Webinar: From Theatre to Treadmill: The Full Hip Replacement Journey

Hello everyone, and welcome. Thank you very much for joining us this evening for our online talk about the full hip replacement journey. I'm Katie, one of the members of the marketing team, and I'm delighted to be joined by Mr Syed Ahmed, one of our consultant orthopedic surgeons here at the Horder Center. Mr. Ahmed specializes in hip surgery, performing over 500 hip replacements annually, and has a particular interest in minimally invasive hip replacement surgery. We've got a great hour ahead of us. So before I hand over to Mr. Ahmed and his presentation, I just want to remind you that it's a live recorded event, and the recording will be emailed to you tomorrow. We do have a Q&A segment later on, so do drop any questions that you have into the box for us to address. But once again, thank you very much for joining us, and please welcome Mr. Ahmed. Katie, thank you so much, and Katie, thank you too for organizing this. So over the next sort of 20 to 30 minutes, I'll take you across minimally invasive hip surgery, what we do, and how we've improved outcomes over the last few years in order to be able to get you back to leading an extremely active lifestyle following major surgery. So a little bit about me. I'm a fellowship-trained arthroplasty surgeon, so I did hip and knee replacements during my surgical training and then went on to sub-specialize in hip and knee arthroplasty and robotic hip and knee arthroplasty at St. Michael's in Toronto and University College London Hospital in London. I play a few roles both regionally and nationally. I'm involved in training junior surgeons, and I also play an active role in the British Hip Society and the European Hip Society. As Katie alluded to, I perform a high number of hip replacements, so I actually do over 650 hip replacements a year, and I've done just over 2,000 hip replacements in the last three to four years. The aim of this talk is really to tell you about what I do when you come to me in clinic complaining of hip pain, what is important, what specific features we're looking for, how we investigate this, and I'll talk to you through hip replacements and what the future in hip replacement surgery is. So the hip joint itself is a ball and socket joint. It's a ball that sits inside a socket, and that gives you this excellent arc of movement which no other joint in the body has. The shoulder joint comes close to it, but the movement that the hip joint has allows us to get in and out of car, horse ride, play sport, and not only flex and extend the hip, but also rotate the hip at a lot of different angles. And the reason why we're able to do this is because the ball is inside this socket, it's deepened by labrum, and you've got some really strong ligaments that are both in front and behind the hip joint. And therefore, the hip joint that the good Lord has given us is very stable despite what we can do with it. Now, in terms of pain, a lot of people come in complaining of hip pain, but the hip joint really is in the groin. So generally, what I tend to ask people is, where is your pain? Can you point specifically to where the pain is? And if people point to the groin, that's pain originating pathologically from the hip joint itself, whereas pain on the outside of the hip and pain in your buttock could be because of other causes. What I also want to know is how this is impacting one's life. Is it preventing you from wearing your socks and shoes? Is it preventing someone from going up and down stairs, going on long walks? Is it reducing walking distance as a result of the pain? And obviously, we want to know what kind of past medical history you have, so any other medical conditions that you're managing long-term. So there are lots of different causes of hip joint pain, and this is what I was alluding to earlier. Lateral-sided hip pain, which is pain on the outside of the hip, and if most of you feel on the outside of your hip, you can feel a bony landmark there, which is your greater trochanter. And pain around there is usually due to an inflammation of a tendon, or it's due to bursitis, which is the trochanteric bursa which sits just under your IT band, and that could get inflamed, and that causes lateral-sided or pain on the outside of the hip. Generally, pain that's present in your groin is due to the hip joint issue. Its most common cause is hip osteoarthritis, which means the cartilage in the hip joint is worn out and the ball is now grinding against the socket. So you have bone grinding against bone, and that causes pain in the groin. Now, other causes in younger, more athletic people would be a labral tear or femoroacetabular impingement, where there's a little bump either on the neck of the humeral head or there's an over-coverage of the socket, and therefore certain movements would cause impingement and pain. Posterior pain, so buttock pain is because either the pain is coming from the hip joint and radiating into the buttock region or, more commonly, buttock pain is sciatica. It's a lumbar cause to the pain. So you've got pain due to a nerve being pinched at the bottom of your spine, and that nerve supplies the buttock region and causes deep-seated buttock pain, and that pain could travel down your leg and cause pain at the back of your leg, and that's generally sciatica. Mostly with hip pain, you'd expect the pain to travel down into the knee. So hip joint pain causes referred pain to the knee because the hip and the knee are supplied by the same nerves. But what you shouldn't get with hip pain is pain that travels beyond the knee. So any pain that travels beyond the knee, the likely cause of this pain is coming from your back rather than your hip joint itself.So the examination of the hip starts with trying to isolate where exactly the pain is coming from. You can see in the picture there on the left, this person is pointing to their groin and also radiating towards the outside of the hip. You also want to check whether they're able to stand on either of the hips or if they're offloading one hip due to pain. The next thing that I look at is how much movement they have in this hip. And you can generally do this with the patient sitting in the chair. You just hold their leg and gently flex the