Robotic hip surgery: is it the future?

Total Hip Replacement with MAKO robot assisted

It has been heralded as the future of orthopaedic surgery, with manifold benefits for the patient and Mr Simon Bridle is delighted to now be able to offer MAKO robotic-assisted hip surgery to his patients at the Fortius Joint Replacement Centre at the Cromwell Hospital in London.

Hip replacement surgery has been performed for over 50 years with great strides made in terms of implant material and technique and current day operations are generally considered very successful and result in a great improvement in the patient’s quality of life. Inaccurate placement of the prosthetic components often contributes to the hip replacement failing.  Component malalignment can result in instability, impingement or leg length discrepancies. The introduction of robotic guidance systems can help the orthopaedic surgeon plan and place the prosthesis with a much greater degree of accuracy.

Using 3D computer mapping, the implant can be aligned precisely – to within fractions of a millimetre. As Simon explains, there is strong evidence that with our standard techniques, our ability to implant hip materials does not compare to using the robotic guidance system.

Precise acetabular cup placement is a key factor in a successful total hip replacement.  In a review of almost 2,000 cases at Massachusetts General Hospital, a 2011 study found that acetabular cups were placed in the ideal position only 47% of the time. In another study that compared 50 MAKO assisted procedures to the same number of conventional hip replacements, it was found that 92% – 100% of MAKO hip replacements were in the two safe zones evaluated, compared to 62% – 80% of conventional surgeries.

How does robot-assisted hip surgery work

The pre-operative planning stage with the robotic device means that you can more accurately implant the components during the surgical procedure. CT scans are taken which allow the surgeon to map the bony anatomy.

Then, when the patient is on the operating table, special cameras in the theatre take various reference points, matching the actual pelvis and femur to the CT images loaded into the computer. This adds probably about 15 minutes to the actual procedure; however, as it will probably cut a few minutes off the surgical process, there is very little difference for the patient.

It’s important, though, that patients realise that the robot is not taking over from the surgeon! We are just using the available technology to enhance our skills, but we are still performing the actual incisions and placement of the prosthesis.

The benefits of robot-assisted hip surgery

From Simon’s anecdotal experience, the most common complaint after surgery is leg length inequality. Leg length is affected by how far you push the femoral component into the bone and anything more than a centimetre difference is noticeable. It is possible to deal with this problem with a shoe raise but most patients find this unsatisfactory, particularly if they are a young, active patient. The MAKO device we use provides leg length restoration accuracy within 3mm.

Patients are also receiving a more bespoke experience – the planning allows implant components to be chosen from the available range, to suit the patient’s individual anatomy.

Simon is sure that these devices will prove invaluable in the training of future surgeons. It has lots of applications in orthopaedics; for example, the accurate 3D models of the bony structure will aid in more accurate planning of bone tumour surgery, meaning surgeons can remove all of the tumour while preserving as much healthy tissue as possible.

After training in Switzerland, Simon has now performed three at The Cromwell Hospital and is discussing it with patients at consultation.

Revision surgery is never a preferred option for patients, so ensuring that the initial surgery is as accurate and bespoke as possible with the assistance of this new technology can only improve patient – and surgeon – satisfaction.

Could this injection be the answer to arthritis pain?

arthritis pain

Scientists have been working on the development of a new drug which could delay the onset of arthritis. The condition, which affects over 8 million people in the UK, in particular those aged over 50. The condition causes pain and reduced mobility in joints and is one of the reasons people are referred for hip and knee replacements.

The new drug is “based on a protein that boosts cartilage generation and reduces inflammation of joints”. It is not capable of curing the condition, but it can slow down how fast it progresses – essentially buying time for those who are affected by it. This treatment is injected into the arthritic site, and the active ingredient is a molecule which scientists have developed. The molecule is called RCGD 423, which stands for “regulator of cartilage growth and differentiation”.

First of its kind

Up until now, there were some injections that could help ease the pain of arthritis, however these were only able to tackle the pain relief, they were not able to reduce the spread of the condition. Not only were they limited in terms of benefits, they also tended to be coupled with some unwelcome side effects such as high blood pressure and stomach ulcers.

