rise in hip replacementsWe hear a lot about medical treatments, practices and patient care in the news, and it doesn’t always come with a positive slant. This can be worrying for patients who are waiting for operations, and may result in them feeling anxious about what to expect.

The financial strain placed on the NHS is well documented, and those who are fighting for additional funding are quick to point out how financial deficits can impact on patient care. A recent report published by the King’s Fund looked at various types of operations and the associated patient care, with a view to assessing just how affected these areas are by the acknowledged funding issues. One of these areas was elective hip replacements, so we were interested to see what the findings yielded.

Findings of the King’s Fund report

The King’s Fund research analysed four key areas:

  1. Genito-urinary medicine (GUM),
  2. District nursing,
  3. Elective hip replacement and
  4. Neonatal services

The results were interesting and differed by area. There were indeed serious challenges faced by GUM and district nurses that the report was able to directly link to funding issues. Neonatal services were standing firm, with the report suggesting that they “appear to have largely maintained quality and access despite a number of longstanding pressures”. Finally, those opting for elective hip replacement surgery were found to be growing significantly in numbers, with patients consistently happy with the outcome of their operation.

This level of satisfaction is encouraging for anyone who is considering this type of operation, and probably due in part to the fact that hip replacements are one of the oldest types of surgery. The current approach to hip replacements dates back to techniques pioneered by surgeons in the 1960s, and they have been undertaken regularly since that time.

Looking into this further, the increase in patients seeking hip replacement operations hasn’t just increased a bit – the rise in hip replacements is massive. The report outlines that “despite funding pressures on England’s NHS, elective hip replacements increased by 90 per cent in the six years to 2016”.

Is it all good news for those waiting for hip replacements?

For orthopaedic surgeons such as Mr Bridle, it is encouraging to see that the report highlights just how happy the majority of patients are following their hip replacements; in fact they say that “patients are overwhelmingly happy with the outcome”. This high level of patient satisfaction is something that those working in orthopaedics are extremely proud of.

Despite this, the report outlined two areas that are a threat to the current system. Firstly, mounting pressures of other departments who work to support, or work in tandem with, orthopaedics put these departments at risk. Secondly, waiting times are increasing – no doubt due to the marked increase in demand.

This feeling of positively following hip replacements is well documented; in the March issue of the Journal of Bone & Joint Surgery, the results of a recent study carried out by researchers at the Cleveland Clinic were published. Employing a standard Quality of Life measurement, the clinicians found that hip replacements can improve patients’ meaningful quality of life for at least five years following the operation.

At times of considerable financial pressure across the NHS, with satisfaction levels with this type of operation so high, if you are considering a hip replacement operation this knowledge should be reassuring and help put your mind at rest.

Increasing numbers of patients are requiring hip replacement surgery and they are one of the most successful operations of their kind, with evidence that the operation gives patients a marked improvement in their quality of life. As with all operations, there are clear risks and rewards that patients must understand before opting for surgery. With this in mind, surgeons are continually learning and exploring more and more about the factors that lead to successful – and less successful – outcomes. It is this process of continual knowledge development that helps push medical technology forwards.

With this in mind, surgeons are continually learning and exploring more and more about the factors that lead to successful – and less successful – outcomes. It is this process of continual knowledge development that helps push medical technology forwards.

spinal problems and hip replacement successWe are fortunate that across our own health service and those in some other countries around the world, there are opportunities to gather and analyse patient data, which can help identify trends and patterns in patient recovery. Results from data collected by the NYU Langone Medical Center/New York University School of Medicine indicate that those with spinal problems have greater issues with hip replacement recovery: “people with spinal deformity also requiring a total hip replacement are at greater risk for dislocation or follow-up revision surgery”.

What this means is that issues that would not usually be seen in the recovery period following a ‘normal’ hip replacement are more likely to present themselves in patients with spinal deformities. The recovery time is likely to be longer, there is a higher chance they will face more complex challenges and in the longer term they are more likely to have to undergo a second phase of surgery to correct a problem caused by the spinal abnormality.

Does that mean that people with spinal deformities are not suitable for total hip replacements?

The answer to this is no – people suffering a deformity of the spine would be classed as a higher risk category, a factor which should be flagged at consultation stage. With this knowledge of a pre-existing condition, the approach taken to their hip replacement surgery would just need to be more bespoke, and tailored more to the needs of the individual and their specific spinal complaint.

