Webinar: Explore leading hip replacement surgery

Mr William Dunnet discusses your patient journey for hip replacement surgery.

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Learn more about the causes, symptoms and treatment options for hip pain with Mr William Dunnet.

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Hip replacement surgery webinar transcript

Anya Sadler

So good evening, everyone. Welcome to our webinar on hip replacement surgery. My name is Anya, and I’ll be your host this evening. Our expert presenter is Consultant Orthopaedic Surgeon, Mr William Dunnet. 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 your name. Please note that the session is being recorded. If you do provide your name and would like to book your consultation, we'll provide contact details at the end of this session. I’ll now hand it over to Mr Dunnet, and you'll hear from me again shortly.

Mr William Dunnet

Well, thank you very much for that, and welcome everyone.

Quite personally, I would say I can't think of any better place to be on a cold, windy, blustery night than being tucked up indoors in your own homes and discussing a topic that's close to my heart, which is orthopaedic surgery in general and total hip replacement in particular. So here we go. The first slide is going to be coming up fairly shortly as long as we go from there to there, so that's me. William Dunnet: I’m one of the orthopaedic partners that work here at Benenden, along with several others who are providing lower limb total hip replacement.

What I’m going to include in this session is a little covering of my own experience, and then I’m going to discuss Benenden Hospital and where we stand in the pecking order of the private hospitals in and around Kent and Sussex. I’ll cover our eight orthopaedic consultants and discuss a little bit about them and discuss the unit volumes that we're doing of total hip replacements per year, and then I’d like to discuss a little bit about hip arthritis because I believe to ensure people get a good result from hip replacement, they need to have a working understanding of the process of arthritis and understand how hip replacement is going to help patients overcome the arthritic symptoms, so we will discuss that in a moderate amount of detail, and then we'll go into the operation itself. There's loads of stuff on YouTube, and you can watch hip replacements. I am going to show you the important things from my point of view without any ghastly photographs that put you off your supper, so you don't need to worry about that, and then we're going to finish up with some patient support tools. All that means is just giving you a little bit of guidance as to where you can get more information online, and then finally, there's going to be a question-and-answer session.

Now what I’d say about that is that these presentations can be quite dull and rather lifeless if I just rabbit on about various things I’m interested in and the thing that really brings it to life and adds colour and enthusiasm to everything we're doing and makes it it's a more engaging process as if you can come up with a few questions at the end that I can try to expand on for you and it also helps me because every time I do one of these presentations I like to make it a little bit different a little bit more varied and even though the slides aren't changed too much I make a point of not rehearsing it too much in advance so I can maintain some spontaneity for you but particularly if you give me some good questions I can then change the presentation next time to align it better to what you really want to hear from me.

So, on we go. That's me. William Dunnet, I did my pre-clinical training at Cambridge and then moved down to Guys to complete my medical training at Guys Hospital for three years. I’m interested in both hip and knee surgery, and I developed these interests at the Royal National Orthopaedic Hospital when I was training as a registral and also at King's College in London. I spent just over a year in Australia where I worked with some absolutely incredible surgeons and the reason most of us try to have engaging fellowships like this is because there aren't many people who are brilliant surgeons but if you can just work with them for a while you can see what surgeons can do when they're at the top of the game most of us are average but what I like to think is that as a surgeon if I occasionally sit on the shoulders of brilliant surgeons I can at least do something to emulate the quality of their practice so that year I spent in Australia was really quite a good year for me in many ways and that has influenced my practice over decades afterwards and as a result of that interest I had in Australia I was the first surgeon to introduce a certain form of keyhole surgery that allows you to reconstruct the anti-cruet ligament of the knee in a quick effective way that allows everyone to return to their quality of living their sports whatever it is that may be in a quicker more effective way so that's what I learned from some of these great surgeons I worked with as a registrar and I belong to the royal college of surgeons the British orthopaedic association British association of surgery for the knee and the general medical council.

