Webinar: A guide to hip replacement surgery

Learn more about hip replacement surgery from our experienced Consultant Trauma and Orthopaedic Surgeon Mr Matthew Oliver.

Watch our hip replacement webinar with Mr Matthew Oliver

Learn more about hip replacement surgeries from our experienced Consultant Trauma and Orthopaedic Surgeon Mr Matthew Oliver.

Please note that any discounts advertised in this video are exclusive to attendees and registrants of the live event

Hip replacement webinar transcript

Vicky Hawkes

Okay, good evening, everyone. Welcome to our webinar on hip replacement surgery. My name is Vicky, and I’m your host this evening. Our expert presenter is Mr Matthew Oliver, Consultant Trauma and Orthopaedic Surgeon. 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 by using the Q&A icon, which is at the bottom of your screen. This can be done with or without your name. Please note that this session has been recorded. If you do provide your name, if you'd like to book your consultation, we'll provide contact details at the end of the session. I’ll now hand it over to Mr Matthew Oliver, and you'll be here for me again shortly.

So we move it on, there we are, so that's me, and I’m going to talk to you this evening about the hip replacement and everything involving it, so including this session is all about me to start off with then about Bon Hospital and my expert orthopaedic consultant colleagues that work here with me. We'll then talk about the causes, symptoms, and treatment of osteoarthritis of the hip. I then spend quite a bit of time talking about hip replacement surgery and what's involved, the different types of hip replacement, the surgical journey, the recovery process, the risks and benefits, and then we'll finish off with some information about patient support tools that are available to help you with your decision-making and to help you review the various surgeons that you may wish to use to do your hip replacement. Finally, there is the question-and-answer session, so I look forward to taking those questions later. I was appointed as a consultant trauma and orthopaedic surgeon back in 2010 at East Kent Hospitals. I started working here at Benenden in 2012 I’ve been on an intensive Orthopaedic fellowship at the university of Calgary in Alberta Canada between 2009 and 2010 where I was fortunate enough to work for six very experienced world-renowned hip and knee Surgeons it was a fantastic experience seeing how the health care system works in a different country and I carried out quite a lot of hip and knee replacements and revision surgeries on this trip when I returned to east Kent in 2010 I started off my hip and knee practice and I also had to carry out quite a lot of hand surgery in the beginning but that's sort of tailed off these days and my prime focus is now on primary hip and knee replacements I do double the national average of hip and knee replacements per year, according to the national joint registry. The average hip and knee surgeon does about 50 to 55 of each of those operations per year, and I’m averaging about 200 or so. According to the NJR report in 2022, my stats revealed that I’d had four primary hip replacements revised in 12 years. The latest report of 23 actually says it's five. Interestingly, all of these hip replacements have been of the cementless or uncemented variety, and I’ll allude to a bit more detail about that later.

The first thing to say about Benenden Hospital is that it's rated Outstanding by the Care Quality Commission. It's very difficult to achieve that outstanding rating, and there are very few hospitals that have managed to hold on to it year after year. I definitely agree that it's a leading provider of private hip and knee replacements in Kenton, probably in England and wider. Certainly, in the last year, we managed to replace just over a thousand joint replacements, including hips and knees. It's certainly a very clean and calm environment here. There's an excellent work ethic across the board, from the porters, the cleaners, the kitchen staff, the nurses, the scrub team, and the administrative staff. the preassessment Everybody is very happy to come to work and provide excellent service. On top of that, you have very experienced physiotherapists, and my orthopaedic colleagues here also have a wealth of experience in lower limb degenerative conditions. Consistently, the hospital achieves really high patient satisfaction rates, and this is evident from Day, which is an online platform where patients can leave reviews about the hospital in general, individual reviews about surgeons, treatments, and tests, and invest investigations that they've had done right from the offset. Since I’ve started working here, the hospital has followed the rapid recovery protocol for hip and knee replacements. This is a multi-disciplinary approach to really making the patient journey as comfortable and smooth as possible, and it involves the physios. The anaesthetist, the preassessment team—everybody's involved, and I’ll elude a little bit more about that later, so here's an example of the DOI feedback. There's much more on the Benenden Hospital website if you wish to have a look, and some of us have live profiles on Doctify, the actual website itself, where you can read a bit more information about the hospital and the surgeons.

These are my colleagues. There are four of us; we've all worked together in the NHS and recently left the NHS, but he's still very much part of the team with us here at Benenden. We've got a wealth of experience amongst the five of us, doing quite a large, high-volume number of hip replacements every year.

