head and may lead to AVN. The risk has been reported to be as high as 10% -40% after a displaced femoral neck fracture. Some of the factors leading to AVN are : PATHOGENESIS : The hematopoietic cells are most sensitive to Anoxia (due to interruption of blood supply causing inadequate oxygenation). Ischaemia causes death of marrow cells, death of bone cells causing necrosis of the affected segment which leads to weakness and collapse of the femoral head. This in turn causes incongruity leading to arthritis of the hip joint. Nature tries to heal this condition through removal of dead cells by osteoclasts and layering of new bone cells by osteoblasts. This natural process of healing takes upto three years, the life cycle of the disease. There are four stages (Ficat & Arlet) of AVN of the femoral head based on the clinical and radiological presentation. Stage 1 the normal congruity of the femoral head is maintained with minimal symptoms and Stage IV is the end stage with collapse of the hip with arthritis. SYMPTOMS :​ Patients with AVN have a varied presentation based on their involvement of the femoral head (Stage of AVN). In early stages, patients present with groin, buttock, thigh pain or even with the knee pain with normal x-rays and an abnormal MRI. In later stages, patient present there is a limp, limitation or decreased movements of the hip joint and restriction of activities of daily living. INVESTIGATIONS :​ Standard plain x-rays of pelvis with both hips (PBH view) and MRI helps in making a diagnosis as well as prognosis of the conditions. In certain cases, radio-nuclide bone scan also helps. Standard plain x-rays of pelvis with both hips (PBH view) and MRI helps in making a diagnosis as well as prognosis of the conditions. METHODS OF TREATMENT :​​ SURGICAL MANAGEMENT​​​ There are various surgical procedures which have been described such as core decompression, vascular fibular bone grafting, osteotomies around the femoral head and vascular pedicle graft, with varied success rate. All these surgical procedures help in early stages of AVN with variable success but adds morbidity to patient. Stem cells implantation is still in experimental stage. The only consistent good results are seen in total joint replacements. MEDICAL MANAGEMENT INVOLVES :​​​ It is combined with Calcium, Vit B12, Folic acid supplements. Bisphosphonate therapy, the only currently available peer reviewed and proven in world literature.

Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage that cushions the ends of the bones wears down over time. It makes joints Stiff and Painful. Although osteoarthritis can damage any joint, the disorder most commonly affects joints in your hands, knees, hips and spine. Causes of osteoarthritis: As part of normal life, your joints are exposed to a constant low level of damage. In most cases, your body repairs the damage itself and you do not experience any symptoms. But in osteoarthritis, the protective cartilage on the ends of your bones breaks down, causing pain, swelling and problems moving the joint. Bony growths can develop, and the area can become swollen and red. The exact cause is not known, but several things are thought to increase your risk of developing osteoarthritis, including: Symptoms: The main symptoms of osteoarthritis are pain and stiffness in your joints, which can make it difficult to move the affected joints and do certain activities. The symptoms may come and go in episodes, which can be related to your activity levels and even the weather. In more severe cases, the symptoms can be continuous. You should see a Specialist if you have persistent symptoms of osteoarthritis so they can confirm the diagnosis and prescribe any necessary treatment. Other symptoms you may notice include: Osteoarthritis can affect any joint in the body, but the most common areas affected are the knees, hips and small joints in the hands. Often, you’ll only experience symptoms in 1 joint, or a few joints at any 1 time. Osteoarthritis of the knee : If you have osteoarthritis in your knees, both your knees will usually be affected over time, unless it occurred as the result of an injury or another condition affecting only 1 knee. Your knees may be most painful when you walk, particularly when walking up or down hills or stairs. Sometimes, your knees may “give way” beneath you or make it difficult to straighten your legs. You may also hear a soft, grating sound when you move the affected joint. Doing daily activities becomes difficult. Osteoarthritis of the hip: Osteoarthritis in your hips often causes difficulty moving your hip joints. For example, you may find it difficult to put your shoes and socks on or to get in and out of a car. You’ll also usually have pain in the groin or outside the hip. This is often worse when you move the hip joints, although it can also affect you when you’re resting or sleeping. Osteoarthritis of the hand: Osteoarthritis often affects three main areas of your hand: Your fingers may become stiff, painful and swollen and you may develop bumps on your finger joints. Over time, the pain may decrease and eventually disappear altogether, although the bumps and swelling can remain. Your fingers may bend sideways slightly at your affected joints, or you may develop painful cysts (fluid-filled lumps) on the backs of your fingers. In some cases, you may also develop a bump at the base of your thumb where it joins your wrist. This can be painful, and you may find it difficult to perform some manual tasks, such as writing, opening jars or turning keys. Treatment and Support: There’s no cure for osteoarthritis, but the condition does not necessarily get any worse over time. There are several treatments to help relieve the symptoms. The main treatments for the symptoms of osteoarthritis include: Lifestyle measures – such as maintaining a healthy weight and exercising regularly. Medication – to relieve your pain. Supportive therapies – to help make everyday activities easier.