So what about Benenden well it's in our nature to be fairly modest I would guess but I don't think we need any modesty about saying that we are in fact a leading provider of private hip and knee treatments in Kent and Sussex we were actually pipped to the post by the Horder centre in the number of cases we do per year but we're pretty much up there in the top leading hospitals within this area of Kent and Sussex now here is me saying that the treatment is in a clean and calm environment I think it's quite important that I expand on this a little most of us are primarily NHS surgeons we spend 70 to 80% of our time working in the NHS and mostly because of Covid but because of other reasons as well the NHS is a fraught difficult environment to work in but nonetheless extremely satisfying but all of us would be exhausted and worn out and burnt out if we didn't have places like Benenden to come to here we don't have an emergency department everything is done electively and when you come into the hospital you come through the incredible great atrium that was developed a few years ago and you realize that this is a very special hospital there is a calm atmosphere here it is tranquil and the staff are happy they're engaging they are supportive and very caring and that happens because of the whole ethos of Benenden and the staff churn rate here is in fact very low because once people start working here they want to stay here and that whole ethos we have here will be transmitted to you the patient because if you enjoy your time here when you come to have your hip replacement surgery you will have a quicker better recovery when you return home.

There's an experienced team of orthopaedic consultants and physiotherapists. I shamefacedly say that we are quite careful in selecting surgeons who are going to work in our consortium. We don't tend to have relatively junior consultants; we tend to invite people to join us who already have an established private practice who are quite experienced because we find it just gels together better and the service works extremely well, so we are quite experienced surgeons that will be working here. Some of us have more grey hair than others, I’m afraid, but that's not a bad thing. We're not old and past it yet, but we certainly are very experienced. There is a high patient satisfaction rate. Like everything nowadays, you actually must listen to your patients first and foremost, and we sort of okay it's a bit boring when you're given compliments; it's actually the things that are criticised for that we learn the most, and I think over the years we've managed to really build up our reputation enormously by being very self-aware and self-critical and improving where is necessary. As a result of this, we now have extremely high patient satisfaction rates when they have their treatment here at Benenden. Now this thing at the bottom, the rapid recovery programme, is something that's quite an interesting concept. it was first developed quite a few decades ago now in its infancy when we recognized that health care is expensive and becoming increasingly so and one of the most valuable resources is time spent in hospital so both in the states and here in the UK we were trying to find ways of speeding up the patient recovery process and the most extraordinary thing we discovered is that okay the reason we were trying to have rapid recover recovery was to get people out of hospital quickly so that operations wouldn't be so expensive but what we realized is paradoxically if you get people home quicker they recover quicker and better and they have less pain and of course when you begin to analyse it you realize the best place for people to recover from surgery is in their home environment where they have all their creature comforts they have their own cooking they have their own bedroom their bathroom and all that kind of stuff so we've recognized now if you can get someone home often after only one night stay in hospital they thrive and do better but of course we don't push people out of a hospital too early we make sure they have good pain relief we make sure they've had adequate physiotherapy and they feel confident to return home but this rapid recovery program is something that we've really developed and adhered to over the last few years and it's just led to incredible results it really has.

So, what about the consultants? Well here are mug shots there are six of us who are now providing hip replacement surgery a few of us also provide knee replacement surgery along with some of my other consultant colleagues and I would say the one thing that describes us is we are a partnership of colleagues we rely on each other for support we discuss difficult cases with them and at weekends we'll often cover ward doctors and cover seeing our patients if perhaps you're going on a holiday or whatever and we'll do that with ease and with no problem at all because we are not what you might see in certain other hospitals downright competitors of each other we are supporters and partners and we have a great sort of comradery between us so that adds to us loving coming here because it is a calm great environment so we can actually enjoy what we love doing which is our practice of orthopaedics and I’d be quite happy for any of those consultants to operate on my hip.

So here we are. Here's the number. Horder Centre has just pipped us to the winning post. I’m afraid with 300, but 290 private hit replacements last year is still extremely good. We are a very successful unit, and we are proud of it.