How different are the risks?

The study looked at over 100 individuals who had undergone almost 140 hip replacements (some individuals had both hips replaced). In this research sample, patients who had an underlying spinal abnormality demonstrated a greater risk that the new hip would become dislocated. The rate of dislocation was 8% in the group with spinal issues, compared with just 1% in patients without. Although both are small percentages when the total research population is considered, the difference between the two groups is significant.

The NHS in the UK is pushing for greater levels of ‘joined up care’ across the whole organisation, which is a more integrated way of managing patient care and rehabilitation. Findings such as this will mean that there will be a greater need for joined up working across orthopaedic and spinal units, ensuring that patients who are in a higher risk category get the more tailored care and support they require.

how do younger patients fare long term after hip replacement?When you’re considering a major operation such as a knee or hip replacement, the chances are you’re reading around the subject, considering where you might choose to have you operation, and looking at the different approaches favoured by different surgeons.

Knee and hip replacement specialist Mr Bridle favours the Exeter femoral stem approach to hip replacements, which is a cemented, polished tapered stem hip replacement. The polished finish has been shown to allow transfer of load from the stem to the cement and bone, allowing the cement to secure the component to the bone and preserving the bone density. The stem has a long pedigree, having been used since the 1960s. Its extensive use in the decades that have passed since it was first introduced, show that the Exeter system has proved itself to be durable and robust.

How do younger patients fare with joint replacements such as these?

One concern for younger patients is that once they have undergone a joint replacement operation, they are likely to put their new joint under more strain than if the operation was done in a more elderly patient.

Recent research published by the Bone and Joint Journal looks at the longevity of hips replaced in patients who were under 40 at the time that they underwent the operation using the cemented Exeter femoral system. The research looks at how they have fared up to 20 years post operatively.

The study shows a very low rate of loosening of the component, with very few patients requiring further operations’, it concludes that “the Exeter femoral component continues to function satisfactorily in young patients for up to 17 years after surgery”. These results compare very favourably with other systems, including cementless components.

Younger patients can be reassured that with advances such as this in joint replacement technology, and the wealth of experience of surgeons such as Mr Bridle, the longevity of joints that are replaced in younger patients is encouragingly good.

Cemented versus cementless stems in hip replacement

The stem in the thigh bone can be fixed with or without cement. If cement is not used, the bone needs to grow onto the component to fix it. Both these approaches do work. The data suggests there may be a higher early failure rate when cement is not used – there is a risk of breaking the femur putting the stem in and of the component not bonding, both of which would require further surgery. There is no evidence that patients function any differently in the longer term with cemented compared with cementless stemmed joints.

One of the reasons the Exeter system is favoured by surgeons such as Mr Bridle is the adaptability that the range of joint implants available offers to the surgeons, and ultimately the patient. This scope and flexibility is simply not available with most other hip replacement systems.

As with all elements of patient care, surgeons will make choices based on the best possible outcome for their patients. The anatomical diversity offered by the Exeter femoral stem system is why it continues to be Mr Bridle’s favoured approach. He understands the importance of ensuring these choices are made in perfect alignment with the patient’s needs, as this gives any new joint the best chance of improving quality of life.

benefits of enhanced recovery after joint replacementFollowing the results of an in-depth study of 4,500 patients in the recovery period following knee and hip replacement surgery, there is robust evidence to support the theory that an enhanced recovery plan is the best approach to a successful recovery.

What is enhanced recovery?

An enhanced recovery plan is one where patients will be recommended a multimodal approach, involving behavioural, pharmacological, and procedural modifications to the ‘standard’ approach to rehabilitation.

The research looked at 4,500 patients, 1,500 of whom were treated with the enhanced approach, while the remaining 3,000 had standard care. The results were positive, suggesting that the enhanced approach is likely to result in faster recovery, with fewer requirements for medical interventions following the surgery.

