steroid injections for hip pain

For those suffering from hip or knee pain, it had long been thought that before going down the surgical route, steroid injections could provide some relief caused by the discomfort of joint osteoarthritis. New research has been published that challenges this belief, suggesting that cortisone injections could actually be doing more harm than good.

Steroid injections are an anti-inflammatory drug that can help numb the pain in deteriorating hip and knee joints. The NHS website explains that “steroid injections in joints are intended to relieve joint pain by reducing inflammation. In the UK, you may be offered this type of injection if you have moderate to severe pain from osteoarthritis.”

The new research has been published by the Boston University School of Medicine, whose findings suggest “that the treatment could speed up a joint’s disintegration and force patients to have total knee or hip replacements.” There is also a higher complication rate in joints following this type of injection, with one in ten hip replacement patients in the study in 2018 experiencing complications and four per cent of those with knee complaints.

The study, comprising data from over 450 US patients, indicates that complications such as “stress fractures, progressive osteoarthritis or even the collapse of joints” were experienced more so by those who had undergone treatment with steroid injections.

Report authors are pushing for greater access to information for patients who are recommended steroid injections. With greater knowledge comes greater opportunity to challenge and to decide whether or not the treatment is something they wish to progress with. Dr Ali Guermazi who lead the research explains “what we wanted to do with our paper is to tell physicians and patients to be careful, because these injections are likely not as safe as we thought.”

Mr Bridle concurs with these concerns and believes that hip and knee steroid injections can sometimes be beneficial to patients, but must be used sparingly. Typically, the kind of patient who would benefit the most from steroid injections is those whose symptoms are not bad enough to consider a full joint replacement. They can also help mask the pain for those who have important events in the near future that they are not able or willing to miss, such as golfing or a holiday. Not only that, much older patients who are not considered suitable for surgery can benefit from the pain relief offered by this type of treatment.

Steroid injections for hip pain

Steroid injections can also sometimes be used as a diagnostic tool. When administered into the joint they can help surgeons ascertain whether or not it is the joint that is the primary source of the pain and mobility issues. When used in this way it can help guide whether or not joint surgery is a suitable and effective next step for the patient.

It is important that if steroid injections are used as part of patient care or as part of a diagnostic assessment, they must be used in moderation. Mr Bridle’s approach is to give no more than two or three steroid injections before switching to an alternative approach or different kind of treatment.

This research is important as it has raised important questions about the possible side effects of cortisone injections, however, the small sample size indicates that there is a strong case for follow up research, with a larger base. The NHS recommends that realistically, “large-scale, long-term studies are needed to give us an accurate picture of the possible risk of joint damage after injections.” Until that data is available, surgeons are best to do as Mr Bridle does, and proceed with caution.

For more advice on the appropriate treatment for alleviating joint pain, call 020 8947 9524 to arrange a consultation at Mr Simon Bridle’s London joint replacement clinic.

revision joint replacement

In an interesting new study published by the National Joint Registry (NJR), data has been shared showing a league table of the best- and worst-performing areas of the UK if you are considering an NHS hip replacement.

The assessment looked at 430 UK hospitals, comprising 145 NHS trusts running 250 hospitals in the UK, as well as 181 private hospitals.

The objective of this piece is not to name and shame hospitals that are underperforming, but rather to look at where the shortcomings are and to ensure that lessons are learned. That said the full list of the 10 worst-performing hospitals in the research can be accessed here.

Higher rates of revision joint replacement surgery tend to indicate that complications were most often due to infections taking hold after surgery or failures due to inadequate supervision of junior doctors.

Using medical data to improve practice

The positive outcome to take from this research is that it can be used to great benefit of the weaker performing hospitals. Those hospitals are able to use the data to look at why things are not going as well as expected and to help guide improvements. One of the weakest-performing hospitals in the report has already reported to be “ensuring supervision of non-consultant surgeons” as a direct result of this data. Another hospital reports having taken measures to combat higher than expected rates of infection following surgery, explaining that “measures had been introduced to reduce risks of cross-contamination, including ring-fencing beds used for planned surgery, and screening patients before operations.