So here we go with the causes of hip arthritis. So, before I go down that slide, I can tell you the commonest cause is idiopathic. We don't know the cause, but it just tends to run in the family and in the genes. So as many great attributes as you might have gotten from your parents and grandparents, I’m afraid to say they're probably responsible for you getting your arthritic hips and knees as well. I’m afraid, but there are also other causes. The general ageing process does lead to a little bit of wear and tear in the joint, but that is not usually sufficient to need a hip replacement. It just gives you a little bit of ache in the morning; that's what we call startup pain that settles after a few minutes, and it can make your joints a bit stiff in the cold weather. But that's nothing to worry about; that's just the fact that you're getting on a bit in years, so we don't worry about that. What you do notice, though, is that arthritis does tend to be a little bit more common in females. Well, actually, probably the reason that we have this statistical anomaly is because women live longer than men, so they are more likely to present with arthritis and obesity. Now, that is a really thorny topic, and one must be extremely careful about that. It's very common to tell people, Well, you're overweight, so you're wearing out your joints prematurely, and they might get better. That's true to a certain extent, but not really, and what do we regard as obesity if your BMI is a little high but below, should we say 35? In other words, you look a little portly, a little plump. quite frankly it is not associated with increased risk of arthritis all the symptoms being significant worse than they would be if you weren't overweight so I try not to be fattiest in my approach because I think it's appalling you know and we're a wonderful sort of humanity is a huge variety of people and you take them in all shapes and sizes if you are significantly overweight and I mean really round then of course it increases the pain you get from your joints and also it makes the risk of surgery higher but that is only with severely elevated obesity so I don't like to mention that as being a cause of arthritis because by and large it isn't and we have to be a little bit more sympathetic and generous in the approach to people joint injury well yes that definitely does I’m afraid to say cause arthritis if you fracture a joint and a smooth joint then becomes unsmooth disjointed with a rough bit of bone sticking into it you will inevitably get premature arthritis because of the abrasive effect of the uneven surface area and finally rheumatoid arthritis and gout are associated with an increased risk of arthritis in the joints.

So, what about the symptoms? Well quite often patients think that they've got a groin strain or they think they've got pain in their knee or they just notice it's difficult to do up their shoelaces or do their pedicure because they're getting a variety of problems that are related to a hip but actually not obviously coming from the hip so it's our job as an orthopaedic surgeon to just listen to a patient's history and try to work out from that the kinds of symptoms that might be coming from an arthritic hip and this is often why the presentation is delayed because a patient doesn't recognize and nor does the GP or the physiotherapist that actually this patient is suffering from an arthritic hip so the joint tenderness is more likely to present for someone who has an arthritic knee because a knee is more superficial than a hip a hip is well concealed within muscle and so it's fairly rare that you'll be able to really palpate and feel the hip proper it's more likely you'll feel a knee and recognize that's where you're getting the pain from but here we are the next line increase pain and stiffness when you haven't moved your joints for a while now there is a difference between the startup pain you get when you're getting well into middle age when you wake up in the morning you're a bit stiff because that settles within a few minutes but pain that persists for more than 20 minutes after you get up is more likely to be pain that's related to a form of arthritis so it's not the pain per se it's the duration of the pain and the time it takes for it to recover that indicates you might have an arthritic joint again more likely with knees and ankles and wrists and things you will see the joint looks a bit knobbly and deformed so that's a sign that yes you're getting some arthritis there now the next line is a grating or crackling sound or a sensation in your joints something we call crepitus I spend a lot of my time telling patients that actually what we call a musical joint isn't necessarily an arthritic joint it can be due to a little bit of scarring of the fat pads in and around the joints it might be due to a cartilage chair in the knee or it might be due to a little bit of air in the joint that can create crack cracking sensation in it so it's not a disaster if you’ve got a cracking joint is something that yes it's an indication maybe a doctor needs to look at it but by and l it's not related to significant arthritis so don't worry about that either the weakness and muscle wasting is often the guide to me when I examine patients that they've got a painful joint due to whatever reason it might be it might be pain because of arthritis it might be pain because of just disuse because they've had a nasty ligament injury or maybe they've been very unwell indeed for a while but it's the cause of the pain that we've got to look at and it might be arthritis but if you have got a painful joint you don't move it so much and the muscles do tend to get weaker and so the caroller of that is if you can then have physio and build up your muscles and strengthen them around your joint then often the pain you get in the joint improves and finally a limited range of motion in your joints I mentioned earlier that if you're having difficulty trimming your toenails and putting on your shoes, then there's a possibility that you've got an arthritic hip that's responsible for these problems.