The areas where benefits to the patient were seen are as follows:

  • Length of hospital stay
  • Mortality
  • Perioperative complications (for example, the need for a blood transfusion following surgery)
  • Overall satisfaction felt by the patient regarding their experience and treatment

Collaborative working methods

We are hearing more and more about the benefits of different parts of the health care system working together, taking a joined up, more collaborative approach to patient care and recovery. This way of working is cited as being fundamental to the success of an enhanced recovery approach, as explained by the US National Library of Medicine National Institutes of Health “a prerequisite for the success of these techniques is a multidisciplinary collaboration between patients, surgeons, anaesthetists, physiotherapists, occupational therapists, and nursing staff.” This approach to enhanced recovery is used widely across the NHS, with ambitious plans to continue pushing this until the health service is fully integrated by 2018.

As a result, the NHS is working effectively to improve recovery following joint replacement surgery. The challenge is to get processes like this working as well in private clinics, as this method (and ability to offer such joined up care and service) is currently inconsistent. Mr Simon Bridle favours this approach and recognises the benefits, so patients treated in his care will benefit from a multimodal design to their recovery plan.

As with all operations and the subsequent recovery process, the most important factor is the best possible rehabilitation for the patients. Getting them back to normal as soon as possible is of the utmost importance to medical professionals, whether working in the public or private sectors.

Fortius Joint Replacement Centre

Mr Bridle and his colleagues at Fortius Clinic have worked with the BUPA Cromwell Hospital to develop an evidence based Enhanced Recovery programme, based at the BUPA Cromwell, to ensure the best treatment and outcome for our patients.

As Mr Bridle will explain to any patient he is treating, an effective, multimodal rehabilitation plan and initiatives that reduce the risk of post-operative complications are at the forefront of his approach to patient care.

To find out more about the Fortius Joint Replacement Centre, please click here.

How to choose your joint replacement surgeonWhen you’re considering joint replacement, it is important to choose the best surgeon for the job. So how do you go about this? You will first want to read around the procedure so that you fully understand what you’re signing up for, and then you’ll want to start researching where you can have the operation and exactly who will be responsible for undertaking it.

Look at the surgeon’s qualifications and professional memberships

Orthopaedic surgeons in the UK will have undergone full medical training and then an additional 4 to 5 years residency programme in an orthopaedic surgery. After this lengthy training period they will qualify as a junior orthopaedic surgeon and will begin practicing. Some surgeons will choose a subspecialty which they will focus on, and this will require a further one to two years training.

Obtaining membership of professional associations

Many professionals will also choose to join relevant professional membership organisations. Many will join these while studying and hold membership of different grades throughout their career.

Mr Bridle holds membership of two professional associations for joint replacement specialists, the British Hip Society and the British Orthopaedic Association. The British Hip Society promotes training, education and research to ensure the very best care for patients who are experiencing hip related conditions. Similarly, the British Orthopaedic Association offers care for patients and support for trauma and orthopaedic surgeons in the UK.

Membership organisations such as these offer services such as training, support and continued professional development (CPD). They also regulate their members to ensure a high quality of service provision. Orthopaedic surgeons such as Mr Bridle will typically list their professional memberships on their website, so when you’re researching surgeons, look out for the logos and feel free to look up the organisations to read more about what is expected and required of their members.

National Joint Registry

All hip and knee replacements in England are now recorded in this registry (the NJR). This allows analysis of how well different types of joint replacement and individual surgeons are performing. An individual surgeon report is published on an annual basis, to include the number of procedures performed, the type of implants used and some results. The surgeon is provided with an even more detailed analysis, to indicate how well patients are doing, to help them improve their practice. This represents an extremely important set of data to help improve quality.

Ready to book a joint replacement consultation?

Once you have done your research and think you’ve found a surgeon you are comfortable with, the next step is to book a consultation. This is an important opportunity to meet with the surgeon, get to know and to talk in detail about what is troubling you and what you would like to achieve. This is a great chance to ask all the questions you may have, so it is advisable to write a list so that you don’t forget anything important.

To give you an indication of the types of questions you might consider asking, these are some of the things patients will typically ask at a consultation:

  • How long have you been practicing for?
  • How many times have you performed the operation I am interested in?
  • Can I speak to any patients you have operated on previously?
  • What is your personal complication rate for procedures of this type
  • What options do I have for this procedure and which is best for me? And why?
  • How long will the operation take?
  • How long is the recovery process and what can I expect during this time?
  • When will I be able to go back to work?
  • When will I be able to drive?

For more information, or to book a consultation with London joint replacement specialist Simon Bridle, please contact us.

