elective surgery post Covid

In mid-March, all non-urgent elective surgery was cancelled in both the NHS and private sector in response to the COVID-19 pandemic. With numbers of infections and related deaths falling daily, Health Secretary Matt Hancock recently announced that some healthcare services would resume over the next few weeks.

Certain areas were to be prioritised, including cancer care, acute cardiac surgery, cardiology services and the management of patients with severe heart failure and stroke services. In a letter to NHS trusts from NHS England’s chief executive, a further directive was that hospitals should also restart routine elective procedures where additional capacity was available, prioritising those with long waits.

So, what does this mean for planned hip and knee replacement surgery? As London hip & knee replacement surgeon Mr Simon Bridle explains, performing major surgery during a pandemic is potentially high risk, with one small scale study from Wuhan, China, that found 20% mortality rates in patients that underwent major surgery during the height of the pandemic there.

Both private and NHS hospitals will need to adopt brand new infection control processes to minimise these risks. These clean hospitals will be called green centres, with hospitals that treat COVID-19 patients deemed blue and the principle is try and keep green and blue apart.  Patients admitted to a green hospital will need to isolate prior to their admission and have a negative COVID-19 swab prior to admission.  Green hospitals will have very stringent infection control policies and pathways in place.

The exact role of the private sector is unknown at this moment. The NHS’s contract with the private sector that is currently in place will end in June. It may well be that in some areas, the NHS will choose to use private hospital as green centres for elective surgery.

Although we hope to resume joint replacement in some patients in the next few weeks, it may be some months before joint replacement surgery is carried out as a matter of course. Patients’ individual risk will be analysed and this will inform decision making between the surgeon and patient about proceeding to surgery, bearing in mind that many patients are in pain and losing their mobility and independence as a result of joint deterioration. Patients will have to accept a small increased risk, which will be weighed against those of not going ahead with surgery at this stage.

To discuss how we are planning to deal with the COVID-19 pandemic and the implications of delaying joint replacement surgery in more depth with Mr Simon Bridle, he is currently offering remote consultations, either by telephone or video link, and face-to-face consultations when necessary. Consultations can be arranged by contacting his PA Adriana by calling 020 8947 9524 or emailing bridle@fortiusclinic.com.

stem cell therapy for knee or hip arthritis

All medical care, whether that’s drugs, surgical solutions or devices, should be both safe and effective. In recent years, stem cell therapy has become increasingly in the public eye, particularly in the treatment of arthritis and joint deterioration, and covered widely in the media as the supposed wonder cure. But does it fulfil those two criteria: is stem cell therapy safe and effective?

In a recent article published in the Bone and Joint Journal, Members of the Biologics Association, an international group established to advocate for the responsible use of biologics in clinical practice and to assess the safety and efficacy of biologic interventions, highlighted the growing concern that clinical centres around the world are making “unwarranted claims or are performing risky biological procedures”.

Stem cell therapy is a fast-growing industry around the world with clinics claiming to be able to treat a wide range of conditions, from erectile dysfunction to autism, often with little scientific evidence to back their claims. It is also increasingly advertised as a solution to joint wear and tear.

The premise is that the patient’s own stem cells are harvested, usually from your bone marrow or adipose tissue, processed and then delivered into the affected joint, thereby using your body’s own healing powers to reverse the natural deterioration that occurs over time. Stem cells are able to differentiate into specialised cells, so may be able to replace damaged cells, including cartilage cells in the joint. It is also possible that they can cause growth factors to flood the joint, helping to repair any damage

Is stem cell therapy for knee or hip arthritis safe?

Stem cell therapy using adult stem cells is generally considered safe because the cells are taking from the patient and therefore the risk of a reaction are minimised. Common side effects are usually swelling and pain at the injection site but that is usually temporary.

Treating knee or hip arthritis is less likely to result in complications compared to some of the other uses of stem cell therapy, but there is some research that suggests it may increase the risk of tumours developing.

Is stem cell therapy effective?