hip to see how far they can take their knee into their chest, and then you rotate it in and out to see how much rotational movements they have in the hip. And usually people who have an arthritic hip are unable to tolerate much in terms of rotational movements. This is a Faber and Fader test. These are tests for impingement that you can specifically do if you're concerned that there's a certain movement that causes bone to impinge against the other surface, and that would elicit pain. The most sensitive marker of a hip joint issue really is rotational movement. So just by rotating the knee in and out, what you can see is the hip joint moves, internally rotates and externally rotates, and if this causes pain, then the pain is coming from the hip joint. Most of the time with investigations, all you need is a plain film X-ray, especially if people have a joint issue where there is loss of joint space or if there's impingement or osteonecrosis where the femoral head has died, then you can see all these on a simple X-ray. It's not that common that you need a CT scan or an MRI scan. It's only if you're not able to ascertain where the pain is coming from on an X-ray, then you investigate this further in terms of a CT or an MRI scan. An MRI is very good at picking up soft tissue abnormalities, including bursitis and tendon inflammation. So trochanteric bursitis, this is what I was talking about earlier, which causes lateral-sided or pain on the outside of the hip, and that's when a bursa gets inflamed just outside the greater trochanter, and that causes a lot of pain on the outside of the hip. Most of the time this can be treated with simple things like analgesia, anti-inflammatories, massaging ibuprofen gel, and if that doesn't help, one can always consider a targeted steroid injection. Likewise with the iliopsoas bursitis which is at the front of the hip joint, and this could mimic hip joint pain and anterior groin pain, but the pain is especially present when you flex the hip because it involves the hip flexors. Then it can be treated exactly the same way which is simple analgesia, anti-inflammatories, if not a targeted steroid injection. I'll start with femoroacetabular impingement here. This generally tends to happen in the younger population where they're athletic or they play sport, and there's certain movements that cause a sharp, severe groin pain. Andy Murray had femoroacetabular impingement. He had quite severe femoroacetabular impingement actually, prior to having a hip replacement. What you find is it's a spectrum in that patients constantly impinge the hip and they start wearing the cartilage out on the medial side of the hip, prior to getting a degenerate hip joint. You can see here if you follow the bottom of the picture there, you can see how-- Let me see if my laser pointer works. You can see there at the bottom of the screen there how that is a nice concave neck that leads to the femoral head but on this side that concavity is lost and you've got a little big bump. You can imagine when this person flexes the hip, that bump will hit against the edge of the acetabulum or the socket and that would cause quite a bit of pain. So the next thing is osteoarthritis, and osteoarthritis or degeneration or wear of the hip joint are all very interchangeable terms. Osteoarthritis is when the normal joint space that's there between the ball and socket which is maintained by cartilage gets worn off, and you have bone grinding against bone. One of the other conditions that causes a similar picture later on is osteonecrosis. Osteonecrosis is because of a number of different reasons. The blood supply to the ball part of the hip gets compromised, and the result of it, that ball and socket joint is deformed, it gets flattened, and eventually the space between the ball and socket wears off. For osteonecrosis, if it's picked up early, there are other treatments like decompression, vascularized bone grafts, but eventually what one ends up needing is a hip replacement. A lot of what I do in clinic is trying to differentiate if the pain in the hip is coming in fact from the hip joint or if it's coming from the back because a lot of patients who have hip joint pain may well also have back pain, or people who have a degenerate hip joint or an arthritic hip joint end up also having an arthritic back. Then you've got to ascertain if the pain is coming from the hip or is it coming from the lumbar spine. As I've said, pain that's in the groin, pain on movement of the hip joint, that is coming from the hip and usually the symptoms are that they can't get in and out of a car, you're not able to put your socks and shoes on, whereas spinal canal pain or pain from the back due to a nerve root impingement causes a sharp tingling pain with a bit of numbness, altered sensation pain going down beyond the knee. So in the examination what I'm trying to ascertain is, is weight bearing on this hip causing pain? Are movements, rotational movements of the hip causing pain or is it buttock pain that comes on when you are stretching the lower back? The hip spine syndrome does exist. The pain doesn't necessarily have to come from one or the other. You could have a pain that originates from both the hip and the back, and the way to try and delineate what is more painful or what you benefit from treating is inject one or the other. So you've got a nerve that's being pinched at the back, you can inject the steroid and see how much of the pain goes away, or if you think the main pain is coming from the hip joint, then you can inject the hip joint with a steroid and see how much of the pain goes away following that. Then you know that a hip replacement is or not going to be as successfulWe're talking about hip replacements, the different approaches or different ways to get into the hip. And I have a lot of patients who Google approaches to the hip and get really hung up on which approach to use. They're like, "Oh, do you use an anterior approach? I've heard the anterior approach is better." And then you've got the posterior surgeons who use the posterior approach and would swear by it. I've done both in Toronto. I've learned the anterior approach, and then when I'm in London, I use mainly the minimally invasive posterior approach. And in all honesty, it's