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Programme 6. - Hip Replacements
RADIO 4
THURSDAY 05/04/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
PETER KAY
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello. When the pain and disability of an arthritic hip become too much to cope with you may well find yourself on the waiting list for a total hip replacement. Exactly what kind of operation you'll be offered depends on how old you are, what your surgeon prefers and what you hope to do on the new joint - do you expect to play tennis or will you settle for a comfortable stroll? The degree of mobility you regain after the operation also depends on a number of things, not least how much physiotherapy you get and how good you are at following the exercises you'll be set. More than 50,000 new hip joints are fitted in this country every year and there are thousands more hip resurfacing procedures; this is a newer treatment, sometimes offered to younger patients in the hope or expectation that it will last longer than the traditional hip replacement.
So if you want to know about either option call us now: 08700 100 444 to put your questions to orthopaedic surgeon Mr Peter Kay. He joins us from the Wrightington Hospital in Wigan, which Peter is in fact the home of hip replacements, is that right?
KAY
That's correct. One of the more - the most successful joint replacements that has been developed was a Charnley hip replacement and it was developed at Wrightington Hospital. I was fortunate enough to be taught by Charnley as a medical student and in fact I still - I do his follow up clinic now and we see patients that have hip replacements in for well 40 years now.
MYERS
So following in very famous footsteps in that case Mr John Charnley. Thank you for joining us from Wigan today. We'll go to our first caller, he's in London, he's David Banford and he is a runner, a runner who's now got hip pain, is that about the top and bottom of it David?
BANFORD
Well I think it is, I hope it's not going to turn into anything too ominous but I'm a little concerned about this. I've been a runner since I gave playing rugby about 30 years ago, so I've been running on average probably five or six days a week, average run about an hour but I've taken part in several marathons - I think four marathons in total. But I've been progressively suffering from hip pain, left hip pain, when I run and it's also beginning to become painful when I walk. Now it may be because I'm overdoing it but it's probably about time for me to have some kind of professional advice Peter and I just wondered what your recommendations on this might be.
MYERS
You've got the right man to ask here, here he is.
KAY
Well what you need to do to begin with is to go and see a general practitioner who will then refer you on either to an orthopaedic surgeon or maybe to a physiotherapist or one of these multidisciplinary clinics where you can be assessed. I mean I think ...
BANFORD
I'm sorry.
KAY
That's alright. When people present with hip pain one's really got to work out where the pains are really coming from. I mean if you go to the clothes shop and you buy a pair of trousers you get measured around your hips, well that place that the clothes shop will call your hips isn't exactly where your hip joint is, your hip joint's lower down, it's in your groin. And people with a hip problem tend to feel pain in their groin, often radiating down their leg towards their knee and even occasionally into the front of the shin bone. If you've got pain over the lateral aspect of your hip - sometimes you've got to be careful because that might not actually be hip pathology.
MYERS
What's the lateral aspect - sorry?
KAY
The lateral aspect is the outer side of the leg ...
BANFORD
Well that is where my pain is, it's on the outer side of my - of the hip but it does seem to be getting progressively worse and is it something that can be assessed by x-ray or is that not necessary?
KAY
Well no an x-ray's a useful investigation if one wants to detect degeneration damage to the hip joint. But there are other reasons for having pain around the hip and one of them can be referred pain from the back, sometimes you can have pain coming from the back across the buttock into the laterally outer side of the hip joint. And that can be one of the confounding factors. One thing I have spent lots of my time doing is making absolutely sure that if we're going to do something to someone's hip that of course the pain is coming from the hip itself.
MYERS
Peter, just a point here about - well David's said he's been a runner and an athlete - a rugby player and so on, so forth - are these well known risk factors in the development of hip problems which may in fact then lead to the need for a hip replacement?
