Medical Tourism for Avascular Necrosis

It’s becoming more common by the day – as medical treatments procedures become costlier in some nations and simultaneously improve in quality in others, more and more people are choosing to travel out of their homelands in search of inexpensive alternatives to the medical procedures they require. Their preferred destinations are countries where healthcare is affordable to those who have money and where the quality of care provided depends on the amount you’re willing to spend.

Medical tourism is popular in and thrives in countries like India where costs are affordable and the care provided is of superior quality. If you suffer from avascular necrosis and need a hip replacement, a hip resurfacing procedure or stem cell treatment, here are a few tips that will come in handy:

• Research your options before you decide to travel abroad for surgery – choose your destination based on a variety of factors, the most important of which should be quality. Cost is a consideration too, but if you’re not careful, you could end up becoming the result of a medical error.
• Ask a friend or family member to accompany you on the trip – you will need their help to move around in the initial days of the surgery, to help you with your physiotherapy, and to ensure your safe travel back home once you’ve been discharged. Most hospitals in India allow a companion to stay with you in your private hospital room during and after the surgery.
• Be prepared to spend between ten days and two weeks for the procedure.
• Understand your legal rights and options in the country you choose to visit for your procedure – it is harder to sue medical practitioners in countries like India than it is in the USA. To avoid legal issues and unpleasantness, choose a doctor who is reputable and experienced in the surgery, or a hospital whose name is synonymous with quality.
• Be prepared to undergo physical therapy soon after your surgery – it is necessary to restore mobility and improve your range of motion.
• Learn a little about the country and city you’re going to be staying in for your procedure so you don’t get cheated or find yourself like a fish out of water when you get there. Use the Internet to find out the best ways to get to the hospital from the airport and read up on the culture of the country.
• If you want to do a few touristy things before/after the surgery, check with your surgeon if it’s going to be possible before fixing your itinerary.
• And finally, be prepared for any eventuality – ensure that you have access to enough funds to cover your stay, ascertain that you don’t break any local laws and rules, and most important of all, establish a good relationship with your preferred doctor/hospital before you get there for the procedure.

By-line:

This guest post is contributed by Rachel Davis, she writes on the topic of Radiology programs . She welcomes your comments at her email id: racheldavis65[@]gmail[.]com.

Avascular necrosis of the hip is a frequently seen condition in young patients. It is of diverse origin and its treatment is controversial. Surgical treatment remains the key stone in late cases with hip replacement as the proved and tested method. Surgeons at the Madras Joint replacement center are proud to announce a novel form of biological treatment with stem cells. It can be performed for patients with the early stages of the disease.
When the disease is detected early by MRI scans, it is possible in India now to perform a biological treatment.

In fact a biological treatment option of early disease is a medical necessity and must be the treatment of choice whenever possible.

A novel approach to this condition is being mooted by a leading Orthopedic surgeon in Chennai, India. This is by means of stem cells. Stem cells have the potential to regenerate any tissue. In this case, bone forming stem cells are utilized to synthesize new bone over the dead bone. Stem cells are harvested from the pelvis of the patient.

There are two techniques being promoted. One is a three stage procedure and the other is a single stage procedure. Both procedures are done in India, implying that you will save thousands of dollars in treatment costs.

The first method is by stem cell culture in the lab to multiply the number of cells several million fold. These cultured stem cells are reinjected into a previous core decompression site.

In the second method, bone marrow obtained from the pelvis is centrifuged in the operating room to yield a Bone marrow concentrate rich in stem cells. These are injected into a core decompression site.

A paper presented at the recent American academy of surgeons meet in New Orleans highlighted the success story of stem cells.

http://www.prweb.com/releases/adultstemcellAVNsurgery/thomaseinhornmd/prweb3813974.htm

To know more about the stem cell option and to determine whether your case is suitable for this unique form of treatment, send an e mail to

Dr.A.K.Venkatachalam at drvenkat@kneeindia.com

Visit http://www.hipsurgery.in/blog

To get more information please e mail us

drvenkat@kneeindia.com

Web site- http://www.hipsurgery.in

Recent reports in The New York Times, Journal of arthroplasty and others talk about the complications associated with metal on metal hip replacements including hip resurfacing.
http://www.nytimes.com/2010/03/04/health/04metalhip.html?partner=rss&emc=rss&pagewanted=all

BHR prosthesis

Sickle cell patients often suffer from avascular necrosis or osteonecrosis. Hip replacement is required for pain relief. They are also prone to develop bone infections due to their lowered immunity. While investigating a patient, the orthopedic surgeon should consider the possibility of a co existent infection in the hip and take steps to eradicate it. Joint replacement in the presence of an ongoing infection is likely to be disastrous.