All surgeons have data held by the National Joint Register on their practice and part of a surgeon’s appraisal process is to reflect on their results and, in particular, their complication rate. Every surgeon will have a complication rate as no surgery is without risk, but minimising the chance of complications occurring should always be the aim.

As with any data analysis, there are reasons behind the data that need to be assessed before the ‘true’ picture can be fully understood. Some of the weaker performing hospitals in this study report an older than average patient profile, which helps explain some of the patterns seen. The medical director of the NJR explains what this means for the report and the associated data “there are many potential reasons why a hospital may be found to have a higher revision rate than expected and the reason for drawing this matter to their attention is to encourage an urgent and thorough review of the hospital’s practice. There is an agreed process to enable appropriate action to be taken to review units which fall below expected performance thresholds.”

Reassuringly for Mr Bridle’s patients, his NJR data yields a positive picture, with low revision rates for both hip and knee replacement surgery. Not only that, on the whole, hip replacement surgery is a very successful type of operation and the vast number that are performed each year means that surgeons are able to continually advance techniques and reduce revision rates. Data in support of this shows that “patients can be reassured that the rates for revision joint replacement have fallen every year since 2011”.

Mr Simon Bridle will be able to discuss all the potential risks and benefits of a hip or knee replacement in full during a consultation. Call 020 8947 9524 to arrange.

Risk of revision hip surgery

A hip replacement is an operation that has been carried out for decades. It is a cost-effective procedure, with well-established benefits, in particular, relief of pain and getting people back to normal function.

Total hip replacements are being carried out on more and more younger patients, thanks to a variety of factors which have made this age group more requiring of this type of procedure, including more active lifestyle choices and advancements in medical knowledge and processes.

A recent study, looking at data from the Dutch Arthroplasty Registry (LROI), set out to explore the risk of revision hip surgery in patients undergoing this type of operation, with a particular interest in understanding whether or not there are any differences for younger patients. The term ‘revision rates’ means how many patients had repeat or follo- up surgery following the initial operation.

Data from almost 20,000 patients was analysed, making this a statistically robust assessment. All patients whose data was examined were younger than 55 years old and had undergone a total hip replacement in the Netherlands between the years of 2007 and 2017. This data was then scrutinised looking for any difference in the following areas:

Potential risk of revision hip surgery factors:

  • Age
  • Sex
  • Diagnosis
  • ASA-classification
  • Surgical approach
  • Fixation method
  • Bearing type
  • Head size
  • Year of surgery

The research concluded that “the risk of revision hip surgery in patients younger than 55 years depends on surgical approach, head size and bearing type. The anterior approach resulted in a decreased risk of revision, whereas the use of ≥38 mm heads and MoM bearings resulted in an increased risk of revision for any reason.” So, a variety of factors could be expected to affect the longevity and risk of revision in younger patients.

Total hip replacements in younger patients have helped many people live with a better quality of life, with reduced/lack of pain and much greater levels of mobility than they were able to achieve prior to opting for the treatment.

According to results of a much smaller study, the prognosis for younger patients living with total hip replacements was positive, with researchers concluding that “today, among the patients still living… 46% of the original hip implants were still in place and functioning. In addition, many of the patients who died in the interim did so with their original implant in place. Overall, 63% of the original hip replacements were functioning at the latest follow-up or at the time of death.”

Risk of revision hip surgery study conclusions

Despite being just a small cohort of 69 patients, these patients were the perfect demographic to complement the bigger research conducted in the Netherlands. This research was conducted with data of patients who had a total hip replacement when they were aged between 18 and 49 years old. Researchers then checked in at regular intervals with the patients to see how they were getting on.

Ultimately, a total hip replacement in a younger patient has a tougher job to do – the patient will likely live longer and put more stresses and strains on the new joint compared with a much older patient. This said, the results of these recent studies are encouraging, suggesting advancements in technology, surgical skill and knowledge are all helping increase the longevity of total hip replacements in younger patients.