The development of treatments like this could potentially save the NHS millions of pounds every year. At the moment, the number of people undergoing surgery for hip and knee joint replacements is growing, and it is no longer just something which affects elderly people. More and more younger patients are being referred to orthopaedic surgeons for help with failing joints, especially those who engage with high impact sports.

One newspaper calculated that the saving that this could generate for the NHS could be as high as £1billion per year and, with growing pressures on budgets, funding, staffing and clinical resources, this is an exciting proposition for an overstretched health service.

Early stages – so watch this space

It is important to note that this injection is still in the early stages. Initial tests have been undertaken on cells from humans and also on rats – and the results are really promising. The next phase of trials will be with humans and it is hoped that this continues to yield successful results.

London hip specialist Mr Simon Bridle believes that this injection is interesting, and it will be good to see results of continued testing in the coming months and years. As it is very much in development / trial stage at the moment but is potentially something that patients will be able to benefit from in the future.

Is skiing after a hip replacement ever ok?

skiing after a hip replacement

Thanks to the Arctic conditions that the UK has experienced recently, more of us have had a flavour for what it’s like trying to get around on unstable, slippery surfaces. While most of us wrap and warm and wait for warmer conditions to return, there are others who love the wintery conditions and love the challenge brought by winter activities. While this is fine for the more able-bodied amongst us, are winter sports every practical if you’ve undergone joint surgery?

Years ago, hip replacement surgery used to be an operation that only older patients were recommended for. This was because older people were more likely to need replacement joints from the natural wear and tear on joints during the ageing process. Nowadays, with more people choosing high impact sports, there is an increase in the number of younger patients undergoing hip replacement surgery and with this comes an increase in the number who wish to return to sports such as skiing.

Medical data looking at those who have returned to winter sports versus a control group

A report published recently by US National Library of Medicine National Institutes of Health looked at the results of a two-cohort study who had undergone total hip replacements:

 

  • The groups were designed to have identical characteristics in terms of age, weight, height, gender and type of implant
  • Each group contained 50 individuals
  • Following surgery, one group regularly participated in challenging winter sports, such as alpine skiing and/or cross-country skiing
  • The other group didn’t engage in any winter sports

Results from these two cohorts are interesting, and somewhat surprising. The report concludes that the results “do not provide any evidence that controlled alpine and/ or cross-country skiing has a negative effect on the acetabular or femoral component of hip replacements. The results of the biomechanical studies indicate, however, that it is advantageous to avoid short-radius turns on steep slopes or moguls.”

Orthopaedic surgeons such as Mr Simon Bridle recommend proceeding with caution if you are keen to participate in winter sports once you have undergone a total hip replacement. Although hip replacements are getting better and better, and the prognosis for recovering well and leading an active life afterwards is very good, it should not be underestimated how important it is to treat your new joint with care.

An article recently by Vail Health reiterated this point, citing the progressive improvement in this type of operation and the expectations of patients that they will be able to enjoy sports again once they have had surgery: “More precise placement of implants, increased durability and functionality of parts and a less invasive approach have all helped to advance this surgical process. Completing a three-phase rehab program after surgery with a physical therapist can give you the best chance of returning to your previous activity level.”

For keen skiers who are skilled in their pursuit and know their limitations, a phased return to the sport with due care and attention to your new boundaries can certainly be possible.

There is no denying the risks though – skiing is a dangerous sport and can result in injury for even the healthiest of individuals. If you’ve undergone a hip replacement and are thinking of trying out skiing for the first time then err on the side of caution – there are many other pursuits that would put you at lower risk of damaging your newly repaired joint.

New recategorisation of osteoarthritis could revolutionise treatment in the future

hip osteoarthritis

Recent research carried out by the University of Manchester has found that the current definition of ‘arthritis’ is too generic and should be split into two different categories depending on the nature of the condition.

The results, gleaned from complex analysis of thousands of genes expressed in the cartilage of 60 individual patients with knee osteoarthritis, suggest that if cases of arthritis can be identified and categorised into one of these two groups, then a more effective treatment plan can be put in place. The report’s authors feel that there is now a ‘once size fits all approach’, which until now has been effective to a certain degree, but this heightened knowledge of the differing types of osteoarthritis now put us in a better position to understand the disease and to make effective treatment recommendations.

The two different groupings are based on the amount of active metabolism in the affected tissue and represent a really significant step towards more efficient treatment journey for the condition.