So, treatment options This is very important, and I mean, I am more than happy as a surgeon to see people with very early arthritis, and remember, I’m not a sort of ghastly sort of crazy mad surgeon who wants to get my knife out and cut into you and put a new joint in as soon as possible. It's quite the opposite. I have the perspective of what a hit replacement can do for you, but at the same time, I am delighted if I can delay or even avoid a hit replacement altogether and find simpler means of helping you overcome your arthritic symptoms. So, what can we do to make lifestyle changes? Well, I saw a patient this afternoon who said, Yes, you know, I normally like to walk for three hours a day with my dog, but as a result of my arthritic hip, I now only walk an hour, and actually, I’m quite happy it's taken away the pain, and that's good enough for me. I that was his opening gambit and he says I’m not quite sure why I’m coming to see you but then when I discussed a few more things in detail I realized there were other aspects of his life he liked doing and his wife that was with me also told me a few more details about things that they were no longer doing or the fact that his walking had slowed up to such an extent when they went on holiday she would have to carefully decide which sites they were going to look at because she knew full well that her husband with his stick was going to be walking very slowly behind her so I sort of drilled down a little bit and I found that even though he thought he'd adapted his lifestyle sufficiently his wife felt that he'd adapted his lifestyle too much and they weren't enjoying some of the best years of their life together so that took a little while for me to just disentangle what was important and what wasn't important and I recommended for that particular patient then yes he should go ahead with a hip replacement but there are times when you can do lifestyle changes that will allow you to enjoy life and you can avoid surgery may be permanently or at least for a year or two What about pain relief medication? This is very important. If you're going to go on a big shopping tour in London, you're going out to the theatre, whatever you want to have your joint as good as possible, then some temporary pain relief is a good thing. If you have to take strong painkillers all the time, that's not such a good thing because they can have side effects, so I'd much prefer that people don't let the arthritis get so bad that they need regular, strong painkillers to try to take the edge off of it. You're then getting close to the stage where maybe hip replacement will be in your best interest, but when it comes to the type of pain relief, we have a pyramid of analgesia, and right at the base of the pyramid, we like to think of medications that have very few side effects and are pretty efficacious for early symptoms. That means the real sort of base building block is paracetamol, two tablets. Four times a day is not going to lead to any harm; it's not going to lead to any addiction or dependency, and it's unlikely to lead to any side effects, and you just add to that the occasional ibuprofen if you can take it. If you're not asthmatic and you don't have GI upsets and ulcers, then that's a lovely sort of base for your pain relief. As soon as you go high out of the pyramid, every form of analgesia has its side effects and has its problems, so we try to play around with that to try to ensure that simple things with few side effects can be efficacious, so that is something that can help a lot of people with early arthritis. steroid injections You may have heard of Yes, there is a role for them, but it is very limited because they do carry risks. Steroids can damage the bearing surface and can lead to infection, so you've always got to have a chat with your doctor and work out the risks and advantages of steroid injection, but in the long-term management of arthritis, they do not play a role in the short term. They can do ten. Now, what is that? Well, tens is transcutaneous electoral nerve stimulation and hot and cold. ice packs What are they doing well? It's all to do with something called the Malac and Wall Gate theories of pain. Now, that's a very grandiose term, but I’ll explain it very simply to you and quite effectively. I think if you bang your head on a beam because you get up too quickly and you rub it lo and behold the pain goes away, that's because the painful stimulus of banging your head has been suppressed by the local pressure of rubbing, and you imagine pain fibres are different in the kind of perception they give your brain. If you have this narrow little gate and you have one load of pain fibres providing a painful stimulus, and then you block that stimulus with lots of low-grade rubbing discomfort, there's nowhere near as bad as pain; it goes through the gate and blocks toxicate to those pain fibres. That's what happens with hot packs. ice-cold packs and even treasonous nerve stimulation You provide non-painful stimulation, but a lot of them suppress a painful stimulus. Most patients tend to put a wheat germ bag in the microwave and put it on their sore hip or their sore knee, and that helps. There's always a role for this to help you get to sleep at night and use it from time to time, but if you're having to use it all the time again, it's more likely we're looking for joint replacement using a stick and a cane. Of course, that helps because, as it does, it takes a lot of the load off the arthritic hip and makes it easier to walk, so that can help in the short to medium term. If you can reduce the impact loading on the joint by wearing a nice soft pad and hotter, they tend to have nice soft pads that can alleviate some of the symptoms of early arthritis and physiotherapy. My goodness, that can help a huge amount because it makes the joint more supple and flexible, and if you have a supple and flexible joint, it makes it easier to reach down to your feet, and it also takes the load off the back and the knee because if the hip is stiff, the back of the knee has to move more to adapt to the stiffness. If you can make the hip more supple, then the back doesn't have to work so hard doing crazy contorted movements to adapt for the horrible stiff hip, so that's how physiotherapy can help, and the surgery that we're mentioning on the right hand side, well, traditionally, in orthopaedics, we do three things for an arthritic joint: either excise it, replace it, or we confuse it. That's traditional orthopaedics. Nowadays, we don't tend to do joint fusions of hips any longer because we've got this wonderful solution, which is hip replacement, nor do we tend to excise the joint because that's very inefficient if you have a wobbly joint with no socket there any longer, so hip replacement is the gold standard treatment for an arthritic hip.

