Louise King

Good evening, everyone. Welcome to our webinar on hip replacement surgery. My name is Louise, and I'm your host this evening. Our expert presenter is Consultant Orthopaedic Surgeon Mr Alex Chipperfield. We're also joined by Jean, a previous patient who will kindly talk about her hip treatment journey. 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 and A icon at the bottom of your screen. This can be done with or without giving your name. Please note that this session is being recorded if you do provide your name. If you'd like to book a consultation, we'll provide contact details at the end of this session.

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

Mr Alex Chipperfield

Thanks Louise.  Hello, I’m Alex Chipperfield. Thanks very much for coming today and listening to the talk about hip replacement surgery. So, what's going to happen in the session? Well, I will talk about who I am, what I do, and where I do it. I'll also speak about Benenden Hospital and how we run things here. Then, I will go through the symptoms, causes, and treatments for arthritis of the hip and go through the typical journey that you would go through with a hip replacement. Then, Mrs. Woods will come along and talk about her experience and how she felt going through all this, and then we'll have the question-and-answer session afterwards. I've been a doctor for 26 years, and for half of those, I've been an orthopaedic consultant working in Kent. I specialize in surgery of the hip and knee, spending about half my time doing hip replacements and half my time doing Benenden Hospital here is there you go we're a leading provider of private hip and knee treatments in Kent and Sussex if any of you have been here you'll appreciate that it's an it's a clean and calm and quiet environment it's a modern Hospital and you feel confident in the place the minute you walk in yeah it's a nice setup here things have done well we've got a good team around us a good team of surgeons of nurses and physios of our ward staff everyone is very experienced and caring and more importantly they have the time to take to go through things with you I think because of the environment because of that time that we have we get very high patient satisfaction rates and very good reviews and feedback we also have a rapid recovery program that means that unfortunately you're staying in Hospital that's actually pretty brief these days when it comes to this kind of surgery.

I mentioned that I'm not the only person who does hip replacements here. There are half a dozen of us who perform the surgery. All of us are experienced local surgeons who specialize in this kind of procedure. As I've said, we do a lot of hip and joint replacements here at Benenden. The numbers are high, and they're getting higher this year. We're nearly at that stage already, and it's not even October again, so the volumes of surgery and the amount of work that's getting done here are getting higher and higher as the months and years go by.

So, hip arthritis: what causes it, what are the kinds of symptoms you get, and what other treatments are available besides surgery? basically hip arthritis is when your hip joint becomes painful and it becomes stiff and it starts to wear out the main cause is exactly that it's old age it's putting a lot of pressure through the joint over an extended period of time and that that will lead to the normally soft smooth surfaces that that Glide over each other they start to become rough and when they become rougher the movements become stiffer and more painful and then you get Associated problems like that so although this is a disease of generally of wear and tear and of age there are also other factors there are diseases that can cause your hips to wear out more quickly there are conditions that you could that you can either be born with or that you can acquire later in life so you can be born with slightly malformed hips  something called hip dysplasia and this can lead to your hips wearing out at a very young age you can develop deformities as a result of overgrowth of bones or due to injuries in and around the hip joint or muscles these can these can lead to the hips wearing out you can get diseases such as rheumatoid arthritis or gout that attack all of your joints not just your hip joint and that can lead to arthritis in many different places but also in the hip the symptoms of hip arthritis they can vary not everyone will have all of these most people have a mixture of both and some that Dominate and others that don't typically though the number one symptom for arthritis of the hip is pain that pain can be anywhere around the hip area commonly though it's right in the front right in the groin most people when they point to their head they tend to point to the side of their thigh or round into their buttock but your hip joint is actually right at the front in the groin area and a lot of people who present who think they have a groin strain or a muscle injury often actually turn out to have a problem with the hip joint but they don't associate that area with the hip itself so pain is number one like I said it can start in the groin it can radiate around it can go into the side of the thigh or into the buttock it can also track down your leg and give you pain in your thigh and also into your knee as well so pain all around that area you do have to be suspicious that the hip is the cause of this needs to be investigated along with the pain you start to develop stiffness restriction in movement that can present itself in in several different ways you know you can notice that it becomes more difficult to cut your toenails to put on your shoes and socks to stand on one leg to put on your trousers or to climb onto a bicycle or get into a car these kind of things they're the kind of the stiffness that sort of creeps up on you after a while you can get grating or crackling sounds that tends to be for more peripheral joints although you do every now and again see hips that are creaking that's a very late stage on the whole things have to be pretty far gone before you can hear and feel that due to stiffness and loss of movement you will get weakness and you can get some muscle wasting as well typically the muscle that you tend to notice that will wither away is the big one at the back the gluteus maximus so you may get some slight asymmetry of your buttocks as one side would be slightly smaller than the other so those are all signs and symptoms of hip arthritis that you may get some or all of treatment options  Ultimately, you know, if all else fails, you end up talking about a joint replacement, but that's very much the last thing that you do after trying all sorts of other things. I mean, the first things that you can do are find ways to live with the pain, find ways to minimize the impact that the pain has on your daily life, and do simple things such as weight loss, exercise, painkilling tablets, gels, or injections. hot and cold ice packs hot water bottles All these kinds of things can make your pain more tolerable and liveable. Some people find that using a stick or walking poles can be helpful. Footwear, so something with more of a cushion that will lessen the impact through your joints Physiotherapy can help build up the strength and confidence in the muscles you can There's a picture there of an injection. You can inject substances into people's hips and hip joints to try to help with the pain. Typically, there are two types of substances you can inject. You can inject a steroid, which is an anti-inflammatory that helps calm down the inflammation of the joint. There are other kinds of injections that you can give, like lubricant injections, that can help smooth the rough surfaces and squeeze a bit more life out of the hip joint. Ultimately, if you've tried all of these and, despite all that, your hip is having a significant impact on your quality of life, then you're looking at surgery. Hip replacement surgery is the mainstay. I know there's a joint Fusion listed on the list here. That's very much an operation from yesterday. Really, the days of fusing someone's hips together are long gone. It's more historical than anything else, so ultimately, you know if you're talking about an invasive procedure, you're talking about hip replacement.