So the condition what causes osteoarthritis at the hip well it's a wear and tear condition really it causes the joint to gradually become painful and stiff there are some risk factors that bring the condition on age is one of them but that's not necessarily the case when I’ve replaced broken hips when the person's had a fall some of these patients are in their 80s and 90s and when we remove the ball from the hip joint we're fascinated to see that it's actually in tip top shape it's the bone that has failed rather than the joint that has failed that has required them to have either half a hip replacement or a full hip replacement so you can go throughout your life without really being bothered by hip arthritis but that's lucky Being a female unfortunately slightly increases your risk of getting an osteoarthritic hip. being overweight or obese definitely increases your chances because you're putting more weight through the joint and it will wear out quicker you can injure your hip for a sports injury as a younger person you can chip the bone damage the cartilage tear the lining of the joint known as the labam and if it's left untreated because you just think it's a bit of a groin strain then that can act as a nidus for the problem to develop later in life there are other causes of the hip failing and becoming arthritic as well such as avascular necrosis which is when the blood supply to the femoral head becomes temporarily disrupted and sometimes permanently disrupted that causes the bone to die and the articular cartilage above the bone has no scaffold to support it so it collapses inwards and the head becomes deformed and misshapen and very painful Inflammatory arthritis such as rheumatoid sciatic arthropathy and gout can also give you an arthritic hip, but we don't see very much of that these days because those conditions are so well treated with medications.

So the symptoms of osteoarthritis of the hip are: The first thing I believe people notice is just a general feeling of stiffness in the groyne. They may be seated for a while watching a movie or having dinner, and when they get up, they just have a slight catching sensation and feel that the hip is a little stiff, and then it momentarily passes and everything's back to normal again. Some people present with a feeling of like a groyne strain and want to go and have some physio, and it sort of settles down, but as the condition develops, the pain gradually increases, the stiffness in the joint increases as well, and you'll notice that you can't do some things that you could have done in the past easily, such as put on your shoes and socks and clip your toenails, get in it out of a car, and run up the stairs. Things like that: as things move and progress, you'll notice that you'll start to walk with a limp, and you won't be able to take part in more vigorous activities such as a hike, walking around the golf course, or other sorts of strenuous activities. If you leave your hip too long, you'll be significantly hampered by it, and you may notice it making all sorts of funny noises like a grating or crackling sound that's usually quite an advanced osteoarthritic picture. Those patients don't necessarily have that much pain in the groyne anymore; the pain is transferred to the knee joint of the same limb. One thing that you may also notice is that there's some wastage of the muscle around the buttock and the proximal thigh muscle because you're not moving the hip as well as you once did. These are the symptoms of osteoarthritis of the hip.

The treatment options are many. The main ones to start off with would be lifestyle changes, so modifying your activities, doing less sort of heavy duty exercise, more light load-bearing exercises, stretches, walking on the flat, no heavy lifting, twisting, and things like that. Also, you could look at your diet and try to lose some weight. Pain medication is available, and you can start off with the basic over-the-counter stuff like paracetamol and then gradually climb up the pain ladder, getting prescription-only medications. The ones that we commonly see patients use are co-codamol and naproxen. These are good analgesics that take the edge off the pain and keep people quite mobile, but eventually they stop working or will become less effective. opioids, or opiate Morphine-based analgesia should only be used as a last resort. It usually means that the hip is extremely arthritic and the patient urgently needs to be reviewed. I wouldn't want my patients to be on morphine by the time I get to see them for the first time. steroid injection I don't use these very regularly as a pain-relieving modality; I use them for diagnostic purposes in my practice. Some of my colleagues do use them, though, and they inject the hip under x-ray control in the theatre. You can also use an interventional radiologist these days to inject the hip. For us down in the radiology department, there's steroid injections. If you do have one, you can't really have a hip replacement for six months, as scientific evidence suggests it increases the risk of getting an infection if you have a hip replacement too soon after these injections. tens machines I don't really have much experience using tens machines in my practice, but I can understand that they theoretically may help with hot packs and ice packs. Certainly, a heated pack is quite soothing after a busy day if you've got a throbbing joint. Ice packs are more commonly used after the hip replacement to take the swelling down. There is definitely some benefit in using a stick held in the opposite hand on the opposite leg, so if you've got arthritis in the left hip, you hold it in your right hand. This reduces the joint reaction force through the polyleg and, therefore, takes quite a bit of the discomfort away. Physiotherapy is important to keep the musculature around the hip joint in good condition and to keep it as flexible as possible. Eventually, the patient will require hip replacement surgery, so the better the muscles, the better the condition the muscles are in preoperatively, the swifter, and the better the functional outcome will be postoperatively. The term that's been coined is prehabilitation, and I'll talk about that a bit more in detail later. the joint fusion procedure I haven't done that as a consultant. I’ve been involved with one or two many years ago in my training, but it's very rarely done these days. Hip replacement is such a reliable functional operation to sort out hip pain that nothing else really is required, so this is an interesting slide with some demographics on it. I was just thinking about this the other day in preparation for tonight, so 47% of hip procedures or hip replacements were done in independent hospitals in the UK in 2022, according to the national joint registry. I think that's partly due to the recovery from the COVID pandemic, where a lot of hip replacements were transferred to the independent sector because NHS waiting lists were, you know, very lengthy and they still are in some trusts, but also I think it's due to the fact that a hip replacement and a knee replacement are very suited to an independent hospital and the processes and pathways that they offer. It's a good environment to have the procedure done in an elective unit, usually with all the whipping noise of trauma and headaches of bed allocation and emergencies all removed. It's a calm and controlled environment to come and have what is essentially an attire change sorted out for you.