Bursitis or arthritis - what's causing your hip pain?Aches and pains in the joints – particularly knees and hips – as you get older are something that we all expect and many of us choose to live with. Depending on the cause of hip pain, this is sometimes an acceptable choice, but more often than not it could be delaying treatment for a more serious condition.

With the amount of information available to read online, sometimes people will ‘self diagnose’ – and this can be risky. Sometimes even expert medical professionals can misdiagnose, so it clear to see that its very easy to make the wrong assessment when reading up online about what is causing your pain and discomfort. Often conditions share similar symptoms, and an expert assessment is required to ensure it is diagnosed correctly.

For people suffering with painful hip joints, two conditions that share similar symptoms are bursitis and arthritis.

Understanding bursitis

A bursa is a pocket of fluid, which helps lubricate movement when a tendon runs over a bone. Bursitis is the name given to a condition where this pocket of fluid becomes inflamed. This can occur when the area is exposed to unexpected pressure or repetitive stress.

When the bursa becomes inflamed, this causes pain and tenderness over the site of the bursa. In the hip the trochanteric bursa is most often involved and patients have pain over the side of the hip bone. Treatment is initially with physiotherapy and an exercise programme to strengthen the pelvic and core muscles and some patients will need a steroid injection.

Understanding osteoarthritis

Osteoarthritis is the most common form of arthritis and occurs in around one in three people aged 45 and over, and in almost half of people aged 75 years and over. It is a degenerative disease which affects the joints by wearing and breaking down the cartilage around the joints. The hips and knees are often affected by this form of arthritis. If left untreated, it can completely wear away the cartilage around the joints, which is extremely painful and will have a significant impact on mobility.

Getting the correct hip pain diagnosis

When assessing hip pain, experts will be looking for clues to help with diagnosis. Things they will be considering are issues such as the specific area where pain is greatest (for example, bursitis often generates pain on the outside of the lower hip whereas osteoarthritis causes greater pain in the bottom, thigh, groin or actually within the centre of the hip itself).

Another thing they will be looking for is what generates the most pain. With bursitis the pain will feel worse when pressure is applied, for example lying on the side in bed, whereas with osteoarthritis the pain will tend to occur with weight bearing and hip movements. X rays are often helpful in identifying arthritic joints, whereas an MRI scan is likely to be needed to confirm bursitis

Seek an expert opinion

The important thing to remember is that if you’re experiencing any form of hip pain it is crucial to see a specialist sooner rather than later, to arrange the appropriate tests and investigations. The correct diagnosis of whatever is causing your hip discomfort is the first step on the road to treatment – and hopefully recovery. The longer you live with undiagnosed hip pain, the greater the risk that you will be doing more permanent damage to your joints, muscles or cartilage.

If you have discomfort in the hip area and have not yet seen a specialist, book an appointment to see a knee and hip replacement specialist like Mr Simon Bridle who will be able to assess your situation and recommend the most appropriate next steps.

Could stem cell injections delay the need for joint replacement?As a knee and hip replacement specialist, Simon Bridle is always keeping abreast of developments within the industry that could benefit his patients. One area that is developing and gaining a lot of attention recently is that of stem cell research, and the benefits this could bring to healing patients who are in the early stages of hip and knee problems.

There are thousands of people each year who develop osteoarthritis in their knee or hip joints, and it can be a painful, debilitating condition, causing the joints to stiffen and be sore and tender. Although there are treatments available such as total knee and hip replacements, treatments for the early stages of this condition vary in effectiveness, as they can only really help patients deal with the condition, rather than reverse the problem or restore the worn connective tissue around the joints.

Understanding stem cell research

Stem cell research is something that a lot of people have heard about, yet many people still have lots of questions about it. What is it? How does it work? Is it available now?

Stem cells are human cells that are able to develop into other types of cells as they are forming. This means that they are being explored as being able to offer healing properties, as they could potentially create more cells that can be used beneficially in a damaged area of the body. The exciting fact about these cells is that when a stem cell divides, each new cell has the potential either to remain a stem cell or become another type of cell with a more specialized function, such as a muscle cell.

This research could mean that people who are suffering with the very early stages of knee or hip joint arthritis may be able to help lessen or reverse the progress of the condition. It is important to recognise the limitations of stem cell treatments, for example it is likely to be that younger patients with isolated small areas of articular cartilage damage are most likely to be those who could benefit from stem cell treatment as a means of delaying the need for joint replacement surgery.

