Mr Alex Chipperfield

Give it another second or two. Good evening. Welcome. Welcome to the third part of the trilogy of my talks. I've spoken to you previously about Arthrosamid® and then about knee replacements.

Today is the time to talk about hip replacements. So, welcome. Thanks very much for coming along and tuning in tonight. For people who haven't met me before, it's me on the screen there.

My name is Alex Chipperfield. I'm an Orthopaedic Surgeon here at Benenden Hospital. I specialise in hip and knee replacements. I spend about half my time I spend half my time replacing people's hips and half my time replacing people's knees, so it's a fairly even split between the two. A little bit of a background for me.

I've been a doctor for 30 years. I mainly spent my days as a junior doctor in the southeast of England. I've spent a couple of years working out in Australia and the Gold Coast, and then down in Sydney for a year as a fellow. I have been a consultant for the last 17 years. 13 of those were in the NHS as well, in East Kent.

Now, I only work in the independent sector, and I've been here at Benenden since 2012. I specialise in hip and knee surgery, like. As previously mentioned, I'm a member of the British Hip Society as well, which is a nice club to be in.

What are we going to talk about today? Well, today's focus is on total hip replacement, but we'll take you through the whole journey that's involved with a worn-out hip.

So we'll start by talking about what happens when you come to see me or one of my colleagues here at Bellington Hospital. I'll go through the consultation and assessment. Then I'll talk a little bit about hip arthritis, what it is, what it involves, and signs and symptoms you need to look out for. We'll talk about the treatment options that are available and the risks and benefits of any interventions or surgery that we perform. Walk you through the hospital stay and the post-op recovery and rehab.

We'll talk a little bit about how you choose whether or not it's the right time to have a hip replacement. And then, finally, my favourite part, which will be a question-and-answer session. So, if you've got any questions at any point. Please click on the Q&A icon at the bottom of your screen. You can either be anonymous, or you can put your name.

Remember that these sessions are being recorded, so if you don't want your name to be on the internet, then just put yourself down as anonymous. Then the questions will pop up on the screen in front of me. If there's something that doesn't interrupt the flow too much while I'm giving my talk, I will leap straight into that question. If not, we'll set aside some time at the end, and I will go through as many as we can in the allotted time. Any questions that are unanswered, we'll do our best to answer over the next few days.

If you're interested in a consultation, having listened to this and had your questions answered, then I'll give you all the contact details at the end and how to do that. So consultation and assessment. So this is where you first would come along to Benenden Hospital. Most people come here; they will either refer themselves, or they will have seen another specialist somewhere else or seen their GP, and the GP will have referred them to Benenden Hospital. So quite often, someone has already done a few tests and investigations before you come and see me.

If we're given enough time and warning, we can gather all that information together so it's there, present at the start of the consultation, which will avoid any duplication or time. Initially, with the consultation, I will go through your signs and symptoms and your general medical history to try and determine what the problem is and whether or not you have any other major illnesses or diseases that might be relevant. We will then go on to examining you. And examining you includes taking your weight and height.

The reason I say that is because I'm trying to flow seamlessly into a question that's just popped up on the stream. Which says, 'Could you please confirm Benenden's maximum BMI requirement for surgery?' Thank you.

For those who don't know. BMI is something called Body Mass Index, and what that is a measure of how big you are. It, they – what we do is we take your height, and we take your weight, and we divide the two together, and we come up with a number, with a value.

and the higher the number, the bigger you are. There are all hospitals, especially all private hospitals. will put a limit, a safety limit, on the highest BMI that they're happy to perform planned surgery on. Here at Benenden, that BMI limit is 40. So, if your BMI is over 40, then you wouldn't be able to have surgery at this private hospital.

You can still be seen, you can still be consulted, and there are other interventions that can be done. And if necessary, we can also guide you through the weight loss journey to get your BMI down to a safe limit for surgical intervention. But here, the limit is 40. I hope that answers your question as far as that goes. Once we've taken your weight and height, we'll – I'll examine you more generally.

