Damien Gregory

Right. We’ll just wait a few more seconds for a few more to join. I see that number's ever increasing. There we go. Okay. Well, good evening, everyone, and welcome to our webinar on treatment for hip osteoarthritis. Now my name is Damien, and I'm hosting this session, and I'm joined by our presenter consultant orthopaedic surgeon, Mr Alex. Chipperfield. Now this presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so using the Q&A icon, which is at the bottom of your screens. Now this can be done with or without you giving your name. Please note, though, the session is being recorded. If you do provide your name. If you'd like to book your consultation, we'll provide contact details at the end of this session.

I'll now hand you over to Mr Chipperfield, and you'll hear again from me shortly. Welcome, Mr Chipperfield.

Mr Alex Chipperfield

Thank you very much. Good evening, everyone. Thank you for tuning in tonight. My name is Alex Chipperfield. I'm an orthopaedic surgeon here at Benenden. I'm going to talk to you about hip arthritis and its treatment. I'll just start with a little bit of background on me for people who haven't met me yet. I was qualified as a doctor in 1997. So, knocking on 30 years doing this, I trained in the southeast of England and then went over to Australia for a couple of years. on fellowship. I've been a consultant surgeon specialising in hip and knee replacement here in Kent since [year], and for about [number] of those years, I've been working here at Benenden Hospital as well. I'm a member of the British hip society, and I like, I say, I specialise in primary and revision hip and knee surgery.

The structure of the talk tonight. I'll talk to you about surgery at Benenden Hospital. I'll give you an idea about hip arthritis, what its signs, symptoms, causes, and treatments are, and treatment options. Then we'll talk a little bit about hip replacement surgery, the process, and the recovery, and then have a bit of a Q&A session at the end. If anyone has any questions during the talk, they type in. If they catch my eye, I'll do my best to answer them as we go along.

First, a little bit of background on Benenden Hospital. We are a leading provider of hip replacement treatments in Kent. According to the Private Health Information network. This hospital, if you ever visit it. You'll appreciate that it is clean, modern, and calm. Environment doesn't feel like a hospital. It's a nice place to be, and it's a nice place to have treatment. where there's a good group of people here. There's lots of experienced orthopaedic consultants, but also the rest of the staff. Here are really good, experienced, kind, and helpful people as well, whether that's the physios on the ward, the admin staff, the nurses, the theatre team, the X-ray team, the catering, the porters, or the admin staff. It's a nice place to be. because of that, because it's a nice environment with good people. You'll see that we have very high patient satisfaction rates and good scores when it comes to reviews. We also have what's called a rapid recovery program, which is. Yeah, trying to make all. Although this is a nice place to be. We try and make your stay here as brief as possible, so we do everything that we can to get you up and about. on, you know. quickly in and out of the hospital as soon as we can. got a question early on in an anonymous question here, saying, I have severe left. Hip arthritis. I am 63, and I'm overweight with a BMI of about 45. Does this rule me out of an operation for hip replacement? Or could this be a viable procedure?

The fact you have severe hip arthritis is one good thing as far as hip replacement surgery goes. Your age, 63, is slightly young for a hip replacement, but not out of the ordinary at all, and that wouldn't be a problem. The one thing that may well be an issue, or rather would probably limit the choice of where you would have your surgery, would be your BMI, for those of you that don't know. Your BMI is the ratio of your weight related to your height. Essentially, the heavier you are, the higher your BMI will be. Most hospitals are independent hospitals, or those that are outside of the NHS. Have a BMI limit that they impose on people who are coming for planned elective surgery, and the BMI limit for a place like Benenden would be 40, so you, with your BMI of 45, are slightly outside that limit. That doesn't mean that you can't come here, get a diagnosis, get treatment, get advice, and get support through a weight loss journey that might end up with you getting down to the level where you could have surgery here.

