Original Article

Osteoarthritis and total Knee replacement on Surgery Rise? A developing country perspective

Sandeep Sachdeva*, S.S. Sangwan**, T.R. Sachdev*** Abstract

Globally population is ageing with associated rise of age-related problems including osteoarthritis that affects one or more joints but more commonly knees leading to morbidity, disability and social isolation. Total knee replacement or knee arthroplasty is a highly successful surgical procedure undertaken to reduce pain, correct deformity, improve functional mobility and quality of life. This review details issues and challenges related to disease condition and orthopedic procedure which is witnessing an upward trend in the world including India. Key words: ageing; pain; rheumatology; morbidity, public health; health manpower; paramedics; medical tourism (Journal of The Indian Academy of Geriatrics, 2013; 9:87-89 )

Introduction Endorsed by the UN and WHO, 20002010 had been aptly declared as the Bone and Joint Decade to draw attention on increasing impact musculoskeletal conditions will have on world health and the overwhelming response lead to renewal of momentum for another 10 years with a vision Keep People Moving.1 It is not surprising that total direct and indirect costs of musculoskeletal diseases have risen to 1-3.5% of gross national product in countries of North America, Europe and Australia.2,3 Osteoarthritis (OA) is associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins. It affects one or more joints but more commonly knees that may lead to morbidity, disability and social isolation. True figure are not available for India but global estimate suggest it being a public health problem especially in developed nations with 9.6% of men and 18% of
*Department of Community Medicine, ** Department of Orthopedics, PGIMS, Rohtak, ***Public Health Specialist, New Delhi Address for correspondence: Dr Sandeep Sachdeva, House No 328, Sector 14, Rohtak, Haryana.- 124001. E-mail: drsachdeva@hotmail.com

women 60 years having symptomatic OA; agestandardized prevalence rate per 100,000 persons for knee OA as 1770 for males and 2693 (females).4,5 Total knee replacement (TKR) or knee arthroplasty is a highly successful surgical procedure undertaken to reduce pain, correct deformity, improve functional mobility and quality of life in these patients. The outcome has been rated from good to excellent in more than 90% of patients undergoing TKR with achievement of postoperative knee flexion of atleast 90 degrees.6,7 The knee replacement can last upto 20 years while patient is able to undertake most of the routine activities except squatting, cross-leg sitting, use of Indian-style toilet etc. Medical/physiotherapeutic interventions are effective during initial phase of disorder and surgery is the last resort depending on radiological evidence. TKR being an elective procedure, its utilization depends on multiple factors- severity of disease condition, socioeconomic class, gender (female), ethnicity, geography, priority/willingness, emotional endurance, fitness, referral and access to competent surgeon and health system. With increase in longevity of life, obesity epidemic, development of durable prosthesis and other technology advancement, primary TKR is being undertaken globally. The rise has been steep with burgeoning elderly population in developed

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nations during last three-decades e.g. in USA (65 years & above constitute 13.0% of total population) a jump of 400% was observed between 1971-2003 and TKR surgeries undertaken in the year 2007 alone were 543,000 twice that of total hip replacement surgeries.8,9 Having set the platform, India is not immune to changes occurring in medical & global community. There is simultaneous intense percolation of TKRs in metropolitan/larger cities of India for both national and foreign patients due to demographic shift, economic independence, social/peer pressure, aspiration to lead a qualitatively satisfying life and medical tourism.10 The procedure came to media limelight following former prime minister undergoing TKR but with evolving time a concomitant unmet need for demand and supply of surgery has been created. Since private sector is a dominant player and offer TKR package in the price range of Rs 250,000 to 500,000 for staged replacement surgery including prosthesis, drugs and hospital stay. Health insurance (government/ private) has emerged as a potential savior for large number of patients-in-need. In government sector also the price may range upto 100,000 INR for the prosthesis and drugs. In our experience large number of patient are unable to bear this level of health expenditure and keep postponing the surgical intervention inspite of pain and deformity. Surveillance for selected non-communicable diseases (NCD) risk factor and communicable diseases have been built into national Integrated Disease Surveillance Project (IDSP) in the country while there have been some additional experience with institutional based registries for diseases/ disorder/procedures e.g. birth defect, cataract; retinoblastoma, national transplant registry, diabetes registry and stem cell donor registry etc. However, these are marred by issues related to leadership, coordination, human-resources, funding, equity, and most importantly sustainability. With this background of learning and experience, will it be premature to call for initiation of national arthroplasty registry for capturing comprehensive Indian database? The first arthroplasty register was created in Sweden in 1975 followed by phased introduction in Europe, Australia and region of America.11 Arthroplasty register data can provide a crucial contribution for development of arthroplasties, quality control, allowing assessment of the number and epidemiology of procedures, rates of revision and corresponding causes of failure.12,13 In this context, burden of rheumatic-musculoskeletal diseases (RMSD) was assessed successfully in project mode (2003-10) throughout various geographical sites in