To discuss the potential risk of revision surgery, choose an expert. Call o20 8947 9524 to book a consultation with leading London hip specialist.

private hip surgery

There has been a significant shift from the NHS to private delivery of hip operations in recent years, which has been the focus of a new study undertaken by researchers from Newcastle University and Queen Mary University of London. The study, which has just been published in the Journal of the Royal Society of Medicine, comprised data from NHS-funded private hip surgery in England during a ten-year period, from 2003/4 to 20012/13.

The figures are surprising when looking at trends between 2007/8 and 2012/13. The number of patients who had their hip replacement undertaken in an NHS hospital declined by 8.6% whereas those treated by private providers saw an increase of 188%.

Ultimately, the concern is that with such a marked increase in patients being treated privately, this is reducing available capacity on the NHS. Researchers are concerned that “continuing the trend towards private provision and reducing NHS provision is likely to result in risk selection and widening inequalities in the provision of elective hip operations in England.” This shift was even more exacerbated when data from wealthy and poorer areas was examined; with an even more significant number having treatment in a private hospital in the affluent areas (increasing to a 288% increase).

This is a trend that many surgeons believe is inevitable. Private hospitals will naturally lean towards the simpler, less risky cases, those that are felt to be best suited to a non-NHS environment. Report authors explain “the researchers found that private providers favour fewer extremes of ages compared to NHS providers. These patients, the researchers say, may represent more complex operations or associated co-morbidities that are excluded by private providers.” By comparison, the NHS hospital environment offers access to a much broader range of specialist medical staff, who are able to assist in more complicated cases and higher-risk patients.

What this means for the NHS

What researchers suggest we need to be mindful of is ensuring that this trend does not affect the access to appropriate health care, as per the 2012 Health and Social Care Act. Professor Allyson Pollock, Director of the Institute of Health and Society at Newcastle University, is concerned that this trend points to just that – a lean towards inequality in the provision of patient care. She believes: “If the trends here continue, whereby private provision substitutes for NHS direct provision, with risk selection favouring less deprived patients, then widening inequalities are likely.”

One argument is actually that by carrying out the less complex cases within a private hospital environment this is more cost-effective. It means that surgeons in the NHS are effectively freed up to focus on the more challenging cases. Surgeons agree that despite the trend towards a growing number of patients choosing a private provider for their hip operations, the NHS will always offer a vital role in supporting complex surgery and surgery on less fit patients.

Online Joint Replacements Tool

Over 200,000 hip and knee replacements are performed in the UK each year – it is a constantly growing surgical field and the medical tools available now are helping improve the quality of life of a significant proportion of the population. As such, any improvements or developments in how to effectively offer these services have a significant reach.

One such development has been announced thanks to the University of Sheffield who, working collaboratively with the University of Bristol, has been busy working on a new online joint replacements tool which will help patients research many questions they might have before deciding whether or not to opt for surgery.

The University of Sheffield has revealed it has developed a pioneering new tool which “gives patients unique personalised information about the risks and benefits of having a joint replacement for the first time.” The tool has been created after an assessment of masses of patient data thanks to information held by the National Joint Registry, which keeps data from over 1 million hip and knee operations.

It promises to be intuitive and easy to use, and “the Patient Decision Aid For Joint Replacement generates an individualised set of results for patients based on a variety of factors including how long the implant will last, predicted pain and function levels before and after surgery and the associated risks such as death rate”. Not only is the usability of the tool one of its benefits, as it is available online it is also versatile in terms of where it can be used. Patients can choose whether they use it at home and access the information on a personal basis, or in a consultation setting with their GP who can help answer any questions as they work through it.

What does this mean for hip replacement patients?

A tool such as this promises to be empowering for patients, as it hands over a greater level of control that ever before and gives them access to greater medical knowledge. With clearly worded language and digestible information available, they can work through many of the questions they might have such as the pros and cons of the different options available, how the different options suit different lifestyles, and when the best time is to consider surgery (for example taking into account factors such as overall health, BMI etc).