So, here's our introduction to hip replacement surgery. a few facts and figures 48% of hip procedures were done within independent hospitals in the UK in 2021 now this is a figure that makes my heart bleed I’m very ashamed of this you know most of us surgeons here we are NHS surgeons we love the NHS that's where we've been taught by great surgeons that's our alma that's where we've been brought up as in orthopaedic surgery and that's our role you know to provide the service to people that perhaps can't afford private insurance can't afford to come to a private hospital and to have to say that 48% of hit proceeding occurred in the independent sector is extremely sad but it's because of what Covid has left us with you know quite rightly cancer has been treated well during Covid and we've made sure that everyone's they've been adhering to their two limits to get effective treatment starting so hip replacements have fallen to the back of the queue and in certain trusts I was told by a patient today there is a three-year waiting this for hip replacement surgery I mean at least where I work in the NHS it's about a year but three years is just makes for heart bleed it's horrendous so okay the independent hospitals are working hard to provide hit replacements and we've got great hospitals like Benenden that can do this but I am very shamefaced when I have to say that's a state of play and I really hope things are going to change for the better within the NHS in fairly short order so over 84,000 primary hit replacement were performed in the UK in 2021 and so that means over 40,000 were done in the private sector hip replacement is the second best operation in the world behind cataracts I must say I thought bypass graft was very high up in good operations because of course that saves lives and improves quality of life, but no, these are the figures, so that means hip replacement is not only extending people's lives; it is also improving the quality enormously so you can enjoy some of the best years of your life by being essentially completely pain-free with a normal hip joint again, and some of the figures we've got here Well, the average age for having a hip replacement is in your late 60s for 60% of ladies, but that's mostly because they live longer, as I’ve said, compared to men. 5% of them are because of trauma, 90% are because of osteoarthritis being the cause, and the other 5% are various other things that people need a hip replacement for. 28.7 is the BMI for the average person having a hip replacement that is regarded as being overweight, but you know, quite honestly, that's just normal for the population as we are now. We're not perfect as human beings; we do tend to eat and drink too much, and so we are a little bit overweight. That is not the cause of the arthritis, nor will it prevent you from having a great result from your hip replacement, so let's not be too concerned about being overweight next.