like comparing a Rolls-Royce to a Porsche, and you could always argue about which one's better. I prefer the Porsche. But what I use is a minimally invasive posterior approach. And the reason behind that is purely because it gives you really good access to the hip joint. And the bottom line is, it's not the size of the incision or the muscle sparing. What you're left with is where you're putting the implants in. And a lot of the times, I've felt that the anterior approach really complicates where one can put the implants in. And as a result of that, I've stuck to and used the posterior approach in my practice. So the traditional posterior approach involves making an eight- to ten-centimeter incision targeted towards going towards the back of your thigh and the hip joint, and then reflecting all these muscles back and approaching the hip joint that way. What I use, as you can see from the pictures, a very minimally invasive approach. I don't go through the piriformis muscle, which is your main external rotator. I reflect the tendons inferior to that and then access the hip joint that way. And what that means, with careful soft tissue handling, what that means is that patients get up and walk straight away with minimal pain. And as a result of that, we were able to do Kent's first day-case hip replacement, where the patient came in, had a hip replacement first thing in the morning and was able to walk unaided at the end of the day. And this is another... I don't know if this video is going to work. Let's try that. Yeah, this works. So this gentleman came in- This is the man ... to have a hip replacement on him. Again, you can see that this is now six hours following surgery. So he had his hip replacement at ten o'clock, to four o'clock in the afternoon, he was up walking, no sticks. You can just about say that's the right hip that we've done. So the minimally invasive posterior approach really works. It helps people to get up and walk unaided fairly soon. And the implants that we have access to now are excellent and have really good long-term outcomes, and we'll discuss that in another slide. But essentially, this is what we are doing. We are replacing that worn-out ball and socket with a new socket, a new ball that goes in, and a stem or an implant that goes down the thigh bone, and that's the new hip replacement that one gets. And it is the operation of the century. It's a very successful operation. It's the second most successful operation in the history of surgery. The only thing being more successful than it is cataract surgery, and coming from a family of ophthalmologists, they keep reminding me of that. So how do we choose implants? I'm not going to get into this in too much detail, but based on what the X-ray appearance is, you've got different classifications of what implants will be ideal for the bone that we're dealing with. And most of the time, in my practice, I use an uncemented hip replacement, but when people who are osteopenic, osteoporotic bone, I tend to cement the implant in. There's no one size fit all, and therefore, we've got an array of designs and components that are available to us, and we can choose based on the patient's anatomy and what deformity we're dealing with. And the choice of implants is you've got what I've mentioned is fixation. We've got cemented, uncemented implants. Then you've got the coating of the implant. It could be completely coated, or it could be half-coated or just proximally coated. And then you've got lots of different options in terms of offset, taper, version, based on what one is dealing with in the patient's anatomy. And as with any procedure, despite as successful as it is, there are some complications associated with hip surgery. The short-term or early complications are things like infection, dislocation, leg length discrepancy, a small risk of fracture, especially in people who are osteopenic, osteoporotic. And the long-term complications are wear, loosening, and again, a periprosthetic fracture, which is a fracture around the implant if people fall while doing crazy things like skiing. We've got strategies in order to try and reduce all these complications. So in terms of infections, we make sure that we give antibiotics for the first 48 hours, so that significantly reduces that risk. And dislocation and leg length discrepancy really is tackled by really good preoperative planning. So a lot of planning prior to going into the procedure itself in terms of what implants you're going to use and what's going to be best for this person's anatomy. We put a lot more colored implants nowadays, which has significantly reduced periprosthetic fractures to fractures around the implant. Now, this is something that people get very excited about, which is metal-on-metal hips because there's been a lot of publications on metal-on-metal hip and a lot in the media about metal-on-metal hips, too. So this is a chart that's been taken directly out of the National Joint Registry. And what the lines represent is cumulative revision rate, so essentially failure rate. And if you have a look, you can see that that yellow line is way higher compared to anything else. Yeah. And that yellow line is metal-on-metal hips. So metal-on-metal hips have a very, very high failure rateAnd that's resurfacing, the second one along there. Again, a very high failure rate compared to all the other different types of hip replacements, which have an extremely low failure rate. So you can see the failure rate is less than 5% at about 19 years, whereas that for a resurfacing or a metal-on-metal hip replacement is between 10 and 25%. So double or four times the risk with metal-on-metal hips or metal-on-metal resurfacings in terms of failure rate long-term. And that's partly because the modern hip replacements do extremely, extremely well. So the polyethylene, the plastic that you put into the socket has really, really low wear at 14 and at 15 and 20 years. So you can see here metal on plastic, oxinium on plastic, ceramic on ceramic, all of them are pretty much at the same level purely because of how well they do at 15, 20 years. What we use in the United Kingdom, which is really good, is this thing called ODEP, which is an Orthopedic Devices Evaluation Panel, and at the Horder Center, we always use a 