Hip replacement is a very common operation; around a hundred thousand are performed in the UK every year, and this number is getting more and more every year. The average age for someone to have their hip replaced is in their late 60s. Men are slightly younger than women when it comes to hip replacement surgery, but like I said, we're performing more hip replacements, and people are having them at a younger and younger age. It's still more frequent to have a hip replacement if you're a lady, then you're a man. Around six out of ten hip replacements are performed on ladies and are the commonest causes of arthritis, but one in ten will be caused by other reasons, such as congenital conditions, trauma, or other types of diseases. It does tend to be an operation again. That happens to people who are slightly overweight. A BMI of 28 is on the slightly heavier side. Again, whether that's a symptom or a cause, whether it's a symptom of inactivity or a cause of the hip to wear around, a combination of hip replacement is probably a hugely successful operation if you look at patient satisfaction and the impact that it will have on your life. It's the second-best operation that you could have. Cataract surgery is the number one operation that is a quick, painless operation that turns you from being blind to allowing you to see again. That's a pretty neat trick, and I'm afraid I can't beat that. But the next best surgery as far as satisfaction, impact, and quality of life go is a hip replacement. If you are heading that way, it's something to embrace and look forward to rather than be scared of. It's a fantastic, life-changing improvement that most people get.

What is a hip replacement? well it's when you replace the parts of the hip that are worn essentially the hip is a ball and socket joint the ball is the rounded part of the top of the thigh bone and the socket part is the pelvis and these two articulate with each other so a hip replacement do you have to recreate both the ball and the socket and there's some pictures on the screen there of a of a of an old-fashioned looking hip replacement with a with a metal shell and a plastic lining that that recreates the socket and then there's a ball that goes on the end of a stick that fits down inside your thigh bone that reproduces the board socket you put those two things together and you get a hip joint that that improves your function and now gets rid of the pain and allows you to walk and move more freely and naturally again.

A question people often ask when they come to see me is: Do I need a hip replacement? And the answer to that is that I always tell them, Well, you tell me that the decision as to whether or not you proceed with a hip replacement really depends on the impact that it's having on your life. There's no particular test, x-ray, or scan that I can do that tells me that you need surgery. it's really about whether or not the cumulative effect of the of the symptoms that you're having are getting to the stage where you can no longer live with what you've got and there's no other way of dealing with it so if you're in pain every day that's limiting your activity if you’re walking distance is decreasing your world is shrinking you can no longer do the things that you enjoy doing it disturbs your sleep at night you're struggling to get dressed put on your shoes and socks all these kind of things you know will slowly chip away at you and you'll get to a point where it becomes a condition that you can no longer tolerate or live with and if it reaches that stage then it's time to consider a hip replacement  Okay, when you're all talking about hip replacements, there are lots of different types. there's different brands and different models and ultimately you will have a choice of materials of brands of implants of designs and of methods of fixing them into you essentially it's the job of the surgeon and in consultation with you to decide what is the most appropriate implant for you so what's the one that is going to last the longest and allow you to within reason live your life as you want to live it and so part of the conversation and the consultation we'll be talking about which particular materials you need which design would suit your particular Anatomy the best and how best to implant it and so all of these things are considered when we when we're looking at which implant that we use here at Benenden we only used we only use implants that are that are trusted that have a track record that are proven to be long lasting hard-wearing and reliable there are always Innovations in in hip replacement surgery and we follow those as much as we can but we are not in the business of experimenting on people and Performing operations using instruments or implants or techniques that haven't been proven as being of long-term benefit.