Although it does limit you, having surgery immediately. It doesn't rule it out altogether. I hope that answers. That is a rogues gallery. This is. There are a few of us here who perform hip replacements on a regular basis. There's me on the left, and then a few of my colleagues there. We all work in the East, Kent, and East Kent region, a variety of both NHS and private practice. All of these guys are experienced surgeons who've performed a lot of hip replacements with very high levels of satisfaction. It's not just about me. There are other people here who are just as good. So now, moving on to the causes of hip arthritis. Well, there are a few associations of hip arthritis, so it tends to be associated with later life. The classical picture of a wear-and-tear or degenerative-type problem is where the joint surfaces slowly erode over time because of that. The older you are, the more worn things will get. Another point. Is that so? If you're putting more pressure through your joints, the heavier you are or the higher-demand activities you do, whether that be work or recreation. Again, there is a higher chance of your joint. Wearing out injury is a big factor. If people have had significant injuries to a joint over their lifetime, or if they have an occupation that provides repetitive stress or strain through a particular area or joint, then you can get damage to a joint that way. There are other diseases that have an effect on joints, so whether that be infections or diseases, such as rheumatoid arthritis, which are when the body's own immune system attacks joints. But to be honest, the commonest cause for a worn-out hip or hip arthritis is family history or just bad luck. If you come from a long line of people with bad joints, then there's a high chance that you'll have that as well. What are the symptoms of hip arthritis? Well, it tends to start with pain. That's one of the things that people notice. The hip joint is not where most people think it is. When people talk about. When doctors talk about pain coming from a hip joint, it's very much in the front, in the, in the groin. That's where the hip joint is located, and people with groin pain often mistake that they think that's a muscular injury rather than a problem with the hip joint itself. Most people localise their hip to the side of their hip, or to the buttock or the flank, and you can certainly feel pain emanating from a hip joint there. But typically, it's right in the front, in the groin. That pain has a habit of radiating as well. It can move around. It will be in the front, but it can radiate to the back. It could also radiate down the leg towards, or also into, the knee joint itself. It's unusual for pain to come from a hip joint. to go far below the knee. If you're having pain in your leg that's radiating right down into your toes, then that could be a sign of a problem a little bit higher up, possibly with your back rather than with the hip joint itself. other than pain. The other type of symptoms that you tend to get are related to loss of movement of the joint, so stiffness in the early stages, that manifests itself in difficulty lifting your leg up to get in and out of the car or get on and off a bicycle, difficulty getting down to your feet to cut your toenails, or put on your shoes and socks or trousers, these kinds of things, these sort of small things that limit your daily activities, that will That will slowly, slowly shrink your world. initially with the pain that tends to be what we call functional pain, which is pain that comes on when you're moving or doing things As the disease progresses, or as the wear inside your hip progresses, then that pain becomes a more constant nature, and you start to develop rest, pain, or pain. At nighttime it can disturb your sleep. your hips as well as stiffening up. They can grate and grind and seize up, or the opposite they can. They can collapse underneath you; you can feel unsteady and lose faith in your hip. Because of restricted movement or restricted function. Things can then progress you can. You can notice muscle wasting and weakness, loss of muscle bulk. Typically, you'd notice that in the big muscle that moves your hip around, which would be your buttocks. It's quite difficult to look at your own buttocks, but if someone looks at your behind, you might notice some wasting of the buttock, or you might notice a change in the fit of your trousers, or that kind of thing, which may be an indication of early signs of muscle wasting. There are a couple of questions here. One of them is about the implants, talking about metal implants in the hip. Later on. One of the slides is about the type of implants that we use.

I'll discuss that at that stage. There's another question about someone who lives up in a flat up steps. Is that an exclusive issue for surgery? No, it's not clear, you know. Most people, by the time they end up needing a hip replacement. They will be struggling, getting up and down stairs independently. Once you've had a hip replacement, it takes time, but you will be able to get back to normal functional activity. If you come from an environment where you have lots of steps, either in your house or in order to access it. Then one of the boxes that you have to tick before you leave the hospital is that you have to be able to demonstrate that you can independently and safely mobilise back in the environment in which you live.

If you need to be able to get up and down stairs, then you will be taught how to do that safely and appropriately before you leave the hospital. Before I start. Before I talk about hip replacement. There are other treatment options. available before things get bad enough to start considering surgical intervention. And essentially what those treatments are is ways to try and minimise the pain. Try and allow you to live with a worn-out hip.

pain-relieving medications. whether those be simple painkillers that you could buy over the counter, either in tablets or gel form, or stronger prescription painkillers that you might get from your GP. There are also other methods of dealing with pain, such as TENS machines, which are little electric shocks. Machines are very good. Heat and cold are very helpful, too. You can try different ways of mobilising, taking pressure off the hip by using different or cushioned footwear, avoiding high-heeled shoes that tend to overbalance you, using a stick, and modifying your activities to not provoke and upset a worn-out joint. Slightly more invasive. We got a picture there of someone. putting a needle into a hip joint and quite a successful operation. Successful procedure in the mild to moderate arthritis. Staged injections are painkilling or anti-inflammatory injections directly into the hip joint. We tend to do those I tend to do, those in the operating theatre under X-ray guidance and also under anaesthetic.

It's not something that you do in an outpatient setting. It is a procedure that involves coming into the hospital for the morning or the afternoon, but that could be quite good at giving some relief at fairly low cost, as in not a big thing to go through. If all of those methods have failed or become unacceptable, then I'm afraid we're looking at surgery. Essentially the main operation for a worn-out. Hip joint is hip replacement. In other joints, there are other types of operations that you can do to clear out the joint or to realign them with the hips with an arthritic hip. It's kind of all or nothing. It's a hip replacement. joint fusion is mentioned at the bottom. There. In the years that I've been in orthopaedics. It's something that is less and less of an option. The only time I come across joint fusion for hip replacement for hip arthritis these days is with people who've previously had fusions, who then end up going on to have hip replacement surgery at a later stage. which is a whole different level of hip replacement rather than a standard implant a question about TENS machines. Where do you place a TENS machine? Most tens. machines will come with instructions on where you place the adhesive pads. It tends to be a bit of trial and error as to where feels the best for you. Typically, people get the most benefit from putting it at the front and side or front and back. the back and side of your hip clearly, if you're sitting down whilst using the tens, then putting an implant, or sorry, an electrode, at the front may get squashed or wrinkled with the sitting movement.