So nearly 100,000 hip replacements have been performed in the UK in 2022 again according to the National Joint Registry so it's a very common procedure it was coined the operation of the century at the end of the last millennium the total hip replacement because it has provided such instant gratification to so many people that were crippled prior to having the operation he got them out of the wheelchair has got them to ditch the crutches and the stick and to get back to a good quality of life it's also been voted the second best operation in the world according to studies that looked at quality life years this is a quantitative and qualitative study that works out the benefit of an operation to someone with giving them their life back so to speak the top one I always thought was cardiac surgery followed second by cataract surgery and then hip and then knee but I’ve I stand corrected if this statement in front of me says it's the second best certainly in the top four anyway and I agree that the vast major majority of patients are very happy once they've had their surgery performed you can see that the number one indication for a hip replacement is osteoarthritis or the wear and tear condition 91% of our patients have this condition; the other percentage is due to trauma. 5%, and the other 4% are rare oddities such as avascular necrosis or inflammatory arthritis. 60% of the cases are ladies, and the average age is about 68–69. The average body mass index is 28.7. I think this is on the rise, sadly, and we need to try and get a message out to primary care of health prevention to try and keep the body mass index in check.

So what is a hip replacement? There's a very basic diagram of one there, showing you all the relevant parts. so you have a shell or an acetabular component that's usually in the modern era made of titanium and it has a grit blasted surface of hydroxy appetite on it or plasma and that encourages your natural bone to recognize it and then your natural bone grows into it over period of few months while that process is happening it has to be pressed fit firmly into the natural acetabula socket and we prepare the socket carefully to ensure that happens inside the shell or the acetal component goes a plastic liner the one that I like to use with the g7 shell here at Benenden has vitamin e in it and that's supposed to sweep up all the free radicals in the area which helps preserve the plastic or polyethylene and means that it doesn't corrode or degrade so quickly and then you have the femoral stem that's normally made out of titanium if it's a press fit stem and again it's coated in hydroxyapatite or boric coating the stems of the for cemented use are usually made out of cobalt chrome and they have different femoral heads. The ones that are commonly used here at Benenden are made out of ceramic. You can also have a cobalt chrome or a metal head, and they come in various sizes depending on the size of the socket used. So how do you know if you need a socket replacement? Well, it's the light bulb moment. Basically, you all know the bad days outnumber the good. Your quality of life is on the slide; you're not enjoying your activities; you can't go dancing; you can't play golf; you can't really walk very far; you're taking painkillers regularly; you're limping; and you've got pain at night. All of these are criteria to consider going to the next step if you have any indecisions.

There are some decision-making tools available out there, and one that I use in the clinic is called the Oxford Hip Score, which is a validated scoring system that looks at the function of a patient with an arthritic hip and just gives you yard stickers to where you are on a spectrum. If you score 48, then you're in tip-top shape; if you're scoring 10 or less, you're likely to be wheelchair bound, and some scientific research has been done to suggest the optimum score to consider having a hip replacement; it's around 26 to 28, so these are the types of hip replacement. I’ve already talked about this a little bit, but a bit more detailed, so the picture of the pink femoral head—that's a ceramic femoral head—and the implant there is called the coral pinnacle hip replacement implant, which is commonly used here at Benenden. It is made by the company Pew and is freely available throughout the world. It's an extremely popular hip replacement with excellent clinical heritage and survivorship. It is a press-fit hip, and it rests on the cut top of the femur with that collar that you can see there, and that gives it rotational stability, and over time your bone bonds with it. The other hip on the shiny hip on the top left of my screen is a cemented hip replacement. There's a highly polished stem there, and I think that's the hip. As you can see, it's got a little centralizer on the bottom there to ensure that it goes in the correct position in the patient's femoral canal, so the cement goes around it in an even manner. That's known as a cement mantle. The other hip replacement used here regularly at Benenden is the taper lock system with the G7 shell. That's my favourite one, and that's been around for many years with excellent clinical survivorship. We decide whether we should cement or use an uncemented hip based really on how good the patient's bone is, whether the patient's bone is parotic or soft, and that's quite commonly the case with ladies over the age of 65. Due to the changes that happen at the menopause, your body's bone density gradually reduces, so it's a best practice, according to various guidelines like the National Institute of Clinical Excellence, to use a cemented stem. The shell doesn't have to be cemented; you can still have an uncemented press-fit AET component that works well.