The findings were the result of analysis of synovial fluid, which is the liquid found inside cavities of synovial joints (the most common and most movable type of joint in the body of mammals, which achieve movement at the point of contact of articulating bones). The fluid is important as it reduces friction inside the joints and allows for effective joint mobility, and it carries a lot of information that is useful for scientists to begin to unpick.

Research can help make cost savings

According to recently published reports: “musculo-skeletal conditions cost the NHS £4.76 billion per year in 2013-14 and there has been little advance in the treatments for osteoarthritis over that past 30 years; new approaches tested have yielded little benefit.”

The benefit of splitting patients into two different groups for treatment of arthritis is that the treatment will be more targeted and should in turn help to ease the burden on our already overstretched NHS budget.

Osteoarthritis can be a debilitating condition, which can cause daily pain and loss of movement in critical joints. It is a widespread issue, believed to be the most common musculoskeletal condition in older people.

Around one-third of people aged 45 years and over in the UK, a total of 8.75 million people, have sought treatment for osteoarthritis.  Those living with the condition will be reassured to hear that thanks to the continual analysis of medical data and the perseverance of specialist scientists, we are making breakthroughs such as this which will help the overall quality of life for those who suffer from osteoarthritis.

Drug trials will soon be underway thanks to the insights gleaned from this new data analysis. The hope is that these trials will yield the opportunity to produce treatment plans for patients which are guided by the stratification group that patients fall into based on indicators assessed in the synovial fluid analysis and thereby provide a more effective treatment for osteoarthritis patients.

Returning to sport after hip surgery

Tennis fans have been nervously watching Andy Murray’s progress in recent months, as he has battled with a recurring hip injury which may result in him needing surgery. Based on Murray’s description of the pain he is suffering and how his injury has affected him, there is speculation that Murray is suffering with a labral tear and articular cartilage damage – which will most likely require surgery to fix. This problem is likely to mean that there is a tear in the cartilage that surrounds the socket of his hip joint.

Implications of this diagnosis

The stress that Andy Murray’s tennis career has put on his joints over the years will have been the contributing factor to this damage. The problem may have been exacerbated by extra bone growth has occurred beneath the ball of his hip joint, and this will be limiting the amount of movement possible from the joint.

What this means for Andy Murray is that it will be getting increasingly more painful to move the joint effectively and he is probably suffering from some loss of movement in the joint as well.

This growth can be fixed with a form of keyhole surgery called arthroscopic surgery, whereby surgeons can remove the new growth and hope to restore movement effectively to the damaged joint. It is, however, a tricky operation, one that is far more complex than the same operation on a knee joint, and it typically takes patients a lot longer to recover from, compared with an arthroscopic knee operation.

The concern for many will be whether Andy Murray ever regains his ability to compete at the top level if he chooses to undergo hip surgery. Although the problem he may be suffering cannot correct itself and surgery is probably an inevitability, the implications for his tennis career will be a cause for concern. BBC tennis commentator, Andrew Castle shared his thoughts on Andy Murray’s professional future: “People don’t generally, in sports like tennis, recover from this level of hip injury – assuming it’s either a labrum tear or full-on arthritis that requires a new hip.

Life after hip surgery

For many people, if they have reached the stage where arthroscopic hip surgery or a total hip replacement is required to improve their quality of life, then they will need to be giving some thought to their approach to rehabilitation, so that they give their body the best possible chance of optimum recovery, following the operation.

In recent years, we’ve seen a marked increase in people under the age of 65 undergoing hip replacement surgery. In the UK, around 35 per cent of patients who undergo hip surgery are undertaking regularly sporting activity before their operation, and there is a strong desire to remain active after surgery.

In a presentation at last year’s Fortius International Sport Injury Conference, hip surgeon Mr Simon Bridle addressed the issue of returning to sport after hip surgery. He quoted a 2005 report that suggested that 56 per cent of patients stopped sport post-operatively, with surgeons advising ‘going easy on the artificial joint’.

Concerns about an increased rate of revision surgery has led surgeons to advise patients on which sports are ‘safe’ to return to. Swimming, biking, rowing or golf were considered acceptable whereas contact sports, tennis, squash or running were usually frowned upon. But is there scientific evidence for these prohibitions?

