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

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

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

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

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

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

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

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

Diagnosing hip pain

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

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

exercise and joint replacement

We are a nation of exercise-lovers, with many of us undertaking regular workouts at the gym or with exercise classes/groups to keep ourselves feeling and looking healthy. There are many benefits of keeping fit and participating in regular exercise, including reducing the likelihood of suffering from some of the most serious health complaints, such as a stroke, heart disease, diabetes and obesity.

Regardless of these benefits, the results of a research project which has been undertaken over the last 10 years, warn of a hidden danger of exercising too much, and putting stresses and strains on other parts of our body. The research suggests that in reducing the risk of certain conditions, we are in fact trading these against an increased chance of developing others.

Compensating for one by trading against another

With increased levels of exercise comes a risk of increasing the wear and tear on our joints. This isn’t just a problem for those who participate in high impact sports (however their risk is greatest) but it also affects those who do a variety of other sports such as running, basketball, racket sports and athletics.

Joint replacements are on the increase and the recently published research attributes this partly to the exercises we choose to undertake. Hip replacement operations, for example, are becoming more and more prevalent in the UK, with the Express reporting that over 70,000 people undergo hip replacement operations every year.  Many of those who undergo hip replacement operations do so because over time, the hip socket becomes worn and begins to seize up, however there is an increasing trend towards younger people requiring joint replacement operations due to their lifestyle choices.

Orthopaedic surgeons such as Simon Bridle believe that it is all about getting the balance right. For those who are in the early stages of developing joint problems such as osteoarthritis, gentle, low impact exercising can help keep the joint supple, and can avoid the dangers of gaining weight through a decrease in activity levels. There is a direct correlation though with those undertaking high impact sports and the development of osteoarthritis at a younger age. It’s all about understanding your body’s limitations and exercising within sensible parameters. 

Take necessary care when starting or finishing an exercise regime

Cast your mind back to school when your PE teacher will have asked your class to do stretches before and after your PE lesson. For impatient children waiting to get to the fun part, this may have seemed like a waste of time, however, this was teaching good habits that will hopefully have remained with you through your adult life – the importance of properly warming up and cooling down before and after a period of exercise.

Failing to warm up and cool down properly will have short-term and long-term effects on your joints. In the short term, you’ll probably ache much more and feel like you’ve really pushed your body, when in reality you’ve just given your joints and your muscles a bit of a shock that they’ll need time to recover from. It’s the equivalent of waking someone up with a bucket of cold water compared with coaxing them out of bed with a cup of tea. If you warm up and cool down sensibly and properly, you’ll find your ability to undertake exercise should continue for longer that if you push your joints and muscles too rigorously and without the correct preparation.

arthritis researchOsteoarthritis is a degenerative condition that causes cartilage in joints including knees and hips to wear away, causing restricted mobility and slight to severe discomfort. It can currently be managed, but not cured, however, treatment for osteoarthritis is costly, and not helped by the fact that, until now, it has not been possible to predict how the symptoms will progress.

Exciting new arthritis research

There has recently been an exciting new revelation from researchers who have been busy studying the progression of osteoarthritis.

Researchers at the University of Eastern Finland have had a breakthrough in being able to predict the course of osteoarthritis in patients. In a pioneering new study that has been undertaken over the past four years, researchers have developed an algorithm that helps identify what will happen to patients with osteoarthritis, and how they expect the condition to develop.

The implication of an algorithm such as this is that it could help direct and inform treatment of patients suffering from this condition.

Current methods of assessing osteoarthritis

At present, X-rays and MRI scans can be used on patients who are displaying signs of osteoarthritis, and this can help doctors establish how advanced it is and how dense the joint cartilage has become. While this is helpful in terms of evaluating the scale of the problem, it does not give any indication whether it is likely to remain relatively stable or get worse.

The research undertaken by the University of Eastern Finland looked at 21 individuals who fell into three different groups:

  1. Those without osteoarthritis
  2. Those with mild osteoarthritis
  3. Those with severe osteoarthritis

Researchers were focussing specifically on the knee joints of these individuals. Each of the study participants were under the age of 65 and hadn’t had any serious knee injury or knee surgery in the past. The same individuals were involved in the study for four years, and during that time the new algorithm correctly predicted the advancement of cartilage degeneration in each of the three groups.

The algorithm can also be programmed to take into account other factors that can affect the spread of osteoarthritis, such as having procedures such as an osteotomy (a surgical operation whereby the bone is adjusted to align it more accurately with a joint or different bone) or meniscectomy (surgery to remove part of the knee joint called the ‘meniscus’), or the effect of weight loss.