So what's involved during a hip replacement you have to have an anaesthetic usually it's a spinal anaesthetic where you have a needle in the back which numbs you from that level downwards you then offered sedation and you can be completely out for the count or completely awake or in between it's up to you and you just need to relax, your anaesthetist will be by your side throughout it takes about an hour or an hour and a half depending if you use a cemented femur because it takes about 12 minutes for the cement to set you're in Hospital for about one to two nights and you can see on that thigh there the surgical scar so what's involved during the surgery so once you're anesthetised you're positioned carefully on the table lying on your side and you're held in place by pelvic positioners that stabilize your pelvis so it doesn't move we then approach the hip with a surgical approach and the various ones to those that have practiced here at Benenden that's dependent on the Surgeon's skill and their preference they all essentially have the same aim and that is to get into the hip joint safely so we can dislocate it safely without causing any further harm once the ball is dislocated out of the socket it is removed with a saw and then we start the preparation of the acetabulum by tying up all of the cartilage that sits around the rim of the acetabulum that's called the loom we then use stepwise greater remaps to gradually increase the size of the acetabulum and the shape to ensure its hemispherical and then we put trial components in and so we have a tight press fit and when we're happy that it's a tight press fit we put the real component in and carefully position it so it's not it has to be positioned extremely carefully because if it's too open or closed or pointing the wrong way it can cause the hip later to dislocate once we're happy with that we then click in the plastic liner and move our attention to the femur the femur is prepared in a similar manner using stepwise progressive sizes of broaches to shape the femoral canal to get a press fit if we're using uncemented hip or to get a reasonable press fit for the trial femoral component if we're going to use a cemented hip once we've got the trial femur in place we then try different offsets that means looking at different femoral neck angles to ensure that the muscle tension in the hip is balanced and like the native hip once was we want to try and replicate the native hip by biome mechanics we then pop a ball on top of the offset trunnion and then reduce the hip back into the new socket it's then put for a range of motion to make sure it doesn't dislocate leg lengths are checked and muscle tension is checked and if we're happy we'll ask our scrub nurse to provide us with the real deal which are the sizes that we've just tried and then they'll be fixed in place either tapped in if it's uncemented or grouted or cemented in if it's a cemented hip replacement so here's some post-operative x-rays The pelvic x-ray showing both hips reveals a hybrid hip replacement on both sides. the femoral stems have been cemented in place and the sockets or acetal components have been press fit you can see that the light grey fluffy sort of appearance around the white femoral stems that's the bone cement and there's good inter digitation there with the bone and the implant and you can see that the components are well positioned and there's no fresh air between them and the bone behind them so they're firmly fixed in or press fit in and on the other side that shows you the coral pinnacle hip replacement which is the uncemented version you can see the collar at the top of the femoral component resting on the top of the femur that gives it initial rotational stability and stops it from sinking while your bone grows into it so the recovery period well if you've had your operation in the morning it would be fantastic by lunchtime or just after lunch to take your first steps and the physios will be keen to try achieve this with you your first steps will be with a frame and then you'll rapidly progress to crutches and you should have confidence that you should be able to put full weight through the hip once your leg has woken up you will have some discomfort but the modern anaesthetic techniques mean that it shouldn't be too bad the first day or so most patients in the recovery we after the operation have an extra injection placed into their hip joint known as a fascia area block which prolongs the pain relief following the spinal anaesthetic and it works really well physiotherapy will then progress you for a series of different exercises where we'll wean you off the frame to crutches you'll be doing the stairs and shown some exercises to do on the bed you you'll have an x-ray on your first postoperative day hopefully as well as a set of blood tests to make sure that your full blood count and your kidney function are all satisfactory You should be eating normal food again and being quite comfortable. Pain relief is available on your drug chart, and you'll be nursed one-on-one. You should receive physiotherapy at least twice each day that you're on the ward with us here. Your surgeon should see you on the first postoperative day as well, along with the resident medical officer that looks after the ward. We'll only let you leave once you're safe, and we'll provide you with some extra kits, such as a toilet seat raise, a frame, and crutches if needed. As mentioned earlier, you will be shown how to safely go up and down the stairs. It's ideal that once you get home, you've already organised some physiotherapy, depending on what pathway you've chosen to go through with Benenden to get your hip physio, and if you live reasonably locally, you'll be able to use the physio service here. If you're more out of area, I’d certainly recommend either through your NHS GP or, if you can do it privately, setting yourself up with a physiotherapist for one-on-one from about the first week or so post-do, just seeing them once a week to check in to make sure you hit the milestones. It really does make a big difference. You should be starting to wean yourself off the painkillers after the first couple of weeks; however, in the first couple of weeks, especially, you'll feel very tired, and this is the time to just recharge the batteries. Eat and drink well, and just concentrate on your exercises. You'll notice that your legs will be swollen, and you'll be bruised from your buttock, sometimes all the way down to your little toe. That's quite normal. It's partly due to the trauma of the operation and partly to the blood-fining medication that we give you for a couple of weeks to reduce the risk of deep vein thrombosis. I use these mobile stitches in my practice, so I’d require my patients to just have the dressing changed for about seven days at their GPs for a fresh one, and then you shouldn't have to worry about anything else after that because the stitches will just dissolve. By six weeks, you should be walking around the house with a crutch or furniture, and outside, you're probably still on a crutch or two crutches. You should be able to start driving your car again, and you'll have a follow-up appointment with your surgeon where you have your wound checked and your milestones checked to make sure you're progressing satisfactorily. I would say it takes a minimum of about three months to get over the hip placement to enable you to return to activities such as playing golf swimming and more energetic activities so a life after a hip replacement is pretty good on the whole there's always going to be a few patients that unfortunately have some chronic pain but the l the vast majority of people their lives are transformed and they're so much better you have to be a little bit careful with some of the activities that you do especially if you put your hip in positions that risk it dislocating however with the modern hip implants and good surgical technique I’m quite happy to remove actually all hip restrictions and precautions after about six to eight weeks high impact activities and I’d count those I guess as contact sports and skiing are certainly at the patient's own risk and it's a risk stratification exercise really you have to remember that it's an artificial implant and it can only take so much if you look after it will hopefully look after you for many years.