Patients who have been able to test this tool ahead of surgery are positive about the amount of information it enabled them to gather ahead of their consultation and claim this helped them streamline/fine tune the questions they asked of their surgeon. One patient explained “Using the tool has given me a whole host of information which I can now talk through with the consultant at my forthcoming appointment. It has been very helpful and I am sure it will be useful for lots of people in a similar position to myself.”

Looking ahead to the future of hip replacements

Ultimately, a tool such as this can offer a great deal of insight and knowledge for patients, it can help prevent surgery that is not suitable and/or necessary for patients and from a budget perspective can also help save the NHS money.

total hip replacements

The National Institute for Health Research (NIHR) is the biggest clinical research funder in Europe and has recently published results of a study looking at the effectiveness of a range of prosthetic implants used in patients who have undergone total hip replacement surgery.

This research is important because total hip replacements are extensively carried out in England and Wales, with almost 100,000 being fitted in 2017.

The research dataset was huge; the team assessed “more than 1 million individual patient-records from national joint registries in the UK and Sweden, countries with similar publicly funded health services.” They looked at how total hip replacements fared for men and women and they looked at the revision rate for all cases (which is the requirement for follow up surgery following the initial operation).

All the different types of prosthetic implant were assessed, of which there are a variety of different types of implants available:

  • Metal on polyethylene – this is the most frequently used implant type and its origins date back to the middle of the twentieth century. It has a long and successful history but over time the polyethylene part can become worn and begin to wear down.
  • Other combinations include ceramic-on-polyethylene, metal-on-metal and ceramic-on-ceramic. These are newer evolutions and cost more to produce. There are also different ways of fixing these newer implants to the existing bone, which can have an impact on their overall effectiveness.

The results are interesting, concluding that there is no evidence of benefit with new more expensive implants over older implants. This obviously has a cost implication too, as many of the newer implants represent a more expensive option.

The implant that fared most positively in the research was actually the cheapest one available, although this finding was only conclusive in the over 65 age bracket. The “small-head cemented metal-on-polyethylene implants” cost around £750, has the lowest amount of follow up surgery and is currently used in around one third of total hip replacements in the UK.

In second place, the “small-head cemented ceramic-on-polyethylene implants were most cost-effective in men and women younger than 65 years ” although the report authors stress that there were some factors that they couldn’t assess comprehensively in this age group, such as predicting the revision rate that might be seen in the future.

What does that mean for patients awaiting total hip replacements?

There are many different factors that affect which type of implant is chosen for each patient. Factors include biological and lifestyle elements, such as age, weight, gender and level of activity (currently and desired). Surgeons often have a preference for the type of implant they choose to use, based on their own research and experience of fitting them.

If it isn’t broken, don’t fix it

What is most interesting is that in this case, newer doesn’t necessarily mean better, and more expensive doesn’t equate to necessarily being better either. The long-standing, older-style implants still offer a sustainable, effective solution for those of use whose joints are deteriorating and are in need of a prosthetic implant.

return to sport after hip surgery

Fans of tennis will be aware of Andy Murray’s hip struggles over the past few years, and many of us were delighted to see him crowned doubles’ champion at Queens with partner Feliciano Lopez. When asked how he felt about his achievement, he said “I just won the doubles here with Feli with a metal hip, it’s mental really. My hip felt great, no pain – I feel good just now.” Watching his progress has been inspirational for us all.

This has been an important step for Mr Murray, both mentally and physically. His hip resurfacing operation was a mere five months ago. He now plans to continue his training and rehabilitation and hopes to push his successes on the singles’ courts too.

Andy Murray has recently returned to sport following major joint surgery and he is not the only one to be keen to return to more strenuous activities after surgery. In fact, one of the most frequently asked questions from patients who are preparing for hip replacement surgery, is how quickly they will regain mobility. Not only that, very many of our patients are not just keen to get back to walking around, they are keen to get back into the sports they love.