The treatments that are undergoing research at the moment involve extracting mesenchymal stem cells (MSCs) and platelet-rich plasma directly from the patient. As the cells come from the body, the expected benefit is that the patient’s immune system should not reject the new cells.

Patience required

There are companies that are already talking about “regenerative” or “bio-restorative” medicine as an alternative to joint-replacement surgery, but Mr Bridle warns that although these technologies sound exciting, they are still in their medical infancy. It is likely to be many years before this kind of treatment could be available more widely.

Nevertheless, it is through research such as this that we keep progressing medical knowledge, so although this is still in the early stages of research at the moment, this is likely to be something that we hear a lot more about in years to come.

Joint replacement - finding your bearings

If you’re considering a joint replacement it is important to understand what will be happening to your joint and what the old bone joint will be replaced with. By understanding the different options available you can make a fully informed decision about which option is best for you.

The bearing is the moving part and in an artificial joint this will inevitably produce debris, which over time can damage the tissues and cause the hip to loosen. Younger patients will tend to be more active and this can increase the amount of debris being produced, which will build up over time.

The choices available

A lot of effort has gone into developing bearings which are more wear resistant, which will hopefully last longer. For younger patients, Mr Bridle suggests the choice is between “ceramic on ceramic” and “ceramic on polyethylene” replacement joints. Both these combinations allow patients to get back to high levels of physical activity if they want to.

Ceramic on ceramic joint replacements are very hard and very smooth, which means that they are a very durable, wear resistant material, with very little friction, allowing a degree of lubrication between the moving parts. Concerns about ceramic on ceramic bearings include the risk of fracture of the material, which can be disastrous (albeit this is a very small risk), along with occasional reports of the joint squeaking, which can be quite disconcerting! Ceramic on ceramic is the most expensive bearing option.

Polyethylene has been used as a bearing in hip replacements for many years. Great efforts have gone into improving this material over the years, as we realised that this was an important source of wear debris, causing hip replacements to fail. Modern polyethylene is far more wear resistant, as we have found ways to make it more durable. In addition polyethylene acts as a ‘shock absorber’ far better than ceramic.

A ceramic on polyethylene bearing combines the advantages of ceramic, which is used for the head component (ball), with those of polyethylene which is used for the socket. Mr Bridle recommends this combination for most of his patients. Testing these bearings in the lab has shown an extremely low wear rate and recent publications confirm that this is reproduced in patients who have had these bearings implanted. We are optimistic that this combination will last just as long as the alternatives, with none of the possible complications.

Making an informed choice

When you’re considering joint replacement you will be able to discuss the pros and cons of the different materials available and make the best choice for you. There is no such thing as a ‘one size fits all’ approach when it comes to joint replacements. Your consultant will be able to offer advice based on your own unique situation, and will be able to answer any questions you have.

Factors such as the age and weight of the patient will need to be discussed and considered, as will the type of lifestyle. These are all important to consider when selecting the most appropriate material for any replacement joint. If you are experiencing joint pain and are considering surgical options, book an appointment today to speak to Mr Bridle so that you can begin exploring different options sooner rather than later.

hip replacement London - how long will it lastWhen opting for any form of surgery one of the first questions patients will need to understand is how long the operation will last for. It is an important consideration when weighing up the pros and cons of whether or not to opt for a surgical solution to the problem you’re suffering with, as redoing the hip is a very major operation.

Hip replacements are done in patients of all age groups and increasingly in younger patients, so knowing how long the hip will last is a major factor in deciding whether to have an operation.

Long-standing history of hip replacements

Hip replacements have been practiced by surgeons for decades, so there is a lot of data available to help answer this question. Hip replacements were first performed in the UK back in the 1960s, and due to its success rate this has become a very popular operation. In England and Wales there are now approximately 160,000 total hip and knee replacements performed each year.

According to the results of a 40-year observational study of patients at the Mayo Clinic in the USA who have had their hips replaced, looking at 2000 patient cases, the hip failed and required revision in only 13% of these.

