Damien Gregory

Good evening, everyone, and welcome to our webinar here at Benenden Hospital on hip osteoarthritis. My name is Damian, and I’m your host for this evening. Our expert presenter is Mr Kumar Reddy, Associate Specialist 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 on the bottom of your screen. This can be done with or without giving your name, so please note that the session is being recorded. If you do provide your name, if you'd like to put your consultation, we'll provide contact details at the end of this session. I’ll now hand it over to Mr Reddy, and you'll hear from me again shortly.

Mr Kumar Reddy

Thank you, Damien, for your introduction. Good evening, everyone. I just would like to give you a brief presentation with regard to osteoarthrosis of the hip, what a hip replacement is, and why people need a hip replacement. If I do a brief presentation, it will allow you to ask some questions, and hopefully I will be able to give you reasonable answers today.

I’m one of the surgeons here who is practicing hip and knee arthroplasty for the last 15 years in Benenden and overall my practice has been for the last 25 years and in total I would have done at least approximately 10 and half thousand joint replacements and I’ve been a locum consultant in university college London hospital for a period of 4 years is and where have been having the most experience in doing complex revision surgeries and we're going to talk about the cause of symptoms cause symptoms relating to hip arthritis and the treatments that are available for these type of condition and I’m also going to talk to you with regard to the types of hip replacements that are available and also briefly with regard to the bearing surfaces of the hip replacement.

Benenden Hospital is a leading provider of private hip treatments in Kent. Hip placements are done in laminar flow theatres, and we have an experienced team of my colleagues who will come in on the next slide. Benenden Hospital has achieved high satisfaction rates with its rapid recovery program.

These are our team of colleagues who are well experienced with hip and knee Alex Chipperfield who is now the medical director and he is one of the lead hip and knee orthopaedic surgeon and he has done his first robotic knee in Benenden Hospital you'll be pleased to know which went successfully well the next one is Mr Dunnet who also is a very experienced hip and knee Orthopaedic Surgeon and other one is Matt Oliver and Raman Thakur all of them are orthopaedic surgeons at Kent hospitals and they provide at Benenden the hip knee orthopaedic service and with regard to hip arthritis what is arthritis it is an inflammation of the bone and it is a disease that common affects the joints mainly the hip and knee and these are covered with smooth articular cartilage and over a period of time this get damaged and you're left with areas of bare bone without any cartilage which results in pain and stiffness.

What are the causes? Natural age and familial predisposition are major factors, as are obesity and any trauma-related factors. When you get an injury to the hip or a subchondral fracture following an injury, you can develop arthritis with a high level of impact. Sports are also a contributing factor in the development of arthritis in any joint, the other condition being gout. Rheumatoid arthritis is another common condition where people can develop degenerative arthritis in the joints. The symptoms that one can experience are usually pain, stiffness, and the inability to walk any distance, even short distances, which are becoming a challenge for them. They also express it when you ask them. Having immense difficulty in cutting the toenails, putting the socks on, tying the shoelaces, and getting in and out of the bath and in and out of the car can also be a challenge, and sleep is constantly affected because of the pain. People also sometimes express that they have a crackling sensation in the hip along with weakness in the muscle; they can't lift the leg up because of the stiffness, the muscles would not fire up, and they go into wasting and become weak in clinical examination.

When you do an examination, people will have extremely limited rotational movements, which are again acutely painful with regard to treatment options. You can take pain-relieving medications such as simple paracetamol and codeine and non-steroid anti-inflammatory medications like naproxen, ibuprofen, and naproxen, which can be useful. However, they do have side effects where they can upset your stomach and your kidneys, so one has to be mindful and careful when taking these ones on a long-term basis. Next are lifestyle changes. One can reduce weight by going on weight loss programs and seeing whether we can reduce the weight that would offload the joints. The next one is a steroid injection. Again, these are not recommended on a frequent basis; one or two injections at the most would be beneficial, and there's also a risk of losing the blood supply to the ball of the head, thereby resulting in avascular necrosis. One can put some h and ice pan physiotherapy, heel wedges or special insoles you can use, and also a walking stick. Using a walking stick on the opposite side of the affected hip can also be beneficial, and when all these conservative methods of treatment, including physiotherapy painkillers, steroid injections, or hyaluronic acid injections, fail to improve your symptoms, the next step is going to be joint replacement surgery.