As Mr Bridle concluded in his lecture, modern hip replacements are able to restore high levels of function for patients and there is little evidence that high impact sport increases complication rate. Dangerous sports always carry intrinsic risks whether you’ve undergone hip surgery or not and although a highly active patient may see a higher wear rate, this may be a complication that patients willingly take, balanced against a return to the sports they love.

Severe occupational strain increases risk of hip arthritis

risk of hip arthritis

Osteoarthritis is a condition that results from weakening joint cartilage, as a result of wear and tear over a person’s lifetime. Although this can happen naturally as part of the ageing process, it has long since been believed that undertaking manual jobs that put repeated strain on joints and muscles can lead to long term health problems such as osteoarthritis in joints such as hips, knees and elbows. Now a new study has found a proven link which adds more fuel to this fire.

The research has been undertaken by the German Federal Institute for Occupational Safety and Health (BAuA), and has assessed patients across 5 cohort studies and 18 case-control studies. The report authors conclude that “people who, in the course of their work, put long-term physical strain on their bodies have an increased risk of developing osteoarthritis of the hip. This is especially the case for those lifting and carrying heavy loads over long periods of time.”

The implications of this are serious for individuals working in environments where repetitive motions and heavy lifting are putting strain on their joints. Osteoarthritis in hip joints can be very painful and debilitating, causing a serious impact on a person’s quality of life.

Occupations that carry higher risk of musculoskeletal damage

According to specialist arthritis website, Arthrolink.com, there are a number of professions where people are at higher risk of developing musculoskeletal problems due to the work they carry out.

Examples include:

  • Individuals who regularly use pneumatic drills – these people tend to have a higher likelihood of developing osteoarthritis in joints such as the wrists, elbows and shoulders
  • Those working in construction – due to the heavy lifting element of many construction jobs, workers are more likely to report osteoarthritis in the hips, knees, fingers and elbows
  • Miners are more likely to suffer from osteoarthritis of the knees and elbows, due to the combination of ground work and lifting.

Prevention is easier than cure

If you’re working in an environment where heavy lifting or carrying are expected as part of the role, it is important to take preventative steps to try and mitigate the risks. Report authors from the BAuA research suggest that individuals should not be attempting to lift loads greater than 20kg without mechanical assistance, and they also recommend that occupations screening of hip joints should be undertaken after 15-20 years (at the very minimum) working within a manual job requiring such tasks.

In fact, new research suggests that it is not just manual workers who undertake heavy lifting/carrying who are at risk of developing musculoskeletal problems – not even orthopaedic surgeons are exempt from issues relating to workplace posture. This warning comes from an analysis of 21 articles involving 5,828 doctors in 23 countries between 1974 and 2016 looking at the disease prevalence for the neck, shoulder, back and upper extremity injuries and any resulting disability.

It suggests that the hunched shoulders that surgeons have while undertaking operations contributes to “four in five surgeons experience significant pain when performing procedures”. Surgeons in some instances are reported to be suffering with greater occurrences of back pain than those working in occupations such as mining or construction, where the assumption would naturally be that they would fall into a higher risk category.

New study focuses on steroid injections for hip osteoarthritis

steroid injections for hip arthritis

Hip replacements are commonplace, with thousands of patients undergoing either partial of full joint replacements each year. In fact, according to the National Joint Registry, the figure for those having total hip or knee replacements each year across England and Wales is now in excess of 160,000.

Before you undergo an operation to replace the joint, there are steps that will be taken to try and mitigate the problem, and to try and give you a better quality of life before you take the surgical step. More and people are asking after the benefits of injectable treatments, which are reported to help ease the pain of a joint that is failing. However, in our opinion, some of these are worth exploring whilst others may provide little more than a placebo effect.

Understanding the limitations of injectables in treating hip arthritis

There are a variety of different treatments for painful joints that can be administered via injection. These include steroids, lubricants, stem cells and many others. While these may garner a lot of publicity, that does not mean to say they are clinically proven to be as effective as they might promise.  There is no evidence that any injection treatment available at the moment will reverse the process, buy somehow re-growing cartilage, as some publicity suggest may be the case.