It tends to be something that you have to do while you're standing or lying down. But it's a question of trying the areas that you find the most benefit from. some data about hip replacements in the UK. One thing is that hip replacements are a very, very common operation. There are about 1 million hip replacements that happen every year.

We do lots, and we do lots of them here, and I do lots of them here as well. I do hundreds of hip replacements every year and have done so for decades.

It's a well-known, safe, common procedure. One thing that has changed post-pandemic with the stress and strain that's gone through the NHS and is still going on in the NHS. We're now in a situation where the majority of hip replacement operations in the UK happen in private hospitals, so whether they are funded through the NHS through insurance or self-funded, there are more planned hip replacements that happen. in the private sector than in the NHS. Which is a good or a bad thing, depending on which way you look at it, but it certainly, you know. It is a change that has happened over the last few years, and I don't see that being reversed anytime soon. hint. Replacement is Like I said, it's a very common operation. It's a hugely successful operation as well. The impact on people's quality of life. The overall satisfaction rates are dramatic. The only operation that gives you more instant satisfaction compared to the risk-benefit ratio is cataract surgery. So hip replacement. Second-best operation that you can have. It's a great operation; it works very well at giving you your life back, getting rid of your symptoms. It tends to be something that comes on later in life. But as I've touched on earlier, it's something that we're doing in younger and younger patients; the average age for surgery is late sixties, but when I started doing them, it was mid-seventies. So the average age is coming down lower and lower. Age is a consideration, but it is not a limiting factor. Every now and again I'll see someone who says that they've been told that they're too young or too old for a hip replacement. And generally, that's not the case. It tends to be whether or not your symptoms are bad enough and what your other treatments have been. Whether or not it's appropriate for a hip replacement. And kind of touching on that. There's a question that's just come through. What's your opinion on running? with a diagnosis of left hip mild to moderate degenerative changes. Would this progress the need to have a hip replacement? Age?

my feeling about exercise and hip replacements, and you know There's more and more evidence when it comes to arthritis of the hip and of the knee. That exercise is one of the best things that you can do to avoid coming into contact with someone like me. If your joint is failing, if it is beginning to wear, if it is. if it is mild to moderate arthritis such as that that question says. if the joint is failing. If you can keep the muscles, ligaments, and tendons that support that joint as strong, mobile, and healthy as possible, that will support the failing joint. joints are stimulated by load bearing. They're stimulated by exercise. There's a lot of work done looking at marathon runners looking at their joints before, during, and after blocks of training and running marathons. And there's huge evidence, more and more coming out, that that exercise is protective and can actually, in some cases, reverse the signs of arthritis in some cases, so Will running with your arthritic hip make you need a hip replacement quicker? No, it won't. And another question from Gail is,Is it too early for a hip replacement just diagnosed weeks ago?" Like, I said I. I've replaced someone's hip younger than you. within the last week. It happens, you know; it's something that happens more and more frequently. Is it too early? That depends on what your level of symptoms is. Your age being is not something that will stop it. Do. I need hip replacement surgery. No one apart from a broken hip. The times when someone comes to me, and I say you absolutely must have a hip. Replacements are very small. No one. You don't need it. It's not like a cancer or an emergency operation. It is a choice. It's a decision that you come to with the help of your surgeon and other health professionals as to whether or not your quality of life, your level of function, would be better. with a hip replacement than it would be carrying on with the way things are.

It's all about risk and benefit. If your symptoms are bad enough, and there's no other way to control them. If your life is being made miserable, if it is dominating your daily living, if you can no longer do what you want to do, or what you could previously do. If your world is shrinking and you are being held back by your hip, then the answer to that question is often, yes, you would be better off. with a hip replacement than you are. Currently, so typically, if you've got severe pain that's limiting your everyday activity, whether that be recreational activities or work, or simply the ability to mobilise, to look after yourself, to get out, to drive, to shop, to wash, to dress, to sleep. All of these things. If you're finding that you're being limited in these kinds of activities, then it's time to have something done. Walking distance. If that starts to decrease. If your world is shrinking like I said. It's time to start thinking about it. If you're struggling with the movement, with the pain, with all of these things with deformity. Then you get to a point where the balance tips, and it goes from a situation that you can live with into one that you can't. When you reach that point, it's time to have a replacement. What are the choices?

this is going back to? Ted's question about cobalt. What are the types of hip replacements? There's a choice of materials, whether these are made of metal, plastic, or ceramic. There's a choice of whether or not you use cement while you're doing the operation or not. This slide I could spend all evening, and probably into the next day as well. Talking about this. I could bore the socks off you talking about implants, different types, and different bearing surfaces. That kind of thing. What Ted was asking about was cobalt and implant side effects.