So, what is a hip replacement? Here's a remarkable thing: we are still not entirely sure where the pain generators are in an arthritic hip. You can see some people who have a colossally worn-out hip, and they just say it's a bit achy from time to time and a bit stiff. other people have relatively minor arthritis on x-rays but my goodness they have disabling pain so given we're not quite sure where the pain is coming from it is remarkable that simply resurfacing the joint leads to such incredibly good results but over the last 60 years we have discovered that if you simply resurface the joint you will get a great improvement in pain and you'll almost restore normal function to that joint point and all we're doing as you can see in this slide here is we are putting in a new socket we are putting in some form of couple which might be metal on plastic or ceramic on plastic or even ceramic on ceramic as a joint and then we put a stem down the femur that will secure it to the body's skeleton obviously Andy Murray who's you know we all sort of love and know well really from his sporting prowess he's had problems with his hip and he had something called a rec surfacing the point of a resurfacing which is a very intuitive nice solution for arthritis which you do no more than resurface a socket and resurface a ball but leave everything else intact is that it leads to a very natural feeling joint that should be very robust and very stable so it allows you to return to all manner of sports and we used to do a lot of them but we've now found there are certain problems with them and the where debris can lead to almost insoluble problems in a few patients so because of that we tend to go back to the more traditional design of having a long stem that goes down the femur and a more robust resurfacing of the of the of the socket or the acetabulum.

So, the question is, do you need a knee replacement, or do you need a hip replacement? Rather, everyone is different, and you need to tailor the operation requirements to each individual patient. We have 20 minutes that we'll spend with each patient that we see in the clinic to really get a feel for their life story. What's important for that patient, what's not so important, and particularly if the wife or the important other is with a patient in the clinic, it can help me get a good insight into how that arthritis is affecting that individual, and it's amazing how much you can glean from someone within the space of 20 minutes, so honestly, I couldn't say there's one typical person who obviously needs a hip replacement. It's much more important to see how it affects that individual person's life, but certainly if you've got severe pain stopping you from enjoying your activities of daily living, so you struggle to get out of bed in the morning, you can't put your clothes on easily, you can't walk up and down stairs because of pain, and you can't go out to enjoy shopping and spending time with friends and family, then clearly you're going to need a hip replacement, but everyone is slightly different. I mean, my father, for instance, had an arthritic hip. He just used to enjoy playing a lot of duplicate bridge, and for him, as long as he could walk between the tables and everyone knew he couldn't go up and downstairs, they always made sure wherever you played bridge there was a lift to use. He was happy, so he didn't bother with a hip replacement. But other people want to go walking for three hours with their dog each day, and if they could only walk for one hour, that's not good enough, so we will do a hip replacement for them. Some people get a lot of pain at night, and if you can't get a good night's sleep, then you'll feel exhausted the rest of the day. You'll be grumpy with everyone, and life is hardly worth living, so we need to do a hip replacement for those patients. hip deformity If you get stiffness in the hip, then that puts an awful lot of loads on the back and on the knee, and in fact, to alleviate that back and knee trouble, you have to make sure you have a supple hip again. If physiotherapy fails to give you suppleness in the hip, then, my goodness, you need a hip replacement. So, on we go. What are the types of hip replacements? People do ask me, Are you going to do Andy Murray's resurfacing? I’ll say no, we're not, because it does lead to a few insoluble problems in the selection of patients, and we prefer to avoid it because we have tried and tested solutions that provide you with a 20-year solution that'll give you a great result if you're going to do a hit replacement on a 20-year-old who wants to achieve world-class athletic pursuits.