10A* ODEP-rated implant. Which means that any implant that we put into our patients has a 10-year, 98% survivorship. So the implants we use are very carefully selected, and all this information is collected by the National Joint Registry. So just to give you an idea of what happens when you've got someone with hip arthritis. So this is an X-ray of a person who has osteoarthritis of the hip on both the left and the right hip, the left being worse. So preoperatively, I look at the X-ray, and I plan using a computer software exactly where I'm going to put my implants in. And not only does this tell me the size of the implants I'm going to use, it measures accurately exactly where to put the implant to the degree and where to put the implant to the millimeter in order to make sure that the patient's leg lengths are fine, and the patient's left with a really stable hip that they can walk on. I then use intraoperative landmarks to recreate my templating plan. And you can see there I've pretty much recreated what I planned prior to going into surgery with the X-ray on the right side. And we've got lots of landmarks intraoperatively that we can look at to make sure we put all the implants in the right place. And this is what I was talking to you about earlier. The lifespan for hip replacement is excellent with the modern implants, 85% survivorship at 20 years. 90% of people are still very successful 15 years post-operation. So it's a really good success rate. And the implants that we have now wear out really slowly over 20, 25 years, too. So what I feel is that this will only improve at 25, 30 years as we start following these modern implants. So this is a previous generation of a hip replacement. It's a cemented hip replacement, where you've got a cemented socket, you've got a cemented stem, and what you can see here is that the socket part of the hip is going into the pelvis, and that's failing. So with these previous generation of implants, the hip did fail, and you can see here on the CT scan, there's quite a bit of loosening between the acetabular component, which is the shell part of the hip, and the native bone. So what we can do here is go in there, take the cup out, and replace that with a new cup, and that's what I have done with this patient. Where I've taken that cup out and put a new cup in exactly where the center of rotation is on the other side. And the stem hadn't failed, so we left the stem exactly where it is. So yes, revision hip replacements are possible. Slightly more higher risk, not as straightforward as primary hip replacements. But certainly when things go wrong, we revise the hip and make sure that we give people a hip replacement that they can walk on comfortably. Again, similar thing here with a cemented socket. You can see the space between the bone and the cement interface. And I went back in there and changed that to an uncemented total hip replacement. So what's new in arthroplasty? So what we're trying to do is, despite the fact that it's such a successful operation, we know that there are complications. So the complications are, I told you with infection, we've dealt with it with antibiotics, and that's significantly reduced infection risk. Prophylactic antibiotics, washes, making sure that we're really clean intraoperatively with the incision, the wound prep and drape. But still with hip replacements, leg length discrepancies of about 1% to 2% of patients feel that one leg is slightly longer or shorter than the other. There is a 1% risk of dislocation where the ball comes out of the socket because nothing we put in there is going to be as stable as what the good Lord has given us. And so this is a real risk. And the way we can tackle that, one of the things, some of the new implants we have is dual mobility implants, where there's a larger ball inside a smaller ball. And this has significantly reduced dislocation rates, especially in the high-risk patients where they have a fusion of their spines or if they have spinal pelvic malalignment and therefore a standard traditional implant will not suffice. This works really well and has extremely good results at five and 10 years. And the next big thing really is navigation and robotics, where instead of having to wait post-operatively to make sure that you have matched what you planned, you can actually look intraoperatively live and see where you're putting your implant and how much you're lengthening a person or what angle you're putting the cup and the stem in, and this really helps. It leads to a lot of precision in terms of accuracy of where you're putting the implants in, which you can't do with the naked eye. And there's less soft tissue damage, less pain, and because you're putting the implants to the degree of where the designer manufactured them to be implanted, the long-term wear is going to be a lot less. And what you have with robotics is this robotic arm. You've got a screen that is visible to the surgeon intraoperatively, and you can see there that actually you can put... implants and using the robotic arm exactly where you plan to put it in. It still needs a surgeon to do the work. The robot is not actually operating on the patient, but it just gives us a lot more accuracy in terms of what we are doing. And I certainly think that although we are at a very early stage in robotics, navigation, and AI in arthroplasty surgery, this is going to be the future of arthroplasty surgery. And you can see here what it allows us to do is look at what the hip does in relation to the back, the spine, and how stable that implant is going to be long-term. And the reason I say this is the future and not yet there is because currently where we stand with robotics, there's no paper that shows statistically significant differences in terms of patient experience or patient outcomes. What it does show is that the implant is positioned in a more accurate manner to the degree or to the millimeter, but it doesn't show that patients actually do a lot better clinically or in real life, so to speak, after having had a robotic joint replacement as opposed to a high-volume surgeon operating on them. So the key takeaway message is hip pain has a number of different causes. It could be bursitis, could be a tendon issue. The most likely cause of groin pain is pain