One of the other types of hip replacement is a short-stem hip replacement. That's when, if we look at this slide, the stem is about 10 or 15 centimetres long and the shorter stem is about nine or ten centimetres, so slightly longer, they're slightly shorter stems, and that can be bone-preserving. Again, the decision as to the type of implant really depends on you, your specific needs, your anatomy, and what's involved with the actual operation itself. The surgery itself takes around an hour, give or take. Sometimes when things run very smoothly, it's quicker; sometimes it's slower. The time taken to do the surgery is however long it takes to do things properly; most of the time, you will be The surgery will be performed under what's called a spinal anaesthetic, which is when you have an injection into the lower part of your back that makes your legs go to sleep, so you can't feel the surgery. On top of that, you do have the option to have sedation as well, so a medicine injected into your veins means that you won't be aware of what's going on; you won't hear, feel, see, or smell anything. A lot of people are worried that having a spinal anaesthetic means that they will be completely awake, aware, and able to hear all the hammering, hammering, and soaring going on. The only time that would be the case is if that's what you want. If you want to be completely awake, most people will have some form of sedation on board so that you won't know what's going on. Following the surgery, most people are in the hospital for one or two nights, typically following the operation, and there will be a scar. The size of the scar tends to really depend on the size of the leg that's having the surgery, so if you are very slim, then the scar tends to be smaller. If you have a bigger leg, then the scar tends to be bigger so that you can get down to the joint and perform the operation safely and properly. Ultimately, the size of the scar is what is needed in order to get the operation done safely. Some people use the size of the scar as a marketing tool or a sales technique, but ultimately, I don't think that's the right thing to do. You need whatever size scar is necessary to do the operation.

Like we said, we're on the previous slide. What's involved is that we recreate the ball and socket that's worn out in your hip by, uh, with a combination of a shell and a stem, we cut away the top of the thigh bone, we hollow out the socket in the pelvis, and we can impact her with what's into those, put them all back together, and sew you up again. So, all very straightforward. 

These are a couple of x-rays of the appearance of hip replacements afterwards. The picture on the left-hand side of the screen is of someone who's had both of their hips replaced. These are what we would call hybrid hips, so they have a cemented stem and an uncemented socket. The single sign on the right is a fully uncemented hip replacement where both the stem and the socket have been uncemented. Both of these are, like, I say, incredibly hard-wearing, long-lasting constructs. The exact nature of which one is right for you will be determined before and during the surgery itself.

Recovering from a hip replacement ideally we get you up and walking as quickly as possible it's perfectly safe to Bear all your weight through your new hip on the day of the operation if you have surgery in the morning you'll be walking in the afternoon if you have surgery later on that day it may well be that the effects of the anaesthetic don't wear off in time for you to walk that day so we give you the night off and then we start chasing you around the place the next day it can be a bit a bit tight and a bit stiff and sore following the operation most people tend to find the pain that they came in with the horrible toothache grinding pain from their hip has gone straight away the pain that you have after surgery is different             People often describe it more as discomfort or tightness around the hip, and that pain will fade and settle as you heal. You may also get some swelling and bruising around the leg; it's very common to get some bruising. One of the medications that we give you after a hip replacement is medicine to try and prevent you from getting a blood clot. One of the side effects of a medicine that stops you from getting blood clots is that it stops your blood from clotting, so any bleeding or bruising that you will get from surgery will be amplified and magnified by the medication that we give you, so you will have some bruising and swelling. It's completely normal; it tends to settle within a few days or weeks. [Music] For most people, you'll be in the hospital one or two nights, and you'll get back to normal around six, eight, or ten weeks, depending on how you respond, and really, it tends to depend on where you've started from if you're starting from a very low point. if you're a very stiff very weak before the operation then it will take you time to build up the strength the confidence the muscles in and around your hip again afterwards so it will take as long as it takes to find your feet but the pain relief is very rapid once you're happy that you can cope and once you've ticked all the boxes or if we're happy with your with your blood test your X-rays and your Mobility you'll go home most people will go home on a pair of crutches and you'll be in a situation where it's safe for you to cope in the environment that you're being discharged to most people get rid of their crutches after a couple of weeks either going from two crutches to One To None or from Two To None depending on you really whatever feels safer with you but that generally you'll be walking around within a few weeks unaided. 