This varies somewhat by the age of the patient, so the report helpfully breaks this down by age group to give a clearer indication of how this differs by age:

  • Patients under 50: One in three required a revision
  • Patients aged 50 to 59: One in five required a revision
  • Patients aged 60 to 69: One in ten patients required a revision
  • Patients aged over 70: One in 20 patients required a revision

So there are definite differences by age group, and this will be affected by factors such as lifestyle choices (how active or sedentary the patients are following the operation), how much stress the new joint is put under, how well the recommended physiotherapy is adhered to following the operation and the overall health and well-being of the patients.

Practice makes perfect

It is an important conclusion that the majority of patients, even in the younger age group will never need another operation on their hip.

The other consideration is that owing to the continued practice of this operation, hip replacements are getting better and more effective over time. A hip replacement operation performed now will benefit from greater knowledge and understanding of surgeons now, compared with one undertaken 40 years ago, so modern hip are likely to do even better than these figures.

The Exeter hip system

Joint replacement specialist Simon Bridle favours the “Exeter femoral stem” model of hip replacements, which are collarless polished tapered cemented hip stems, first developed at the University of Exeter. At the time of its design, scientists were grappling with how to best fix the stem to the bone.

Because the Exeter design is polished and collarless, it allows very good transfer of stress from the stem to the cement and this means that the bone is loaded and the cement is protected and allowed to last for a long time.

The authors of another Bone and Joint Journal article found that 99% of the stems were still well fixed and working at 22.8 years from the replacement. They look at the X rays and found that a “radiological review showed excellent preservation of bone stock at 20 to 25 years, and no impending failures of the stem.”

In summary, the approach of conducting total hip replacements using an Exeter stem is one that has been trusted by experts such as Mr Bridle for many years and patients can have confidence in this approach. For more information or to book an appointment, please contact us.

London joint replacement specialistFor anyone who is considering a hip replacement, it is likely that you’ll be reading around the subject and making sure that you’re up to speed on what to expect from the procedure.

There has been a flurry of news recently about the speed and efficiency of anterior hip replacements, with stories about patients having this operation and being discharged later that same day, but this has some consultants concerned.

What is an anterior hip replacement?

This type of hip replacement is designed to cause minimal damage to the tissue and muscle that surrounds your hip joint. It is a very different approach to total hip replacements, requiring surgeons to learn a different technique.

Surgeons work by making a small incision on the front of your hip (rather than the back or side, which is more typically the case with total hip replacements).

Back to a more effective approach

Joint replacement specialist Simon Bridle recognises that hip replacement technologies have progressed significantly over time, although it is his belief and recommendation that approaching the joint from the posterior (back of the joint) is the safest and most effective means of undertaking this operation.

Although the posterior approach requires an incision through the gluteus maximus muscle, it requires the fibres to be separated, not actually cut. A small group of muscles called the short rotators are cut off the back of the hip and repaired back at the end.

There is no evidence that this approach results in any detectable muscle weakness in the long term. Mr Bridle believes that the anterior approach does not provide tangible advantages in terms of limiting the amount of pain or discomfort experienced by the patient, or to the overall effectiveness of the operation.

With modern anaesthetic techniques and pain relief many patients are leaving hospital in 2 or 3 days after a posterior approach, with rapid rehabilitation, so the short term potential benefits of an anterior approach are probably overplayed, with no evidence of any long term benefit at all.

Concerns with the anterior approach

In fact, the anterior approach raises some significant concerns for surgeons such as Mr Bridle. By making the incision at the front it is much closer to the lateral cutaneous femoral nerve (this runs along the front of the hip and supplies the skin on the side of the thigh).

In some cases patients have reported feeling numb in the top of their thighs following an anterior hip replacement, as a result of damage to this nerve and this can be very troublesome. The anterior approach is more difficult, increasing the risk of other surgical problems. It has been shown that it takes surgeons a long time to learn how to do it well.

Special implants have been developed to make it easier, but these often have no track record, so we don’t know how well they will do. All these issues are avoided with a conventional posterior approach.

Best foot forward

As with any medical professional, surgeons will select and recommend the treatments that they believe are best suited to their patients’ needs and requirements. Although a shorter stay in hospital – which an anterior hip replacement may offer – may be attractive, when the overall risks and benefits are weighed up, it does not fare as favourably.

Mr Bridle believes that the posterior approach offers a safer and more reliable technique for his patients.