Osteomyelitis & Avascular necrosis in sickle cell patients

Avascular necrosis of bone is a common problem in patients with sickle cell disease.

Hip is the commonest joint driving patients to seek hip replacement.

However this scenario can be complicated by osteomyelitis (bone infection)

In this case report, we discuss how this combination was approached.

Case report

The patient was a 34 year old Nigerian male, one out of 6 siblings. All other siblings were normal. Both parents were haploid for sickle cell trait.

He presented with severe avascular necrosis of the left hip needing a hip replacement.

Work up included a complete blood count, ESR, Haemoglobin electrophoresis, blood culture, pre operative X-rays of the hip. The ESR was elevated at 121 mm/ hr and his WBC count was 12,000/cu mm. Blood culture was negative.

The x ray of the pelvis revealed avascular changes of both hips with secondary osteo- arthritic changes. The proximal portion of the left femur showed a bone in bone appearance with some discontinuity seen in the region below the greater trochanter.

An MRI with contrast was done. This showed a breach in the cortex with a bright signal intensity which was negative to fat suppression. There was edema in the surrounding tissues and an effusion was present in the hip joint. A CT guided biopsy was taken from the area and this drew a sample of yellowish fluid. This fluid was set up for culture in two labs. One lab reported a negative culture and another lab reported a growth of scanty “coagulase negative staphylococcus.”

With a near positive diagnosis of chronic osteomyelitis, the patient was taken up for an open debridement.

The hip was approached by a lateral approach with division of the vastus lateralis.

A cavitary lesion was identified below the greater trochanter.

It was debrided thoroughly and specimen sent for culture.

Bio absorbable bone substitute of Calcium sulphate and antibiotic was packed inside the cavity to deliver a high local concentration of antibiotics, Vancomycin and Tobramycin.

In addition intra venous infusion of Vancomycin and Clindamycin was started.

The patient is making progress.

Discussion

This case helps to draw attention to the co existence of infection in sickle cell patients with avascular necrosis. Performance of a hip replacement without eradication of infection would have lead to disastrous results.

This cautious approach can possibly eradicate infection and allow a safe hip replacement later on.

Another aspect is the method of local antibiotic delivery. It is well known that intravenous antibiotics have poor tissue concentration in the affected bone. The prevalent method of local antibiotic delivery is combination of antibiotics with Bone cement (Poly methyl methacrylate). This comes in the form of Septopal beads which contain Gentamycin. This is impregnated into the affected area after an open operation; however this restricts the choice of antibiotics. It requires another operation to remove the beads after 6 weeks.

The main advantage of our technique is that the procedure achieves two purposes. Firstly it allows packing of the bony defect with a bone substitute. This substitute is resorbed over 60 days and osteogenesis occurs. Secondly antibiotics are delivered in high concentration locally for duration of three months. There is no need for a second operation to remove the beads as it is self absorbing.

Dr.A.K.Venkatachalam

MS Orth, DNB Orth, FRCS. M.Ch Orth

Consultant orthopedic surgeon

Madras Joint Replacement center

www.hipsurgery.in

Hip arthritis is of two types. Young and middle aged persons suffer from secondary osteoarthritis. Primary osteoarthritis can affect middle aged and elderly. Surgery in this group of relatively younger patients requires newer techniques like hip resurfacing.

Hip Resurfacing is the preferred option in young & middle aged males with primary

Types of Hip arthritis

Hip arthritis is classified as Primary and secondary Osteoarthritis.

Primary osteoarthritis is age related wear and tear arthritis. It is rare in India.

Secondary osteoarthritis occurs at a younger age and is more common. Rheumatoid arthritis, avascular necrosis, traumatic arthritis and other connective tissue disorders like SLE, Psoriasis etc. all lead to secondary osteoarthritis.

Rheumatoid arthritis is an auto immune disorder, affects all joints particularly the small joints but also does not spare the hip and knees.

Avascular necrosis is a condition that reduces the blood supply to the end of the bone. It affects patients with excess alcohol intake, consuming steroids, connective tissue disorders like SLE. Systemic lupus erythematosus (SLE) is a connective tissue disorder affecting mainly young women A photo sensitive rash on the cheeks, renal involvement and arthritis are some notable features. Avascular necrosis affects a proportion of the patients with SLE.

Gaucher’s disease is a rare genetic storage disorder.

Post traumatic arthritis occurs after a severe injury to the hip. Fractures of the ball (top of the femur) or socket (acetabulum) can lead to arthritis after inadequate treatment.

Hip arthritis is very disabling as it is a small ball and socket joint. In advanced disease a total hip replacement was recommended by Orthopaedic surgeons until recently. The ideal age for a hip replacement is 74 years.

