joint replacement surgery guidelines

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. Founded in 1999, NICE was tasked with the remit of reducing ‘variation in the availability and quality of NHS treatments and care’. Since then, NICE has also taken on responsibility for ‘developing public health guidance to help prevent ill health and promote healthier lifestyles’, and the organisation has recently been asked to write a clinical guideline on primary hip, knee and shoulder joint replacements.

The necessity to craft guidelines such as this stem from the Getting It Right First Time (GIRFT) initiative, initially an orthopaedic initiative, which has been rolled out all across the UK in a number of specialities. GIRFT is responsible for improving the quality of medical care by ensuring as much consistency as possible in the way in which operations and aftercare are carried out.

Why were these guidelines required?

The key reasons why guidelines have been created in this area as follows:

  • Hip and knee joint replacement surgery is very prevalent, with tens of thousands of these operations being carried out in the UK every year
  • There is a great deal of variance in how these operations are done, with surgeons choosing different operative techniques and different materials, with huge variations in implant costs.
  • Aftercare programmes are similarly varied, with different advice given to patients from different practices. NICE’s aspirations from these guidelines are that “identifying the best approach for recovery and rehabilitation will enable all healthcare professionals to offer more effective and efficient treatment.”

The guidelines will assess nine key areas linked with hip and knee replacement surgery and will aim to make recommendations in as many of these areas as possible:

  • Assessment and shared decision-making
  • Preoperative rehabilitation
  • Anaesthesia
  • Tranexamic acid
  • Preventing infection
  • Wrong implant selection (left, right and incompatible components)
  • Joint replacement surgery
  • Postoperative rehabilitation
  • Long-term follow-up and monitoring

So, what does this mean for orthopaedic surgeons?

The answer really depends on the methods of practice that they favour at the moment. Some will need to adjust their methods while others will carry on as normal, within the boundaries of the new guidelines. Interestingly, these guidelines indicate that conventional ‘tried and trusted’ components put in with a conventional approach have great results and it is expected that this will form part of the recommendations moving forwards.

This is a market that has benefited from a lot of innovation and component testing over the years, and because of the vast number of these procedures that are carried out each year, there is a lot of available data to look at the relative strength and weaknesses of any new approach. It is important to remember that any new way of working – whether that is methodological, product driven or relating to aftercare – needs to be thoroughly tested and only the best will be recommended moving forwards.

NICE summarises, “it is important that all healthcare professionals, including surgeons and allied health professionals, and commissioners are involved in the entire care pathway (from community to hospital) to ensure people receive the best care, recovery, rehabilitation and follow-up monitoring after these common orthopaedic procedures.”

The guideline is due to be published in 2020 and we await its findings with interest.

hip replacement and quality of life

According to the results of a large-scale observational research study undertaken by a team of scientists in Sweden, the positive effects of choosing to have a total hip replacement extend to more than just an improved quality of life. This new research suggests that people who have had their hip joints replaced can actually expect to live for longer.

Dr Cnudde, working with the Swedish Hip Arthroplasty Register, Gothenburg, explains “Our study suggests that hip replacement can add years to life as well as adding ‘life to years’ – increasing the chances of longer survival as well as improving the quality of life.”

How have these conclusions been reached?

All medical studies strive to have as much data as possible so that their findings are robust and can stand up to external scrutiny and questioning. This was a very large-scale study, taking into account data from over 130,000 cases of people who had undergone surgery to have a total hip replacement. The study was carried out in Sweden and looked at data collected over a 13-year period, from 1999 to 2012. The survival rate of these individuals was the focus of this research, and this was then compared to data from the general population.

Key facts and figures from the research are as follows:

  • The average age that these patients underwent treatment for a hip replacement was 68
  • The sample make-up ensured that demographic criteria, such as gender, were comparable when undertaking the analysis

Researchers found that:

  • In the first year after the operation took place, survival rates for those who’d had their hip joint replaced were 1% higher than the comparable sample in the general population
  • After the first five years, the gap hid widened even further, showing a 3% difference in survival rates of those who’d had total hip replacements versus the general population
  • By 10 years post-operatively, the difference was still in the favour of those who’d had treatment, although it had reduced to a 2% gap
  • At 12 years there was no difference in the matched samples

This is a really encouraging report, which shows how the known physical benefits of a total hip replacement (such as the ability to increase mobility, reduce pain, and improve general quality of life) can also have an effect on more emotional elements and feelings of general well-being. Researchers in Sweden who have authored this report agree that there are many factors at work that will have helped contribute to this greater life expectancy amongst those who have had hip replacements: “the reasons for the increase in relative survival are unknown but are probably multifactorial.”

Primary researcher Dr Cnudde adds “while no surgeon would recommend THA [Total Hip Arthroplasty] to the patients just to live longer, but it is likely that the chances of surviving longer are associated with undergoing the successful operation, for patients in need of a hip replacement.”