You may find that you're back driving within the first six weeks, or so I tell most people to not make any big plans for the first three months following an operation, so that includes long-distance travel, getting back to high-demand work activities, and exercising. You know, it's a gradual process that will take as long as it takes for you to get back to life after a hip replacement. not a fan of this slide because this shows you know lots of situations where you're not allowed to do things. The whole point of this operation is to allow you to get rid of the shackles that are holding you down, get rid of the thing that's holding you back, and get back to living your life in a much less restricted, pain-free way. There are some activities that common sense would say you shouldn't do. You know, bungee jumping or some high-impact sports hip replacement surgery is not carte blanche to start running marathons again, but you know that, within reason, most people are able to get back to doing most things. It may take some time to build up the strength and confidence again to get there, but you know you will be able to get back to 99 of the things that you used to be able to do. 

There are some restrictions that we put on you for the first month, six weeks, or so while things are knitting together and healing, but once that healing period has gone, the chances of you causing damage to your hip without doing something either incredibly unlucky or incredibly stupid are very small, and it's something that you wouldn't need to worry about after that initial betting period. 

Although hip replacement is a great operation and works very well, there are potential risks. There are things that can go wrong either during or immediately after the surgery, and you know these are the facts. It's not 100 percent guaranteed to be perfect. Sometimes bad things can happen. Everything that we do in the build-up to and during the surgery and afterwards is all designed to minimize the risk and the likelihood of anything bad happening, but still, sometimes things can happen. If bad things do happen, then we do our best to make everything right, and most of the time you can do that. But sometimes things can go very wrong, and you end up in a worse state than you were beforehand. That is, fortunately, very rare, but it can happen. I mean, there's a list of potential problems here. I could spend all night talking about those and others. Fortunately, hip replacement infections in an environment such as Benenden are very rare, but when they do happen, they are serious. revision surgery I wouldn't say that's a risk. You know, artificial joints. If you have an artificial joint for long enough, it may well wear out. I mean, most modern implants last for decades, but if you're having a hip replacement, say, in your 30s or your 40s, then it's not so much of a risk that that hip replacement It may well wear out in later life; it's pretty much a certainty that eventually things will last long enough, so revision is more of an end point than a risk, and it may work. There's a chance that you might end up needing further surgery later in life if the hip replacement that you start off with does wear out.

How do you decide whether or not to have a hip replacement, and who and where to have it done? There are lots of decision-making tools out there. The NJR—let me talk about it here. This is the national joint registry. Every joint replacement that is performed in England, whether it's in the private or public sector, is registered on a joint registry. This has been the case for the last 15 to 16 years now, so the national joint registry is becoming a more and more powerful tool. It's a very useful source of information about what particular hip replacements or joint replacements in general are, how long they last, and how well they perform compared to other types of joint replacements. Also, all of us are registered on the NJR, so if you go to the National Joint Registry, you can click on my profile, and that will show you exactly how many operations of this kind I perform every year, what my complication rate is, and how long my surgery lasts. What I would recommend that you do is look for someone who performs these operations frequently. You want what we call a high-volume surgeon, so someone who does half a dozen hip replacements every year is not what you're looking for. You want to see someone who does hundreds of hip replacements every year. What they do morning, noon, and night is this type of operation because the more experience you have, the more familiar someone is with the procedure, and then the more likely it is that things will go smoothly. Look at my data, and you'll see that I'm one of those people who performs this operation regularly, many hundreds of times every year. It's what I do, so from that point of view, look for me or someone like me who has that kind of number that will give you the confidence that you need that we know what we're doing. You can also look at review sites such as Doctify or Top Doctors if you want great care. All of these websites out there that give you an idea of how people interact with you, what people's bed-sized manner is, and how institutions and individuals are and how nice they are won't give you an idea of the success rate. That's what the joint registry will do, which gives you more of the cold hard data as far as that goes. There's also a website at the bottom here that is part of the national joint registry website that is called a patient decision support tool, and that gives you an idea. You go on to that website, and you can put in your symptoms and how your joint is affecting you on a daily basis, as well as a few other details about your general health, age, and mobility. That website will use the experience of millions of joint replacements that have happened before you to give you an idea of what kind of change, what kind of impact, and what kind of benefit you would expect from a joint replacement. So, if you are considering surgery, that is a very useful tool to look at to give you an idea of how things might work for you. So, in summary, a hip replacement is a very common operation that we perform very frequently here in a very clean, safe environment. It has a significant impact on your quality of life and will make a big difference. It's reliable, it's safe, and its good surgery, so if it is appropriate for you, my advice is don't worry. Come here, come, and see someone like me; come and see the environment; come and talk about your problems; and if there's something that we can do to help; and if we're looking at hip replacement, don't be afraid; it will make a huge difference. 