at a very simple level. the ball and the socket. Those things rub against each other. And you can decide, or your surgeon can decide, what you make the ball from and what you make the socket from. The problem with conventional hip replacements was that you had a metal ball with a plastic socket, and eventually that metal ball would wear away that plastic socket. And you know. , years ago, the main reason why people's hip replacements failed was because they wore out those surfaces, wore away, got eroded, and the plastic deteriorated, and as a result, you needed further surgery to redo everything. One of the solutions that people came up with to try and get hip replacements. To last longer was to change those surfaces, change the bearings. and what they thought was that a metal ball is incredibly hard-wearing. Why not have a metal socket as well? And then you've got metal surfaces rubbing against each other, which in theory will last an incredibly long time. And the theory of that is true. A metal-on-metal hip replacement does last a very long time. The problem with some metal or metal hip replacements is that, at a microscopic level, those surfaces will still start to wear, and you get debris that is produced.

Now, when you've got a metal ball and a plastic socket, the debris that's produced is plastic, and that plastic is an inert substance that has no effect on your body or your health. What people found is with the metal debris, that metal debris, and particularly cobalt and chromium. Those are the types of metal that most metal-on-metal hip replacements started to produce. those, those metal debris, those metal ions could be poisonous. They could cause quite significant damage to the soft tissues around the hip and also further afield to make people feel unwell. And

we, you know, in the early s, late s. There's a lot of trouble with metal-on-metal hip replacements that people had done because they thought they would last forever, and they end up failing early and causing a lot of collateral damage because of that cobalt chrome poisoning. There are still some centres that perform metal-on-metal hip replacements, and in certain people in certain environments, they work incredibly well. Andy Murray, the tennis player. He has a metal-on-metal hip replacement.

you know. These things do work well. But a significant proportion did fail and did require monitoring. It is not something that is part of my practice. And it's not something that we do here at Benenden Hospital. The way that we get around the wear problem is by using modern plastics that are much harder wearing and also by the use of ceramic, which is a much harder wearing, kinder bearing surface. And it's a nice pink colour as well, which is good. So Ted, I hope that answers your question about bearings; like I said, I could talk all night about this kind of thing. but I'm not going to, because there's still more to cover. But what I will say is that modern hip replacements. The wear problem, although not completely solved, is much less than it was. These things now last for decades and decades, and the main reason why people might end up needing further surgery on a hip. Replacement is no longer because they wear out. That problem is essentially solved when we talk about choosing a different bearing for you or a different fixation method. That is a discussion on an individual basis that you would have during your consultation with me or whoever you come and see here. I've kind of already mentioned this, what's already involved during a hip replacement. Well, it's an operation. There's no getting away from that. And that operation typically in a normal person lasts somewhere between an hour and an hour and a half. There's a question on the screen. Saying, is surgery always via epidural? And if

What's the benefit of this? About % of the hip replacements we perform here are done by what's called a spinal anaesthetic, which is an injection into your back. On top of that, you also have sedation.

People worry that when they're going to have a spinal anaesthetic, it means that the top. Half of them will be wide awake, and they will hear, or see, or feel, or smell whatever's going on in the operating theatre. By all means. If you want to be wide awake, you can be. Most people choose to have sedation on top, so they won't be awake. You won't be fast asleep. Either you'll be in a sort of happy grey area where you really don't realise what's going on. You'll have no memory or sensation of the events at all. The advantage. The benefit of a spinal anaesthetic is that you? There are less powerful drugs that go through your system during and after the surgery. This means that you'll have less of a hangover from the anaesthetic, less sickness, less constipation, and less nausea. Most people with a spinal anaesthetic tend to be able to get up and about much more quickly, and the spinal anaesthetic has a longer-lasting pain-relieving function than a general anaesthetic as well, so it's a good, good anaesthetic with less hangover, more pain relief, it's safer, and it allows you to get up and about a bit more quickly. So if I were having my hip replaced, I would have a spinal anaesthetic when I was having it done. But I also have sedation. What else is involved? Most people are in the hospital for one or two nights following the surgery. The question about the stairs. We'll go back to that as well. You know What determines when the time is right for you to go home is when you feel you could cope in that environment. Some people feel fine the next day, and they've ticked all the boxes with the physios and the nurses and the X-rays and the blood tests, and everything is fine. If you're ready to go home the next day, you can average the length of stay here at Benenden is nights in, but everyone is a little bit different. Here are some pictures of hip replacements. Hopefully, none of you will end up having hip replacements. A pair of hip replacements on the right there. Those are. Those are well, they're called hybrid hip replacements.