I hope that you are cognizant of the other methods of treatment of your problem which has been discussed with you by me, my staff, and assistants in my clinic, in advance, at the time of your consultation, and I trust if you have had any queries, they have been answered. Based on our discussions, we have determined the suggested plan of action as the best option under the circumstances, keeping in mind your requirements and our current expertise. To help you understand the process, I am comparing it to taking a flight from Mumbai to a foreign destination. Just like before a flight, you need passports, visa, ticket bookings, likewise for the operation, you need to book a date for admission and a date and time for surgery. Just like the visa process, we need to know that you are fit for surgery and therefore, you need to share your medical history with us, along with ALL the medication that you normally take including tablets such as Aspirin and Clopilet which are blood thinners and can cause bleeding at the time of surgery, and medication for Asthma (you may need more oxygen during the surgery) and Diabetes (if your blood sugars are high, then wound healing is very poor). All inputs by you help make us more prepared to help you. Specific medication & conditions of the heart (ECG, 2D Echo), lungs (PFT/X-rays), liver and kidney etc., need to be known as various drugs can interact with these functions. The physical act of giving you anesthesia may require extra tests like specialized x-rays of your spine, CT or MRI screening of parts of your body, so that we are better prepared to tackle your spinal position during the process of the surgery. Just like you have a security check before taking a flight, we need the Physician and the Anesthetist to look through these pre-operative medical reports and to examine you so that we may reduce the risks still further. Just like in an aircraft before take-off, there is a safety drill in case of any risks, likewise, in any surgery we are taking RISKS but minimizing it by trying to cover as many events as we can. Just as every landing at an airport, the pilot has to contend with cross-winds, haze, other flights, weather changes, quality of communication etc., similarly every surgical procedure is individualized, some are longer, some are shorter and there are multiple variables. The OTC is like a ticket. Just like you pay for a ticket before your travel. The Hospital expects you to do an OTC (Operation Theatre Clearance) so that the hospital and you are both aware of the expected expenses. Against your paid ticket you get a boarding pass, likewise against an OTC, the institution permits you to be taken to the theatre for surgery. This is based on averages, but in your individual case the total expenses may be more if there are complications or emergency requirements which may or may not be related to the actual surgical procedure. You need to be aware therefore that this is an estimate only based on an AVERAGE and is NOT a PACKAGE. Recovery thereafter is a natural process, and we as doctors help nature help you, with medication, nursing, physiotherapy and other techniques required for your recovery. I reiterate that healing is a process dictated by nature, we only help in this. Just as nature has storms, weather changes, etc, recovery can sometimes in your individual cases be slower and therefore worrisome to you. Such delays are also worrisome to us as individuals and as a team. The nurses, other staff and my team help the recovery process. Your concerns will be addressed. Just like in the airline industry the cost of the ticket for travel supports the airline staff, the salaries, the fuel for the aircraft etc., for our team to successfully execute the whole process, there is staff in the hospital which is supported by the expenses incurred for your case, for administration, security, laundry, dining, meals, air-conditioning, water, catering etc., Like certain budget airlines offer cheaper fares and skeleton services many doctors and medical facilities will be able to offer you these at lesser rates. In our institutions we have overheads to ensure that checks and measures are carried out for your safety, and these necessitate the charges quoted by us. Just like in any travel there is an Economy class or Business Class or First class at different charges, helping you reach the same destination, similarly in the hospital there are various classes of admission with different levels of comfort, helping you attain the best results. My team’s training, experience, etc., should make this a smooth landing. I hope this helps you understand the process and I really look forward to greeting you on the other side with every success in your case.