Now I'd like to hand it over to Mrs. Woods. Here's a lovely picture of her, and she can talk to you about her experience going through this kind of operation, so I will put myself on mute and hand you over to Jean.

Jean Woods

Hello everybody. Can you hear me? Yes, good, okay, thank you, Mr Chipperfield.

Hello everybody, as Mr Chipperfield said, and as you can see, my name is Jean Woods. Mr Chipperfield performed a hip operation on me this year at the end of January. Just to give you a little bit of background, he's mentioned symptoms, and mine followed that sort of trajectory. I started with pain in the groin three years ago and actually went to Seven Oaks Hospital, where they gave me some exercises, and that seemed to keep it in check for quite some time, I would say, but then it travelled down to my knees, and I also had some pain in my back. But the main issue is that it did impact my life in the autumn of last year. As you can see, I had difficulty climbing over stiles. I belonged to a walking group that meets monthly and everybody was surprised that as I'm the tallest in the group that I had difficulty getting over the stiles it seemed to happen quite rapidly I also couldn't tie my shoelaces and this all cut my toenails and that did distress me so I went along to the GP again and said please can I have some more exercises to which he replied having tested some flexibility Etc and movement rotation he basically said sorry it's hip replacement time and if you're listening to me then you yourself would actually know when that moment has come and so the next thing is of course to have an appointment at the Hospital where you go through pre-operative assessment where you're asked what medication you're on and all sorts of things on that occasion  I took my son with me and I'm glad I did because he was able to take some notes because I was in a little bit of shock because I'd gone along thinking that I would have a  general anaesthetic only to be told that recovery was much quicker from an epidural which Mr Chipperfield sorry has referred to this caused me quite a lot of anxiety unfortunately but my nickname for Benenden Hospital is the Hospital that listens because if you listen to this to this evening have got any sort of problems or issues that are personal to you do share them when you go for the assessment because the nurse there really listened to me and she wasn't happy until she felt I was reassured now she also mentioned that anaesthetist would ring me to assure me even further which indeed he did and just to give you an indication she took so long with my son and I that in actual fact my son began to get really worried because his son his son was at a sports practice after school and he was my son was meant to meet him so he ended up ringing his wife so we were I'm sure holding up other people but I didn't go until I felt reassured so of course the next step from that is that you have a consultation in my case it was with Mr Chipperfield and immediately to that one I took my sister I sort of showed the burden and basically immediately we felt his warmth we liked him I hope all this isn't going to go to his head but we felt something that you can't touch intangibles we trusted him and I felt happier knowing that he would be the Consultant who would be performing the hip replacement on me now if I sort of say that Mr Chipperfield has referred to the Joint registry then I do like stats it's just the way I'm made and so I did have a look at his stats and of course that also was very encouraging now I have sort of mentioned that at the pre-op I was concerned about the epidural but unfortunately when the day of the operation came it really raised its head again and I'm quite ashamed to say really it was embarrassing but when the atheist came into my room he could see that I wasn't the happiest bunny around to put it mildly and he basically said that I was third or fourth on the operation list that afternoon and that for me to wait around all those hours would not be good for me which I concurred with completely and so he said that if they hadn't got the equipment in the operating theatre for the first person on the list then he would see if the order the schedule could be changed around and indeed it was and I was first on the list now which Hospital would do that for you not only are they listen to my concerned but they'd actioned around it on the day of the op and of course what helps you feel reassured as well is that as Mr Chipperfield said the facilities and the surroundings given that Benenden is in quite a rural location are both very quiet and comforting you have your own room and that certainly really does help tremendously and during the time that you're in your room I can't fault any sort of care I received from the staff but just going back to the surroundings I have to say something that maybe some of you appreciate is that touch wood  I haven't needed to be involved in hospitals very much so far in my life, but my sister is not a very good lady, so I've accompanied her, and I don't even like going into her hospitals because they smell horrible. Now, I've got no medical background whatsoever, but I was in education, and people told me that schools have a strange smell. Benenden has no smell whatsoever. it's like a hotel you go into the reception area and it's like going into a rather nice hotel that's what I think going back to the staff everybody seemed to work very well together and what I liked although I hadn't got experience of sort of staying in Hospitals so to speak it's the fact that the nurses seem to anticipate what I wanted so it wasn't always a case of me thinking I need this or I wonder if it was a case of let me get or they would as I say know the next stage and that was lovely the physio team were very helpful everybody can't really do enough for you I felt anyway and now if I move on to the fact that my life has really got back to where it was before I love walking you probably gather from the fact that I couldn't go over the Styles I belonged to several walking groups and in fact used to lead a walking group as well so I was delighted what I really wanted was once Mr Chipperfield had discharged me or before then even I'd had my eye on one or two holidays and in June I went on a holiday to France northern France it wasn't built as a walking holiday but it was actually it did say that if you couldn't walk x amount then please stay in the hotel for the day that week I walked four miles every day now some of you will say poor that's not very much or whatever but I was pleased that I walked more than a marathon in a week's away that that was good for me even though I'd walked a little longer during other days before my holiday but not all in one session that was the important thing so moving on to advice to any of you this evening that are considering hip surgery I would say a couple of things really I think first of all it was very helpful that I had family members with me and basically if you're at the stage where you haven't had any consultation yet or whatever if you could take like a good friend with you or a member of your family I think that would be helpful I mean I've accompanied my sister many times but you feel quite different because you're the one taking the notes when you're accompanying but I felt that I'd missed one or two things and it was reassuring that both my son and my sister told me one or two things after the actual appointments the second thing is when I talk to friends who'd had hip replacements before I went in they all stressed it was very important to do the exercises now I may walk but I'm not I did I used to do quite a lot of swimming but I'm not what you call a gym buddy at all I don't like weights I don't like doing exercises in a gym so it was quite demanding for me to actually discipline myself to do these exercises three times a day in so many different sets but I realized that maybe that was one way to get me back to where I wanted to be and would Aid my recovery better so if you can discipline yourself to do that I would say that's quite important also as you have heard me say that I had anxiety over the ark well if you have any anxiety for whatever reasons it might not be for the same as my concern the epidural but basically steal yourself to have the op because the situation isn't going to get any better and you know sort of have the little argument or conversation with yourself internally and go with it and so I think those are really the three main points  The other thing is, I just do not think you could have better care than at Benenden, and if you decide to go ahead for whatever reason, etc., then I wish you all good luck and I hope it's as successful for you as it has been for me because I feel like, regarding my hip, I'm a new person truly.