Setting aside whether stem cell therapy is safe, the other consideration is its efficacy. Proponents will cite anecdotal evidence of positive results, but no large-scale studies have taken place and some evidence suggests that it doesn’t work any better than a placebo. The challenge is that there is no standard treatment which can be tested – every clinic may follow a different process and there is no guide as to how many stem cells need to be harvested to treat specific conditions.  At the moment evidence that there is any benefit from stem cell treatment is limited, despite some of the claims made.  For this reason, it is important that this therapy is properly evaluated in a scientific manner in properly controlled clinics.

The recent article in the Bone and Joint Journal also pointed out that certain clinics are being less than scrupulous in how they exploit the hype surrounding stem cell therapy and may be guilty of false advertising, making it harder for the prospective patient to evaluate the safety and efficacy of the treatment offered.  Stem cell treatment can be very expensive and it is important that patients understand that this remains a relatively experimental intervention, before agreeing to undergo this treatment.

“Regenerative medicine is one of the most dynamic fields of science and medicine. While cell-mediated tissue formation and repair characterize all of biology, the prospect of specific augmentation of cellular processes through harvest, processing and transplantation remain in their early stages of development… The challenge facing regulators is to balance increasing calls for faster access to medical products, while protecting the public from unnecessary risks including delayed effective treatment, adverse events and financial loss.”

During this current unfolding situation with Coronavirus, Mr Simon Bridle is still available for consultations. He will be able to see clinically urgent cases in his clinics, but most consultations will be remote by telemedicine, either telephone or video link. Appointments can be arranged by contacting his PA Adriana on 020 8947 9524 or email bridle@fortiusclinic.com.

Coronavirus and private healthcare

The advent of Coronavirus has resulted in the immediate and complete cessation of all private, elective surgery and medical care, with the agreement made in March between the private healthcare sector and the NHS. The independent sector agreed to reallocate almost all of its hospital capacity to the NHS, involving 8,000 hospital beds, over 1,000 more ventilators and many thousands of nurses, doctors and clinical staff.

As NHS hospitals clear the decks, cancelling all routine operations such as hip and knee replacements for the next three months, it does mean there will be many left in limbo with no idea of when they will be able to undergo a much-needed operation.

Earlier this year, we covered a recently published study that highlighted the importance of joint replacement timing; specifically, leaving it too long could have negative implications, such as a greater risk of surgical complications and potential issues with the effectiveness of the surgery in terms of mobility and function.

So, although the demand for joint replacement surgery will likely not decrease, Coronavirus may impact how we provide patient care in the private sector in the future.

Medical consultations post-Coronavirus

The UK Government’s current Stay at Home policy means we have all had to embrace new technology, such as Zoom, Facetime or Skype, to stay in touch with family and friends or to work effectively from home. Remote consultations, follow-up appointments and access to imaging could all become more widespread in the future to minimise risks for patients.

This will affect both the NHS and the private healthcare sector. From this April, all NHS General Practices in England and Wales were expected to be able to provide online consultations and, from next April, they will be required to provide video consultations.

The General Medical Council’s basic good practice principles should apply to both remote and in-person consultations. The onus on practitioners is to obtain adequate patient consent, ensure patient confidentiality and make an appropriate assessment of symptoms. It is important that the patient is aware of any potential limitations of the clinical assessment that can be made remotely. As practitioners, we must be aware that we are communicating clearly and that we can deliver high-quality audio-visual technology.

Mr Simon Bridle is still available for consultations. He will be able to see clinically urgent cases in his clinics, but most consultations will be remote by telemedicine, either telephone or video link. Appointments can be arranged by contacting his PA Adriana, or by contacting the appointments team at Fortius Clinic, Parkside Hospital or St Anthony’s Hospital.

Adriana: 020 8947 9524 or bridle@fortiusclinic.com

Parkside Hospital: 020 8971 8026

St Anthony’s Hospital: 020 8335 4678 or 020 8335 4679

Fortius Clinic: 020 3195 2442

hip arthritis

Hip pain is something that many people suffer from and it can be caused by a wide variety of factors. Here we explore some of the common causes of hip pain and look at whether or not these should be cause for concern.

