Damian Gregory

Right, let's begin. Good evening, everyone, welcome to our webinar on hip osteoarthritis treatment. Now, my name is Damian. I'm your host for this evening and I'm joined by Consultant Orthopaedic Surgeon, Mr Raman Thakur.

Now, this presentation will be followed by a question-and-answer session, so 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 screens. Now, this can be done with or without your name, but please note the session is being recorded if you do provide your name.

So, if you'd like to book your consultation, we’ll provide contact details at the end of this session. So, I'll now hand you over to our expert and you'll hear again from me shortly. Mr Thakur.

Mr Raman Thakur

Thank you. Hi, good evening, everyone. I'm Raman Thakur, one of the orthopaedic surgeons here at Benenden Hospital. I do hip and knee arthroplasty.

In this session, we will cover my experience, a bit about the hospital, talk a bit about the team here at Benenden Hospital and then delve into hip osteoarthritis; what causes it, how we treat it, hip replacement surgery, both looking at the surgical - understanding the surgery itself, understanding the reasons why we do them, what are the types of hip replacements and the pathway and the process around the surgery and recovery. What’s available, what are the risks associated with surgery and what are the support tools available for you, the patient.

So, my orthopaedic career started in India. I was based and I come from Hyderabad, which is in South India, and I did my masters in Orthopaedics there. I moved to the UK and joined the training rotation in South East England - Guys and St Thomas's rotation.

Having completed my training here, I did a year's Fellowship in hip and knee reconstruction in New York. I've been a Consultant hip and knee Surgeon practicing in Kent and at Benenden Hospital since 2012. My specialties include hip and knee replacement surgery, robotic knee replacement and ACL reconstruction.

Benenden Hospital is a leading provider of private hip treatments in Kent. The CQC has awarded Benenden an ‘Outstanding’ rating for a clean, calm and professional environment with an experienced team of orthopaedic surgeons and physiotherapists - and there's a high patient satisfaction rate. And we do use the rapid recovery programme.

The hip arthroplasty team includes myself, Mr Alex Chipperfield, Mr Dunnet, Mr Matthew Oliver and Mr Kumar Reddy. We have five consultants working as a team here.

Hip arthritis or osteoarthritis is a condition that causes the joints to become painful and stiff. There is higher prevalence of arthritis as we grow older and is slightly higher in ladies compared to men.

Obesity is certainly known to predispose to arthritis both in the hips and knees. The majority of the younger population who develop arthritis could be due to a how the hip has developed and hasn't developed completely normally and might have had impingement or other problems, which could predispose, or dysplasia which can dispose certain individuals to developing osteoarthritis at a much younger age.

But, by far, the majority of people we see and operate on are between 65 to 85 age groups. Any history of injury to the joint - whether from a road traffic accident or fractures around the hips - can also subsequently predispose this joint to develop post-traumatic osteoarthritis in the hip.

Non-osteoarthritic conditions such as inflammatory causes, including rheumatoid arthritis and ankylosing spondylitis and gout could also subsequently damage the joint and be indications for hip replacement. Thankfully the treatment for rheumatoid arthritis has become so good with medical management that the incidence of hip replacement just for rheumatoid arthritis has declined considerably in the UK.

How does osteoarthritis present? Pain, which is progressively getting worse. Arthritis does have a waxing and waning situation; it can be cyclical just like (for an analogy) cycle of the moon - having a New Moon, full moon or various phases of the moon. Similarly, arthritis can be really very painful, intrusive, disabling or it can be minimally aching pain and you can have variations on that, with some days being really bad and some days being good. And you might be surprised sometimes, that where it has been really bad, in a few months’ time that hip actually does not seem to hurt as much and you wonder whether the arthritis is gone, in fact.

It is that peculiar nature of the arthritis that it does that waxing and waning symptoms. It can produce pain in the groin region, pain around the side of the hip or in the buttock with pain radiating down the thigh, sometimes to the knee and also beyond into the foot and ankle.