coming from the hip joint itself due to osteoarthritis or wear in the hip joint. Buttock pain, pain radiating down the back of the leg is usually coming from the spine, and that's what we call sciatica. Most of the time, all we need is simple X-ray to diagnose where the pain's coming from. The ladder of treatment with osteoarthritis, as with anything else, is simple analgesia, anti-inflammatories, weight loss to try and reduce the forces going through the hip. And eventually, if none of that works, then a joint replacement. And I will stop there, and we will take questions. Katie? That's great. Thank you very much for giving us an overview of what to expect on hip replacement journey. Thank you. Some important details being discussed. I can see it's triggered some questions, but we have received a few in advance. I will just start with those. We've got plenty of time, so- Yeah ... I think we're going to get through a fair amount. So, let's start with do you also do hip resurfacing, and what are your views on the potential benefits and drawbacks versus total hip replacement? So, as I showed with the slide from the National Joint Registry, hip resurfacing has a role, but it's a niche. Andy Murray had a hip resurfacing purely because he was going back to playing Wimbledon and doing what he needed to do with the forces that were going through his hip. So there are benefits of hip resurfacing, essentially in younger active patients. It preserves bone. There's lower dislocation rate when you're putting the hip in an extreme position due to the large head. However, there are drawbacks. There are metal-on-metal concerns, the ion release, the soft tissue reaction, the tumors that the metallosis causes. It's generally not suitable for women, not because we're being sexist, but because of the sizes. The larger heads tend to do better, the smaller heads tend to do worse and have a higher failure rate. It's slightly more technically demanding, there are fewer surgeons that do it, and I used to do hip resurfacings, but I stopped purely because of the excellent results that you get from hip replacements. For the majority of patients, modern total hip replacements is a much more predictable, safer, and longer-lasting operation. So resurfacing is certainly not a better option, it's a selective option. Great. Okay. We'll move on to can I horse ride after a hip replacement? Definitely. I wouldn't recommend it immediately. Usually, it's safe to go back to horse riding at three to six months, depending on the approach that's been used, the strength in the muscles. Are you comfortable mounting and dismounting on the horse? And people have. I'm not a rider myself, but I've operated on lots of patients who've gone back to riding, and how quickly you can go back depends on which hip I'm doing and which leg they use to mount and dismount off the horse. And higher-level riders return back fairly quickly at about the three-month mark. Great. I'll stay on that line actually, and just jump to this one. I swim, do Pilates, and yoga. When can I do that again after hip replacement? So again, very similar to the previous answers, going back to all these normal activities like Pilates, swimming, going back to playing simple sport like cricket, tennis, you can go back to all of this as soon as the strength around the hips feels normal and if you feel you're able to manage standing on the operated hip, balancing on the operated hip without having the other leg on the floor, then you can generally go back to most of these. A lot of my patients go back to activities like Pilates and playing cricket and sport at the three-month mark. Great. I know you mentioned this, but no harm in a bit of repetition. Can the hip dislocate, and what is the immediate action required? So dislocation is one of the risks, and high-volume hip surgeons have lower dislocation rates. Like with anything, no one's born to be an amazing surgeon. The more you do, the better you get. It's really as simple as that. So you should ask your surgeon what their dislocation rate is, what they do to prevent dislocations, and yes, it is a known risk factor following a hip replacement, and it most commonly occurs in the first sort of three months, the first three-month mark, and that's why I've told you with sports and all these kind of things, you're best going back to it after the first three-month mark when the soft tissues, the tendons, ligaments, muscles have all healed and have got used to where the new hip replacement is. What tends to happen is if you put the hip in an extreme position, yes, it's a ball inside a socket and the ball can pop out.And you'll have sudden pain. You're not going to be able to get up and walk on this, and you will need to come into the emergency department to have it reduced. Okay. Best to delay or be ahead of the game, someone says. That's a tricky question. What I tend to advise people is that you want to have a joint replacement, whether that be a hip replacement, knee replacement, when you feel it's impacting your quality of life. If you feel that your world around you is shrinking and you're doing less and less and less, you're not going out, your walking distance is reducing, you're getting reliant on painkillers, and despite taking painkillers, you're still complaining of pain, then you've got to the stage where you need a joint replacement surgery. If you feel you can manage and if you feel you can do most things by taking simple paracetamol, ibuprofen, then you can carry on. You shouldn't need to have joint replacement surgery when you're able to cope and manage and do everything you want to do. But when it's starting to impact activities like putting your socks and shoes on, getting in and out of the car, getting in and out of the bath, then you're getting to a stage where you want to have this investigated and replaced so you can go back to normal life. Absolutely. It's all about that quality of life. Mm-hmm. So I'm an NHS patient. Will I be able to discuss the prosthesis with the surgeon before surgery? You won't be choosing from a catalog. So we don't open this catalog up and say, "Oh, which one would you like? The pink one looks good." But what you will be able to discuss is, as I've told you, at The Hodor Center, we use 10 A star rated implants, so