Trochanteric bursitis

This condition results from inflammation of the greater trochanter, which is part of the hip joint. Symptoms include localised pain when sleeping in particular ways or walking up steep gradients. It is possible to seek help for this kind of condition from a rheumatologist, and it is also recommended to take guidance on pain medications and undertake some stretching exercises.

Hip arthritis

This is one of the most common reasons people have hip pain, and it is particularly common in older people. Hip arthritis causes inflammation of the joint which can restrict mobility and cause much discomfort, it also causes the cartilage that protects your hip joint to wear away, leaving it more vulnerable. Arthritis won’t get better on its own, so if you are worried that you may be experiencing it then it is important to seek medical advice.

Simply overdoing it

Some of us are just guilty of pushing ourselves too far and making our joints and/or muscles ache as a result of the activities we choose to do. You may have strained muscles or tendons, which usually get better of their own accord after a few days of causing discomfort. This should, however, act as a gentle reminder that you need to be mindful of your body’s limitations, especially if you’re getting a bit older.

More brittle bones

As we get older, our bones become more prone to breaks and fractures, they become less robust as they age. If you have had a fall or a trip and are subsequently feeling hip pain that you didn’t have before, you may have fractured your joint and will require an X-ray to diagnose this for certain.

Knowing when to ask for help

In the early stages of hip discomfort, advice indicates that it is often possible to manage this with a combination of rest, a change in the intensity of physical activities you choose to do, a course of anti-inflammatory over the counter drugs and targeted stretches/exercises. However, if the pain is not helped by these strategies, or it appears to be worsening then listen to your body and make an appointment for an orthopaedic assessment to get your joint checked out.

knee and hip surgery

Even before the advent of COVID-19, our A&E departments were recording record waiting times and it is the same for many overstretched GP surgeries. Unfortunately, the picture is the same across so many parts of the NHS; demand for services is currently far higher than the available supply.

Long wait for hip and knee surgery

A new report published recently in the Telegraph claims “patients in need of a new hip or knee are increasingly being left in agony for more than a year”, which is a worrying statistic for degenerative conditions such as these, were waiting for a long time before receiving treatment can have a detrimental effect on the effectiveness of the procedure.

The report goes on to explain “the figures show that in 2018/19, 55,251 patients waited at least 18 weeks for hip and knee surgery – a more than doubling from 25,704 such cases in 2013/14.” While this in itself is frustrating it also means that a large number of people who are eligible for a hip or knee replacement are having to wait while experiencing significant pain in their failing joints. According to data published by the Daily Mail, the pain experienced by some is excruciating, and the waiting times are just not sustainable. “Some 19 per cent of those waiting for a hip replacement were in extreme pain. The figure was 12 per cent for those waiting on an artificial knee…The level is so poor it is defined by experts as ‘worse than death’ – more painful than chronic health conditions such as diabetes, heart failure or lung diseases.”

How concerning is this?

To contextualise the scale of the problem, there are around 175,000 hip or knee replacement operations carried out in England, Scotland Wales each year. Eligibility for the procedures is generally because the cartilage that holds the hip or knee joint in place has started to disintegrate or become worn away. There are a variety of different factors that can cause this to occur, but a it generally occurs in older people whose joints have naturally undergone more wear and tear or those who have developed conditions such as osteoarthritis. Some younger patients who are particularly active in high impact sports can suffer as well.

Hip replacements are typically carried out amongst those aged 60 to 80 (although there are increasingly younger patients who are in need of this type of procedure too). Once a patient has reached the stage of needing one of their joints replaced, their mobility will be impaired, and it is likely that they will be in a significant amount of discomfort. The longer they wait, the worse it will become, and the greater the chance of needing further work along the line.

This pressure on the NHS to deliver this type of surgery increases the reliance on the private sector, a development that London orthopaedic surgeon Mr Simon Bridle has noticed in his London hip and knee clinic.

benefits of robotic joint surgery

The utilisation of robotic surgery across all medical specialties is on the increase, with surgeons believing they are able to offer greater benefits to patients by utilising robotic technology. Although this sounds really encouraging, with patients benefiting from a wide variety of factors, there is currently limited data in support of these practices.