KAY
Not particularly for the hip, I mean footballers often end up with damaged ankles and knees. There have been some associations with some sports, and the biggest association is perhaps occupationally with arthritis of the hip which is being a farmer in fact. But actually using your joints - playing sports, going running - is not a bad thing to do. I think one of the problems with jogging - marathon running - is that I'm not sure that we were really designed to do that, from the point of view that if you were running with your foot hitting the ground in exactly the same position step after step, mile after mile, hour after hour that can sometimes cause pain in joints whereas if you engage in activities which allow a much wider range of movement, like playing rugby of course where you may be sprinting walking, stooping, jumping, when the hip's exercised to a wider range of motion like that it's probably much more beneficial for the joint. But jogging's notorious I think for later on in life perhaps just putting strain on - well certainly it can be the hip but any joint of the lower limb.
MYERS
David thanks very much for your question if you do continue to run I'm sure you will do so advisedly now, having heard what Peter has to say and maybe it is worth indeed getting an investigation as to just where that pain is coming from. Thanks for the call. We'll go to Mary Thomas, she's in Carmarthen and is wondering about a hip replacement and you've had one yourself have you - both, both hips?
THOMAS
Yes I've had both - I've had two hip replacements. The first one 18 years ago and the second one nine years ago. And my question really is: how long do they last, I mean is 18 years getting on for a hip replacement, and also what are the signs and symptoms if they are starting to sort of need replacement?
KAY
Okay. It's a very good question. There's no set answer to this, it's a bit when cars come off a production line, you know some cars have got the same - the same model of car some will last five years, some may be going after 25 years. What we know about conventional joint replacement, probably the joint replacement you had 18 years ago, which may well be a cemented type joint replacement, is that if we look at the long term follow up of these is that you can expect that 75% of these are still working after 20 years. So you're at 18 years now, the chances are that this joint will continue to carry on working. I mean I routinely see patients that have had hips in 40 years in the clinic that I do. So there's no set time. I mean often when we talk to patients we may be more pessimistic and we'll say you know 10-15 years...
THOMAS
I think that's what I was told in the beginning.
KAY
That's usually what we say and because it's not - it's very difficult to be specific with an individual what we do know on the larger population studies that many hips - you have a 75% chance probably of a hip lasting you 20 years, which means that there are other hips lasting much, much longer than that.
MYERS
Mary, I'm wondering whether your hip, particularly the one that was done 18 years ago, is showing any signs to you of wear and tear?
THOMAS
No not at all, I mean that replacement was excellent from the start. The second one wasn't so successful. But the first one has - from the beginning it's been fine and I'm not having any problems with it.
MYERS
And so for anyone thinking or perhaps they're on a waiting list and wondering what will happen to them you've got some reassurance then that you have had a new spring in your step since you've had your replacements have you?
THOMAS
After the first one within sort of six weeks I was walking without a stick and walking as I was walking before. The second one there were more problems because I'd had a spinal fusion and there were - there'd been a lot of surgery done that side and it was sort of more problematic. But I have a leg that side that's a bit weak, the pain has gone but I can't stand on it and have to walk with a crutch.
MYERS
Well it's interesting isn't it - may I just share this with Peter - it's a little bit perhaps like each pregnancy is different isn't it, it's almost as though each operation, even in the same person in this case, it's probably even the same operation, but just because of how it was done, who did it, when it was done and so on would make a difference to how it feels and how it performs.
KAY
I mean it's quite rare actually for a patient to have - if a patient's had both hips replaced that they often feel that one is maybe a little bit better than the other but as you say you've had spinal problems and as we discussed with the first caller I mean sometimes you can have problems from the spine referred around the hip, the muscle weakness that you describe it may have been with your second hip replacement that there could be some muscle weakness related to the spine.
THOMAS
I think it probably is muscle weakness because I'm unable to stand on that leg without support. I can walk perfectly well with no pain with a crutch but I can't stand on that leg - the muscle seems to have weakened.
MYERS
And is this where physio comes into play a bit more?
