Stem cells are not a cure for osteoarthritis of the hip, and their use is very limited at the moment.

A worrying report from Canada recently stated that:

‘Premature enthusiasm and protocols that are not fully vetted are dangerous and result in negative publicity for the field of stem cell research, and more importantly, may result in disastrous outcomes with no benefit to the patient. Although there is promise, a large gap still exists between scientific knowledge and clinical translation for safe and effective stem cell-based therapies.’

These new forms of treatment must be regarded as ‘work in progress’.

‘As fears over these issues grow, sales of resurfacing implants in Britain have fallen. Surgeons say patients with pain-free resurfaced hips should have no cause for concern, but younger women are being counselled against it because surgeons have no way of predicting those who will be affected. However, the surgery remains an option for younger, robust men who appear to fare best with it. Kevin Jervis, 49, a police sergeant from Norwich, was a perfect candidate. He lived in continual pain so intense he couldn’t put on his own shoes, so had both hips resurfaced in 2003.  He has since gone on to achieve the highest Tae Kwon Do ranking, and says hip resurfacing has given him back his life.

Jeremy Latham, consultant orthopaedic surgeon at Southampton General Hospital, says: ‘Some orthopaedic surgeons who do a lot of hip surgery have some concerns about resurfacing. But this needs to be kept in perspective.

‘Hip resurfacing remains a good option for the right patient. I think we need carefully to screen and select patients so we can tailor the best procedure for every patient.’

The New York Times article is mainly concerned with an implant called the ASR.  I have never used this device, and it is no longer being sold.

There are some concerns about soft tissue reactions to metal ions, but the vast majority of patients who have had a resurfacing are very happy with the outcome and can look forward to many years of pain relief and excellent function. If you have had a hip resurfacing and are experiencing problems such as pain, or it doesn’t ‘feel right’, you should speak to your surgeon and ask for advice.

‘INFORMATION ABOUT REFERRING PATIENTS IN THE PRIVATE SECTOR
To All General Practitioners March 2010

Dear Doctor,
You may receive this letter more than once from various consultants and if so please accept our apologies. FIPO represents the profession in the independent sector and we are writing out to General Practitioners about some changes in the way in which certain insurers may deal with their subscribers when you refer them to a specific consultant.
Some insurers are implementing a ‘preferred provider’ strategy and whilst this may only affect a few patients who you refer for a private consultation or treatment you should be aware of the potential implications. It is possible that attempts will be made by the insurer at preauthorisation (when the patient phones the insurer to obtain authorisation to see the consultant you have recommended) to deflect the patient towards certain other consultants even though a specific consultant has been chosen by you, the GP and/or the patient. In some cases, the patient may have been under the care of their consultant for years and is then sent elsewhere. The reasons given for this deflection may vary but often it is stated that the consultant’s fees are too high.
Your patients should be warned to ignore this type of diversion as patients should always be able to obtain a fee estimate before deciding for themselves if they wish to proceed with their first choice of consultant.
Be aware that this is not in any way an attack on any specific insurer nor is it our intention to advise patients to change their insurance company. We are only asking that you warn your patients of this possibility. It applies to all specialties and whilst at the moment only a small number of patients may be affected there is an increasing trend towards this type of American styled “Managed Care”. All professional bodies have made it clear that patients should have the right to see the consultant of their choice and that they should not be diverted for any reason by the insurer. We hope that these types of restrictive networks do not take root because if they do then continuity of care and choice for GPs and patient will be significantly restricted.
In summary, please reinforce this message to your patients when you refer them for private treatment and make sure they insist on seeing the consultant of their choice. More information and also the FIPO Patients’ Charter can be seen on our website (www.fipo.org) and this defines the correct relationship between patient and doctor.
Thank you for your help
From the FIPO Board’

Total procedures:    243

• Resurfacing: 42
• Ceramic hip replacement: 68
• Revisions: 42
• Bilateral hip operations: 17
• Average age: 64 (25-89)
• Male/female: 98/145

• Complications: no dislocations, one pulmonary embolism, one readmission for wound infection

This is a fairly typical year’s activity for me. I will publish more outcome data from previous years in the coming weeks, and hope that you will find this information useful when it comes to choosing which surgeon/operation is the right one for you.