When drawing up the list of pros and cons of whether to opt for a total hip replacement, the physical benefits alone are likely to make the operation look like an appealing option and, according to this new research, the supplementary benefits are important to consider too.

hip resurfacing

Hip replacements are one of the most common joint replacement operations, and they help improve the quality of life of thousands of patients in the UK every year. The typical age range of a patient seeking a total hip replacement has tended to be between 60 and 80 years old; however, in recent years there has been a marked increase of younger patients requiring this type of operation. The reason for this trend is thought to be that some younger people are engaging in much more active lifestyles or are pursuing high impact recreational sports that have put increased pressure on their joints.

There are different types of artificial hip joints that can be used to treat patients, and the materials that they are made of can have a real impact on their effectiveness. In the continual strive for improvement in medical techniques and practices, different materials are tried and tested to try and find the best ‘fit’ for the required purpose.

Hip resurfacing

Mr Bridle explains that “resurfacing the hip with a metal on metal implant became very popular about 15 years ago.  Results of this technique have been generally very disappointing, and many designs have been withdrawn.  The small amount of metal debris which is produced can damage tissue and bone, leading to early failure and need for revision in some patients.”

Hip resurfacing has resurfaced again (if you’ll excuse the pun) and is pitched as one of the newer techniques that are offered today (compared with the conventional full joint replacement). It is described as being more suitable for younger patients because potentially “the surgeon only removes the diseased cartilage of the hip joint and resurfaces the joint – until now with a metal-on-metal implant. This approach is less invasive and leaves the patient with greater mobility after surgery”. This technique leaves more of the original bone in place, which is meant to make the reconstructed joint feel more natural. However, this is only available for male patients, as women’s hip joints comprise a different shape which means that this is not a suitable operation for them.

Until now, hip resurfacing was done with metal components, but as Mr Bridle alludes to, there have been reports of tiny metal particles working their way inside the body as a result of wear and tear on the new joint. This reportedly causes pain and discomfort around the joint and can have wider implications if these work their way into the bloodstream. As such, a new ceramic material is being trialled to try and get around this issue. The challenge with this approach is the lack of data for ceramic joints in support of their effectiveness. There is an absence of firm evidence that ceramic resurfacing provides any functional advantage, which leads some surgeons to believe this is a solution to a non-existent problem.  The surgical approach is not less invasive than a traditional replacement.

Clinical trials in the pipeline

Nevertheless, there is interest and momentum behind these innovations and clinical trials have been set up to test the effectiveness of ceramic joints (versus their metal counterparts). The aim of these trials is to provide the much-needed data to support or refute the effectiveness of ceramic resurfacing replacements.

According to Imperial College London, “the trial is designed to show that the ceramic implant is suitable for both men and women, as conventional methods for hip resurfacing are not suitable for women. The implant being tested is also the first to resurface patients’ hips without using metal.”

hip implant dislocation

When considering any life-altering operation, we consider the benefits and potential challenges that may arise after the procedure, and weigh these up against quality of life if the decision is taken not to have the operation.

Total hip or knee replacements are chosen/recommended for over 160,000 people every year in England and Wales, and the procedure involves substituting a patient’s original bone joint with an artificial replacement. The results are usually very positive, with improved mobility, reduction of pain, and a better quality of life typically experienced in the months and years following the operation.

With any artificial hip, there are risks, and something many patients seem to be concerned about is whether the artificial joint could dislocate. In fact, hip implant dislocation is probably the short-term complication which patients worry about the most.

Although it is a rare complication, it does happen. Around 1% of patients are at risk of this occurring, and there are certain characteristics which place some people at greater risk than others. Recurrent dislocation is the most common reason for revision in North America and also a common reason in the UK, so avoiding this has obvious health and also economic benefits.

A new hip implant solution in development

It has recently been reported that there are now ways to identify which patients are most at risk from a dislocation in their new joint. The announcement was detailed in the Best Poster in the Adult Reconstruction Hip at the American Academy of Orthopaedic Surgeons (AAOS) 2018 Annual Meeting, held recently in New Orleans.

Researchers at NYU Langone discovered that there was a link between those who have a spinal deformity and those who tend to pose a higher risk of hip replacement dislocation and the need for follow-up surgery. This discovery enabled researchers to address this link head on, and they began working to develop a ‘predication tool’ which would identify those who fell into this higher risk category.  If patients are identified as sitting within this higher risk bracket, then surgeons can “implement a treatment algorithm to help reduce that risk”.

Choosing the right approach for the patient

An appropriate treatment option for someone in the high-risk category would be and using an alternative bearing type – the ‘dual mobility’ joint is ideal for cases such as this. A dual mobility joint is a newer model of artificial hip joint, it is designed to have a greater range of motion and this helps mitigate the risk of dislocation.

Essentially, it’s about ensuring that surgeons are given the information required to be as proactive as possible, rather than having to react retrospectively to problems caused post-operatively. Dr Jonathan Vigdorchik, an assistant professor of orthopaedic surgery at NYU School of Medicine and associate fellowship director of the Division of Adult Reconstructive Surgery at NYU Langone Orthopaedic Hospital, explains “Orthopaedic surgeons need to be more aware of this problem and think about the risk of dislocation prior to performing a hip replacement instead of just dealing with the complications after the surgery. We need to be proactive in our approach.”

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.

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.

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.

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.

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.

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,, 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.