The research has been published and praised by nature.com’s scientific report: “[the] algorithm shows a great potential to predict subject-specific progression of knee OA [osteoarthritis] and has a clinical potential by simulating the effect of interventions on the progression of OA, thus helping decision making in an attempt to delay or prevent further OA symptoms.”

returning to sport after hip replacementIf you’re an active person and enjoy getting outside and exercising, the thought of undergoing an operation such as a hip or knee replacement might seem daunting. People may wonder whether their days of exercising are over, but with the right approach to rehabilitation after an operation, there is no reason why undergoing a joint replacement should stop you participating in the exercise that you enjoy.

At the recent Fortius International Sports Injury Conference, orthopaedic specialist Mr Simon Bridle presented an insightful piece on the changing attitudes, desires and limitations of returning to sport after undergoing a significant joint operation.

Evolving knowledge

Over the years, surgeons have increased their knowledge of how to perform successful hip and knee replacements in humans. Through decades of research and many, many operations, surgeons have been learning about what works well, and what doesn’t, and developing materials, procedures and recommendations accordingly.

In the 1960s, doctors were performing total hip replacements, however these tended to be in elderly and disabled patients, with a view that it was a ‘salvage procedure’, rather than something that would offer them an enhanced quality of life.

Nowadays, there has been a threefold increase in the number of patients in the UK and the USA who are opting for hip replacements, many of whom have a desire to remain active after their operation. With new, much more effective pain relief, patients are often able to push themselves further in the days, weeks and months after a total hip replacement, and begin the road to rehabilitation and recovery.

Getting back on the bike….

…or into the swimming pool, or into your walking shoes….

There has also been a shift in patients’ mentality regarding how active they expect to be following an operation like this. Mr Bridle reports that 35% of hip replacement patients do sport pre-operatively, and the desire to return is major expectation.

Whereas high impact sports come with significant risks of damaging a prosthetic joint, low impact sports can be good for building up your muscles, keeping healthy and maintaining good mental wellbeing too.

The prosthetic joints that replace worn out, arthritic, natural joints have also improved significantly through years of testing, advances in research and the benefit of medical data. The bearings are now designed to minimise friction while ensuring optimum mobility. They are also designed so that they optimise muscle function around the implant site.

So all things considered, recovery and the ability to return to exercising after a total hip replacement is significantly better nowadays than it used to be when it was first introduced. Many patients are seeing high levels of joint functions restored following complete joint replacements. The desire of patients to return to sports is high, and with the right expectations and a structured approach to rehabilitation following the operation, many are able to do so.

cost of arthritisAll ailments cost money to treat, but often the true cost is only known by medical professionals, with the general public unaware what the larger scale costs are of treating and curing conditions. It’s often not until someone does the maths and shares this information publicly that we have any idea how expensive it is to treat, cure and manage different conditions.

That’s exactly what happened recently thanks to the UK’s leading arthritis charity, Arthritis UK, which shared its research into the true cost of arthritis on the nation’s health service. Key findings illustrated by the report include the following:

  • There are over 10 million people in the UK living with arthritis
  • The condition can cause high levels of daily pain and fatigue
  • It is believed that one in six people in the UK currently suffer from either osteoarthritis or rheumatoid arthritis

Cost of arthritis to the UK economy and to individuals

  • Over the next 10 years, the report estimates £118.6 billion will be spent on managing/treating arthritis
  • Those who live with the condition can often feel like they are a burden to their families/carers, suggesting there are secondary impacts of the condition that can sometimes overlooked

It is also reported that arthritis-related conditions cause over 30 million sick days every year, indicating the true scale of the condition for employers who are having to cover this shortfall. Not only that, at a time when professions are struggling to recruit newly qualified workers, yet also risk older members of staff retiring early, it is believed that one in four people with the condition give up work or retire early. This is exacerbating the recruitment/retention challenges experienced by many industries.

We need to start taking arthritis more seriously

The challenge that arthritis suffers face is that due to a relative lack of awareness of the condition, it is sometimes overlooked and considered just a normal part of the ageing process. Whereas aches, pains and general joint stiffness are something that can be expected as we grow older, the comparative discomfort and lack of mobility caused by osteoarthritis or rheumatoid arthritis is severe.

Arthritis UK would like the condition to be regarded more seriously by the UK government and given access to greater levels of funding to help treat and manage the condition. They claim that the condition should be given the same priority as other conditions such obesity, that are managing to build awareness – both of the condition itself and the ways in which to help those who are suffering.