THOMAS
Yes well I did have physio for quite a while after, that's nine years ago you see, I was told it would improve probably with time but it hasn't.
MYERS
Okay last work on this, sorry to interrupt you Mary, let's just see if we can get a last word on this.
KAY
I mean the other part of the question you asked was about what to look for in hip replacement if there was - if it was starting to wear out or fail and the obvious one is pain, if pain comes back, often particularly pain in the thigh and pain in the groin. Some people get a sensation of clicking or instability of their hip, that can be because the socket is becoming worn so the ball part of the hip joint might be moving around more than it should in the cup, in the socket, because there's more space for it to move. And the later sign sometimes is that people may feel that their leg's getting a little bit shorter because if the hip is getting lose sometimes you can lose some length of the leg. But if your hip's feeling fine after 18 years and there's no great change in the symptoms then you just keep doing what you're doing, you're doing the right thing, it's there to be used.
MYERS
Keep on keeping on. Thanks for that Mary. We'll go to Mike Adams next, he's in Dartford in Kent. Hello Mike.
ADAMS
Hi.
MYERS
And your question.
ADAMS
Yes. I'm due to have a hip replacement in June of this year a BHR, I'm really thinking that I would like to get back to running and more active yoga and things like that, is there any specific type of hip that I should try and get my surgeon to put in?
MYERS
Ah well the $64 dollar question - what's the best hip?
KAY
Well you've just said that you're having a BHR, which is a Birmingham Hip Resurfacing I take it?
ADAMS
That's right yes.
KAY
I mean there's a lot of discussion about what is the best hip to have, I mean currently there are about a hundred different types of hip replacements available to be used in the United Kingdom...
MYERS
As many as that, that's the actual prosthesis themselves is it - a 100?
KAY
Yes and the National Joint Registry, which is an organisation that collects information about hip implants, shows that there's just over a hundred different stems - that's the bit that goes down inside the femur, inside the thigh bone, and about 70 different types of socket that are available. And of course they can - to an extent they can be combined. Really nobody has produced a hip replacement that can last forever yet, I mean people have made claims for that. Conventional hip replacements - cemented hip replacement - has really served us very well and there's some excellent long term results on that. Hip resurfacing, that you describe, has been around maybe 12 - 12 years, 13 years, the results of that so far have been really quite good, there have been some issues around the risk of some fractures around the hip and some discussion about the type of articulation and metal and metal articulation, about metal on metal debris being released, though no definite problems have been identified from that in patients, there have been some concerns around it. So what I'd say to you is that there isn't one best hip replacement and this is a discussion you need to have with your surgeon. It's true to say that resurfacing procedures are being done more in the younger patient but of course this is an experiment to an extent and that's a discussion you have to have with your surgeon because we don't have the results of what the hip might be like after 15, 20, 25, 30 years.
MYERS
Mike stay with us if you will but I would like to bring in Joe Burrows, sorry let me bring in Joe from Cumbria because I think he's perhaps got the same issue as you and maybe you can talk to each other about this, wanting to know what are the benefits of one procedure versus another - replacement versus resurfacing. Have you been advised either way at the moment?
BURROWS
Good afternoon, good afternoon Peter and Barbara. I received conflicting advice in effect. I'm an active 66 year old who's able to do still quite a lot of walking and cycling but I am increasingly after four years of osteoarthritis in the left hip finding that the pain is increasing and the referred pain that the doctor described earlier is becoming more noticeable now. But as I say in enquiries I made to the Birmingham Nuffield Hospital, just to gain information, it was very clear that they were quite upbeat about the whole Birmingham hip resurfacing and when I took this back to my own consultant in Cumbria the opposite was - effectively my local consultant is saying it's hogwash basically, words to that effect. So I'm sort of wondering what is the best ...