People often complain of difficulty in putting on shoes and tying shoelaces, socks and cutting toenails. Activities of daily living such as climbing stairs and slopes can also be affected, and walking distances are significantly reduced. It can, as symptoms progress, it can also affect sleep and people notice particularly when they move around in bed.

As arthritis progresses and it becomes more severe, then grating or cracking sensations and sounds can be produced from the joint. As the function declines, then weakness and muscle wasting around the hip is fairly noticeable. And part of the progression of arthritis will lead to gradual stiffness and restricted range of movement in the joint, which would be the ones that are responsible for getting the foot into the right place and difficulty with day-to-day activities.

How do we manage arthritis? Obviously, one would like to avoid surgery for as long as possible and manage this non-surgically, and the treatments include pain medication, hot and cold ice packs, physiotherapy and using a stick can definitely relieve the pressure on the hip and some other joints and make it more tolerable to walk longer distances. With a stick, if one uses it on the opposite side, as it spreads out the load and reduces the pressure on the on the affected hip. Pain relieving medications, paracetamol, anti-inflammatory medications can help and also sometimes a TENS machine seems to help some patients with early arthritis.

If there are obvious other conditions, like plantar fasciitis or some foot deformities, having special footwear and insoles or can help make this easier and reduce the pressure on the hip again. From a surgical perspective, hip replacement surgery is the norm in most modern situations. Joint fusion used to be quite common back about 30 years ago, but this is now extremely uncommon and rare option as a primary surgical treatment of arthritis.

Hip replacements. Over 99,000 to 100,000 primary hip replacements have been performed in the UK since 2022 and 2024. 47% of these were performed in the independent hospital sector. It has been labelled as the second-best operation in the world behind cataract surgery to improve the quality of life of patients. 96% of patients have been reported to be happy that they had the surgery performed. So, 5% of these operations were performed for patients with acute hip fractures and over 91% were performed for osteoarthritis.

The hip replacement itself is made of the femoral side and the acetabular side, which is the ball and socket. So, the ball is essentially on the top of the pin and the pin is inserted into the femur. And, at the top of the pin, is the ball - which can be either a metal or a ceramic ball. On the socket side, you have a metal socket with a plastic liner which then accommodates the ball and then it moves as a ball and socket joint. It helps relieve pain, reduce stiffness and increase the movement around the hip and the ability to walk.

Hip replacement becomes more likely and a beneficial operation when severe pain in osteoarthritis is affecting day-to-day activity and walking distances are severely restricted due to significant pain. And then having moderate or severe hip pain while resting either during the day or night and there is stiffness and inability to bend or reach your foot and associated with pain along with occasionally a hip deformity.

What are the types of hip replacements? We have the materials which are the bits the prostheses are made of, which is the metal, the plastic and the ceramic. The ceramic is usually for the ball and the plastic is for the socket and the metal are the two sides of the socket as well as the pin, where we use either a cobalt chrome alloy prothesis (which is used in a cemented prothesis) or a titanium prothesis which is used primarily in uncemented hips. And using a choice of either cement or uncemented prothesis is usually a choice for the surgeon; slightly different philosophy and the outcomes of either a cemented or uncemented hips are essentially similar.

The operation lasts approximately an hour in duration, and I would say - though it says 70 to 80% - I would say over 90% of my patients have it done under a spinal anaesthetic, which is an injection of anaesthetic in the back, causing and making numbness in the legs. And along with that, usually patients are sedated to keep them comfortable and mostly unaware of the operation.

Patients usually spend one or two nights in the hospital post-surgery. The criteria for going home or being discharged, are that patients are safe and mobile, walking with the help of crutches independently and have done stairs and we are happy that the wound is clean and dry. Obviously, secondary to all the incisions and deep tissue cutting, there will be scarring both from the skin and also the deep tissues which can occasionally be responsible for some ongoing pain in patients.

This is an example of an x-ray. On the left side is a hip replacement done on both hips, which have been done using a cemented femur prothesis and an uncemented acetabular cup. So, you can see that there is a bit of white out in the canal on the femur here, around the prothesis and that is where the bone cement has been used. Whereas the X-ray on the right you can see is an uncemented prosthesis both on the femur and the established side. And the way this works is that the bone grows into the prosthesis and integrates. Initially it is a pressfit prothesis.