Evolution of thinking

Total hip replacements have been performed for decades; they are one of the oldest and best practised joint surgeries. When first introduced they were regarded more as a ‘salvage’ operation, as explained by the National Centre for Biotechnology Information (NCBI) “originally considered a salvage procedure, the initial goal was simply to allow people to perform basic activities of daily living without experiencing excruciating pain.”

When things had become unbearable for patients in terms of pain and lack of mobility, this operation could help reduce pain and give them the freedom to move around again. Fast forward to the modern day and our thinking regarding this type of operation has changed significantly. Our expectations of what it can achieve – and very often the realities of this too – are far greater.

Taking a positive approach to return to sport after hip surgery

Mr Bridle’s approach to advising patients on when they can return to sports is that anything is achievable within reason. The important thing to remember is don’t rush things; listen to your surgeon and your body, ensure you take your rehabilitation and physiotherapy seriously, and you’ll soon find you’re able to start participating in the leisure pursuits you enjoy.

This forward-thinking approach is supported and recommended by leading medical literature, as outlined by the NCBI; which explains that data supports a managed return to sport after hip surgery and yields no evidence that this adds undue wear and tear on the new joint. “There is little prospective evidence regarding the likelihood of poor clinical outcomes with higher level of sporting activity. There is some evidence to suggest that wear may be related to activity level, but the impact on clinical outcomes is conflicting.”

It goes on to advise surgeons “when advising an athlete considering returning to sport after THA [a total hip athroplasty/replacement], consider their preoperative activity level, current physical fitness, and specific history including bone quality, surgical approach and type of prosthesis.” If the patient is keen to get active again, there is no medical reason why this shouldn’t, in theory, be possible.

To discuss in more depth what you can expect in terms of return to sport after hip surgery, call 020 8947 9524 to book a consultation.

self-funding hip surgery

It is no secret that the NHS is overstretched and under-funded, which can lead to painfully long waiting times for operations and in some areas, lack of access to some procedures. This is unlikely to change any time soon. Despite the best efforts of those working in and managing our health service, the supply, demand and ultimately the funding, just don’t balance effectively.

This leads many of us to question whether the NHS will be able to continue to fund operations such as joint replacement surgery in the future?

Controversial NHS fixes

Recently, some NHS trusts have been criticised for allowing some patients to jump the queue by paying significant sums to jump the waiting list. In a scheme that has since been cancelled, “Warrington and Halton Hospitals NHS Foundation Trust had been “accused of ‘disgraceful’ privatisation for trying to charge £18,000 for hip replacements”. For a service that is meant to be available for everyone, this has caused waves of protests and a lot of negative feeling has been voiced; “a photo of a poster about ‘self-funded procedures’ has also been posted online and people railed against the hospitals charging for once-free treatment.”

Self-funding is clearly a very practical answer to a very real problem, but it is just not seen as an acceptable answer for the NHS problem.

At Mr Simon Bridle’s hip surgery practice, we are seeing a real growth in patients deciding to remove themselves from the NHS pool and to seek a private alternative for their hip replacement needs. The demand for such operations is rising due to a variety of different reasons, including the fact that there are a growing number of people who need hip replacements younger than they might have been done in the past. This increasing pool of patients requiring a hip replacement means that there is just no way that everyone will be treated quickly and efficiently on the NHS.

The demand is simply too high; according to projected figures from a 2015 study published in the Osteoarthritis and Cartilage journal, “the NHS will need to perform an estimated 439,097 hip replacements and 1.2 million knee replacements by 2035 to keep the population in England and Wales mobile and pain-free”.

What to do if you are considering self-funding hip surgery

There are many benefits in self-funding hip surgery and many people are choosing to do just that. Patients are able to pick the time, place and surgeon that they feel most comfortable with, and this simply isn’t possible if you are having a joint replacement done on the NHS. If you are interested in finding out more about this then the first step is to make an appointment to talk through your requirements with Mr Bridle.

He will be able to assess your case, talk to you about your preferences and give you all the information you need to make an informed decision about whether to wait on the NHS or to opt to have your operation privately.

revision joint replacement

There has been a lot written recently about the relative strengths and weaknesses of the different approaches to carrying out a total hip replacement.

