Rise of Revision Arthroplasties in Indian Subcontinent: An Inadvertent Future

摘要

Introduction In the past two decades, developing countries like India have experienced a surge in joint replacement surgeries, driven by an aging population, rising lifestyle diseases, and increased awareness of arthroplasty’s benefits. However, this growth has led to a rise in revision arthroplasties due to complications such as implant failure, infection, and malalignment, placing a strain on both patients and healthcare systems [1]. A better understanding of causes, preventive strategies, and advancements in implant technology and surgical techniques is crucial to address this issue. Understanding the Rise of Revision Arthroplasties Suboptimal implant survivorship The increasing incidence of revision arthroplasties is largely attributed to the limited longevity of implants. Contributing factors include the use of potentially less durable implants, a younger, more active patient demographic, and a high prevalence of osteoarthritis and avascular necrosis. Globally, implant survivorship typically exceeds 15–20 years, but in India, revisions are often needed within a decade due to wear, aseptic loosening, or mechanical failures [2]. Periprosthetic joint infection (PJI) PJI is among the most challenging and common complications following lower-extremity joint arthroplasty and are a leading cause of revision surgeries [1]. Reported infection rates after primary total knee arthroplasty (TKA) range from 0.51% to 1.55% [3], while for total hip arthroplasty (THA), the incidence is estimated at 0.5–0.7% within the 1st-year post-surgery. Late-onset infections present a cumulative incidence of 0.04–0.06% per prosthesis-year [4]. Alarmingly, studies from India indicate infection rates as high as 87% [1]. Aseptic loosening and wear Aseptic loosening is the leading cause of implant failure, accounting for approximately 55% of hip revisions and 31% of knee revisions [2]. Aseptic loosening is often linked to polyethylene wear, where particulate debris triggers osteoclast-mediated bone resorption, leading to periprosthetic osteolysis and eventual loosening. This issue is particularly pronounced in younger, more active patients, suggesting a rising prevalence in this population [5]. Instability and malalignment Joint instability, resulting from factors such as ligament imbalance, improper component alignment, and surgical errors, is another significant cause of revision surgeries [1]. Malalignment, particularly of the femoral component, has been strongly linked to increased revision rates [6]. Poor positioning can accelerate wear, diminish functionality, and compromise the overall outcome of the procedure. Furthermore, mechanical malalignment that fails to replicate natural joint movement can lead to long-term complications [6]. Patient-related factors The growing trend of joint replacements in younger, more active patients has been associated with increased revision rates. Elevated activity levels in this demographic often result in accelerated wear and degradation of prosthetic components [1]. Whereas, in older adults, increasing comorbidities and associated ailments are the major cause of implant failure or decreased satisfaction rate. Prevention: The Key to Curbing Revision Burden Advanced technologies Recent advancements in surgical technologies aim to improve precision and accuracy in orthopedic procedures. Innovations like patient-specific instrumentation, navigation systems, smart tools, and computer or robotic-assisted surgery enable tailored interventions based on individual anatomy and ligament characteristics. These technologies enhance 3D surgical planning, optimize implant positioning, and improve alignment precision, leading to superior outcomes [7]. Modular operating theaters (OTs) Modular OTs equipped with advanced infection control technologies significantly reduce PJI and post-operative complications. Featuring HEPA filters, laminar airflow systems, and efficient sterilization, these OTs ensure a sterile environment, enhance