So the risks you have the usual surgical risks of blood clots in the leg and the lung DVT and PE so we give you blood thinners river oxen usually for a month loosening of the joint means it wears out but with modern implants you should get at least 15 to 20 years of longevity everything being equal it can dislocate so it's down to surgical technique making sure the implants are appropriately positioned in the correct size and it's down to the patient not cutting corners and doing anything too silly in the first few weeks there is a risk of leg length discrepancy it normally can get your leg within about a centimetre of the upper leg sometimes it has to be lengthened if the muscle tension is poor but that's usual unusual infection is a risk The national average for a deep infection of a hip joint is just over 1%, and I’d say at Benenden it's closer to zero than 1%. this is an extremely clean environment to have your hip replacement carried out in and very low rate of infection you can get some damage to nerves which can cause a foot drop that normally recovers you can bleed and may need to have a blood transfusion but it's unlikely these days the bone can be broken during the operation but we have the kit on the shelf to deal with this if we have to you can also break it if you're to stumble and so you have to be extremely careful in the first six weeks revision if you're around the age of 70 and you have your hip replacement and everything goes to plan it's unlikely that you'll need to ever worry about having a hip revision but unfortunately sometimes you can get an infection elsewhere in the body that travels to the hip that causes it to go wrong and in the younger generation sort of the 50 to 60 year old group where they're more active on their hip it is likely to not last them their lifetime that said there are some hip replacements that are in people that are 40 plus years old now and they're still going strong these are the decision support tools that are out there in the public domain you can look us up on the NJR Surgeon's profile that's going to have more information added to it as it evolves but you can look at our mortality rates it should be almost zero for elective surgery you can see the volume of operation that we carry out and where we operate and other sort of demographics are on there then you have the private health care independent network or fin this has evolved over the last four or five years and you can now look at the Surgeons reviews on here now and where we work and our prices and there's a lot of information on there and then you've got the various review sites such as top doctors iwantgreatcare.com and then finally you've got the web address there you can see that takes you to a scoring question and answer tool that helps sort of make your mind up whether you need a hip replacement or not so now we're going to move on to the question and answer session I hope you found that informative and thank you for listening so far.

Vicky Hawkes

Thank you, Mr Oliver, for that interesting presentation. We will take some questions, so we've got time, so please do ask away.