I will look at the range of movement, the power, and the strength in your legs and look for any signs of joint impairment, muscle wasting, or damage, and we'll also look for other reasons why you could be having, yeah, pain. Not just necessarily your hip; it could be coming from a different part of your body, and the history and examination that we do will help determine and localise the area that we need to focus on. Next, we'll talk about investigations. If you haven't had any x-rays or scans, then you may well have some of those. X-rays happen immediately on the day.

MRI scans – sometimes we can do them on the same day; sometimes it takes a couple of days to get an appointment for a scan. Not everyone needs a scan; it really depends on what your symptoms are, what your signs are, and what previous investigations you've had. So we'll go through that. Not everyone will have all of the tests done. It really depends on what we need to fully determine your condition.

Once we know what the problem is, we can then talk about possible treatment options. Whether that be conservative measures, so things that don't involve operations, or surgical measures. and we'll talk about the risks and benefits. Merits, or otherwise, of all of those particular options. And off the back of that, we'll come up with a treatment plan that best suits you.

If it looks like you're heading for surgery. Then the next step, apart from the BMI limit, is the other thing that we need to look at: is it safe for you to have an operation in a private hospital? And a general health assessment will be the first step of that. The next step, the more advanced step, would be after your name is put on the waiting list; you would have to come back here for what's called a pre-assessment. Which is essentially an MOT, where they look at your general health and suitability for surgery in a private hospital.

What is hip arthritis? Essentially, hip arthritis is when you get pain and inflammation associated with a damaged or worn-out hip joint. The damage or wear inside the hip joint can manifest itself in lots of different ways. But the main feature consistent across most people is pain. Most people tend to localise their pain right in the front of their hip at the groin, but it can be around the side of the leg, into the buttock, and it can radiate down the leg into and towards the knee.

Some people get different patterns of disease. I've done a clinic today where I've had someone whose only pain has been in their buttock and another person whose only pain has been in their knee, but the underlying pathology in both of their cases was a worn-out hip.

Apart from pain, people often get problems associated with that, like decreasing walking distance, difficulty sleeping, and stiffness. Difficulty in doing everyday tasks, particularly tasks that involve putting stress through the hips, so flexing the leg up, so putting on your shoes and socks, or cutting your toenails – that can be quite difficult. Lifting your leg to get into the passenger seat of a car can be awkward as well, so you tend to notice a restriction in your movement, and the movements that you do have are painful.

If you move a joint less, then the muscles that normally support and are stimulated by movement may start to wither away as well. So you might notice asymmetry, particularly in your buttocks. And you may notice a weakness in the leg muscles as well, as a consequence. What are the causes of arthritis? As I said, it's a damaged or worn-out joint.

So it can be age-related, what we call wear-and-tear arthritis. It can be traumatic in origin. If you've had multiple injuries, such as a dislocation of your hip joint in the past, or major trauma, then that can accelerate the degenerative process. It can be related to how much you load the joint, so obesity is a risk factor for joint disease. Previous injuries we've spoken about already.

Occupational hazards as well. If you've got a job that is very hard on your hips, then that may manifest. However, the main reason why most people develop arthritis in their hip joint is a genetic reason. It tends to be passed down from generation to generation. A couple of pictures here of what a healthy versus a diseased or arthritic hip looks like.

So, essentially, your hip joint is a ball and socket joint. The ball is made of the top of the thigh bone, and the socket is the pelvis. They articulate together, and that movement of the ball in the socket Ideally, it is as smooth and as frictionless as possible. When you develop arthritis, what happens is those lovely, smooth surfaces that coat the ends of the bones start to wear away and degrade and degenerate. So instead of smooth surfaces gliding, you have rough surfaces which grate and grind and scratch against each other.

And eventually, you can get to the point where the smooth surface of the bone erodes completely, and then you're left with what we call bone-on-bone arthritis. And in that situation, you'll have a very painful, stiff, difficult joint. Treatment options – I said we'd speak about treatment options at the time of the consultation. Essentially, when it comes to arthritis of the hip. You can divide those into three main categories, really.