Joint replacement surgery is mainly to relieve pain and improve your quality of life, and with regard to hip replacements, the primary hip replacements are nearly 100,000 that have been carried out in the UK in the last year and are mainly done for osteoarthrosis. I hope you know you're aware that hip replacement surgery is the second-best operation in the world behind cataract surgery, and 96% of the patients are happy with the outcomes of the hip replacement with regard to hip replacement. The hip joint is a ball and socket joint where you got the pelvic bone, which contains a cup-shaped bone, which is called a slum or a socket of the bone, and you got a ball in the thigh bone, the top end of the thigh bone, which is the femoral head, so I can show you in the picture where you can see this is the socket of the pelvic bone, and this is what we call the acetabulum. I hope you all can see in the picture that this is the top end of the thigh bone, and you can see the hip being inserted into this bone. On the top of the neck, you put the ball, which is a ceramic head, or you can put in a metal head. Again, these are uncemented and cemented implants, depending on the surgeon and the patient's choice. The main aim is to relieve the pain, reduce the stiffness, improve your ability to walk, and get back to your normal activities again. Do I need a replacement hip? Certainly, one may benefit when their pain limits their day-to-day activities and also their recreational activities like playing tennis or golf and their walking distance. If it is significantly impaired because of the pain, you would certainly need hip replacement surgery that would benefit you, provided all the conservative methods of treatment have failed to improve your symptoms.

I’ve explained to you earlier what types of hip replacements you got cemented hip replacements where the implants are being cemented and you also have uncemented implants with uncemented implants are usually hydroxyapatite which is a type one collagen that this encourages your natural bone to get on integration and it would binds it like a glue rather than the cement and you also have hybrid top replacements where the socket is uncemented and the thigh bone would be cemented where you put the stem in both have got very good data of the last 30 years and majority of these hip replacements they last minimum 20 years or more and with regard to the timing of surgery that people generally ask how long does it take it normally takes about an hour duration an hour to hour and a half so majority of the patients do have spinal anaesthetic which is an injection in the back to numb the lights and they give you some sedation so that you won't hear any noises of the saw or the hammer usually nowadays the discharges are pretty quick and majority of the patients they stay in the hospital for a day or two and as soon as they're up and about and given a green signal by our physios they'll be discharged home as they are better of being in their home environment rather than being in the hospital so I’ve earlier told you it is basically replacing the arthritic parts of the socket as well as your top end of the thigh bone the femoral head by doing this hip replacement so patients are encouraged following replacement to get up and walk as quickly as possible with the help of a physio and either the same day if I do the surgery in the morning our physios are very enthusiastic in getting up the patients by afternoon and they'll get them up encourage them to get them going and our physios are also there to help you with the regard to the dos and don'ts that you're supposed to do following hip replacement surgery if you got stairs at home or physios or very helpful in making you do the stairs, and once you're safe to go home, only you'll be discharged home with a pair of clutches if you can use them or otherwise a Zimmer frame, and you'll be shown how to use them safely in going up and downstairs.

In general, people do need some painkillers to start off with, especially at night, to get them comfortable sleeping, and usually, within three to four weeks’ time, people tend to get rid of the clutches once they regain confidence. When we do the hip replacement, it's like for patients to develop confidence and to walk again, so once you develop confidence, you can get rid of the clutches indoors quickly and outdoors, I would say within about four to six weeks.

The potential risks and complications of surgery or one deep pain thrombosis which is a 4% and also where you can develop plots in the veins of your leg and sometimes they can migrate into the lung and cause a pulmonary embolism that's one of the reasons why we give each and every patient following hip replacement surgery 35 days of anti-coagulants mainly to prevent thrombosis in the leg or in the lung and again the in risk of infection and I’m pleased and proud to say that Benenden Hospital have got very low infection rates when compared to any other national hospital or national average the other one is dislocation where this is a ball and socket joint the ball can come out the socket and cause a dislocation and in majority of the times the risk is very low probably one in a thousand but when the dislocation occurs usually we tend to treat them very early and to get back in the right place so and one can experience leg length discrepancy one leg can be slightly longer shorter than the other but up to 2.5 cm people can accommodate within few months and if necessary they may be given some insoles in the shoes to match for the leg lens next one is a neurovascular damage people can develop some numbness and also food drop can occur again it's a very rare entity one in a thousand and people can develop per prosthetic fractures while doing surgery and again one when the surgeon come across we tend to stabilize then and there during surgery and loosening of the implants after a period of time these implants can become loose and where we might have to redo them again the loosening of these implants or the incidence is very less in the first 20 years again.