Surgical solutions

are the mainstay of treatment as conservative measures fail to relieve pain. Total Hip replacement (THR) is a time tested operation and has a success rate of 93 % survivor ship at 10 years.

Who needs a hip resurfacing?

In India, many young patients with ankylosing spondylitis, avascular necrosis, post septic arthritis, post injury suffer from hip arthritis and are advised a hip replacement for disabling pain. Thus many hip replacement operations are performed in younger patients. The surgery should cater to the enhanced demands on an artificial joint by younger and more active patients. Naturally an operation designed for Western elderly patients is not suitable for younger patients.

Hip Resurfacing vs Hip Replacement

In this operation the ball shaped upper end of the thigh bone (femur) and the socket (acetabulum) are replaced. The ball is replaced with a long metal stem that is fixed into the upper end if the thigh bone. Its upper spherical end articulates with a cup shaped polyethylene socket that is cemented into the pelvis.

Conventional hip replacements sacrifice a great deal of normal bone as the head, neck, and upper part of the thigh bone is removed for implantation of the prosthesis. Moreover wear debris from the poly-etheylene liner lead to osteolysis and bone loss. When this first hip is to be changed or revised after its lifespan more bone loss occurs. Conventional hips have a small ball to reduce friction and wear, but the ill effect of this is an increased risk of dislocation. An average dislocation rate of 3- 4 % has been reported. These implants do not last very longer than 20 years and revision rates of 50% at 20 years have been reported. Survival rates are less satisfactory for the relatively younger active patients. Thus a total hip replacement is not an ideal implant for younger patients less than fifty years old who need a new hip.

Problems with conventional total hip replacement:

• Excessive bone sacrifice and loss
• Increased risk of dislocation
• Patients cannot squat or sit cross legged on the floor with out the risk of dislocation.
• Range of movement is less
• Patients cannot involve in sports
• Poor survival in young and active patients they require earlier revision.
• Revision surgery is difficult
• The hip feels less like a normal hip
• The cup wears with time and plastic from it harms bone
• Change in length of the leg after surgery leading to leg length discrepancy.

Why remove normal bone when only the surface of the ball is bad?

This is the logic behind hip resurfacings. This bone preserving hip resurfacing involves replacing only the diseased bony surfaces of the head of femur and acetabulum. This involves sculpting the head of the femur and covering it with a metal cap and fixing an uncemented socket into the acetabulum to receive the head.

Hip Resurfacing- A bone preserving hip replacement!

Preservation of bone and less stress shielding makes it easy to revise this hip if needed. The large head size provides a very stable joint and recreates the sensation of a normal hip joint. Patients have gone back to playing Judo and Squash after this operation. Advances metallurgy makes the metal on metal articulation likely to survive longer in the young and active patient. With less metal inside the bone and less invasion of the medullary cavity of the femur, the risk of infection is reduced. Rehabilitation is faster and better.

Advantages of hip resurfacing:

• Allows the patient to squat and sit cross legged on the floor safely
• Allows a normal range of movement
• Sacrifices only the surface diseased bone and preserves normal bone
• Imparts a more normal sensation
• The joint is likely to last longer even in younger and active patients.
• Earlier and faster rehabilitation
• Less risk of dislocation
• Easier to revise if needed.
• No leg length discrepancy.

In summary a Hip Resurfacing offers several advantages in young patients in young patients.

Are you suffering from hip arthritis? Has your surgeon advised you a hip replacement?Hang on! If you need a hip replacement, please read the following information on facts about the operation and a more advanced bone preserving option called hip resurfacing.

What is the hip joint? Watch video on hip joint anatomy and hip replacement operation

The hip joint is a ball and socket joint which connects the torso to your legs. It is formed by the upper end of the thigh bone ( femur) and the socket of your pelvic bone ( acetabulum). A natural shock absorber tissue called “articular cartilage” lines the ends of the bones and allows painless smooth movements.

What are the symptoms of hip arthritis?

The patient complains of pain and restriction of movement. Pain may often be felt in the knee alone with no hip symptoms. Occasionally the pain may be felt more in the buttock area rather than in front of the groin. Gradually you will loose your ability to retain a active life style through exercise and sports.

Diagnosis

Your doctor may advise x rays on which hip arthrosis is seen as a loss of joint space or narrowing of the gap. Loss of this lining shock absorber articular cartilage results in pain while you walk.

Treatment options

Initially your doctor may prescribe you pain killers and suggest you to perform exercises to retain flexibility of your joints.

When you have run out of non operative options like pain killers, physical therapy your orthopedic surgeon might advise you to seek a hip replacement.