Category number one is non-surgical things, so things that you can do to try and take some pressure off your hip or minimise the amount of symptoms that you're getting. So, it's lifestyle modification, and it's pain medications to alleviate the pain, to allow you to sleep and move more. Some people get benefit from changing their footwear, using walking sticks, or even insoles in the feet, just to modify the way that you bear weight through your legs. A lot of people's trouble can be due to that secondary weakness that I mentioned earlier, and so seeing a physiotherapist will help you regain what strength you've lost and try and maintain the amount of movement that you possibly can in your hip joint. The next level up from non-surgical treatment would be smaller interventions.

And the main one of those that we can provide here at Benden is injections into the hip joint. Not everyone is suitable for an injection in the hip joint. But there are some people, especially those who have a significant amount of inflammatory change around the worn-out joint, who can get quite a lot of benefit from an injection into the hip joint. So that typically would be a steroid injection into the joint. One of the treatments you would have heard me speak about in my previous lectures on the knee is an injection called Arthrosamid®.

Arthrosamid® is a much longer-lasting injection when it comes to dealing with inflammatory change around a knee joint. I'm often asked whether or not Arthrosamid® is suitable for injection into the hip. I can't see a question like that on the screen yet, but it may come. Hopefully, this will avoid it. The short answer is no.

At the moment, in the UK, Arthrosamid® is not licensed for use by injecting into people's hips. There is work being done, there are some clinical trials being held, and it may be that down the line, it becomes a viable treatment option, but at the moment in the UK, outside of an experimental trial, it's not widely available for hip joint injections. If we have exhausted those conservative measures and injections either haven't worked, or aren't suitable, or have worn off. Then the next thing would be surgical intervention, option 3, and in the case of a hip, that's a hip replacement. There are lots of different types of hip replacement, and a lot of people would talk about a hip resurfacing or a hip replacement.

Essentially. They're similar operations in the fact that they replace the worn-out socket and the worn-out ball. There's a slightly different technique to both of them, but they're the same. They both involve removing bone and replacing that bone with an artificial joint that will then articulate painlessly, instead of the worn-out joint. At the bottom, in small print, it says HIP Fusion.

Hip fusion. is very much an operation of the past. In the old days, when hip replacements didn't last for decades. If someone had a very, very painful, worn-out joint but was too young for a hip replacement, then you might consider a fusion operation, where you simply fuse the joint solid. It tended to be used in young male manual labourers with very hard jobs.

And like I said, you know, with modern implants and modern techniques, the indications for hip fusion these days are incredibly narrow. Like I said, I've been a doctor for knocking on 30 years, and I've been a consultant for 17 of those. I have never seen anyone in my practice or anyone's practice close to me go through a primary hip fusion, so it is a very rare thing these days. What do these have to do with the components of the hip replacement that we've touched on? I've got some models here, which is always good.

But essentially, your hip replacement is made of – it says two parts there – four parts. Each of those two parts is made of two parts. So you've got a ball and a socket. The socket – got one here. The socket consists of two elements.

So the first one here is a hemispherical shell. That is made of metal, and that sits inside the pelvic bone. Into the socket, you would then put a liner, which I haven't got in front of me, and that, typically, that liner of that socket is made of plastic. Then into that liner goes a ball. So the ball fits into the socket, and that ball sits on a stem.

Which then sits inside the thigh bone. Like this. So you have a stem, and you have the top of the thigh bone, and the stem goes into it. With the ball on top, the ball then articulates with the socket. Hey, presto, there's your hip replacement.

Typically, these bits are made of metal. The stem and the socket are made of metal. There is some modularity; there are some options when it comes to what you make the liner out of and what you make the head out of. You've got ceramic, which is a lovely pink colour. You've got metal, which is a shiny metal colour.