With regard to the NJR, it's a national joint registry. It's a tool to monitor the surgeons and also to monitor the implants that we use. All the implants that have been used in Benenden have been time-tested over the last 30 years, and the majority of the implants last a minimum of 20 years or more. They do have a good adapting with regard to these implants, and even the public can have access to the surgeon's profile, how they've performed in the last 10 years, their volume of surgeries, and their complications, which you can visualize on the NJR. If you wish to see a small, brief video from one of our patients who had a hip replacement, I’m happy to share it with you, so you can if you should.

Jean Woods

I’m Jean Woods, and on January 30th, 2023, I self-paid for a complete hip replacement on my left-hand side. I was in quite a bit of pain; it emanated from the groin, but it was also on my back, and on Sundays, it was down to my knees. Benenden were very good at making contact. I had a series of emails and the preop assessment, and from there everything went very well indeed, but I would like to say that I personally was very anxious on the day of the operation. However, the anxiety reared its head again. Benenden are outstanding and absolutely amazing. The schedule was changed so that I could go into the theatre first, as he said waiting several hours would not help me. It was absolutely excellent. Benenden maintained contact and wanted to know my feelings or thoughts on quite a few issues regarding the operation. I was absolutely staggered at how quickly I was up out of bed, and the physio was there a few hours afterwards. I was actually taught how to use the crutches, and again, people were patient with me. Well, it might seem like a simple thing to some people, but I can actually tie my own shoelaces. It's wonderful to be independent again, but not only that, my life is back to where it was. Benenden will do their utmost to make you feel at ease and help you through this journey from start to finish.

Mr Kumar Reddy

Right, I’m just going to pass it on to Damian before I answer your questions.

Damien Gregory

Yes, thank you, Mr Reddy. Yes, really interesting. Thank you very much. So yes, please use the Q&A icons for questions. We've got some rolling in now, so we've actually got Teresa Morgan. This is the typical question that I’d ask as well. Actually, being a bit sporty, is it better to continue playing tennis with this condition or stop it until it is treated? I don't know if she's referring to a complete hip replacement, but what are your thoughts?

Mr Kumar Reddy

If you do have arthritis in the joint confirmed on the plane imaging, I think any impact activities are going to progress your arthritis, so my recommendation is that if you do have a lot of pain, just wait until you have your hip replacement, and then you can carry on after 3 months. That would be my sincere advice if you have proven arthritis in the hip.

Damien Gregory

Yeah, no, perfect. We've got an anonymous attendee who has asked why steroid injections are not recommended. I think you had a limit on them, didn't you? Why is that?

Mr Kumar Reddy

I mean steroid injections. You can give one steroid injection into the hip, mainly if you suspect early arthritis. It would certainly help in relieving symptoms. The first injection is always the best, and subsequent injections may last about 2 weeks to about 6 weeks maximum, and you'll be back to square one. The risk of giving a steroid injection is that once the pain is relieved, you tend to load them more, and it becomes even more arthritic. The other reason is that there is a risk of avascular necrosis, where the blood supply to the femoral head or the hip joint gets lost and your femoral head can crumble, sometimes resulting in a vascular necrosis of the hip, where you may then need an urgent hip replacement.

Damien Gregory

Okay, understood. Yes, so we've got Jill Horton. She mentions that she had minimum degeneration loss of the left joint cyst. Is this enough for a hip replacement?

Mr Kumar Reddy

Right Jill with regard to this sub condole and impingement for a hip replacement you need to be in significant amount of pain we see with even earlier degenerations you have some subcaudals but at the same time patients come and say that they're happy to live with by taking some paracetamol or so in that case I would allow them to do it but if you got minimal degeneration on the plane r grounds it's worthwhile trying an injection under image guidance or fluoroscopy or ultrasound guidance which may help in relieving the pain but one has to be really realistic that these are temporary measures and in the long term you may well benefit from a hip replacement surgery if you already have got a degenerative process with the loss of joint space and if you got multiple.