the country and efforts are under way to bring out a registry.14 Osteoarthritis and ageing of population is inter-linked issue. Before moving any further lets peep into our demographic profile. As per 2001 census, geriatric population (60 years/above) constituted 7.5% of total population in India i.e. 77 million persons; male (38 million) and female (39 million). Report of Technical Group on population projection under office of Registrar General of India states that this population segment is projected to climb to 8.3% (2011), 9.3% (2016), 10.7% (2021) and 12.4% by 2026.15 Currently, less than 15% of population (all ages) have some form of health insurance while in-contrast more than 70% of household expenditure on health comes from out-ofpocket. Further, nearly 30% poor incur indebtedness and fall below the level of poverty due to household emergency hospitalization. It is estimated that 11.88 million households are falling below poverty line every year because of health related expenses. In the current era with a world average of 3.96 hospital beds per 1000 population India stands just a little over 0.7 hospital beds per 1000 population.16 Under these challenging circumstances, on a conservative estimate for population base, the need, demand and supply of complex intervention, the scenario appears to be gloomy inspite of presence of policy, legislative, financial, institutional, and social measures for the protection of elderly in the country. However there is intense debate for the first time in the country for establishment of an exclusive National Institute of Arthritis and Musculoskeletal Diseases during Twelfth five-year plan period (2012-17). Private sector has realised business opportunity and are bringing out innovative technology using In India, for India approach including knee implants and other prosthesis/ devises etc. It has been estimated that around 80% of medical technology market in India consists of imports with current market value of around $2.75 billion and is expected to jump to $14 billion by 2020. We are aware that necessity is mother of all invention as shown by low cost Jaipur limb that created a revolution for amputee people not only in India but across the globe. Therefore looking forward with a positive note and a close watch on inflation, open market competition and enhanced indigenous manufacturing, a hope still exist and cost for procedure may show a decline. With ensuing discussion the resulting interlinked emerging issues are determination of true burden of OA in the country, need for research to assess epidemiology and formulation of local solutions, cost control, newer approaches for pain

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management, capacity building through establishment of centre of excellence, enhanced production for skillful trained orthopedic surgeons and paramedical human resource especially physiotherapist/nurse/OT assistants, mushrooming of publicprivate partnership, ethical referral/ investigation, strict adherence/compliance to guidelines for surgery, resurgence and adaptability to computer assisted orthopedic surgery (CAOS), development of durable low cost technology, potential employment market due to local as well as international collaboration/foreign patients; scope for expansion of indigenous industry for production of prosthesis & allied equipments/instruments, exploration of greater role of AYUSH (ayurveda, yoga & naturopathy, unani, siddha, homeopathy) system, advocacy, awareness generation, obesity/ trauma/ diabetes prevention and control, counseling, rehabilitation, ensuing continuing debate/conflict of public investment in preventive vs. curative health and community mobilization for sustained investment in health insurance instruments. All said and done, with diverse and other pressing commitments/challenges/issues to be tackled, government is unable to bear the entire financial burden of all surgical patients. Therefore large number of people in developing nations would continue to suffer in pain/deformity/seclusion not because they are not eligible for interventions but because of most imminent exorbitant cost and limited access to competent orthopedic surgeon/ health system. Today we may debate that there does not appear to be a crisis situation and hence rest in peace but at the same time cannot totally ignore without thoughtful pondering and a vision statement for action. Let us be informed that with galloping graph of surgeries including other major cardiac interventions, a sizeable number of citizens would be carrying body implants and may be classified as potential security alerts during metro, malls or airport check-in! References
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