You've got ceramicised metal, which is kind of in between the two, which is a nice sort of dark grey colour. So there are lots of different combinations of different articulating surfaces, and your surgeon will discuss the right combination for you. Looking at the data, looking at the evidence, looking at how hip replacements perform in the real world. The best combination, in my opinion, is a ceramic ball with a plastic socket. That gives the best combination of a bit of cushioning but is incredibly long-lasting and hard-wearing.

The aim of this surgery is to get rid of your pain; that's the number one aim. Once that happens, once you no longer have a painful hip, everything else gets easier. So you no longer have a restriction of movement, so your muscles can start to stretch and move and build up the strength again, and so that will allow you to function more normally. You can walk better, you can move more freely, you can sleep better, and life just becomes better. The aim, the gold standard, what we hope for and what we achieve most of the time with a hip replacement, is something called a forgotten hip.

And that's essentially when you just live your life; you forget you've ever had your hip replaced. and just live a normal life. I've mentioned the different bearing surfaces and different materials. There are also different types of hip replacement. There are different ways that you can fit the hip replacement into the body.

I've got two different examples here. You can see that this one is quite smooth but rough at the top. This one is rough all the way down, and these are both what we call uncemented hip replacements. So they fix into the bone, and then the bone grows into the implant itself. There are other types of hip replacements, like the one on the left there, which is a cemented hip replacement.

And essentially what they do is you use what we call cement, bone cement, which is actually a polymethyl methacrylate polymer. That we use, we inject that cement into the bone cavity and then put the stem inside the cement. It allows enhanced fixation, and it can strengthen weak bones. The philosophies on whether or not you have a cemented or uncemented hip replacement will very much depend on the surgeon that you see. In some parts of the world, you'll have surgeons who only perform cemented hip replacements.

In other parts of the world, you'll have surgeons who only perform uncemented hip replacements. I'm somewhere in the middle. My default setting tends to be that I use an uncemented hip replacement, but if warranted, or if needed, or if you need that extra stability, particularly in particularly weak or osteoporotic bone, then I would use cement to augment that fixation and strengthen the bone. I noticed at the top, there was a question from Shirley. I have osteoporosis and wonder what restrictions there will be.

Well, there won't be any restrictions on you; the whole point of this operation is to allow you to live your life without restriction. But, as I mentioned, osteoporosis is a weakness of the bone, and so it may well be that your surgeon chooses to use a cemented implant rather than an uncemented one. To minimise the risk of loosening or damage to the bone. If you look at the long-term data. Cemented and uncemented hip replacements are equally as good as each other, so it's a philosophical as well as a biomechanical decision as to whether or not you use a cemented or uncemented one.

But surely, in your case, if your bone is slightly weaker, then I would certainly tend towards a cemented stem in your case. So I've spoken about the benefits of hip replacement. The benefits are that it will take away your pain and allow you to get back to your life. There are risks. It is a big operation that involves a hammer and a saw, and although it's routine, and we do – I did 6 of these operations yesterday – we do a lot of them, it's still a big deal; it's still a big thing to go through.

There are lots of potential risks. We do our best. Both before, during, and after the surgery to ensure that that risk is minimised or eliminated, anticipated, and avoided. But having said that. Still, sometimes bad things happen, either during or after an operation, that, despite our best efforts, we can't avoid. If you do develop a complication, then we will do our best to make things better, make things as good as possible.

But sometimes, things don't work out as well as either of us wanted, and that, I'm afraid, is a fact. Specifically during operations. If you're having an operation that involves a hammer and a saw, then you can damage other parts of you, not just the diseased part that you're removing. So there is a risk of injury to the bone, or to nerves around the area, or to blood vessels, or ligaments, or tendons. Typically, if you identify an injury at the time, you can repair it or make good, but sometimes the injury doesn't appear or doesn't become apparent until afterwards, in which case you might need further procedures to remedy that situation.

After an operation. You can develop problems with the wound; you can have an infection or delayed healing in the wound. You can get blood clots. Orthopaedic surgery, hip and knee surgery in particular, is at risk of developing blood clots. And, although we do give you medication to minimise that risk, it can still happen.

