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.

Osteoarthritis 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.”

All 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.

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.

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.

The 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.