Okay you have to discuss slightly different solutions but for the majority of people who are over the age of 50 a traditional hip replacement gives you a lovely result but people do ask well what about the materials what should I have should it be metal plastic ceramic should it be cemented or uncemented well if you are an engineer you want a bearing surface that leads to the least amount of debris and last the longest possible time and we've done a lot of work where we have jigs where you have bearing couples inside bine serum and you go through millions and millions of cycles of joint loading and you discover how well these joints will actually do over five 10 20 or even 30 years of use and what we find is the best couple from the point of view of debris is ceramic on ceramic It's a very hard surface, and it provides very little debris. However, occasionally, ceramic, which is a very hard, brittle structure, can fragment, and if it fragments, it creates a very difficult problem to solve because the ceramic debris is an irritant to the surrounding soft tissues, and it's very difficult to get rid of that irritant when you have to do the revision hip surgery, so it's something that you carefully select and choose the right patient for ceramic. probably a safer bearing couple and recently in the hip society there was a show of hands from the members of the audience who are all orthopaedic surgeons and it was suggested what would you like if you were going to have a hip replacement and the couple that most of them went for was what's called hard on soft which is ceramic on polyethylene that is a more forgiving couple doesn't tend to lead to the ceramic debris that you get from ceramic on ceramic and it's probably going to lead to probably the potential of 20 to 30 years of good use before you get unacceptable debris being produced at the bearings bearing site metal on plastic is the most established couple that we have and we tend to go for that if you want the safest possible hip replacement in people that in general are aged in their 70s plus because we know it is going to last for 20 years ceramic on poly we are probably looking at 30 years life but this is all theoretical because what really matters is the interface of the component with a bone because that's where a hip replacement fails you get loosening of that interface the reason you get loosening is because there's a slight mismatch in the stiffness of any form of metal component and bone which is a biological structure that's changing its density and its stiffness with the aging process and when you get a big mismatch you can get loosening but the debris from the bearing surface can also contribute to this loosening so really when it comes down to it rely on the surgeon's preference as to what is going to be the bearing couple because there is very little difference between the couples we use nowadays they're all pretty good and whether you cement or un cement again is down to surgeons preference really whichever fits well with their technique of hip replacement surgery If you go into the national joint registry, it will give you some fine nuances and differences between them, but honestly, they're all pretty good.

So, on, we go short stem. Where do I remember talking about the loosening of components and the breakdown of the bond between the metal and the bone? Well, if you have a shorter component, it will then lead to an easier revision, but we won't mention any more about that.

So what is involved in a hip replacement? the operation normally takes about an hour and we like to do it under a spinal anaesthetic but that'll be discussed with your Anaesthetist and nowadays you're just in hospital probably for one night maybe two nights and the scar yeah that's a sort of fairly standard length scar and it looks a bit pink there that's because that's a fairly immature one as the months go by it becomes a very light colour and you barely see it so what is involved during the surgery it is disgracefully straightforward really it's a matter of getting good access to the hip and we do that by dividing a small number of muscles in and around the hip to make sure we get good access those muscles that are divided will take at least three months to recover from the surgery and that's why the hip will feel a bit sore and a bit weak during that time and we will resurface the socket and we will put a new stem onto the femur and here's pictures of hip replacements afterwards these are the x-rays The x-rays on the left show a cemented component. You can see the cement around the femoral canal on the right-hand side that's fully uncemented. Both give equally good results for those components.

So, the recovery from a hip replacement is your hospital stay. We want to get you up and walking as soon as possible after the surgery because we know that gives you the best possible result and the least amount of pain after the surgery, and your physiotherapist and nurses on the ward will help you get up, usually on the same day as the surgery. if it's been in the morning if it's an afternoon this then it may well be the following day when you get up and the physiotherapist will instruct you in your exercises that you're going to do religiously when you get home and normally you find you are back to activities of daily living within six weeks of the surgery and usually at that stage you're walking with one or no stick at all and once you go home we're going to make sure that you're going to be safe at home so we'll know you'll be able to get from bed to chair yourself and you should be able to get yourself to the bathroom and back without needing any assistance from anyone and I like you to go up and downstairs it's always a bit of a nonsense patients to say you know should I have my bed moved downstairs from next to the next to the no I want you to have that exercise of being enforced to go up and downstairs each day to build up the strength in your hip and get better so after leaving hospital after certainly during the first two weeks you'll need a lot of painkillers and things are going to be bruised and you're going to feel quite sorry for yourself but you'll be doing all your exercises and by about the end of two to three weeks you'll think yes things are beginning to improve and at six weeks we would hope that you're walking outside your home and you're considering getting back to driving and by three months you'll be feeling pretty good but the maximum recovery from hip replacement is probably about sort of nine months to a year actually for the full recovery.