Louise King

Thank you, Jean. Thank you very much, Jean. That was really, really good, and really informative, so thank you for joining us there. I'm just going to go through some questions now if that's okay. We have quite a few that come through. The first we have is from Alan, and he says, How soon after a steroid injection in the hip can I go and undergo a hip replacement operation?

Mr Alex Chipperfield

I guess that was for me then, rather than Jean.

Louise King

Yeah, yes, let's assume that for you, unless I say otherwise.

Mr Alex Chipperfield

Okay, well, the first thing to say is that ideally you shouldn't have to, because if a steroid injection works, then you know that would get rid of your pain and help things, and steroid injections can give you several years of pain-free living. if the if the injection hasn't worked or has worked but now has worn off and you're thinking about hip replacement then I get you know that's a different question there is this is going to come back this this this question has come back to haunt me so many times when I was a junior doctor this was about 20 years ago one of the things that you have to do in order to progress as a surgeon apart from learning what to do and how to do it one of the other things that you have to do is you have to do some research and you have to publish some papers and this kind of stuff and so I was working in a department in Eastbourne at the time and we looked at the risks of having surgery after having a steroid injection and what that research showed was that if you have a joint replacement within sort of six to 12 months of having had a steroid injection there is approximate yeah there's a slightly higher risk of developing of getting an infection after the surgery now this was this was a study that I was part of so I know it in quite a lot of detail and I do also know that the risk of a developing infection is really tiny it's a very small increase its barely statistically significant but it was enough to publish a paper to allow me to progress in my career but the trouble is you get haunted by these things and the number of times people worry that having an injection completely negates or limits the time before that you before you can have a definitive procedure so the answer is the real risk is minimal and negligible.  If you want to be 100 percent safe, try and wait around six months to a year following an injection before you have a joint replacement. That makes sense to me.

Louise King

Thank you.  We've had two questions about how long a hip replacement lasts. Both people are younger, so they're just wondering how long if they had one. If they've had one now, how long would it last, approximately? Would they have to have another one?