You can get a lot of swelling and stiffness and bruising in the early stages after a hip replacement. Typically, that tends to fade and settle as a couple of weeks go by, but it can be a problem in the early days. And further down the line, you can get problems associated with the joint replacement itself. Although modern hip replacements last an incredibly long time. Eventually, things can wear or start to loosen or fail in some way, and if that happens, then you might need further surgery to address that.

Here's a picture of this. Sorry, that was a picture of my operating theatre, so that's theatre 3, which I do all my operations in. It's a nice place to be. This is a nicer place, though. This is the ward. This is a typical bed; what you can't see there is the ensuite bathroom and the nice big TV on the wall as well.

Most people are in hospital for one or two nights. To give you an idea, of the six people I operated on yesterday, one of them has gone home already; the other 5 will go home tomorrow. So, one stayed in for one night, and five have stayed in and will have stayed in for two nights. All of those people got up and walked on the same day that they had their operation, and they've been spending today doing more walking, getting up and about with the help of the physiotherapists. Initially, it's going to be painful; it's going to be stiff and tight and swollen.

But the physiotherapists and the nursing team and the doctors will get you through those early stages, and then, you know, once that storm has passed, you'll find things get better and easier. Typically, like I say, you'll be discharged home after a couple of days. Normally you'll be on a pair of crutches when you leave hospital, and you'll get rid of those crutches as you feel comfortable in the days and weeks ahead. A couple of weeks down the line. You'll come back and see the physiotherapist, who will take you through the next stage, the next level of exercises.

And normally, within about 6 weeks, most people are back behind the wheel of a car, back driving and doing most normal daily activities. The six-week period is also when you normally would come back to the clinic to come and say hello, and we would check up and go through everything and make sure everything is progressing nicely. The healing process will continue over a period of weeks and months, but most people are back doing most things up to 3 months after the operation. There are 5 of us here who perform hip replacements; that's the Rogues Gallery there. They're not in order of preference or anything like that; they're all very nice people and highly qualified and good at what they do.

So, when do you decide? When the time is right to have your hip replaced. Well, at a very basic level. You'll get to a point; you will know when it's time to have your hip replaced. You'll get to a point where you can no longer live. with your hip the way it is.

When your symptoms reach a point where they're shrinking your world and having an impact on your quality of life, it's time to have something done. There are lots of patient decision support tools. There's lots of information on the internet as to what the typical symptoms are and what the time is to have my hip replaced. The one that I found particularly useful is the National Joint Registry. There's a patient decision-making tool, if you go onto the National Joint Registry website, that will analyse your symptoms and give you a visual idea of where your symptoms are and how much better you'd be following a hip replacement.

So that's something worth looking at. When you've decided that you're going to proceed with a hip replacement, the next thing to do is to decide who to do your surgery. There is the National Joint Registry, which will show you your chosen surgeon's practice. And what that will show you is how many operations they perform a year and how that compares with the national average. Ideally, you want someone who performs a lot of something that you do.

You don't want someone who does one or two a month. You want someone who's doing a high volume of hip replacements in order to get the best results. You can look on review sites, such as Doctify, which will give you a rating, a 5-star rating for each individual consultant. This is me. It's a bit out of date.

I've now done another 15 or so reviews since that one was taken. I'm still agonisingly at 4.99 out of 5 rather than 5, but it just shows I'm human. So take a look at a surgeon, take a look at their reviews, look at them online, look at what they do, look at their practice through the NJR, come to a decision, and at the end of the day, go along and say, 'Hello, come and have a chat.' See how you feel. You'll know if you get on with someone, if you trust them, if you feel safe.

Coming along to Benenden will also give you a chance to look at the environment to see what a nice place it is as well. I'm here; we got some. I was talking about the National Joint Registry. The NJR is a fantastic resource that just keeps getting better and better. Every joint replacement operation that has been performed in England since 2003, so the last 23 years, is logged and registered on the National Joint Registry. So that's huge data.