So, both work well, both have slightly different philosophies but in terms of functioning both do very well.

On the hospital pathway and hospital stay. The aim - and the reason why we want people to get up and walk as early as possible - is because it increases the well-being, it increases the chances of having less complications like chest infections, water infections, get things working more normally. So, the idea is to try and get up and move as quickly as possible after surgery. Sometimes if we do the surgery in the morning and if all the effects of the anaesthetic are worn off, then you’re able to walk on the same day as the surgery. There will be some discomfort in the leg, and swelling of the feet and leg is a fairly common occurrence.

Your Physiotherapist will be there monitoring and guiding your rehab to help your mobilisation as well as strengthening exercises for the hips and giving instructions about the do’s and don'ts following hip replacement surgery.

The average hospital stay, as mentioned before, is one to two nights and the wound takes about 2 weeks to heal. Most people discard their walking aids by 4 weeks and tend to start getting back to normality at about 6 weeks, however full recovery can take anywhere from 3 months to a year.

So, we mentioned this before; when do we discharge patients? Once we are happy that it is safe, frames or crutches are provided to safely negotiate stairs. And after about a week it says most people can walk independently with sticks or crutches

How does it evolve over the few days to weeks to months? Over the two-week period, usually it is a bit sore, so painkillers are provided and there can be some visible bruising because patients are on blood thinners to reduce the risk of blood clots. So, the blood is a bit thin and there can be more visible bruising which can extend down the knee, down to the ankle sometimes. Some surgeons use staples, and they need to come out at two weeks. And progressive exercises too as per the advice of Physiotherapist.

At 6 weeks most people are able to walk inside as well as briefly outside the house, and once you deem yourself as safe behind the wheel then you can start short distance driving. And your follow-up appointment is at 6 weeks. By 3 months most people would feel the benefit of surgery and start returning to normal activity and follow the advice and exercises as per the physiotherapy regime.

Most people experience reduction of pain. Over 95% of people are pleased and happy with the outcome of surgery; it allows patients to return to most of the normal activities of daily living but is not something that would be suitable to get back to active sports or heavy labour. High impact activities can actually hasten the wear process on your prosthesis and therefore it may not be an appropriate procedure for achieving those type of activity levels.

The precautions which we usually recommend to avoid hip dislocation are bending further than 90°, crossing your operated leg or turning the operated leg and hip inward. And those precautions will certainly be there for a minimum of 6 weeks and sometimes up to 10 to 12 weeks. This is what we are worried about, as one of the potential complications. The x-ray shows a dislocation of the hip. Other things which are probably more common than the dislocation is blood clots in the leg, clots going to lungs, the risk of pulmonary embolism is extremely low, but DVT is certainly a lot more common and that's why we give blood thinners to reduce the risk of this embolism or thrombosis.

Dislocation, leg lengths, we aim to make them equal but cannot guarantee it. Less than one in 30 of patients will have an appreciable difference in the leg length, which may require an adjustment to the shoe. Infection rates at Benenden are extremely low but can happen; up to 1% deep infection can affect the prosthesis in hip replacements. Damage to the nerves and blood vessels because of the structures. The hip is a deep joint, and all these structures are very close by. The bone is what we are operating on, so there is a small risk of damage to any of these. And sometimes we may have to use wires or cables to fix the bone during the hip replacement operation. If, obviously, the prothesis comes loose or wears out or indeed a fracture happens down the line, then it may require revision surgery.

What can you use to help make a decision or get more information on hip replacements? You can look up on the National Joint Registry which has information on both the surgeon and the hospital profile. The other place that can give you the similar information is Private Healthcare Information Network and review sites such as Doctify.

This is a video from one of our hip replacement patients. I will let it run and then we will come to the Q&A session.

There we are, okay, thank you.

Jean Woods

I'm Jean Woods. On January the 30^th 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 some days, down to my knee.