Researchers have been studying data from a huge amount of records held by the Michigan Surgical Quality Collaborative, a partnership between the hospitals and Blue Cross/Blue Shield of Michigan. The focus of this partnership is collecting and analysing data that focuses on quality improvement for surgical care. Researchers have been able to study “clinical registry data for 169,404 patients from 1 January 2012 to 30 June 2018, who underwent robotic, open or laparoscopic procedures at 73 hospitals across Michigan.

Despite the benefits being hard to prove with the current big data sources, very many surgeons are advocates of this technology. The perceived benefits to orthopaedic surgeons include greater accuracy of joint implantation, lower risks of there being complications with surgery (in particular with joint dislocation and the overall leg length for hip replacement), better functional outcomes and faster rehabilitation – especially for patients who have had knee replacement surgery.

Who is really in charge?

One of the perceived concerns with robotic advances in surgical technology is the level of autonomy that the machine has. Some are worried that the decision making is moving away from the surgeons into programmable robots, and there is some degree of concern with this. Orthopaedic surgeon Michael Suk, MD, chief physician officer at US medical company Geisinger, reassures that this really shouldn’t present a cause for concern, “The thing to keep in mind is that the robots involved in the surgery are not completely autonomous. They’re controlled by the doctor, which allows doctors to combine their knowledge and judgment with the precision and control of a robot. The robot isn’t doing the surgery—the doctor is, but with the help of the robot.”

Orthopaedic surgeons are utilising a robotic surgical arm known as Mako. It is designed to help increase precision and accuracy, enabling surgeons to carry out their work faster and to a more precise degree. The really clever thing about MAKO is just how precise it is able to carry out the tasks it is programmed to do.  And it is able to benefit surgeons who carry out both knee replacement surgery and hip replacement surgery. “Mako is extremely precise—it allows doctors to do partial knee replacements two to three times more accurately than conventional partial knee replacements. Mako hip replacements are shown to be four times more accurate and reproducible than conventional hip replacements.”

Patient safety at the heart of everything

Medical regulators are keen to stress that, as with every advancement in medical practice, this will be vigorously analysed and tested to ensure that it is working in the best interests of the patient. As always, patient safety is at the forefront of any new initiative. Helpfully, with many surgeons exploring this new technique and working with Mako technology, the available data is growing and will enable researchers to continue to assess the benefits of robotic joint surgery and any potential weaknesses it presents.

To discover more of the benefits of robotic joint surgery, call 020 8947 9524 to arrange a consultation with Mr Simon Bridle at his London joint replacement clinic.

joint replacement timing

“Don’t put off until tomorrow what you can do today.” Although Benjamin Franklin, one of the founding fathers of the United States, wasn’t specifically talking about knee or hip replacement surgery, it seems this sentiment is very apt. A new study has revealed that as many as nine in ten of us who suffer from osteoarthritis in our knees ignore the problem for much longer than we should.

The report, published in the Journal of Bone and Joint Surgery, looked at the knees of almost three and a half thousand patients, almost a third of which went on to have knee joint replacement surgery in the research time period. Over double that number (over 2,800) opted not to have knee surgery, despite researchers believing they were medically eligible for it.

Joint replacement timing

The report warns that joint replacement timing, and leaving it too long specifically, can negatively impact how effective the surgery will be. The longer you leave it, the greater the risk that there may be complications of elements of the surgery that would simply have left you with a better quality of life if they had been done earlier. The report authors explain that there are a wide variety of implications that can occur for putting your head in the sand and ignoring the need for joint surgery. These include:

  • Greater risk of complications with surgery
  • Higher likelihood of needing revision surgery further down the line
  • Potential issues with the effectiveness of revision surgery
  • Reduced mobility compared with those who opted for surgery earlier
  • Other health problems caused by the lack of mobility in the joints, such as weight gain, depression, etc.

Hassan Ghomrawi, an associate professor at Northwestern University Feinberg School of Medicine is one of the lead investigators on this research, and he explains: “When people wait too long, two things happen… The osteoarthritis causes deterioration of their function. Some of them wouldn’t be able to straighten out their legs, affecting their walking and mobility. When you can’t get exercise, you can start to develop other health problems such as cardiovascular problems. You may also become depressed. The overall impact can be huge.”