And that gives you – it shows you which joint replacements work well, which ones don't work quite so well, and what combinations of bearings work well, and, you know, so you can look at implants, you can look at institutions, and you can look at surgeons. All of that data is out there, publicly available, really useful, and interesting. So if you decided that you want to come along and see me or one of my colleagues to discuss your hip, or knee, or whatever you want. Come along. There's a special offer associated with this webinar.

You get a half-price initial consultation from the webinar, and this also gives you an idea of the guide price for a hip replacement. Don't forget that as a Benenden member, you would get a 10% discount on that price as well. We also have a price promise, where you won't find You won't find a more competitively priced surgical package within 30 miles of this hospital. So there we are. I will leave that open.

That gives you the numbers and the 50% off offer as well. What I'll do now for the next 10 to 15 minutes is work my way through what questions we've got here and see if I can answer them to the best of my ability. Now, what I often end up doing is I start at the top and work my way down, but I'm going to mix it up this time. I'm going to the bottom; I'm going to start my way up. Michael, sorry, Michaelia.

Michaelia says, 'When could I start running again, not marathons, just a few miles, and returning to the gym?' Well, Michaelia, The answer is that you can start running again when you feel comfortable doing so. Most people find that that process will be somewhere around 2 to 3 months following the surgery. People start gradually. Obviously, if you've had a hip replacement, in the build-up to a hip replacement, you probably wouldn't have run for a while anyway.

That's why you're there having the operation. So don't expect to bounce back and have the same 5K time or the same half marathon time that you used to have 10 years ago; you will have lost muscle as well as movement and support from the hip joint. So, you need a chance to heal. Most people find that they start getting back to exercise that's not just physiotherapy after 6, 8, or 10 weeks, that kind of period. Most people start slowly, starting with run-walking.

Most people start indoors on a treadmill in a safer, more controlled environment before they go out and about outdoors. Typically, I would have no objection to you getting back to running in the longer term. I have many patients who run for pleasure and continue to run after hip replacements, lots of park runners, and lots of 10Ks. I've got a few patients who run half marathons on a fairly regular basis. I've yet to hear of anyone who's run a marathon yet, but it's just a matter of time.

I would have no objection to it. I think if that is what you want to do, then get back to it. I wouldn't expect you to get a PB with your marathon time, but if you've got to scratch that itch. By all means, do. How long does the operation take?

That depends on you, and it depends on your surgeon. There, in the same way that there are people who talk quickly and people who talk slowly, there are people who write quickly and people who write slowly. Different surgeons operate at different rates. I'm very lucky.

I work in this theatre, in this environment, at Benenden Hospital. We have a fantastic team, and what that means is that I work with that same team week in, week out. That familiarity, that recognition of the pattern of how you work, how you flow, and how you proceed, means that the operations Move very smoothly and quickly without rushing. If my scrub nurse knows what instrument I'm going to ask for before I ask for it, it will be ready before I ask for it. There's no hanging around, there's no waiting, everything flows very well.

So, operations here move quickly, which is why we do 6 or 7 or 8 joint replacement operations in a day here; compared to when I used to work in the NHS, it would be a struggle to do 4 hip replacements in a day. So we've got a good team that works smoothly and works well. The other thing I say is it depends on you. Is it that bigger people who have bigger-sized bones or who have bigger legs? The operation takes longer to get through that. The size of the leg to get into the joint to replace it. A typical hip replacement will take somewhere between an hour and an hour and a half.

But I've had hip replacements that have lasted 45 minutes, and I've had hip replacements that have taken 2 hours. Lots of variables. But hopefully that gives you a bit of clarity on that. Yeah, so how long does a hip replacement typically take? How long does the operation take?

Hopefully, I've answered both of them. I've got the question here: how long, you know, can you have a hip replacement with a pacemaker? How long after having a pacemaker inserted should you wait before you have a hip replacement? It is perfectly possible to have a hip replacement after having had a pacemaker. We need to make sure that that hip replacement, the hip replacement, and the pacemaker are functioning well, and so, it needs to be long enough after the pacemaker goes in that you've had that pacemaker check, and you know that there's been a benefit from it, and it's functioning normally.