Damien Gregory

Right, thank you, Mr Reddy. We got another anonymous attendee who has asked that she doesn't believe she's at the hip replacement stage but never gets through a night's sleep without it being interrupted due to pain through the knees and hips. any advice or preferred exercises

Mr Kumar Reddy

That's why we stand here to help you guys. A diagnosis is crucial for this type of condition. We need to establish if you have pain radiating from your buttocks up to the knee. The first thing we need to do is rule out whether you've got any back problems. Whether there's an impingement of the nerve that is causing you these symptoms, once we establish the diagnosis and once the radiographs or MRI scans confirm that you have significant arthritis, yes, you may benefit from hip replacement surgery, but not until you've been diagnosed where the symptoms are arising from. We have to rule out whether it's coming from the back or arising from the hip.

Damien Gregory

Yeah, okay, lovely, thank you. We've got Kal Malden, who's inquiring about scars and where exactly they are and how big they will be.

Mr Kumar Reddy

It is basically centred around the hip joint, mainly around the prominence of the bone called greater truant, just about 3 to 4 cm distally and 3 cm approximately, I do, and a couple of my colleagues also do minimal invasive surgeries so I don't cut through the tendons like in the past people used to take off the pile form is tendon now we do a spare approach called form is sparing approach and I don't even cut the quadratus so we try to spare it just go and then do the surgery to relieve the need to do the joint replacement so it's a minimal invasive surgery we can get away with the less than 10 cm incision most of the incisions are less than 10 cm

Damien Gregory

Okay, Grand Camila is also asking: How do I know I’m at the stage of needing an actual hip replacement? I’m guessing it would be some sort of pain or something.

Mr Kumar Reddy

Camila Again, with regard to the stages, it's for me to determine your pain and your quality of life. Also, if you're having difficulty cutting your toenails or putting on socks, your sleep is constantly disturbed, and your ability to walk a distance is getting less and less, then it's time for you to have a hip replacement.

Damien Gregory

Okay, thank you. We got another anonymous attendee who's asking, Well, their biggest issue is again pain at night, and their most effective pain relief is co-codamol. It looks like they're taking two every night. How bad is that? What are your recommendations for that sort of dosage?

Mr Kumar Reddy

Yeah, I’m quite happy for you to take a couple of co-codamol at night, but please be aware that it can result in quite a bit of constipation, so it's not a great idea to take it in the long term.

Damien Gregory

Okay, thank you. Kate Macallan is asking, Yes, this is quite a long one. Is there research happening with regards to injections into the hip that put gel or some form of lubricant into the joint to basically help slow down the degeneration, maybe to stop the need for an operation?

Mr Kumar Reddy

There's quite a lot of research going on around the world with regard to injections. Now we have hyaluronic acid injections, where it's type 1 collagen that has been injected into the hips, and we also inject into the knees. There's also prp injections, where they can be used for hip injections, but I cannot see any sufficient significant data to say that this has significant statistics that can help you in the long term.

Damien Gregory

Lovely, thank you. Actually, Kate also asks; she's quite active as well, but maybe not to do the high-impact sports, but would something gentler like Pilates and yoga be okay?

Mr Kumar Reddy

Yes, of course, you can do gentle yoga. These are all very helpful, and yeah, you can do them; it's not a major concern.

Damien Gregory

Okay, thank you so much. So, we've got a question: I’ve been told I have arthritis in the hip area by a physical therapist. I’ve not had an x-ray, have been referred, and have been refused an x-ray. Sorry, my hip is quite mobile, but I have pain down the front of my upper thigh. Does this sound like arthritis to you, or could it be something else?

Mr Kumar Reddy

I think the important thing is to establish the diagnosis here, so if you go if you have a quite mobile hip and if your pain is not in the growing area, then it is quite likely to be arising from the back, so I think it's important that you see a consultant orthopaedic surgeon here or anywhere you like, and to establish the diagnosis. Once we get the diagnosis, your condition can be easily treated with the recommendations.