A problem that is unlikely to go away

Unfortunately, osteoarthritis rates show no signs of improving as we move from generation to generation. Decades of medical records combined with some pioneering ancient skeletal assessments allude to a concerning trend with regards to the prevalence of arthritis. Medical Daily reports that “Individuals born after World War II are twice as likely to develop knee arthritis, also known as knee osteoarthritis, than those born in generations before them”.

This recent arthritis study has yet to conclude what is causing the increase, but the rate at which it has been increasing suggest that there is more to this than simply lifestyle factors, such as people living longer and those who are carrying excess weight. Although these undoubtedly have a role to play, the patterns suggest there is more to this than meets the eye.

Arthritis UK would argue that figures such as this compound the necessity for arthritis to be taken more seriously as it is not something that is going to go away on its own.

arthritis and exerciseIt has long since been recognised that dog owners are healthier than those of us who do not own dogs and now the correlation between dog ownership and healthier people is scientifically proven in two recent studies.

A daily walk with your four-legged friend ensures regular, gentle exercise; a recent study found that dog owners walk for 22 minutes more per day on average and, what’s more, they did so at a moderate pace which is just as effective as running in lowering the risk of conditions such as high blood pressure, Type 2 diabetes or high cholesterol.

The responsibility of owning a dog means that you can’t make an excuse of bad weather, either. According to research reported recently in the British Medical Journal, owning a four-legged canine friend is likely to be the catalyst needed to encourage adults to get outside and do some exercise.

When compared with the amount of regular exercise undertaken by non-dog owners, the BMJ reports that “regular dog walkers were more active and less sedentary on days with the poorest conditions than non-dog owners were on the days with the best conditions. In days with the worst conditions, those who walked their dogs had 20% higher activity levels than non-dog owners and spent 30 min/day less sedentary.”

Arthritis and exercise: medically prescribed dogs?

Some researchers have taken these findings one step further and have recommended that the advantage of getting outside for exercise each day is so beneficial; dogs should actually be prescribed to older people as a way of keeping them active and physically fit.

The interesting thing about this research is that although the findings don’t reveal anything that we didn’t know before (taking regular gentle exercise works wonders for your health as you get older) what it does show is the true extent of just how good even 30 minutes of exercise per day can be for your overall health and wellbeing.

It is especially helpful for keeping your weight at a healthy level, as if you’re carrying too much weight as you get older then this can increase the amount of pressure and strain on your joints, which can in turn lead to the development, or increase, of conditions such as osteoarthritis. For osteoarthritis suffers, the surfaces of the joints become damaged and are not able to move as freely as they used to. This is painful and can cause restricted mobility, which in turn can make it harder to exercise. It becomes a vicious cycle.

If you’re already living a more sedentary lifestyle it will be harder to introduce exercise into your routine once your joints begin to cause problems. However, if you’re undertaking regular gentle exercise as you get older, not only should this help keep problem conditions at bay for longer, but if you start to experience the tell-tale signs of osteoarthritis, it will be easier to manage the condition if you’re already leading a healthier, more active lifestyle.

We’re all well aware of the challenges facing funding of the NHS. With the recent election still fresh in mind, the process of how funds are allocated within the NHS has been discussed at length, with almost everyone holding an opinion about which areas are most deserving of retaining, increasing or decreasing funding levels.

With increased pressures on the NHS due to an ever-increasing older population, there is arguably a degree of management required to ensure that those who are deemed most deserving are able to receive access to treatment, ahead of those who are perhaps regarded as less suitable, or less in need of surgery.

So, how can suitability be effectively and fairly judged?

One idea that has been mooted is that those who are prepared to demonstrate that they have done everything they can to ensure that their overall health is as good as it can be, are given preferential access over those who indulge in damaging lifestyle habits. An example of this is the refusal of the NHS to offer orthopaedic treatments such as knee and hip replacements to those who are smokers, or who are classed as obese.

Access to additional NHS funding for joint replacements

When patients require certain treatments on the NHS, doctors can make a request to their local Clinical Commissioning Group (CCG) to receive extra funding for this. According to information sourced by Arthritis Research UK, tens of thousands of these requests were made in the past year, and around half of these were approved. With requests for funding growing year on year, there are a significant number each year that are not able to benefit from this additional CCG funding.