The stems on both sides have been cemented. The sockets on both sides have not been cemented. The single hip replacement on the right-hand side is an uncemented hip replacement, where neither the stem nor the socket has been cemented in both of those, so the one on the left is called an Exeter hip. The one on the right is called a Karai hip. Those are both incredibly long-lasting, hard-wearing hip replacements that look like they've been done very well and should last for decades. Recovery from hip replacement. Your hospital state. As I touched on earlier, we get you up and about very quickly following the operation. That's part of the rapid recovery process. It's also part of the spinal anaesthetic, which means you're able to get up and about more quickly. When I operate on people here, when they have their hip replaced in the morning. We get them walking in the afternoon. If you have your operation later on in the day, we might give you the night off, but then we start chasing around the next day.

you know. Most of the time we'll get you standing, putting all your weight through your leg the day of surgery, even if it's just to stand or take a few steps. That means the next day, when the physios really start cracking the whip, you'll already have the confidence. You'll already know that you can stand on it and get going. It is a big operation it does involve. It's an invasive procedure; you will get bleeding and bruising and swelling after this operation. Initially, that bruising and swelling will be around the hip joint itself. What happens over time with gravity? If you're spending more time up and about on your feet, you may well find that that swelling will sink down your leg, so it's quite common for people to get a bit of swelling that tracks down into their thigh and knee and lower down, as well as the days and weeks go by. That's completely normal, and it resolves. So initial discomfort and swelling physiotherapy. Will has aims. Really, the first is to show you how to get up and about, how to move and transfer safely in the early stages while your hip is healing and strengthening, and then the second phase is guiding your rehabilitation, strengthening your muscles, and getting things going again. Like I said. Average hospital. Stay one or two nights, and it says back to normality within weeks. Most people are back doing most things at that stage. But I'm a bit of a pessimist at this point. I tell people if you're planning on having a hip replacement. Don't make any big plans for the first months afterwards. In some parts of your recovery, it will be very rapid. Your pain relief will be very quick. Your mobility will bounce back pretty quickly, but there may well be other parts to your rehabilitation and recovery that take time. You need time to heal from this.

Give yourself that time. Don't put yourself under too much pressure, committing to things too soon in your recovery process. You go home when you're safe to do so. When you go home, you'll have a pair of crutches that you will get rid of, as You feel comfortable over the days and weeks ahead. You'll be shown how to safely navigate the environment that you go back to. You'll also be given a little grabby thing, so you can avoid bending down and picking things up, and you'll also be given a very good toilet seat. Raise the old people have. You'll be able to get rid of that pretty quickly. But it's just in the early stages to stop you bending your hip too much when you're sitting on the loo. Everyone's healing journey is different.

Giving you milestones at weeks, weeks, and months, in a way, is helpful because it lets you know what to expect. But also it's difficult because everyone is different. Yeah, you know. I've known people who are driving after weeks and other people who aren't driving until months. You know. Some people get quite a lot of bruising. Other people barely notice it. Some people get rid of their crutches immediately. Other people. It takes time.

You know all of this stuff. Don't beat yourself up about reaching a certain milestone at a certain time. The healing process is a gradual one, and as long as you are improving and making steady progress, your recovery will be unique to you. What a lot of people find is that in the early stages, one after their hip replacement, if they're worried about something, there'll always be someone particularly unhelpful who will pop their head up, saying, I had my hip replaced X number of weeks ago, and I was already doing this, that, and the other at your stage. These people are not very helpful. Everyone's journey is unique. Don't listen to them. Just listen to yourself. and me when you come back and talk to me, and I reassure you that everything is okay. Life after hip replacement. Most people who have their hips replaced, like I said, they're delighted with it. It's brilliant for getting rid of the pain, and it gets rid of the pain very quickly. Most people get back to most activities. including sporting activities as well, there was a runner earlier. Oh, and I've just spotted. There's something about a marathon runner in the questions coming up. I've got many patients who are sportsmen and sportswomen who do a lot of sports, a lot of swimming, a lot of cycling, and a lot of running, and the majority of them get back to it as well. Now, personally, my advice is that having a hip replacement should not be an excuse to try and get your marathon PB. Or embark on an ultramarathon career. People following hip replacements can run for pleasure. Park runs Ks. I had a patient who I replaced both of his hips last year. Who's back to running half marathons because he had some unfinished business before his hip replacement. Yes, absolutely. Do run. Do what feels comfortable and what feels right for you. But you do need to remember that it is an artificial joint. You do need to look after it to a degree. So be sensible; be safe. Choose your activities wisely. But yes, you will get back to the ability to do certain sporting activities, maybe not at the level you were doing as a younger person before the hip arthritis took hold, but certainly enough to be able to enjoy what you want to do now. Precautions to avoid dislocation. There's a big list of do's and don'ts in the early stages while things are healing up, and some people get quite hung up on these early stages about not bending too far, not lying on one side or the other, and not indulging in certain activities for a certain period of time. In a way these are helpful because they allow the hip time to knit together, heal, and strengthen. but they can. You know, people can get quite fixated on them as well. Essentially, my advice in the early stages is to try and stick with that advice. Try and do what you're told. If you're finding things intolerable or unbearable, stick to those quite rigid regimes. The general advice is if you're doing something. and it feels all right when you're doing it, the chances are you're not going to come to any harm. You won't cause any damage to a new hip replacement without plenty of warning beforehand. So as long as you listen to your own body, you're going to be okay. There are risks with hip replacement surgery. There are risks with any big operation. like I said, those risks are real, but they are low, as in low likelihood, and you know the overwhelming majority of people who have their hips replaced are absolutely fine, delighted in the same way that I could have spent all night talking about different types of hips and different bearings and different fixation methods. I could spend all night putting you off having a replacement as well. I could talk you through all the potential things that can happen, whether that be blood clots, or bleeding, or infections, or nerve damage, or broken bones, or dislocations, or you name it. leg lengthening leg, shortening. All these kinds of things can happen. I do everything in my power to anticipate, prevent, and avoid complications before, during, and after surgery. But sometimes bad things happen, and despite your best efforts in those cases where bad things happen, we do everything that we can to reverse them, to avoid them, and to make things good again. But ultimately nothing in this life is guaranteed, and sometimes there are people out there. Everyone has patients whose hip replacement hasn't turned out the way that either the surgeon or the person who's had it has wanted.