Benenden were very, very good at making contact. I had series of emails and the pre-op 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 to wait 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 after the operation, I was absolutely staggered at how quickly I was up out of bed and the physio was there a few hours afterwards and I was actually taught how to use the crutches and again people were patient with me.

Well, it might seem a simple thing to some people, but I can actually tie my own shoelaces! It's wonderful, 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. Truly I don't think it could be bettered.

Damian Gregory

Right, thank you for that presentation, very interesting, much appreciated, and I think we'll move on to some questions. So, feel free to type those in the Q&A icon now.

We've got some rolling in now so, actually, thank you Eve. So, Eve asks, she actually has osteoarthritis in both hips but more severe in her right-hand side. Her main problem is her legs give way when walking. Would a hip replacement solve this?

Mr Raman Thakur

Eve, thank you for that question. I think that my understanding - and correct me if I'm wrong - I would suspect that the reason why the hip is giving way is because of the pain you experience in the hip which can happen, sometimes. Sharp, shooting pains when people put pressure on the hip. And if it is from the hip, then certainly a hip replacement will help this.

Damian Gregory

Yeah, grand. We've got another question from Steve. So, Steve's actually had both his hips replaced. The left in 2017 and right in 2018 all before the age of 45. So Steve's now 50 years old and would like to ask how long might his replacements last before he needs surgery again?

Mr Raman Thakur

So that's a good question - and a difficult one to say. How long is a piece of thread? But generally, in looking through the data from the National Joint Registry we know that hip replacements fail at the rate of 1% to 1.5% a year. What does that mean? To put it into another way, if we did 100 replacements or 100 hips replaced today, 10 to 15 of these might fail in 10 years. And 20 or 25 would fail in 20 years.

So, it is important how you’re looking after your hips, how you are caring for your hips and so long as you are using them sensibly and looking after them then hopefully they will last a very long time!

Damian Gregory

Good, thank you. So Kim's asking (and I'm assuming she's referring to osteoarthritis in the hip, I guess) but can it affect pain in her lower back?

Mr Raman Thakur

So hip replacement is primarily being done for a hip pathology, however some people with hip arthritis - because their hips are extremely stiff - can put excessive pressure on other joints, such as the opposite hip or lower back. The fact that after hip replacement, that hip has got more freedom of movement and more mobility in the joint, that can reduce the stress on the back and that may indirectly make the back symptoms a lot easier.

So, it is not a direct effect of the operation, but sometimes indirectly it can help because it has taken some of the pressure of the back. Obviously, the back pathology on its own would determine how it will respond long term, and if you have got quite significant back problems then it may still continue to be painful.

Damian Gregory

Okay, thank you. So, we've got an anonymous question here and that is: What is pseudo-arthritis? I've been told following an x-ray that I have it in my knees. I'm currently 77. I guess the question would also be, does that exist in hips as well?

Mr Raman Thakur

So, I think what has probably been said to you is that it is probably pseudo-gout that is a very common condition in the knee and also sometimes called chondrocalcinosis, where there is calcification within the calcium deposits within the cartilage in the knee. And therefore, it manifests itself with pain, swelling and symptoms similar to osteoarthritis. And that is because of a buildup of calcium in the knee.

So, it is not that common for this condition to happen in the hips.

Damian Gregory

Okay, thank you, Mr Thakur. So another anonymous question: is there a maximum age for the operation? So, what are the risks to people who have received heart surgery already?

Mr Raman Thakur

So obviously, if people have got medical conditions they will need to be evaluated and appropriately counselled regarding their risks, which will be more individualised. But if people have heart, chest or lung problems then the risks of having another heart attack or a stroke or chest infections - all that can increase.

The maximum age for surgery? My oldest patient was 95 years old for a hip replacement and my oldest patient in a hip fracture for a hip replacement was 98 years old. So, I don't necessarily discriminate on the basis of age. It is realistically how active, how well and fit people are that determines their ability to undergo the surgery and have it done. So yeah, I don't think the age on its own is a no-no.