you've got to be reassured that no matter which surgeon you go to, we use the best implants that are there in the market, whether that's a private patient or an NHS patient. You should be able to discuss with your surgeon the rationale behind the implants that he or she uses, whether you're going to have a cemented, an uncemented stem, whether you're going to have a metal or a ceramic head. There's little theoretical differences. But yes, you should definitely be able to ask your surgeon what implant they're using and why. But I wouldn't Google things and say, "Oh, I want you to use implant X." Don't select your own. No. Good advice. Can a hip replacement be done a second time? Yes. That's what we're talking about, the revision hip replacements. The previous generation of surgeons, the implants that they were dealing with, the plastic that they were dealing with, which goes inside the socket, was not as good as the plastic that we have nowadays that we put inside the socket. And therefore, wear was a much more common issue, and therefore the revisions that I do are for wear or long-term infections. But wear is the most common thing that I revise a hip replacement for. So go back in there, take the old implants out, and put the new implants in. This is because that's what the previous generation of surgeons had. The next generation of surgeons I don't think will be dealing with wear as an issue because the implants that we are putting in currently are excellent. They have excellent survivorship at 15, 20, 25 years. So I don't think wear is going to be a problem in the future. I think what may well be a problem in the future is things like periprosthetic fractures because we're getting people back to doing so much more than what they were doing previously- Mm-hmm ... that there's a higher risk of falling and fracturing around the implant. So yes, revision is possible. Again, it all depends on the cause. Perfect. What is the enhanced recovery program, someone asked. So the enhanced recovery program is something that we do in order to get people up and about, walking and doing most things straight after surgery. And the benefit of that is that you are functioning the muscles, you are back to all normal activities. It significantly reduces your risks of forming a clot chest infection by just laying in bed in a hospital. When I started off as a junior trainee surgeon, patients following a hip replacement or a knee replacement were in hospital for four to five days. So I used to have my old bosses who did a joint replacement, and they were in the hospital one day in the week, and the next week when they came, they'd still see their patient there. We don't tend to do that anymore with modern hip surgery, muscle preserving approaches. Pain is a lot less of an issue and also what's significantly improved is the care that we provide around the surgery itself. So the anesthetic, spinal epidural anesthetic with blocks, which allow you to feel less pain on the day of surgery and the next day following surgery. The physiotherapist will come and see you immediately on the ward and get you mobilizing in a very comfortable manner using crutches or a frame, depending on what you need. And the analgesia that we use is multimodal pain control, which specifically targets muscular pain. And we give you plenty of painkillers to go home with so you're comfortable in the first two to four weeks up until the wound heals. Because you've got to remember, the pain that you have following a hip replacement is now different from the pain you had prior to the procedure. The pain you have prior to the procedure is because you've worn out your joint. The pain you have after the procedure is because of the surgical wound and the incision and the muscle that has been bruised slightly during the procedure. And so as long as you can control that, you want to be up and about walking and doing most things as quickly as you can. And so enhanced recovery program promotes that and facilitates you getting back to normal activities very quickly. Great. Apologies for my pronunciation. I have spondylitis. Can I have an epidural? Usually yes. There are very few patients who can't have an IPOL, a minority of patients who can't have an IPOL. Spondylitis, a degenerate spine, or lumbar fusion makes it more challenging for the anesthetist because there's slightly altered anatomy. But in my experience, most of the time a skilled anesthetist often can do a spinal. And if a spinal fails, then there's always the option of general anesthetic. If both hips are bad, is a bilateral hip replacement a viable option if you're young, bracket 55, and fit, so only one operation and recovery, or is it better to have it done separately? So simultaneous bilateral hip replacements is an option, and there are benefits to it. The pros are that you have one anesthetic, it's one recovery, you're taking four to six weeks off from work, you recover from both hips at the same time. There's a faster overall return to you leading a normal life as opposed to staging it. The risks or the challenges are that there's a physiological stress on your body when you're having two major operations in one sitting. It's not suitable for everyone, and therefore, you've got to be someone who's young, fit, when you're replacing one hip and you're able to rely on the other side, and what you've got to then do is if you're replacing both, you've got to have some upper body strength to be able to use crutches and- Mm ... a frame up until you can walk comfortably on both hips. I've done quite a few bilateral hip replacements in younger patients because they don't want to take three months off work. They want to recover in six weeks. Of course. Great. Okay, will the scan always show if someone needs a hip replacement? So a plain film X-ray will show if someone needs a hip replacement in 95% of patients. You can see that the joint space has been lost, and it's very easy to spot. You don't need to be a trained hip surgeon to pick that up. People who see the X-rays on the screen when they're in a consultation room with me can usually tell the difference between the right hip and the left hip if the right hip is really badly worn. So yes, 95% of the time you can tell that the hip is worn and you can see why it's