MYERS
Well you'll have had this Peter, can I just put it to you because I presume patients will do a little bit of research these days, they will have heard about these different procedures, maybe not have gone into detail on all hundred possible prosthesis that they could be supplied with but certainly this major sort of division between the resurfacing and the total hip replacement using other means. What would you advise - is it about choosing a surgeon who himself or herself prefers to do one procedure, in which case they'll presumably get good results because they're tried and tested, so if you like first find your surgeon - is there something in that?
KAY
Yes I mean there are 2,000 orthopaedic surgeons in the United Kingdom and you need to have access to surgeons to talk about the possibilities of treatment. Some surgeons will prefer one type of procedure to another, obviously in Birmingham, where the Birmingham hip replacement was developed, there may well be enthusiasm for that and indeed there is enthusiasm for the Birmingham hip replacement in other parts of the country as well. But equally what we do know, as I considered before, is that the results of many other types of total hip replacement are truly excellent and many patients have been very active, been restored, going back to their employment - being builders and doing a lot of walking and playing some sports, not necessarily all sports because there's an issue about if you do have any form of hip replacement how hard you punish it. And I think what you're getting them in terms of conflicting advice is really where we are in hip surgery is that we don't actually have all of the answers, there isn't one thing that's really the best to have. And I think what you need to do is to weigh it up, talk to people and sometimes it means getting other opinions as well.
BURROWS
Can I just say in relation to possible referral as well that it also seems that there's a conflict insofar as the consultant in Birmingham was saying you just need to get a referral letter from your local GP if you want to come up and be examined. Whereas my own GP, when I mentioned this to her, is quite clearly saying oh you can't go outside your own PCT.
MYERS
Well that's a slightly different issue which I think is quite hard for us to deal with in terms of availability of where you can go, I mean there is obviously the business now of choosing where you go for operations, that doesn't always follow through exactly. But can I just return to this - the major theme really that you're rehearsing here is Peter as to which procedure to opt for. If either Joe or Mike, as a matter of fact, came to you in Wigan, you having learned your procedures at the hands of John Charnley, which was the sort of traditional, the original, work, is that what you would be recommending because of your experience in doing that?
KAY
I mean we have - we have nine consultants at Wrightington that performs hip surgery and we perform slightly different - each of us perhaps slightly different philosophies of what we do. I personally do not do resurfacing hip replacement at the present time because I'm still fairly convinced about the long term results of conventional hip replacement, maybe with some more modern materials in terms of ceramic bearings. I have other colleagues that do resurfacing and if patients want to discuss the options I will often refer them to a colleague so they can have an understanding of what the potential benefits are. It's very difficult sometimes to weigh up what might be a theoretical potential benefit for the future in the long term, against something that we know about the tried and tested. I mean I wouldn't say that hip resurfacing is completely experimental at all because it's been around a long time. I mean there have been attempts at resurfacing for 30, 40 years, it's only perhaps in the last 10, 12 years because of engineering developments and changes in materials that we seem to have got a device that's more successful. But still the discussion needs to be have with a surgeon because we really don't know what the long term results are going to be with these procedures.
MYERS
So we're clearly on a subject here that's exercising the profession as well as the patient.
KAY
Absolutely and we discuss this all the time.
MYERS
Okay, let's go to, if we may, and thanks for your calls so far on that, but let's go to Mrs. Dreyer, who has had a hip replacement - don't know which kind - but only 11 weeks ago, got some problems - some pain Mrs Dreyer?
DREYER
Yes.
MYERS
What's the problem?
DREYER
Well it's - yes it was 11 weeks ago and the mobility is proceeding quite well I think but I've got this smarting or tingling or stinging in both feet and up through the leg, it seems to be as far as the bottom buttock and principally round the base of the spine and it wakes me up - I go to bed and two hours later I take a couple of paracetamols I'm awake again and the same thing happens. And it's just sort of getting me down.
MYERS
Oh I can imagine it is when you were hoping to have ...
DREYER
I am sorry, I had a replacement 10 years ago when I was 71 and that was a Charnley by the way and that was marvellous, I have no recollection of any problems like this.