There's never a 100% guarantee. But the overwhelming majority of people who've had them are better off with them than without them. deciding whether or not to have a hip. Replacement is a difficult thing to do. There are loads and loads of different resources out there, whether that's just talking to people that you know. talking to people like me face to face. going on the Internet, looking at support groups, looking at this kind of presentation, or other things from other hospitals that may not be quite as good as this. But you know there'll be some information out there. Looking at, choosing your surgeon, you know. choosing your hospital, choosing your surgeon. Everything that I do as a professional, as a surgeon, is, you know. all of my results. Excellent, good, or they're all out there on the Internet for everyone to see. We're in a situation these days where we're constantly being assessed, reviewed, and monitored; our outcomes are looked at, and it's all publicly available. If you go onto the National Joint Registry, which is a website that looks at every joint replacement that's been put in in the UK in the last years. Every single surgeon in England who performs joint replacements, whether they perform one or a thousand. They will all be registered on that national joint registry, and their outcomes will be there. Look at my outcomes; look at anyone's outcomes; see how many joint replacements. People do look at what their revision rate is. Look at what their mortality rate is. Look at their case, mix. Look at all of these things. A lot of people these days know a lot about me before they come and meet me. Look at the review websites up here; this is one of those websites. It's called Doctify, which is where a lot of patients can leave their reviews of you during and after consultations or operations. Again, it gives you an idea of how many people these doctors see and what kind of satisfaction rates they give. I'm quite proud of my score of .; is pretty good. hundreds of reviews on there for people to look at. Not only are we as surgeons reviewed and monitored, but institutions are as well.

Look at how Benenden Hospital compares with your local other hospitals as far as these scores go. So there's a lot of information out there. I would go for independent reviews rather than surgeons blowing their own trumpets. There are a lot of people with their own websites who will sell themselves in one way or another. But there's a lot of objective, independent data out there as well, which you can look at and make decisions based on that. Come and say hello! See if you like the look at me or not; you know this talk may have put you off. Who knows? Like I said, if it's put you off me. There are others here that might be your cup of tea instead. That's me done, sorry. The question-and-answer session. Let's have a look at what we've got here, Damien. You've been sitting in silence while I've been doing all the talking.

Damien Gregory

Absolutely. And no, thank you. That was really, really, that was a great presentation, very informative, especially about Andy Murray. Actually, that was one thing I hadn't known.

Mr Alex Chipperfield

Probably shouldn't have mentioned that. It's probably better.

Damien Gregory

Yeah. It's common knowledge. Yeah, no, okay, no, thank you. We've actually got a few here relating to posterior or anterior. I just wondered if maybe you could chat about what your preference is, or does it change for the patient? There are a few questions relating to that, so we can hit one there.

Mr Alex Chipperfield

Yeah, no problem. When people talk about anterior hip replacement, posterior hip replacement, posterolateral anterolateral, direct, anterior, and minimally invasive, that's what they're talking about. There is the way that you get into someone's hip in order to do a hip replacement. Your hip is surrounded by soft tissue muscles, ligaments, and tendons. The trick with a hip replacement is to get in, to be able to take out the old hip, and put in a new one, causing the least amount of damage to the surrounding soft tissues. Because. You know, you need that soft tissue. You need those muscles. You need those ligaments to support the hip and move it afterwards. There's no point in doing an operation that destroys everything around the joint.