causing you pain. In 5% of patients, the hip joint looks normal on X-ray, and they need to investigate this further with a CT scan or an MRI scan based on what the symptoms are. Okay. Someone here who's post-op. So I am six weeks post-op. I still have restrictions in my hip. When can I expect full pain-free mobility? Six weeks is still very early stages. With the minimally invasive hip replacements, yes, we try and get people back to doing most things at six weeks, so my patients go back at four weeks to driving, six weeks to walking without any aids, but it's still very early stages. Complete recovery takes anything between three to six months. So the six-week mark, if you're walking without any aids or if you're able to walk with one crutch and you're relying less and less on painkillers, you're winning. By the three-month mark, you should be walking without any aids and not using painkillers. Fantastic. Just to recap again, what is minimally invasive surgery? So the idea behind minimally invasive surgery is not just the size of the scar, but it's also preserving the muscles inside the hip, so you're not taking off the muscles that traditional posterior approach surgeons used to do or the anterolateral approach surgeons used to do, where you took the muscles off the hip and then you repaired them back, and then it takes quite a bit of time for that muscle to heal for you to be able to walk comfortably on that hip. With minimally invasive surgery, it's a smaller wound. You're respecting the soft tissue, you're preserving the muscles. So then yes, you will have pain because you've still had major surgery, but you should be able to go back to normal activities a lot earlier. Great. Thank you. So is it normal when sitting on occasions it feels like there is something there, almost like having something in your pocket? I'm not sure what that means. I wouldn't say that's normal. When you're sitting, you're not sitting on your hip joint, you're sitting on your ischium bone. If there is some bruising, swelling that's tracked towards the back, yes, that may cause a bit of discomfort when one is sitting down following a hip replacement, but ice packs should generally help with that, and usually by the six-week to three-month mark that should resolve. If it hasn't, you've got to see your surgeon again. Okay. Oh, sorry. It's loading. I'm struggling to know when to consider surgery. I was told I was eligible for a hip replacement last November. I'm concerned that movement will be permanently restricted after surgery and the replacement won't last my lifetime. Have you any advice to help me decide? We don't know how old this person is. Unfortunately, no. If you've been offered hip replacement surgery last year, November, we're what, now four months down the line since then, I can't imagine that the movement you currently have is good. Because what happens is that you've lost that space between the ball and socket, and therefore you're going to have restricted external-internal rotation in that hip. So a hip replacement will definitely give you better movement than what you have now. This is obviously me without having looked at you and examined you, but if you've been offered a hip replacement because you've got an arthritic joint, there is no way that you have good movement in that hip. If you've got good movement in that hip despite having an arthritic joint and you're able to manage without painkillers, then no, don't have a joint replacement. You're not treating the X-ray. You've got to treat your symptoms. You've got to improve your quality of life. So if your movement's restricted, you're reliant on painkillers, then yes, you need a joint replacement. Okay. We've spoken about when we can return to stuff, but someone has said here, what are the limitations of a hip replacement? Are there things that can never be done again? We used to previously say you can never go back to jogging and running, but now there's literature out there that shows that you can actually go back to jogging and running, and it doesn't wear the hip out long-term. Obviously, this is after the first three to six-month mark when the implants have completely bedded in. There's certain things that you're going to be unable to do following a total hip replacement, which is you're not going to be able to do things like the splits. You don't want to be going back to high impact activity like playing rugby or playing football. You can still play football casually in the park, but you don't want people tackling you, taking you down because then you risk fracturing around the hip joint. And therefore, contact sport like rugby, football, karate, I'd avoid things like that purely because of the significant complication that you could have if someone takes you down in an awkward manner. But apart from that, yes, you can go back to most normal activities. A few things. Okay then. Is it possible to be on your own after the operation at home? Ideally not. You've had a major anesthetic, you've had major surgery, you don't want to be on your own. You'd rather have someone there who can keep an eye on things, make sure everything's okay. Not that you should have any problems, but you'd rather have a friend or a relative who's staying with you for the first couple of weeks and tell people that they'll need some help with cooking and shopping. So it's useful. Now, we get shopping delivered to us, but it's useful to have a bit of help with cooking and shopping. Yeah. That extra support's always handy. I am a yoga instructor. Time off, question mark . That's tricky. Yoga instructor, it really depends on what you need to do with your hip and what you're trying to demonstrate following having had a hip replacement. A minimum time off of six weeks, I'd say. But if you're going to go back to doing awkward poses with your hip, it'd be at the three-month mark that you can go back to that, depending on what feels safe for you. If a patient has a spinal stenosis and neurogenic claudication as well as hip OA per MRI, would the spinal issues impact on decision to replace hip? It shouldn't impact on decision to replace the hip, and this is what that slide that I had there. I deal with a lot of people who have a degenerate or worn-out spine, back, and they also have a worn-out hip. It's