Taking steps to address the issue

Medical professionals believe that there is an educational role here to help patients understand the impactions of delaying surgery. With a greater understanding of how delaying surgery could impact on them and their lives in the future, there may hopefully be a positive shift towards fewer patients waiting until it is too late.

Although there is probably never a ‘convenient’ time to choose to have major surgery such as this, understanding the implications of delaying is critical to ensuring that you’re not doing lasting damage to troubled, failing joints.

To find out more about optimal joint replacement timing and whether you’re suitable for surgery at this time, call 020 8947 9524 to arrange a consultation with Mr Simon Bridle.

skiing after a hip replacement

Hip and knee replacement surgery can be life-changing for those who are suffering from deteriorating joints. The pain and limited mobility are likely to have been holding you back from many things that you enjoy, and the operation can restore a great deal of this back again. For some patients, just walking around again, being able to go up and down stairs or undertaking gentle exercise is rewarding enough, whereas others may wish to return to much more strenuous leisure pursuits.

Skiing is one of these pursuits that we discuss with a number of our patients. For those who have enjoyed winter ski holidays for many years, they can worry that needing a hip or knee replacement might signal the end of this pastime. Encouragingly, this is not often the case.

Whether or not you can ski after a knee or hip replacement largely depends on your level of competency before you had your operation. If you were already a competent skier then there is no reason why, in time, you can return to skiing again. If you are a complete beginner, then it is really advisable to choose a different hobby to learn. Learning to ski after you have had a hip or knee replacement is not a very sensible choice as all novice skiers take their fair share of bumps, falls, knocks and jolts – none of which are ideal for a replacement joint.

Skiing after a hip replacement: walk before you can run – so to speak

It is important to understand that you will need adequate time to recover from hip or knee replacement surgery. As a rule of thumb, you shouldn’t consider an activity such as skiing for at least three to six months after you have had the operation and, even then, you should be prepared to take it nice and easy. A ski holiday this soon after surgery really should involve nothing more strenuous than building your strength back up on nursery slopes. If you push yourself too hard, too soon, then you risk damaging your joint and wishing you had been more patient.

Skiing after a hip replacement: take sensible precautions

If you decide to ski, there are also decisions during the trip you can make which limit the risk to your new joint. Check the weather reports and avoid icy conditions. If you become tired, call it a day, as you are much more likely to fall when fatigued.

In summary, skiing is a sport which gives a lot of pleasure to many people. Being able to enjoy the snow, the speed, the scenery and the overall experience is something that many of us enjoy; although it is not without risk for anybody. Anyone can injure themselves skiing, no matter how careful or experienced they are. For patients who have had a hip or knee joint replaced, the main concern is a bad accident can cause a more complicated problem than if the patient had not had a replacement. For skiers who have had replacement joints, it is a case of weighing up the level of risk and making an informed choice whether or not returning to the slopes is the right decision for them.

For more advice on skiing after a hip replacement, call 020 8947 9524 to arrange a consultation with London hip expert Mr Simon Bridle.

hip labral tear treatment

It’s the time of year when we are all making new year’s resolutions and trying to put in place plans and strategies to be healthier in the upcoming months. For some of us, this doesn’t just mean something like a gentle jog, it can mean something much more strenuous – marathon training. Most marathon training programmes last 16 weeks so this week sees runners competing in the London Marathon starting to ramp up their preparation.

Although competitive running has many health benefits, it puts a great deal of stress on your joints, which can lead to long-term problems if not managed correctly. One very common running-related problem is hip pain, which is often attributed to an inflamed labrum, or hip labral tear. The labrum is a fibrous rim on the socket of the joint, which is liable to damage in some situations.  Runners suffering from a labral tear actually describe it as “a dull, burning sensation that wouldn’t go away”, rather than a more traditional ‘tear’ that is instantly obvious and causes a sharper, more immediate pain. Some people don’t even know that the tear has occurred when it first happens. The problem with this kind of pain is that, to a certain extent, people can get used to it and learn to push through the discomfort. This is the worst thing you can do for a labral tear as this will be making the problem worse and prolonging/exacerbating the pain in the longer term.