There are lots of different ways to get into someone's hip, and each of those ways to get into the hip has advantages and disadvantages. And each Surgeon you meet, there are 5 Surgeons. on that slide earlier. Of those 5 surgeons. 2 of them use an anterolateral approach; 3 of them use a posterior approach. Most people, most hip surgeons. If you go to the British Hip Society, if you look at people that do high-volume hip replacement surgery, most hip replacements are done through a posterior approach or a variation on that, and that is the go-to approach that I use when I'm performing a hip replacement. The reason I use that is exactly that it gives you the best combination of access to allow you to visualise the joint and put it in properly with the least amount of damage to the soft tissues to allow your function to be as good as possible. The anterior approach is a new kid on the block. But it's not really the anterior approach to a hip that has been around for decades. But the popularity of the anterior approach to do a hip replacement has really only taken off in the last, you know, 10 or 15 years, slightly more. And it tends to. It's been mainly driven by the surgeons in America. There are potential advantages of hip anterior approach replacement in that in the early days following a hip replacement within the week to days. You are able to do things more quickly. What that means. In a competitive environment, such as an American healthcare system, surgeons who use an anterior approach can post videos on their own websites of patients walking without crutches after a week, and they can sell themselves as fantastic hip replacement surgeons.

It's a very good marketing technique. And there's no doubt that anterior approach hip replacement in the early days gives you a bit of a head start. When you see people a month or 6 weeks into the line, that head start has gone. I trained in anterior hip replacement surgery. When I was out in Australia, I performed quite a lot when I was out there as well, and like I said in the early stages, it was good. In the later stages it made no difference, and the problem that I found with anterior approach hip replacement is that the other side of the coin. So the access, the visualisation, and the ease of putting in a hip replacement through the anterior approach. It's more difficult. There are more potential pitfalls. There are more. There's more chance of intraoperative problems, bleeding, nerve damage, and broken bones. In my book, in my opinion. There are no lasting advantages of anterior approach surgery and only disadvantages. It's not something that we do here at Benenden. It's not something that I do in my practice. I tried it, and I didn't see the benefit of it for patients in the longer term. There you go. That's something else I could witter on for ages, but that's that.

Damien Gregory

No, thank you. Very informative. Now I know that you clocked Terry's question a little earlier. Terry's a lifelong marathon runner and gym-goer. Now, in, well, what seems like quite severe pain, he doesn't run and continues with the gym, but he has very limited range of motion movement. The radiologist described via X-ray that his hip is moderate and not severe. However, I think he feels very differently.

Mr Alex Chipperfield

Congratulations on your marathon running. That's the difference. A lot of people come, and they say that they've been told that they have mild, moderate, or severe arthritis. And what they're talking about there is that that is how someone who is sitting in a dark room looking at an X-ray describes the appearances of that X-ray.

There is a classification system of mild, moderate, or severe, or grade 1, 2, 3, or 4, whichever you prefer. People who've never met you, who aren't, who don't know your story, your symptoms, or anything about you. All they know is they've got a picture of some bones in front of them and they're describing that picture. So what they're not looking at is the effect that the arthritis in your hip is having on your life. You are describing arthritis that's having a severe impact on your life.

An X-ray doesn't tell me whether or not it's time for you to have your hip replaced. An X-ray will tell me whether or not you've got arthritis. how severe it is, whether it's time to have something done about it. That is what you tell me by describing your symptoms and by me looking at your function. and how your life is being affected by your arthritic hit. So that description of mild, moderate, and severe is a radiological diagnostic criterion rather than a judgement on how bad your hip is.

If you're struggling with what's being called moderate arthritis, it's not because you're a wimp. It's because when they're talking about moderate arthritis, they're talking about a radiological scale rather than the impact it's having on your life. Sounds to me like you need to keep doing. Come and have a chat.

Damien Gregory

Yeah, thank you. Thank you, Mr Chipperfield.

Mary's asking she's recently recovered from cervical cancer, which included radiotherapy and brachytherapy treatment. How soon after these treatments is it safe to have a hip replacement?

Mr Alex Chipperfield

Basically after a big intervention like that. And a big, I mean, obviously, you may well have had surgery on top of that as well. If you're going into a planned operation, you need to be feeling good, feeling healthy, feeling strong. You need to have recharged your batteries. You need to, you know. have enough reserves to go through another big life event. Another big trauma. My advice to people is to give yourself a good month, if you can, between big operations. If you're months down the line, if you're feeling good and healthy and strong again, then it's time. But give. Give yourself that amount of time to fully recover. and all to build up. Build up those reserves before you go through. Another big thing like that.

Damien Gregory

Lovely. Thank you. Graham's asking, and we're back on implants. And this one might be a little bit more familiar to yourself. But do you use ODEP-rated implants? And actually, what are they?