Steroid injections are commonly given to patients who are suffering with a deteriorating joint, however, it is important that their limitations are understood. Whilst they may ease the pain temporarily, they are only masking the problem. Steroid injections will not repair the joint; they will merely help patients live with the discomfort.

In a report published recently at the Radiological Society of North America (RSNA), following a period of research whereby X-rays of patients who received steroid injections to help them live with joint discomfort, were directly compared with X-rays of patients who didn’t opt for that treatment. The study comprised 102 patients who received two steroid injections, and two control groups of similar scope, with correlating demographics.  They found that “osteoarthritis patients who received a steroid injection in the hip had a significantly greater incidence of bone death and collapse compared with control groups.”  This suggests that the injection may actually cause further damage to the joint.

No need to be anxious about joint replacement surgery

Steroid injection can help control pain in patients where there is no alternative to hip replacement, so even though this study shows that they can cause problems, Mr Bridle thinks that, used judiciously, they do have a role in managing patients with hip osteoarthritis.

Although a hip replacement can sound like a daunting prospect, it is one of the longest standing operations with the first hip replacement undertaken in the 1960s and has been helping people achieve a better quality of life for decades.

Surgeons such as Mr Bridle will ensure you’re in safe hands and have all the information you need to fully understand the process and the recovery period. Aftercare is very important and you’ll be guided every step of the way to make sure that you know what to expect from the recovery time and what exercises to undertake to help the new joint settle in.

‘Tried and trusted’ implants found to perform same as newer implant materials

Exeter Cemented Stem implant replacement materials

Hip replacements have been around for a long time, with the first recorded total hip replacement taking place in the USA in the 1940s. Since this pioneering operation, countless patients have had their quality of life improved by the skill of surgeons who are able to replace a faulty joint with a complete (or partial) synthetic replacement.

Over the years, medical skills have been fine-tuned and different materials have been tested, all in the pursuit of ensuring that the patient receives the best possible treatment and care. Researchers at Bristol Medical School have just completed a comprehensive review of the materials used in modern-day hip replacements, to understand whether or not new innovations have really surpassed the older, more traditional offerings.

The headline findings from this research correlate with views held by Mr Bridle and his team, that “there is no evidence to suggest that any of the newer hip implant combinations, such as ceramic or uncemented, are better than the widely used small head metal-on-plastic cemented hip combination, which has been commonly used since the 1960s.”

Research in the spotlight

The team responsible for this research at the University of Bristol made use of all available data for their evaluation, dubbed the most comprehensive review of this type of information to date:

  • 77 controlled hip trials (selected randomly to avoid any selection bias)
  • 3,177 individual hip replacements
  • A variety of different component combinations used, ranging from metal-on-plastic, ceramic-on-ceramic, ceramic-on-plastic and metal-on-metal. Different joint head sizes were also evaluated.

The results offer patients the reassurance that although medical techniques and patient care have evolved and improved over time, the components that have been used in hip replacement for decades are regarded as leaders in their field.

Tried and trusted for a good reason

Many patients come to us asking about implants; in particular procedures such as custom implants, mini hips and resurfacing, and all the evidence we see suggests that the ‘tried and trusted’ implants work just as well as the newer innovations. Sometimes even better.

Mr Simon Bridle has been working as an orthopaedic surgeon for many years and recommends the following to his patients:

  • He recommends to his patients that an Exeter cemented stem is used. This type of stem is made from hard-wearing stainless steel and has outstanding long term results; this stem should be expected to last up to 30 years once fitted.
  • The stem is attached to the bearing, and Mr Bridle favours a Biolox ceramic femoral head fitted to the stem, with a highly cross-linked polythene, which lines the acetabulum (the socket of the hip bone, into which the head of the femur fits).

To find out more about different joint replacement options, call us on 020 8947 9524.

Obesity crisis driving up joint replacement figures

joint replacement and obesity

According to new data published recently and reported in the Express, Britain now has one of the highest obesity rates in Europe, with around one quarter of the adult population clinically obese. This means that they have a body mass index (BMI) of 30 or above. To put this into context, a healthy BMI should be between 18-25, if you’re in the range between 26 and 30 then that classes as overweight, and 30+ is into the realms of obesity.

The risks of carrying too much weight are widespread. Risks include a greater likelihood of developing conditions such as diabetes, cancer, having a stroke or developing a heart condition. Being seriously overweight also puts a great deal of stress on your joints.