MYERS
Okay, well let's see if we can get some advice.
KAY
I mean you say that you've got problems affecting both legs now ...
DREYER
Principally the operated leg, although there's some in the - there is some oedema of course in the operated leg and there was a bit in the other. I've had two scans because they feared there might be DVT, both were negative, so I'm taking some diuretic tablets.
MYERS
Okay enough information on that but just as general point are we saying this is a well known risk or complication of surgery?
KAY
You've obviously done absolutely the right thing here because you've gone back and you've been seen again and an attempt has been made here to exclude here some of the known complications and one cause of course is deep vein thrombosis and it's very important that that's been looked at. I mean you talk about some pain affecting the lower part of your back as well and obviously ...
DREYER
... if I touch the top of my bottom it's tender and if I press to the base of the spine. I had an epidural, I don't know if that's anything to do with it or whether it's to do with the nerves that are touched or what.
KAY
It's early days yet and I think the chances are this will probably settle. I mean I think it's quite a few years since you had your last hip replacement and sometimes when people mobilise it can put extra stress on the lower part of their back, there may be a little bit of wear and tear in your back and some of this pain may well be back related and referred pain. But the important thing is if you carry on having discomfort like this you must go back again, don't be put off just because they've looked at you once, do ask the questions. But in my experience it's not uncommon for patients to have problems like this and providing the main complications and risks have been excluded, which is sounds like it has in your case, usually with time everything settles down - the oedema, the swelling goes, the scar tissue settles down and usually the discomfort goes. And even if it's coming from the back that tends to go as you regain your normal walking pattern.
MYERS
Okay, good luck with that, thanks very much for the call Mrs Dreyer. We go to Somerset and Nicholas Zelle wants to talk about his mother. Hello are you there Nicholas?
ZELLE
Yes I am.
MYERS
Yeah tell us about mum.
ZELLE
Hello. Well I've got a 99-year-old mother, 99½, and the half's quite important. But she's - she was very active and she's had one hip done about 15, 20 years ago and the other hip is giving her considerable pain and the question really we need to ask really is whether she should - at her age - there's any point in even looking at the possibility of a hip replacement and what are the benefits and what are the questions we should ask of a specialist?
KAY
Certainly. I mean what's important really I think is how fit you are. And you know I've seen patients - a very memorable patient, a 99 year old patient of mine who was a school teacher who had a hip replacement, probably gave me the hardest time of any patient in terms of being a school teacher. But I mean if your mother is disabled because she has arthritis in that hip and that's stopping her doing the things that she wants to do, the pain's not controllable, it wakes her up, she can't get about then I don't think hip replacement is contraindicated because of age. Clearly she would need an anaesthetic assessment, need to go over her previous medical history, but the way hip replacements are often done these days, I mean maybe when she had it done 15 years ago she may have had a general anaesthetic, I mean we do much more in the way of spinal and epidural anaesthesia now which puts a lot less stress on the system.
ZELLE
So you think I should ask?
KAY
Absolutely, I think you need to ask the question - to be absolutely sure the pain is coming from the hip of course but then you need to discuss it really with the consultant and with the anaesthetist to make sure that it's going to be safe. Because at the end of the day we don't want to take risks with your mum altogether.
MYERS
Would you like to have the challenge of replacing that hip?
KAY
Well certainly if she's fit and well as she sounds like.
MYERS
Go for it. Thank you very much indeed. Thanks to my guest today - Mr Peter Kay from the Wrightington Hospital. Thanks to all of you who have contacted us with your questions and your comments, I hope we've been able to answer them but you can get more information about sources of advice if you call our free and confidential helpline that's 0800 044 044. You can listen to this programme or indeed any of our recent editions again on our website at bbc.co.uk/radio4. You can also leave us a message there about this or any of our programmes or indeed about any subjects you would like us to cover in our next series. This is the last in the current series, thank you very much for joining me, take care and I look forward to your company again later in the summer.
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