So, what exactly is a labral tear or inflamed labrum?

To begin to understand more about the problem, we need to start by understanding what the issue is and how it occurs. The labrum is a cartilage ring that stabilises the hip joint. It behaves as the hip’s natural shock absorber, so really gets put to the test with high impact sports such as long-distance running, HIIT training, basketball and so on.

The causes of these different conditions are also very similar, they tend to be caused by really pushing yourself when undertaking a sport such as running but while not ensuring that you are taking time to build up the muscles suitably at the same time. Strength training is very important for looking after the joints of athletes such as runners. If people take the time to build up the muscles around key joints then this will pay dividends in the long run as it will help them absorb as much ‘shock’ as possible.

Hard to pinpoint the problem

Diagnosis can be tricky, especially without consulting orthopaedic experts, as the symptoms of a labral tear van be very similar to a joint which is just struggling with early-onset osteoarthritis or inflammation of the joint.

Here at the Fortius Clinic, we see a lot of patients – particularly younger patients – who have been keen runners and who are now struggling with inflammation of the labrum or a labral tear. In some cases, patients can get better with appropriate physiotherapy and a tailored rehabilitation programme. It does not necessarily mean the end of their running ambitions, but it is time to take stock and make sure you’re looking after your joints appropriately. Physiotherapy can help build up the muscles around the joint and provide the dexterity and support that the joint needs. If this approach isn’t successful though then patients will need to consult a hip surgeon specialising in hip arthroscopy to discuss if they do need an operation.

yoga and hip replacement

Hip and knee replacement surgery was once thought of as something which tended to be something just older people needed. This is no longer the case, with the increasingly active lifestyle that people are choosing sometimes having negative side effects on their joints. There are some pursuits that put more strain on joints than others, and recently it was revealed that those who practice yoga are putting their hips under a significant amount of pressure.

Concern with sports which push the joints into unnatural positions

Leading physiotherapist Benoy Matthews, who is a member of the Chartered Society of Physiotherapists, shared insights recently that he is seeing a trend of yoga teachers in their forties who are in need of hip replacement surgery, due to the unnatural positions that they are forcing their hip joints into, and the regularity in which they are doing this.  He believes it is all about getting the balance right.

Activities such as yoga are undoubtedly good for some joint and muscle complaints and can be beneficial to help keep the body fit and supple. But for those who are pushing their bodies too far – such as yoga teachers who practice the sport day in day out – the effect is that it is causing their joints to deteriorate.

As Matthews explains, “we all know about the health benefits of yoga – but, like anything, it can cause injury. We can’t put it on a pedestal.” He is keen to stress that when practising something such as yoga it is important to listen to your body’s limits. If you strive for a position that you want to be able to master, his advice is not to push yourself too far. Listen to your body and only push yourself within reason, or you might find that the damage you are causing to your joints will set you back significantly in the longer term.

Everything in moderation

Orthopaedic surgeons and sporting specialists alike are in agreement that it is all about taking a sensible approach to being active and looking after your joints. With yoga, in particular, benefits are “it improves flexibility, strength and balance and can be beneficial for people with high blood pressure, heart disease or stress.” But for those who are teaching yoga (or practising yoga daily), it is important to understand that this could be causing damage to joints that may ultimately result in the need for hip replacement surgery much younger than many may expect. It is thought that there are around 10,000 yoga teachers in the UK, so not an insignificant number who this could affect.

Whilst yoga teachers are the focus of Matthews’ assessment, this pattern is also seen amongst those who regularly undertake sports such as ballet, gymnastics and athletics such as hurdles. The word of warning here isn’t just for yoga enthusiasts, but for anyone who is undertaking these kinds of leisure activities.

For more advice on hip replacement and the benefits of robotic-assisted hip replacement, call 020 8947 9524 to arrange a consultation at Mr Simon Bridle’s London hip clinic.