Yes, it is the answer. So ODEP Orthopaedic Devices Evaluation Project. I think that's what ODEP stands for. So what that is when it comes to joint replacements, whether you're talking about hips, knees, shoulders, ankles, wrists, or whatever. There are lots of different manufacturers out there, and each of those manufacturers makes different models and types of replacements. It's like cars. There are lots of big manufacturers and lots of big models. There are many dozens of different implants for surgeons and patients to choose from. and what you want as a patient and as a surgeon. What you want is a replacement implant that has a proven track record that is reliable. that works well, that lasts an incredibly long time, and reproduces or near-replicates a normal joint. one of the ways that they look at how implants function and whether or not they work. And last is the national joint registry, which I spoke about before. The other thing that manufacturers have to satisfy is their ODEP rating an ODEP rating is. Look is a manufacturing assessment. Looking at how good these implants are! How long they last, for ODEP ratings come in different. They have different numbers, so you will have an ODEP 3, or an ODEP 5, or an ODEP 7, or an ODEP 10, or an ODEP. 15. Related rated implant. and the number next to them indicates the number of years that these things can reliably last for as a minimum. So A hip replacement that's been around for many years and lasts a long time will be ODEP 15 or above. If you've got a new implant that's brand new, that's just on the market. It may have an ODEP, one or an ODEP 3- or 5-year rating, depending on how long they've been for It's not saying that these only last that period of time. It's just that those things only have a certain amount of history track record because they've only been around for long enough. At Benenden. We have a policy that we don't use implants that have less than an ODEP 10a rating.

We need implants that have got a proven track record. And so yes, we do them. All of our implants are 10 or above on the ODEP rating. What do we use. The commonest hip replacements that we use here are something called a CORAIL® hip replacement, which is made by Johnson and Johnson or a Taperloc® hip replacement that is made by Zimmer Biomet. Those are the two main hip replacements that we use. We do use a couple of others in certain circumstances, a meta hip, or a c-stem, or the other ones that we use. The majority of hips that we do here are either CORAIL® or Taperloc®, so there you go, so that makes sense. Thank you.

Damien Gregory

You might be able to interpret this one. You might have had this before, but Graham also asks if he can travel home in a car where his knees would be higher than his hips. Maybe kind of cover that. Cool.

Mr Alex Chipperfield

Yeah, I wouldn't recommend trying to squeeze yourself into a convertible MG or something like that on the way home. Most cars, you know you can. You can sit in the back seat, and you can stretch your leg out, or you can sit in the front seat and ratchet the chair all the way back, so it's unusual to be in a position where your knee is high, higher than your hip. In a car. If you, I wouldn't recommend being shoehorned into the front of a sports car. It may be that you ask a friend to drive you home rather than that at Benenden. One of the nice things about being here is it's peaceful, calm, and quiet. The bad thing about that is that it is in the middle of nowhere there are, you know. There will be travel involved coming to and from here. Everyone who has a hip replacement here is within walking distance. Lots of people get cars or taxis home. You don't need to be lying on a stretcher in the back of an ambulance to come home. Most normal cars will be fine. Absolutely, and I'll tell you what we get.

Damien Gregory

Sorry, Alex. Probably got one more.

Mr Alex Chipperfield

Yeah, absolutely.

Damien Gregory

And perhaps maybe we'll revert back to an anonymous question here and see what your memory is on that statistic. What is the success rate for the operation? Can the operation fail and result in a worse situation than before?

Mr Alex Chipperfield

The success rate depends on how you manage. It depends on how you measure success. If you're looking at patient satisfaction. You're looking at high nineties percent, as in, you know. Are you better? before, after a hip replacement than before. So that's how I would measure success. Do you feel better than you did before you had your operation? The overwhelming majority, 97, 98%, 99%. The answer to that question is yes. Can the operation fail? Yes, it can. Can you result? Can it result in a worse situation than before the operation? Yes, it can, but the chances of that are very rare.

I do thousands of hip replacements. I do hundreds of hip replacements every year, and I have for the last few years. I've done tens of thousands of hip replacement operations in that time. I'd say, of those thousands and thousands of people I've operated on. There will be some who wish they'd never had their operation. But off the top of my head, I can count that number. On one hand, it is very small. It's single digits. It's a very, very low percentage. less than you know, point zero of a percent of people being worse off. But yeah, it can happen.

Damien Gregory

Okay, thank you, Mr Chipperfield, and thank you. Everyone. I'm sorry we couldn't answer all those questions.

Mr Alex Chipperfield

Sorry. I don't mean to end on a downer like that. Really good operation.

Damien Gregory

Yeah. No, absolutely. We saw some of those statistics earlier, which are very, very promising.

If any of those questions hadn't been answered, if you did leave your name, we will be able to reply to you via email. So as a thank you for joining this session, we are actually offering 50% off the value of hip for your initial hip consultation. a callback from your dedicated private patient advisor, an email thankfully, with the recording, with some of those questions that were asked. Treatment, information, and loyalty reward points, as well as updates on news and future events. We'd be really grateful if you could complete the survey at the end of the session to help us shape future events, and if you'd like to discuss or book your consultation, our private patient team can take your call up until 8pm this evening or 8am to 6pm Monday to Friday.

We have more events and webinars coming up on ENT and varicose veins, which you can sign up for via our website.

On behalf of Mr Alex Chipperfield and our expert team at Benenden, I'd like to say thank you for joining us, and we hope to hear from you soon. Thank you, Mr Chipperfield. Thanks.