The chief executive of NHS Clinical Commissioners, Julie Wood explains that, “unfortunately, the NHS does not have unlimited resources, and ensuring that patients get high-quality care against a backdrop of spiralling demand and increasing financial pressures is one of the biggest issues CCGs face.” This is exactly why the NHS are having to impose additional criteria (such as being a non-smoker and not being obese) to help identify which patients are most deserving of funding for the operations they require.

Some CCGs have introduced guidelines to help identify the more disabled patients, which means patients will only be approved for hip and knee replacement operations if they are in such pain that sleeping and incapable of performing simple, everyday activities. The concern is that delaying surgery till that point only results in higher treatment costs overall and a less than optimal outcome for the patient.

Ultimately, despite the NHS wanting to offer support, treatment and operations to all who require them, there will always be a limit to what is achievable when demand outstrips supply. While this continues to be the case, the NHS will argue that the only way forward is to set additional stipulations and criteria in which to evaluate patients, so they can try and fairly assess how to prioritise available NHS funding for joint replacements.

Robots have featured quite frequently in the news recently, with most people seeing the security robot ‘drown’ in the office complex in America. While this made us smile and the media delighted at the opportunity to share some witty headlines about the robot’s demise, it was an illustration of just how far we have come with robotic technology. Security robots are an exciting new development, designed to help make modern day lives better and easier. Robots are being increasingly used in surgery. There is now good evidence that prostate and other forms of abdominal surgery are safer and more effective when robots are used. The world of orthopaedics is no stranger to this idea either.

Robotic Joint Replacement from Mako

According to the Bone and Joint Journal, “the use of robots in orthopaedic surgery is an emerging field that is gaining momentum”. Although it is relatively early days at the moment, medical professionals are recognising the benefits that robotic technology can bring. If all goes to plan, it will be able to help with accuracy of operations and with this increased accuracy, faster recovery, better function and the hope that the new joint will function well for longer.

Robotic equipment is a considerable investment, but the benefits should be significant to the patient. What robotic orthopaedics is missing at the moment is robust data. This is always the case when something new is introduced. Already we have some data indicating that hip replacement components can be implanted more accurately. As more units invest in robotic technology, more data will emerge confirming improved accuracy of component placement and link this to faster recovery and improved functional outcome.

What types of operation are best suited to robotic assistance?

Partial knee and hip replacements are amongst the first commonly performed orthopaedic operations to take advantage of the potential benefits of robotic and computer-assisted technology. Malalignment of hip and knee components can cause instability, increased wear, loosening and early failure, requiring revision surgery. Modern robotic technology uses computer mapping on CT scans of the joint to plan the optimal position into which the components should be implanted. The robot acts as an extension of the surgeon’s eyes and hands and guides the surgeon to ensure to components go in the pre-planned position, potentially using smaller incisions, with less soft tissue trauma.

One of the reasons that hip and knee replacements are at the forefront of robotic technology is because demand for these operations is rising. The ‘baby boomers’ are now reaching an age where their joints are typically starting to wear out, stopping them carrying on with the activities they enjoy. At the moment joint replacement is the only way to get these patients back to their sports and activities to help improve their quality of life. The use of robots to improve the positioning of the new joint will hopefully make these operations even more reliable and successful.

Investing in the future

Many orthopaedic surgeons like Mr Bridle are interested in the potential that robotics can bring to the profession, it feels like an exciting development within the industry and one that can help make orthopaedic operations even more of a sure thing for patients.

In the world of orthopaedic surgery, it is always encouraging to see when new clinical trials are set up, as they help to develop, strengthen and expand our knowledge. Trials are welcomed as they offer a unique insight into how patients respond to treatments, surgical methods, aftercare, medication and so on.

joint infectionThe University of Bristol is currently running a new trial which is designed to look specifically at the risk of developing an infection after patients have been fitted with prosthetic joints. If patterns can be identified, steps can be taken to address these, which will ensure that patient care and rehabilitation is improved even further.

Understanding the problem

If patients have undergone a total hip or knee replacement, the risk of developing serious side effects are small, but when they do occur, they can be very problematic. To put it into perspective, the number of patients who develop periprosthetic joint infection (PJI) is only 1%, however, if you’re in that 1% then it is a very unpleasant experience. Antibiotic treatment alone is not successful. Sometimes the joint can be salvaged with further surgery to remove the infected soft tissues, along with a course of powerful antibiotics.

Usually, the artificial joint needs to be removed and replaced with a new one, either as a one or two stage procedure. The orthopaedic community has long debated whether a one or two stage approach is preferable. If this is not successful the joint may need to be permanently removed and very rarely an amputation may even be required. So, for that 1% who develop PJI, the implications can be life changing.