Mr Alex Chipperfield

Like I said in the talk, these things do have a finite lifespan; they don't last forever; modern hip replacements do last for decades. A lot of it depends on you, what you do with them, and what kind of stress you're putting through them. If you look at the survivorship of joint replacements on the national joint registry, you can also look at the part of that patient decision tool that I spoke about. One of the things that it will give you when you put your numbers in is the likelihood of you needing to have a revision later in life as a rough estimate. So, like I said, the average age for someone to have their head replaced is in their late 60s. If you have a hip replacement in your late 60s, the chances are it's going to last you the rest of your life. There are, yeah, from a wearing-out point of view, some reasons why you might need a redo hip replacement that are outside the remit of the hip wearing out or not. You know infection can strike at any time, trauma, so you know. falling down a flight of stairs breaking the bone around the hip joint that kind of thing you know there are some conditions that mandate revision that don't involve the hip joint wearing out so what I'm trying to say but  generally if you're in your late 60s and you have your hip replaced there's a more than nine out of ten chances it will last you the rest of your life if you're in your 50s that chance is lower but it's still more likely than not that it will last you the rest of your life the like the survivorship of a hip replacement of a modern hip replacement performed in someone in their 50s you know you're looking at seven out of ten chance that it will last you the rest of your life if you're in your 20s then you know it's unlikely you know there's a that then the numbers are reversed so it will be a seven hour eight out of ten chance that it will wear out before you do you do but so  generally young people with ink replacement still have many decades of life left in them there are causes for revision that don't come from the hip wearing out but just from bad luck or other problems but on the whole modern hip replacements last an incredibly long time hopefully that's answers enough yeah it's comprehensive so keeping with the age theme someone has asked me is there there's an upper age limit for hip replacement so and is it better to do it earlier even if the symptoms are not too bad yet so the second part of that question no it is not better to have any you know this is a this is a big destructive operation to have and the only reason to have it is if you need it at the time don't have an operation in and it's not one that you don't get any bonus points for getting this done early in life you know it you have it when you need to have it done when nothing else is working is there an age limit no not really what it boils down to is yours is your  general Health rather than your age so it depends on how healthy you are what other medical conditions you may or may not have what your  general physiological state is like if you and that will be assessed before the operation at the pre-assessment so I've known some incredibly healthy 90 year olds who've had hugely successful hip replacement operations  I've known some incredibly unhealthy 50-year-olds who've been refused surgery on the basis of their health, so age is not an issue; your health is, and that will be looked into extensively before you end up with a hip replacement.

Louise King

Thank you for this nice and simple one. I would be able to use my private medical insurance at your hospital, and I think I know the answer to that. That's definitely yes, sorry, yes, yes, Anthony. I asked how long after surgery you have to adhere to the 90-degree rule. Is it six weeks?

Mr Alex Chipperfield

Yeah, generally, it's around six weeks. To be honest, it's not. You're not going to have to stand there with a protractor in life, you know, measuring every seat that you're about to sit in to make sure that you don't bend too far. Really, what it boils down to is that you just have to take a little bit of care while things are healing up. As a general rule, if you're living within the limits of what feels comfortable, if you're doing something that feels unusual or uncomfortable, then pull yourself back from that. So really, it's about you rather than focusing on a precise number; it's more about you. Listen to your body; it will tell you if you're doing something that has the potential to do harm or not.

Louise King

Okay, we just have a couple more questions. Would you mind moving on to one slide? Please, just get a couple more, either that one or the next one. Yes, if you go on to the next one, just in case, we do have enough people, which I'll go over in a minute. This person says I'm waiting for a hip replacement, but I have also been diagnosed with rheumatica. Thank you.

Mr Alex Chipperfield

Yes, yes, and no, so polymyalgia rheumatica You don't need me to tell you because you're suffering from it, but it's when you get inflammation and pain affecting multiple muscles and joints. In fact, I had a patient this afternoon who has it. When it was bad for him, when it was so bad, he couldn't even move; he couldn't get out of bed or out of the chair, so it can come on like a wave, and it can you. Redness alone is a steroid, which is an anti-inflammatory, and that seems to be the mainstay of treatment for this person. The problem is that when you're first taking those steroids, you take very high doses. You have to hit this condition hard with a high dose of steroids, and steroids are one of these medications that you can't just start and stop; they have an effect on your body as a whole. Generally, once the high dose has gotten your polymyalgia under control, you would then tail off the number of steroids that you take, ideally to the point where you're not taking any anymore. Some people, though, are on a maintenance dose of steroids that they have to take for the rest of their lives. The good thing about those steroids is that they keep the polymyalgia at bay. The bad thing is that steroids can have an effect on the rest of your body, and that's where it comes into play when you're talking about surgery, so it may well be that you need an extra dose of steroid during the operation at induction. Quite often, people who are taking long-term steroids are given an extra shot of steroid during the surgery to make up for the trauma that their body goes through. It can have an effect on your soft tissue, so it can make your skin quite thin and weak, it can make you more disposed to bruising and bleeding, and it can make your bones weaker, which would have an impact on the kind of implant that we might use for a hip replacement. People on steroids with weaker bones are much more likely to require a cemented hip replacement than an uncemented hip replacement, so you'd reinforce the weaker bones with cement around the hips themselves. The other thing that steroids do, especially in high doses, is that they suppress your immune system, which can put you at a slightly higher risk of developing an infection following surgery. So, all of these things would need to be considered, ideally if you can get to the point where you're no longer on steroids. I would wait to that point before you have a hip replacement. If you are stuck on a maintenance schedule, then those things will be considered. There will be some modifications in what happens before and during the surgery, but there's still a chance that your surgery will be a huge success, and it'll be a great thing. What it won't do is that it won't have an impact on the rest of your body, which will still be suffering from pain.