Damian Gregory

Okay, thank you. Yeah so, we've got a question from Uma. I have osteoarthritis also in both knees. Would you advise a hip replacement before the knees are fixed? I could walk and do activities with the knees such as physical therapy and swimming, but with hip arthritis the hip pain is excruciating and reduces her mobility to almost zero. I'm unable to walk for more than five minutes continuously.

Mr Raman Thakur

So, hips before knees, knees before hips. Yes, it is it is a difficult one. But if the hip definitely is the worst joint then it certainly makes sense to tackle the hip before the knee. It just aligns the limb from the top down. That is one of the philosophies. But sometimes people have got quite severe arthritis in their knees and less arthritis in the hips, then we would say have the knee done before the hip.

But it is a question of really understanding the relative contribution of pain - whether it is from the hip or the knee and the severity of arthritis. Even if arthritis is severe in both your hip or knee then, if the hip pain is significantly worse - and sometimes pain in the knee could be actually referred from the hip - and the hip arthritis may be making your knee pain worse. So, it is all a question of assessment; working out.

So, if you certainly want to use the opportunity to come and see us, we can assess the hip, certainly arrange for your images to be sent across then we can have a look through and we can make a decision which one would be the more appropriate one to sort out first.

Damian Gregory

It's an interesting one, thank you. So, we’ve got Helen asking. So, Helen's had an x-ray and shown a total loss of space in the joint and is in considerable discomfort. How much worse can the discomfort get until having surgery of the joint? I'm guessing you already touched on that.

Mr Raman Thakur

So, Helen good question. We don't fully understand what causes or precipitates pain in in various joints, even arthritic joints. I see patients sometimes who have got quite - I won't say normal - but nearly normal or minimal arthritis - in their hips but they are in a lot of pain. And then on the other hand I see patients who have got quite a lot of wear in the joints and don't have significant symptoms.

So, it is it is sometimes difficult to be able to advise, because - as I said - we don't fully understand what produces what, what are the pain pathways, what are the pain producers and how some people get a lot more pain than others. If you're describing the discomfort rather than pain then and you can live with it, then possibly you can carry on. However, if the pain is getting worse and your function is deteriorating then I think you are heading for having the hip replaced.

Damian Gregory

Thank you, Mr Thakur. So, we’ve got another anonymous question here. This person was diagnosed with osteoarthritis in the hips about seven years ago. They've been managing this with the help of Pilates which, that's quite interesting, but the last few months they've started having particular pain in the middle right buttock. No pain in the groin. Is this due to arthritis and, if so, how best to treat it?

Mr Raman Thakur

I think this is going to be difficult to tell without an examination. You can have sciatic pain, you can have pain related to tight muscles in the back hip extensor, hip external rotators, piriformis syndrome or indeed arthritis in the hip. So, it will need a proper clinical evaluation and then determine what is the best way to treat it.

Damian Gregory

Okay, yeah, thank you. So, Sharon's asking she has moderate osteoarthritis in her right hip as per an x-ray a few years ago. I've been told just to take pain relief medication. She has a leg discrepancy in the left leg which is 18 mm shorter than the right. This was only discovered in 2018 by accident, so she now has adapted shoes and trainers insoles. I guess for her left foot, this would have increased her risk of developing osteoarthritis.

Mr Raman Thakur

If you have had quite significant leg length discrepancy and been walking you would have probably noticed you've been limping on that leg for a long time and, obviously, if people have been doing that then you put excessive pressure on different joints, and particularly the opposite hip.

So, it’s difficult to say without complete assessments but if it is moderate arthritis, and you are managing your symptoms fairly well with shoe modification and simple analgesics then you can carry on. Whether you need a hip replacement or not is not just because you have arthritis, but obviously will depend really on your worsening symptoms and worsening function.

Damian Gregory

Okay, thank you, thank you, Janice, that's a really lovely review for you to leave here. Yeah, I've had both hips replaced and would like to say that her pain has disappeared immediately after surgery, so thank you. Thank you, Janice. Yeah, that's lovely.

We've got a question from Sam. So, Sam's a very active, 60-year-old man currently walking and cycling and would like to get back to climbing and mountaineering. Would that be possible after a surgery?