What is the new trial all about?

The trial is being funded by the National Institute for Health Research, an organisation that works with the NHS and funds “health and care research and translate discoveries into practical products, treatments, devices and procedures”.

The University of Bristol is planning to investigate patients with infected joints in this clinical trial, which will be comparing one-stage with two-stage revision for the hip. As well as infection eradication, one of the key things the trial will be looking to understand is how the patients feel afterwards; both in terms of physical elements such as pain, mobility, dexterity and joint stiffness; and also emotional elements such as how they feel in themselves.

The surgical approach taken in each case will also be reviewed, to understand if there are any differences in terms of how expensive the different approaches are versus their outcomes, and also the level of complications experienced with each approach.

The final element is an open dialogue with both patients and surgeons. How did they feel the process went? Was it a positive or negative overall experience? What could have made the process better? How are they left feeling afterwards?

This is a very important study, as we have very little prospective data in this area. We will look forward to the results to see if there are any changes that can be made to our approach to this problem to treat the infection successfully and in particular improve the overall patient experience.

Joint replacement specialist Mr Simon Bridle is highly experienced in treating patients that have experienced PJI. Alongside his colleague, Mr Philip Mitchell, and their outstanding medical team, they often are referred patients that have experienced an infection after a hip and knee replacement and require management and revision surgery to produce the best possible outcome. To arrange a consultation with Mr Simon Bridle, call 020 8947 9524.

Eamonn Holmes double joint replacementIf you’re considering having your knee or hip replaced it’s a really big decision. Questions such as how much pain to expect, how long will it take to recover, what complications might there be, are all things that would need to be explored thoroughly before you make the decision to commit to the operation. But what about people who are recommended to have BOTH joints replaced at the same time?

It’s always helpful when someone in the public eye chooses to have the same operation you’re considering, as you’ll get the chance to hear firsthand how another person has approached the decision-making process and how they have found the overall experience.

It has been reported that Eamonn Holmes recently had a double hip replacement, and although he was anxious in the lead-up the operation, he is an advocate of the approach. Living with a joint that needs replacing can yield a whole host of problems; in Eamonn Holmes’ case his hip problems were affecting many other parts of his body too: “people think hip problems mean hip pain but it can also mean knee, ankle, foot, back, neck, shoulder and head pain. I had all those and more.” Having both hips replaced has given him a new lease of life – greater mobility, less pain in other areas and a more positive outlook on his health. Recovery may have been challenging at times – but definitely worth it.

Why would people choose to have both joints operated on simultaneously?

It’s a matter of personal choice. Some would prefer to have one joint fixed, recover fully from that and then fix the second once you’ve healed from the first. Others would prefer to have everything done in a single time period. Admittedly, in the short term it will be harder to have both done at the same time, but in the longer term, it is just one period of rehabilitation.

Eamonn Holmes is quoted as giving his reasons for having both done at the same time as he wanted to get it all over and done with in one go: “I couldn’t have faced all the pain and disruption of major surgery to then have it happening all over again a few months later.”

Who is suitable for a double joint replacement?

Given the added strain on your body of having two joints replaced, rather than just one, there are certain requirements that patients must meet to be considered suitable. Double joint replacements are not recommended for people over the age of 75, for example, and as a rule of thumb, “patients must be in excellent physical condition, aside from the arthritis, and have no underlying health problems.”

Positive approach to rehabilitation

You might think that if you have both knees or both hips replaced you should expect a lengthy period of bed rest – think again. You will start to get out of bed with the physiotherapists the day after the operation and you will be encouraged to begin physical rehabilitation very quickly. The sooner you begin working your new joints and encouraging the muscles to work again, the faster you’ll begin to heal and your new joints will begin working in tandem with the rest of your body.

If you need both hips or both knees replaced then the most sensible starting point is to draw up a list of pros and cons of having both done together or staggering them. You’ll soon be able to identify which option looks best for you, but if you’re in any doubt, don’t make the decision alone. Your GP or surgeon will be able to help outline fully the benefits versus the risks so that you can make an informed decision, ideally with the help of family and/or friends who will be supporting you through whichever option you choose.

Get in Touch


Fortius Enquiries Line:
020 3195 2442

PA to Mr Bridle: Adriana Espinel-Prada
T: 07765 190703
E: bridle@fortiusclinic.com

Fortius Joint Replacement Centre
Spire St Anthony’s
801 London Road, North Cheam, Sutton, SM3 9DW

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