The Bone and Joint Journal published a thorough assessment recently which evaluated “five commonly used surgical approaches with respect to the incidence of surgery-related complications”, the findings of which are helpful for both patients and surgeons, when considering which approach to use.

The following five approaches were evaluated:

  • Posterior
  • Anterior
  • Direct lateral
  • Anterolateral
  • Northern approach

A number of the more common complications were then recorded against each approach. These complications included “prolonged wound drainage without infection, superficial infection, deep infection, dislocation, aseptic loosening, and periprosthetic fracture” and also the rate of revision joint replacement surgery required.

London hip surgeon Mr Simon Bridle favours the posterior approach, which comes out well in the evaluation. In fact, of all the methodological comparisons that have surfaced recently, the posterior approach is regarded positively. The report concludes: “we found that the posterior approach had a significantly lower overall complication rate compared with the anterior approach, with an equal dislocation rate.”

The interesting finding of this recent report is how the anterior approach fares in the comparison. There are a lot of practitioners who offer this approach and it is heavily marketed, but the data here shows that it actually comes out with the highest complication rate.

Anterior versus posterior approach to hip replacement

There are some key differences in the anterior approach versus the posterior approach, which are detailed below. These differences will ultimately be responsible for the differences in how these two approaches fare in a comparative exercise. Firstly, the incision is made in a different place. With the anterior approach, the incision is at the front of the hip whereas, with the posterior approach, it is done at the side.

The challenge for orthopaedic surgeons carrying out the anterior approach is that it is much harder to see what they are doing, compared with the ease that the posterior approach allows. This is because the anterior approach allows surgeons to work between the muscles, whereas the posterior approach involves cutting through the muscles and then repairing them once the new joint is inserted.

Although initial healing time may be faster for the anterior approach, the relative lack of complications associated with the posterior approach and how it relates to revision joint replacement is one of the reasons this approach is used by Mr Simon Bridle. To discuss the procedure in more detail, call 020 8947 9524 to arrange a consultation.

hip implant recovery

One of the first questions patients ask when they are preparing for a hip replacement is how long the recovery takes. Understanding what the hip implant recovery period will be like and how long it will be until you start to reap the benefits of your new joint.

Although everyone is different, most patients are able to fully utilise their replacement joint between 3 to 6 months following surgery. Patients will need to reach certain milestones in the shorter and longer term, and this will gradually build over time to result in significantly improved mobility once the joint is fully healed.

In the shorter term, there will be milestones that kick in almost immediately, such as getting out of bed for the first time and going home. In time, weaning off painkillers is also a good sign that recovery is progressing well. Patients are encouraged to reach milestones such as this as quickly as possible, as it is important to get people feeling normal as quickly as possible.

As the shorter term moves to the more ‘medium’ term, milestones become things such as managing to have a full night’s sleep without waking due to joint discomfort and walking without the use of a frame or sticks. As time moves on, the milestones become slightly harder to measure, as they relate to how well the wound is healing and how the muscles and ligaments are repairing. This takes time and requires hard work and dedication to help the healing process along.

Hip implant recovery: making sure you help yourself

There are some important things that you can do to help ensure a thorough and timely recovery. The amount of effort that you put into your rehabilitation will have a direct impact on how quickly and how well you recover.

The first thing is something that you can do before the operation, and that is to ensure that your house is as best suited as possible to your needs when you are recovering. In the early stages, you will find getting around the house challenging, so having things on the ground floor and within arms’ reach will be extremely important. It is vital that you don’t over stretch for items and risk falling, so rearranging your key household items in advance is very sensible.

Make sure that (following your surgeon and physiotherapist’s advice) you begin exercising regularly. This is important to ensure sufficient blood flow to the healing area of your body and it is also key to start building the muscles back up and ensuring you are using the joint fully from the offset. Make time each day to do your leg exercises and stick to this. It will pay off in the longer term if you are strict with your physio.

For more aftercare advice, call 020 8947 9524 to book a consultation with Mr Simon Bridle.