In recent years, robotic knee replacement surgery has revolutionized the way we treat advanced knee arthritis. Gone are the days when joint replacements were purely manual and heavily dependent on surgeon experience. Today, with the help of robotic technology, knee replacement has become more accurate, personalized, and efficient than ever before. If you or your loved one is considering a knee replacement, this blog will help you understand why robotic-assisted surgery might be the best choice. What is Robotic Knee Replacement? Robotic knee replacement is not a surgery performed by a robot alone. Instead, it’s a highly advanced procedure where a surgeon uses robotic assistance to place the knee implant with extreme accuracy. The robot acts as a precise guide — based on your unique anatomy — ensuring the implant is positioned perfectly. This improves joint function, reduces pain, and helps you recover faster. How is Robotic Surgery Different from Traditional Knee Replacement? Feature Traditional Knee Replacemecnt Robotic Knee Replacement Planning Manual measurements 3D CT scan-based planning Implant Placement Based on surgeon experience Based on robotic accuracy Bone Cutting Manual tools Robotic precision tools Outcomes Effective More precise and consistent Recovery Gradual improvement Faster return to function How Does the Robotic System Work? Pre-surgery CT scan: A 3D model of your knee is created using advanced imaging. Surgical planning: The surgeon plans the implant position tailored to your knee shape and movement. Intraoperative precision: During surgery, the robot guides the surgeon, ensuring accurate cuts and alignment. Real-time feedback: The system provides real-time data, adjusting the plan if needed. Who is a Candidate for Robotic Knee Replacement? You may benefit from robotic-assisted knee replacement if: You have advanced osteoarthritis or rheumatoid arthritis Conservative treatments like physiotherapy or injections haven’t helped You have knee pain affecting your daily life or sleep Your knee is stiff, misaligned, or unstable Benefits of Robotic Knee Replacement Better alignment of the implant Faster recovery and shorter hospital stay Less post-operative pain Lower risk of revision surgery Improved joint function and satisfaction Common Types of Robotic Systems Some commonly used robotic systems include: MAKO SmartRobotics™ (Stryker) VELYS Robotic (Depuy) ROSA® Knee System (Zimmer Biomet) CORI Surgical System (Smith+Nephew) CUVIS Robotic System (Meril Maxx) Each system uses different technologies, but all aim for one goal: greater precision and better outcomes. What to Expect During Recovery? Recovery after robotic knee replacement is typically: Hospital stay: 1–3 days (sometimes even same-day discharge) Physiotherapy: Begins on Day 1 after surgery Walking: With support on Day 1 or 2 Return to work: Desk jobs within 2–4 weeks Full recovery: Within 6–12 weeks, depending on your health FAQs Q1: Is robotic knee surgery safe? Yes. It’s FDA-approved and done under surgeon supervision. The robot never works independently. Q2: Will it cost more? Slightly higher cost, but often balanced by shorter hospital stays and fewer complications. Q3: Can older adults undergo this surgery? Yes! In fact, it’s especially beneficial for seniors needing better precision. Q4: Is the surgery painful? Pain is much better managed now with modern anesthesia, early rehab, and robotic precision. Final Thoughts Robotic knee replacement is a cutting-edge advancement offering patients a more personalized and accurate approach to surgery. If you’re considering knee replacement, talk to Dr Vinayak Ghanate about whether robotic-assisted surgery is the right option for you. Precision today, better mobility tomorrow.