Damien Gregory

Perfect, thank you. Now we have Nick asking. Nick's 56, and he's been told that he's too young to have a hip replacement, but he's in pain and knows he will need one. What are your thoughts? Is he too young?

Mr Kumar Reddy

Again, Nick, for me, it is establishing the diagnosis. If the radiograph shows that you have advanced arthritis in the hip, it is not unreasonable for you to have a hip replacement surgery because it will improve your pain and quality of life. I know people are concerned with regard to the age because my youngest hip that I’ve done was 32 years of age, a patient who had gone for the London Marathon, and she couldn't unfortunately walk following this, and she came with the avascular necrosis where the hip had crumbled, so the only way I could get her back on her feet was to do a hip replacement with ceramic bearings because they tend to give long-term survivorship rather than metal heads. So, in your case, once the diagnosis is established, you're 56, and we get the technology, and when it wears off, we can redo it again, then leave it as long as possible. If you can't, then it's time for you to have it done. People are apprehensive about recommending hip replacements in young patients because you distribute a lot of cycles of stress through the joint through the artificial joints. So, in cases where revision surgery is complex, this can be done. We have the technology nowadays to do revision surgeries, so it can be doable. So, if you're in a lot of pain, by all means, do not hesitate to seek a consultation from the consultant orthoptic surgeon.

Damien Gregory

Lovely, thank you. We've got Anne Foe, who explains that x-rays are showing that she has, or they have arthritis in both hips and knees. Which is preferable, the hip or the knee replacement?

Mr Kumar Reddy

Normally, if you have arthritis in both hips and knees, my recommendation would be to do the hip first, and then we go for the knee, so the majority of the pain if we do the hip would also be relieved from the knee, so that's why we tend to do the hip first before we do anything to the knee.

Damien Gregory

Perfect Thank you, and we've got Todd Elliot. How aware are patients while being operated on? I was actually quite interested to learn that I assumed it was a general anaesthetic, but after seeing.

Mr Kumar Reddy

Yeah, it's an interesting question. I mean, I only had about three patients who asked whether they could watch the surgery while I was doing it. We do have monitors in the theatre; if they're really interested, we can put the monitor up so they can be awake and watch the surgery, but only two patients out of several thousand patients have asked for this. If you don't want to hear any noises, you'll be sedated, and you can also have general anaesthesia. It's no problem, but the majority of these surgeries are done by injection into the back with spinal anaesthesia, where they numb the legs and give you some sedation to go to sleep.

Damien Gregory

Okay, thank you. Camila Malden's back is asking a question and asking roughly how long a hip replacement would last.

Mr Kumar Reddy

Camila With regard to hip replacements nowadays, because of the improved nature of the implants, the majority of them have been lost; 95% of them last; they're lasting about 25 years or more; and the data we use here shows that their survivorship is about 95% of 20 years.

Damien Gregory

Okay, thank you, another anonymous attendee, and actually, I think you half answered this earlier, and again, it relates to the longevity of the joint. If ceramic is better than metal, wouldn't we all wish to have ceramic?

Mr Kumar Reddy

Of course, yes, that's what my practice has been for the last 20 years. I always do a ceramic head on a crosslink poly bearing because I believe the ceramic heads, and the evidence has shown that the ceramic heads do survive and have long-term survivorship better than the metal heads. Of course, yes, you do need a ceramic head.

Damien Gregory

Okay, perfect. Okay, thank you very much. Well, yeah, I think that's all the question, so yeah, thank you very much, Mr Reddy. If we could just move over to the last slide, that would be excellent. So, as a thank you for joining this session, we are actually offering you 50% off your initial consultation. A call back from a dedicated private patient team advisor and an email with a recording of the session and further information and updates on news and future events.

We'd be grateful if you could complete the survey at the end of the session to help us shape future events if you'd like to discuss or book your consultation. Our private patient team can take your call until 8:30 this evening or between 8 and 6 Monday to Friday using the number on the screen. You can also book your consultation on our website with the discount code HIP50. A link to the book will appear once you've submitted your survey response. Our next webinar is on knee replacement surgery, which you can sign up for via our website. On behalf of Mr Reddy and our expert team at Benenden Hospital, I’d like to thank you for joining us and hope to hear from you soon.