Pacemakers have a limited shelf life as well; their batteries don't last forever. So, if it's been a decade or 15 years since you've had your pacemaker, then we would like to have it checked. Make sure it's functioning normally before you come in and have your surgery. So the answer to that question is long enough for it to be proven to be working, but not so long that it's no longer working. So there's a sweet spot there. Sorry, I can't be more specific than that.

Does it always come? Does it always come to having the other hip joint done? No, not necessarily. Although you would expect it to, wouldn't you? If you've lived the same life, if you've done the same things over the years, then why shouldn't both hips wear out? There is a slight tendency for left hips to wear out more than right hips; I don't know why.

People who've had injuries or developmental problems or diseases or trauma that have only affected one joint, then, you know. It may well be that you only ever need one hip replaced. What we tend to do is we look at both hips in that initial consultation. Typically, although I would see advanced arthritis on one side, you'll tend to see a bit of wear and tear on the other side as well. It may well be that down the line.

It follows that you need the other one doing it, but it's by no means a given. Can steroid injections have any adverse effect on the bone or hip? Yes, they can. Steroid injections. Well, a single, one-off steroid injection to deal with an acute inflammatory response is a perfectly reasonable treatment.

But the problem with steroids is that they wear off. And when they wear off, you might have to have them repeated. Repeated steroid injections and multiple high doses of steroids over a long period of time. Directed into one small area in your body, not a great thing. You can have problems locally with weakness of the tissues or damage to the bone, or they can have a more systemic effect.

They can have an effect on how the hormones are regulated and produced in your body. They can have an effect on how your skin is, the texture and quality of your skin, and also the density of your bones. So, although a steroid injection is a viable option. As an acute treatment for an inflammatory condition, it's not a viable long-term management strategy for a worn-out hip. There are a couple of questions.

About approaches to the hip replacement. I've got one that says, 'Is there a reason why so many surgeons don't do the anterior approach?' And there's another question from Marjorie. What method of surgery gives the best and quickest recovery: anterior, posterior, or lateral? So, let's talk about This will be the last question, but I'll drag on a bit, so I'm sorry if I haven't got round to your questions, but we'll do our best to answer them down the line.

But approaches – so what we're talking about here is a way – the way that you get inside someone's hip to actually do the operation. The hip joint is buried deep down inside, and you need to cut through tissue in order to get to the hip to replace it. Typically, you can go in through the front, you can go in through the side, or you can go in through the back. And so those are the medical terms for that: anterior approach, lateral approach, and posterior approach. One of the questions is, why don't many people do lateral or anterior approaches?

The anterior approach is probably the least common of all three approaches. Last time I checked around 10-15% of hip replacements in the UK were reported to be performed through the anterior approach. That leaves the other 85% split between the lateral approach and the posterior approach. There is, amongst hip surgeons and specialist hip surgeons, a majority of hip surgeons who use a posterior approach, but there's still a significant number who use an anterior or lateral approach. Going back.

To my colleagues, we'll get there eventually. Of those 5, there are 3 who exclusively use the posterior approach. There is one who used to use the lateral approach as a routine and has switched over to the posterior approach, and there is one who does the lateral approach. So there you go, that's the split amongst the surgeons in this hospital. Each different approach, as a merit, has advantages and disadvantages.

What you're looking for in a hip replacement approach is, one. That causes the least amount of damage when you're going in. Allows you to see what you need to see and perform the operation safely, properly, and well. And if there are any complications that you encounter during the operation, then having the ability to deal with those complications There and then is a big advantage as well. So to go through them very briefly, I use the posterior approach, and the reason I use that is because I feel that that gives the best balance of exposure, minimal damage, and ability to perform the surgery.

anterior approach, causes the least amount of soft tissue damage. But it has the worst exposure and the most association with perioperative or immediate postoperative complications. So, the anterior approach is very good if it goes well; the anterior approach is fantastic for getting you back on your feet quickly. But it is risky. And it is not for learners, not for occasional surgeons.

