Not all bones are alike. Foreign surgeons, working in India, have found that Indian bones tend to be weaker, more prone to osteoporosis and more apt to be deformed than are those in either the U.S. or England. Erik Zeegan, a Las Vegas based orthopedic surgeon, said that knee replacement surgeries in India tended to be different from those in the U.S. because of the more deformities of the bones found in the sub-continent. “The deformities here are significant. The knees are more worn out. We do not see such deformities in the U.S., ” Zeegan said in the press release.
Bones in India Weaker Than in West

One of the reasons for this, according to Ameya Velingker, a Goa-based specialist, is that Indian patients tend to take their osteoarthritic knees to the very terminal stages before choosing the surgical option to overcome a bad knee situation. He also said that a lack of exercise “further deteriorates their growth in most cases in India.” He blames a lack of a physical regimen in India for the “bad bones” phenomenon there. The obsession with fitness in Western countries has resulted in better quality and denser bones in the U.S. and Great Britain, he added.
To illustrate his point about the difference in bone mineral content Velingkar said that one surgical saw blade suffices for three to four knee replacement surgeries for Indian patients. “For UK patients, I need to use one new saw every time, ” he said
One of the reasons 700, 000 knee replacement surgeries are conducted in the U.S. every year as compared to 70, 000 in India, is because in the U.S. the procedure is considered a natural extension of knee treatment, Velingkar said, adding that patients in India remain nervous about knee replacement surgery because of a few failed cases in the past.

Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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