Louise King

Okay, and we just have time for one more question: what's the difference between having a cemented hip as opposed to a non-cemented hip, and how do I know whether my first hip replacement is cemented or not?

Mr Alex Chipperfield

So, if you've had one, the best way to find out would be to ask your doctor or your surgeon, because they will tell you, "The thing is, yeah, the difference between the two is that you wouldn't notice the difference because it's not something that you register as cement." Whether a cemented hip replacement, a half-cemented hip replacement, or a completely uncemented hip replacement, they all feel the same. When you've had them, what's the difference? If you have quite weak bone, then an uncemented hip replacement. There's a risk of a broken bone with an uncemented hip replacement, and there's a risk during the surgery, but also afterwards, there's a risk that the bone around the hip replacement could be the weak thing that fails, so to hold the hip replacement in more firmly and to reinforce the bone around it, you would use cement in that instance. So, if there is very weak bone, extremely osteoporotic bone, or if you have a disease or medication that weakens your bones, chances are your surgeon will probably use a cemented implant to help reinforce that. Learning to be a surgeon is an apprenticeship, and you learn your surgery over the years by working in different hospitals with different people and observing their techniques, taking on the good bits, and disregarding the bad bits. I trained mainly in the southeast of England and then I went over to Australia and performed a fellowship over there and the southeast of England is traditionally an area of the country where we use less in the way of cement and the Australia that's when I was in Sydney and also in Brisbane again it tends to be a less cemented part of the world so the majority of people who taught me hip replacements taught me uncemented hip replacements now being a fully rounded individual I learned how to do cemented hip replacements as well because you shouldn't only know how to do one thing but there are other parts in the world so if you were to go to the north west of England around Manchester or if you were to go down to the southwest of England around Exeter you would find that the overwhelming majority of hip replacements that are performed in that part of the country are cemented again because of that's the philosophy that's the training in that particular region if you look at the outcomes if you look again I keep harking back to the National joint registry and other registries around the world but if you look at the difference between how a cemented hip replacement and an uncemented hip replacement how they perform in the long term if you look at the outcomes they are indistinguishable in the early days of uncemented hip replacements the argument from the cemented group used to be that cemented hip replacements have the longest Heritage the longest track record and last the longest now the uncemented hip replacements have been allowed around as long they have demonstrated the same Heritage the same longevity and in some instances actually better longer lasting results than the cemented so it's a treat; it's a matter of necessity.  Philosophy: it's what happens when you get a group of hip surgeons together at a conference. It's what we spend hours arguing with each other about, um, my best friend, who is also a hip surgeon who works down in Exeter. It's what we bore our wives about constantly when we all get together and have a chat. We've bitten about this kind of thing, so there really is no difference as long as it's done properly. It's an approach whichever is most appropriate for you, and the way to tell would either be to look at the X-ray or to ask your surgeon exactly which one they've done because you won't notice a difference.

Louise King

Great. Thank you for that very comprehensive answer.

Yes, I think that's the end of our Q&A session. We have run out of time, but if we do notice a few more questions, if we've seen your name, we will answer yours via email afterwards. I hope that's okay, so thank you for joining the session.

As an exclusive September offer, we are providing the value of your consultation refunded back upon booking the operation. I also get a call back from my dedicated private patient advisor, and you'll receive an email tomorrow with a recording of these sessions and further information, so if you missed any of the questions or information, you could watch it all again or just remind yourself, and of course you will then get any updates on news and future events. If you'd like to discuss or book your consultation, our private patient team can take your call until 8 PM this evening, or they're available between 8 AM and 6 PM. Monday to Friday on that using the number on the screen, but also be grateful if you complete the survey when the session closes to improve our future events. Our next webinar is quite a different subject, some breast enhancement surgery, which you can sign up for via our website. We will have a list of various other webinars as well, so on behalf of Mr Chipperfield, Jean, and our expert team at Benenden Hospital, I'd like to say thank you very much for joining us today. We hope to hear from you very soon, so thank you very much and goodbye.