If you have a surgeon who has done the anterior approach for many, many years, many hundreds of operations every year, then it's a reasonable thing, but it's not for people learning to do that approach. It is a very What we tend to see in anterior approach surgeons is that they tend to publicise the rapid recovery. So, two weeks down the line, you can tell someone who's had an anterior approach because they are walking better. That advantage disappears after 6 weeks. And like I said, the revision rate, the complication rate, is actually higher in anterior approach surgery than the other approaches.

So buyer beware, it does get you back quicker, but it comes at a price. The lateral approach is a good approach to get into the hip joint, but it causes more damage to muscles. Than either the anterior or posterior approach. There is a higher incidence of long-term limping following the lateral approach. But the complication rate is about the same. Posterior approach.

gives you that combination, like I say, that sweet spot of exposure versus lesser damage, but in the early stages of a posterior approach, there's a higher risk of dislocation than there is with an anterior or lateral approach. So each of them has risk-benefits. The idea is it's best not to chop and change between them. Ask your surgeon what their approach is and whether they're comfortable with that. I would go with that, rather than asking a surgeon to do a particular approach.

If they're not familiar with it, then that's not going to work well. Sorry that was a long and rambling answer, but hopefully that will give you an idea of different kinds of approaches and the advantages and disadvantages of either. Essentially, what I would recommend is trust your surgeon; go with them. The last one is from Howard.

How awake will I be with an epidural? Typically, the anaesthetic that you would have with a hip replacement is what we call a spinal epidural anaesthetic, which is similar to an epidural. Essentially, what that means is you have an injection into your back, which puts your legs to sleep. Now what people worry about is that that means that they will be completely awake from the waist up during the operation, and they'll hear every hammer blow, every, you know, everything that's going on during the operation. The truth is that, yes, you would have a spinal anaesthetic that puts your legs to sleep, but on top of that, you will also have sedation.

fairly heavy sedation. Now, we can tailor that sedation to however you want, ranging from a sort of comfortable, fuzzy feeling that you might get after a couple of drinks in the evening to being fast asleep and snoring away through the operation. And really, so, how awake will you be? However awake you want to be. If you don't want to know what's going on, you won't.

If you want to be wide awake, if you want to chat away to the anaesthetist throughout your operation. Then by all means, do. If it were me, I wouldn't want to know what's going on, but that's just me. Everyone's a little bit different. Thanks for the questions.

They're always interesting, and like I say, it's my favourite part of the talk. Hopefully, I've answered a few of them tonight, and hopefully you'll feel a bit more educated about what's involved with a hip replacement. Please get in touch; come and have an appointment if you want to talk about things further, or if you've decided that it's the right thing for you and you want me to replace your hip, let me know; I'd be more than happy to. Like I said at the beginning, there have been 3 of mine; I've done 3 presentations in a row. They are available online.

You can have a look at those if you want to listen to me talk about knees or Arthrosamid® injections in more depth. There's a rolling programme of lectures that we do here at Benenden, not just orthopaedics, but all sorts of different topics as well. Upcoming webinars: we've got one on varicose veins, we've got gynaecology, we've got cataract surgery, and we've had urology in the past. weight loss and plastics and all sorts of different stuff, so take a look at the website.

If there's anything that grabs your attention, either look at it if it's been in the past or sign up in the future, and it'd be great to see you here in the hospital, for whatever you need. Thanks for coming along tonight; hopefully, you'll find that useful. Give us a call. The lines will be open until 8pm tonight if you want to arrange anything, or further down the line, please feel free to talk. I do a clinic here at Benenden.

I also go up to London for a clinic, so either way, if travelling down here is too far, we've got that covered as well. So, yeah, thanks for tonight, and I may well see you at some point down the line in the future, but goodbye for now.