Mr Raman Thakur

There are a few people who have been, who are you know, experienced climbers and mountaineers and they do get back to doing that. Hip resurfacing was introduced as a way forward to allow people to do high impact stuff and highly risky stuff and trying to get back to more normality.

But it has obviously, you know, over the years people have noted the bad effects of having metal on metal hips and it has got now completely bad press and very much out of mode, but still a pretty good traditional hip replacement would still allow most people to get back to pretty much full activity and it is a question of being mindful how you are pushing your hips. And so, there are people who still go and do these activities after hip replacement, though not all surgeons will recommend it.

Damian Gregory

So, we’ve got another active member here in Richard, who asks whether breast stroke swimming can help or hinder? So, the question here is whether this would be related to whether you're talking about osteoarthritis or hip replacement.

So, if it is with arthritis and you're trying to increase your range of movement and things like that you can actually push it beyond the level of comfort and aggravate your hip symptoms. So sometimes how it is easy or not easy, just be mindful of that you don't aggravate your hip symptoms.

After hip replacement surgery, the majority of the surgeons will say no to breaststroke and advise that you use the standard stroke for front crawl and back crawl up and down.

Damian Gregory

Okay, interesting, thank you. So, we’ve got Susanna. I've had severe pain in both hips. I've had various treatments over the last 10 years; however, the pain is getting worse. I'm no longer able to walk any long distances and I've had to change my car, bed etc to ease the pain. She's now 54 but the NHS surgical team are still reluctant to operate due to her younger age, or age I would say.

Mr Raman Thakur

You would think the amount of pain that she's in should she have a hip operation! I would certainly get another review, new investigations if you haven't had any and see how bad your hips are. And if obviously you are in a realm of needing a hip replacement, then I wouldn't have any hesitation to recommend that.

Damian Gregory

Okay, thank you. So, Sam's asking is there any evidence that joint supplements help to rebuild joint cartilage? I don't know which supplements they would be.

Mr Raman Thakur

Yeah, I mean people use various supplements including cod liver oil, glucosamine, chondroitin, collagen and various other stuff. And there are some who swear by it and, you know, come and tell me that they have been trying all these and it has really worked for them. But unfortunately, there aren’t any scientific papers that show that one is superior to the other - or they do help in the long term or indeed reverse the arthritis. So, on that scientific basis I can't recommend and there is no evidence.

Damian Gregory

Okay, thank you, interesting. And we've got Pat Armstrong asking. So, Pat's 58 and had both knees replaced in 2019 and 2020. She now has osteoarthritis in both hips with the right one being more severe. She gets terrible pain in her hip. It radiates down her thigh and into her artificial knee. Is this normal to have pain in her knees as well?

Mr Raman Thakur

Yes, that is a very common presentation of hip arthritis. Sometimes I have had patients who come to me with painful knees and have ended up having their hips replaced. Because they never had any pain in their hips, they never felt any pain in the groin, and they were surprised when I told them that their knee pain was from their hip. So having a pain in the knee is a very, very common presentation of hip arthritis.

Damian Gregory

Okay, thank you, well much appreciated. Thank you for your input and thank you everyone else. If we were unable to answer any of your questions, if you have provided your name, we will be able to get back to you via email. So, if I can just move over to the last slide. Here we are.

So, as a thank you for joining this session, quite rarely here we're actually offering free consultations. Now that is actually for a limited period or a limited amount as well. So please do take advantage of those. We'll also offering a call back from our dedicated Private Patient team, an email tomorrow with the recording for you to watch back and treatment information as well as loyalty reward points and updates on any new and future events.

So, we would 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 up to 8:00 p.m. tonight or between 8:00 a.m. and 6:00 p.m. Monday to Friday using the number on the screen.

Our next webinar is on tummy tuck surgery, which you can sign up for via our web page. So, on behalf myself and Mr Thakur and our expert team at Benenden Hospital, I'd like to say thank you for joining us and we look forward to seeing you soon. Thank you, goodbye.