The NHS reports that recommendations for joint replacement surgery are increasing amongst younger people; most shockingly, even in children. This surgery was previously only really required for older people, so this is a worrying trend and something that we need to work hard as a nation to address.

Joint replacement operations on the increase

The number of patients classed as obese, who have either hip, knee or other major joints replaced each year is rising. In fact, over the past three years, it is reported that this has increased by 60%. The fact that a proportion of these requiring joint surgery are children is awful.

Children’s joints are still developing as they grow. Once their natural joint has been replaced with a synthetic alternative, it cannot grow and develop with the child in the same way that their original joint would have done. Although it will undoubtedly help if their joints have been put under so much stress and strain that intervention is required, we need to do something to ensure that this is not happening in the first place.

The other challenge with having joints replaced very young is that the chance of repeat surgery is high. Unlike patients who have joints fitted when they are much older, young patients will suffer wear and tear on an artificial joint over time. For young patients, the likelihood of needing a replacement joint fitted in later life is fairly probable.

Lifestyle choices that increase the need for joint replacement surgery

There are choices we can make in life that can help deter the chance of serious medical conditions arising. Those who undertake high impact sports are more likely to require joint replacement surgery in later life due to the levels of stress placed on their joints.

On the flip side, eating a healthy, balanced diet, undertaking regular, more gentle exercise and not smoking are all choices we can make that help reduce the risk of developing serious ailments later in life. The formula isn’t guaranteed, but those whom adhere to more healthy principles of living tend to have a better chance of avoiding painful or debilitating conditions that can set in in later life, such as osteoarthritis.

The challenges in diagnosing hip pain

If you’ve ever studied a model or picture of how the human body is made up you’ll know just how complex the elements such as our skeleton, muscles, tendons and nerves really are. Our bodies are an intricate mass of interlinked, incredible components that should all work together to enable us to move around effectively. It’s very easy to take this complex structure for granted – until something goes wrong.

If you start to experience pain or discomfort in certain areas of the body it is very easy to diagnose where that pain is coming from and work out how to fix it. However, other areas can be more challenging.

In a recently published article, the phenomenon of ‘hip-spine syndrome’ is explored. Research undertaken by the American Academy of Orthopaedic Surgeons suggests it can be very challenging for surgeons to identify whether the cause of patients’ pain stems from the lower part of the spine or the hip, because of the complexity of that area and how pain can spread from one source to another.

For anyone who has suffered with lower back pain it will be easy to relate to just how painful this can be. Discomfort that might start in your back, may soon have travelled to your hips, pelvis, buttocks or groin. You may find other aches and pains arise as you try to alleviate the pain by using different muscle groups or adjusting your posture. This in turn will put stress on different areas of the body as well, while not always fixing the original problem area.

One example of this is if a patient has developed arthritis in the hip joints, this often manifests itself as pain in the lower back, so it can be very hard to isolate the correct cause of the discomfort.

According to Afshin Razi, an American orthopaedic surgeon and clinical assistant professor at NYC Langone Hospital for Joint Diseases, the similarities of these symptoms cause a real headache for surgeons who are trying to help work out the best course of action for patients “in these instances, similar or overlapping symptoms may delay a correct diagnosis and appropriate treatment.”

To add further complications to the scenario, the outcome could be one of a number of quite serious hip or back complaints:

  • Osteoarthritis in the hip joints
  • Pinched nerves
  • Narrowing of the spinal chord
  • Sacroiliac joint disfunction
  • A stress fracture
  • Restricted blood flow to the hips (a condition called osteonecrosis)
  • Cartilage damage in or around the hip joint

Diagnosing hip pain

The complexity of the challenge means that surgeons have to really work hard to establish the cause of the pain so that they can recommend the most appropriate treatment. A comprehensive review of medical history, tests on how patients are walking (gait analysis), testing the alignment of joints, muscle tests and detailed questioning will all help point the diagnosis in the correct direction.

An orthopaedic surgeon that specialises in a specific area of the body is best suited to providing a correct diagnosis and, from there, advising you on the best treatment or procedure to restore optimal quality of life. To arrange a consultation with London hip specialist Mr Simon Bridle, email bridle@fortiusclinic.com or call 020 8947 9524.