all related. What you should be able to discuss with your surgeon is a realistic picture of what the hip replacement is going to treat. So it's not going to get rid of all the pain going down that leg. It will get rid of the groin pain, it will get rid of the pain that you have from movements of that hip, but it may well not get rid of the buttock pain, the pain traveling down your leg. And therefore, an injection in your spine or injection in your hip will give you a more realistic picture of what you'll be left with following having had joint replacement surgery. Because what you don't want to do is you don't want to have major surgery if all your pain is coming from your neurogenic claudication, and then you have the hip replacement and you go back and see your surgeon and you say, "Thank God, mate, the pain's still completely there because we've treated something that wasn't causing the pain." So it's useful to have that discussion, and we can only have the discussion when we're examining you. Great. Can I cause further damage elsewhere by postponing surgery? Generally, sort of. You'll make the procedure slightly more challenging depending on how long you postpone it for, because as I've said, you've got a ball that's going into the socket and it's starting to grind against bones, grinding against bone, and it starts wearing out the ball part of the hip, and you start losing height in that leg. And then you've got to recreate that height, and that becomes a bit challenging if you've left it for too long. What also happens is you start getting used to walking on a limb that's shorter than the other side, and when you put it back to where it belongs, you then feel, whoa, you've lengthened my leg quite a bit. So you want to try and avoid walking on a short limb for too long, because that becomes tricky to recover from. When you've got one hip that's worn out, you start leaning more towards the other side, and you can start wearing out the other hip because you start loading the other hip more and you offload, for example, your right hip because it's painful, and you start wearing out your left hip. And depending on how you're walking, you could put more pressure on your knees too, and therefore start wearing your knee joints out. So long-term, yes, you can wear other joints out depending on how you're compromising for the pain in the one joint that you have. Okay. What anesthesia will be used? So most hip replacements now are done using an epidural anesthetic. Hip and knee replacements, for that matter of fact, are done using an epidural anesthetic, which is an injection that goes at the bottom of your spine. It works for about two to three hours, and it numbs you from the waist down, and it's really good pain relief after the procedure. And what it also means is that you don't have to have a general anesthetic, so you don't have a tube going down your throat and a machine breathing for you. You have a bit of sedation, so you're asleep and you're not hearing me using my tools and the work that I'm doing in theater. That's never pleasant. But you have a bit of sedation, so you're in deep sleep and you wake up in recovery. Initially, you're unable to move your leg, and that spinal anesthetic wears off over two to three hours. Okay. Are blood thinning injections required after surgery? Can an oral medication be an alternative? We use oral medications now as an alternative, otherwise we have to give you all these injections to take away. So unless you have allergies or you have a specific condition which prevents you from using oral medications, you will receive oral medications. There's national NICE guidelines for that, so that's what we all use across the country. Okay. What support is available after leaving hospital Sorry, I missed that last bit. What support is available after leaving hospital? So it's usually physiotherapists. The physiotherapist will see you day one post-operatively. They'll get you up walking, watch you using crutches, watch you doing going up and down the stairs, and make sure that you're safe prior to you being discharged to your house, and then you have two to three physiotherapy sessions post-operatively. Not everyone needs them following a hip replacement. You need it more following a knee replacement. With a hip replacement, it really depends on how well you're doing. A couple more here. So how soon can a patient fly after hip replacement? Usually six weeks, and that's not to do with the hip joint itself, it's more to do with the risk of forming clots. If you're in a high-pressure cabin, the risk of throwing off a clot to your lungs is higher following having had major surgery, and therefore we ask people to wait for six weeks prior to doing those. Okay. We've had this one. So how long after surgery does it become possible to sit comfortably on the floor? Will it be possible to sit cross-legged? Will it be possible to kneel fully with weight on heels? Again, difficult to say because it varies from person to person, but usually by the six-week mark you should be able to sit on the floor, you should be able to kneel down, you should be able to sit cross-legged. It really depends on what approach is being used and how quickly you recover. Okay. Fantastic. And we've got through quite a number of questions here in a decent amount of time. So I think unless there's anything that you wanted to add any of your own just before I wrap up, Mr. Ahmed? No, brilliant. Thank you so much. Thank you for organizing this, and thank you to Casey too. Great. I hope it was useful. Thank you. What I will say is thank you all so very much, all of the attendees for attending this evening. If you did want to book a consultation with Mr. Ahmed here at the Horder Centre, please do get in touch. The details were on the screen, which you'll see in the recording, but I will just repeat our telephone number, which is 01892 600865, or you can email our patient advisory team, which is the letters pp@horder, H-O-R-D-E-R, .co.uk. And when you receive the recording of tonight's online talk, you'll also receive a couple of questions in the survey, so it'll be really helpful to hear what you thought about this evening. But once again, thank you very much for joining us and enjoy the rest of your evening. Thanks very much.