So life after hip replacement most patients get a great reduction in pain it allows you to get back to your normal activities sports heavy labour no but you'll be back playing tennis you can get back to s gentle skiing you can do loads of stuff and essentially you'll have a normal joint but high impact activities like doing a lot of road running not so good we prefer swimming and cycling which is a low impact activity for keeping yourself nice and fit there precautions A hip replacement is almost as good as a normal hip, but you don't want to go crazy with your yoga exercises because you shouldn't push it right to the limit because it's not quite as stable as a normal hip, so these are your rules. Don't bend more than 90°; don't cross your operated leg; and try not to twist it into contorted positions just to try to look after your hip.

Potential risks We always have to discuss the risks of surgery, and we'll remind you about that when we see you in the clinic, and we'll also sign a consent form that you understand. the vast majority of patients do extremely well but some do not do so well first risk is thrombosis that's where you get a blood clot in the legs that's bad because these blood clots can go up to the lungs it blocks them stops them working and I’m afraid that kills you risk of that one in a thousand loosening of the joints they don't last forever we always tell patients we'd expected to last for 20 years but that's just the average some of them can only last 12 or 13 years some keep going for a lot longer they can dislocate remember we've had to divide a few muscles to get into the hip joint to start with that leaves the hip quite vulnerable to dislocation in the first two to three months and if it does dislocate normally we can just put it back under sedation and get you going again and it recovers nicely very occasionally when it dislocates the joint is loosened and we have to revise the whole operation leg length we try our very best to get the leg lengths right and we do a lot of preparation beforehand to do that but sometimes it's necessary to change the leg length to ensure we have a nice stable hip during the surgery most patients will adapt to that sometimes they find it a bit of a nuisance and we might need a raise but that is fairly rare infection that is the worst possible complication there is about a 1% risk of that and if you were to get a deep infection after hip replacement that is a complete total disaster it means we've probably got to take the hip joint out we wash and clean the cavity we give you strong antibiotics we put a temporary cement spacer in the hip and that stays in for a month or two and we make sure the infection goes completely and then we put in another hip replacement but I wouldn't wish that on anyone and as surgeons we forget our successes but whenever you get an infected hip that patient you remember them for the rest of your professional career because it is a downer for the patient and also for the surgeon it's horrid so it's fortunately only 1% and I can quietly say that here at Benenden our infection risk is lower than that because we do have a very clean very privileged environment we work in here damage to nerves and blood vessels Yes, nerves are very close to the operation site. You can get occasional stretching and bruising of the nerves, which can lead to temporary numbness and weakness. Occasionally, it is permanent. Sometimes the bone can crack around the hip replacement, which can delay recovery. Sometimes we even need to sort of fix it with screws and plates, so there are risks, but they are rare.

Finally, patient decision support tools The national joint registry provides information on all surgeons that provide hip replacement in the United Kingdom and is a great resource for giving you other links to give you information about hip replacement surgery, and I think that is it.

Here's the summary: it's a highly regarded operation; it gives effective pain relief to the majority of patients, and it's not just for older people. As you know, hip replacement is for anyone who has disabling pain. The youngest hip replacement I’ve done is on a 28-year-old physiotherapist who had a nasty road traffic accident when she was in her teens. She was 28 at the time, but we had to do it there, and then she got a lovely result that can give you your life back.

Question and answer, please.

Anya Sadler

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