The hip joint may need to be replaced with an artificial joint when it is irreversibly damaged and cannot be salvaged by alternate surgery. The patient complains of pain and restriction of movement.

Who needs a hip replacement?
In India, many young patients with rheumatoid arthritis, ankylosing spondylitis, avascular necrosis, post septic arthritis, post traumatic arthritis, are advised a hip replacement for disabling pain.

Thus many hip replacement operations are performed in younger patients. The surgery should cater to the enhanced demands on an artificial joint by younger and more active patients. Hip replacement is a successful operation for patients above 60 years

What is a total hip replacement?

In this operation the ball shaped upper end of the thigh bone (femur) and the socket (acetabulum) are replaced. The ball is replaced with a long metal stem that is fixed into the upper end if the thigh bone. Its upper spherical end articulates with a cup shaped polyethylene socket that is cemented into the pelvis.
Conventional hip replacements sacrifice a great deal of normal bone as the head, neck, and upper part of the thigh bone is removed for implantation of the prosthesis. Moreover wear debris from the polythetheylene liner lead to osteolysis and bone loss. When this first hip is to be changed or revised after its lifespan more bone loss occurs. Conventional hips have a small ball to reduce friction and wear, but the ill effect of this is an increased risk of dislocation. An average dislocation rate of 3- 4 % has been reported. These implants do not last very longer than 20 years and revision rates of 50% at 20 years have been reported. Survival rates are less satisfactory for the relatively younger active patients. Thus a total hip replacement is not an ideal implant for younger patients less than fifty years old who need a new hip. It is however the best option in elderly people.
Problems with conventional total hip replacement:
A total hip replacement is an excellent & time tested operation in the elderly. However in the young problems may arise. These are
(1) Excessive bone sacrifice and loss
(2) Increased risk of dislocation
(3) Patients cannot squat or sit cross legged on the floor with out the risk of dislocation.
(4) Range of movement is less
(5) Patients cannot involve in sports
(6) Poor survival in young and active patients they require earlier revision.
(7) Revision surgery is difficult
(8) The hip feels less like a normal hip
(9) The cup wears with time and plastic from it harms bone
(10) Change in length of the leg after surgery leading to leg length discrepancy.

Why remove normal bone when only the surface of the ball is bad?

Video shows comparison of Hip replacement and hip resurfacing

This is the logic behind hip resurfacing. This bone preserving hip resurfacing involves replacing only the diseased bony surfaces of the head of femur and acetabulum. This involves sculpting the head of the femur and covering it with a metal cap and fixing an uncemented socket into the acetabulum to receive the head.
What is Hip Resurfacing?
It is a bone preserving hip operation. In this operation only the worn out surface at the top of the femur bone is scraped and shaped into a cylindrical form from a spherical form. A metal spherical cap is glued or cemented over the cylindrical stump like a tooth crown over an old stump.
This restores the normal shape & size to the upper end of the thigh bone. Next the socket in the hip bone is scraped into a hemisphere. A metal cup is impacted after complete cartilage removal. This cup will integrate with the body’s bone on the back side as it has a layer of the same material as bone. The hip shape is thus restored to normal. Bone is preserved in the head of the thigh bone. If a hip resurfacing were to fail for some reason, it would be still possible to change this to a conventional hip replacement later on.
Preservation of bone and less stress shielding makes it easy to revise this hip if needed. The large head size provides a very stable joint and recreates the sensation of a normal hip joint. Patients have gone back to playing Judo and Squash after this operation. Advances metallurgy makes the metal on metal articulation likely to survive longer in the young and active patient. With less metal inside the bone and less invasion of the medullary cavity of the femur, the risk of infection is reduced. Rehabilitation is faster and better.
Advantages of hip resurfacing:
(1) Allows the patient to squat and sit cross legged on the floor safely
(2) Allows a normal range of movement.
(3) Sacrifices only the surface diseased bone and preserves normal bone
(4) Imparts a more normal sensation
(5) The joint is likely to last longer even in younger and active patients.
(6) Earlier and faster rehabilitation
(7) Less risk of dislocation
(8) Easier to revise if needed

So in conclusion although total hip replacements remain an excellent option in a specific elderly age group, Hip replacement alternatives like Hip surfacing should be strongly considered in young and middle aged patients ( less than 60 years) requiring a hip replacement in India.

Dr.A.K.Venkatachalam is a consultant Orthopaedic surgeon in Chennai.View Patient stories here-

Visit http://www.hipsurgery.in

Nigerian patient underwent multiple Orthopaedic surgery by Dr. Venkatachalam. These included a Total hip replacement, ankle arthrodesis, femoral supra condylar ostetomy