I’m often asked what is my ’standard’ hip replacement, the one that I use for the majortiy of my patients. The answer is that I don’t have one. Choosing the right hip replacement for a patient is as much an art as it is science. One of my old mentors called it the Zen of hip surgery.

For younger active patients I tend to use uncemented stems and cups with a hard bearing such as metal or ceramic. In older patients I use a large double bearing hip replacement which gives an excellent range of motion and dramatically reduces the risk of dislocation. I use whatever is necessary to give my patients what they want – pain relief and restoration of function, whilst minimizing the risk of complications.

Every time I do an operation I set out with the intention that it will be the best one that I have ever done, and seeing happy patients getting on with their lives a few weeks after sugery is hugely rewarding.

If you would like to discuss which hip replacement might be the best one for you, please get in touch.

‘At first he tottered gingerly from edge to edge like a beginner. Then, realizing his new hip was strong and stable, he began carving from side to side in long, elegant turns. Where strength had faded over the years, grace took over. He turned down a bumpy blue run, slipping easily through small moguls.
At the bottom, his hip was feeling so good that he decided to do it again.
And again.
He hopes to ski 15 days in this season.

‘I didn’t think it would be possible for anyone to ski until 100 he said at the end of his third run, but now that’s only four years away, I just might make it.’

A remarkable story. If you want to ski after hip surgery, my advice is to:

• Make sure that you are fit enough before you go

• Choose a time when the slopes will be less crowded (out of the school holidays)

• Avoid difficult runs, moguls and ice

Osteoarthritis is the commonest form of arthritis. It particularly affects the weight-bearing joints of the legs and back, becoming more common with age. Many people take glucosamine sulphate tablets with or without added chondroitin. Cartilage contains substances related to glucosamine and chondroitin and taking supplements of these natural ingredients may nourish damaged cartilage.

The research findings are conflicting, but more evidence is accumulating that some people, at least, will benefit from this therapy. Much of the research has been undertaken on people taking a combined daily dose of 1500 mg of glucosamine and 1200 mg of chondroitin and so this would be a good combination dose to use if you wish to try them. They can also be taken separately if you prefer. Glucosamine should not be taken by people who have an allergy to shellfish, although there is now a vegetarian version that can be substituted. In some people glucosamine can increase the level of sugar in the blood, so if you have diabetes be sure to check your blood sugar and discuss with your doctor if your blood sugars seem to be higher. Also if you are taking warfarin your blood-thinning control (international normalised ratio, or INR) may be affected, so make sure you have your regular blood checks and again discuss this with your doctor. Try glucosamine and chondroitin supplements for 3 months and if your joint pain is much improved you may wish to continue with them.

Researchers at the Hospital for Special Surgery in New York recruited 405 patients, all of whom were about to undergo total hip replacement, which is a common treatment option for people with severe osteoarthritis.

Patients – who had an average age of 66 years at the start of the study – were interviewed before their operation and asked to list their physical and psychological expectations.

They were then re-interviewed approximately four years after their operation and asked whether each of the expectations they had previously listed had been fulfilled.

Nearly half (43 per cent) of the patients said that all of their physical and psychological expectations had been completely fulfilled, while an extra 32 per cent revealed that all of their expectations had been somewhat fulfilled.

Overall, 87 per cent of expectations had been fulfilled and the researchers noticed that high levels of satisfaction tended to be reported by people who were young, employed, had a body mass index (BMI) of less than 35, had not developed a post-operative limp, and who had not experienced any complications.

Writing in the Journal of Bone & Joint Surgery, the study authors concluded: “Our findings may be useful for counselling patients and for providing a framework for using fulfilled expectations as another patient-centred outcome of total hip arthroplasty.”

I first started doing bilateral simultaneous hip procedures about three years ago, and the results have been very good. If both hips are as bad as each other, it makes a lot of sense to have them both sorted out at the same time. It sounds daunting, but it means having only one anaesthetic, one hospital admission and one period of rehabilitation. We have developed an efficient and safe pathway of care which means that most patients are in hospital for about a week, and are usually back to work/normal activities three months after surgery.

Careful patient selection is very important, and not everyone is suitable for the procedure. In this case we usually perform the two operations about 3-6 months apart. A recent meta-analysis looked at the results of 2063 bilateral simultaneous hip replacements and concluded  ‘This procedure was..found to be economically and functionally efficacious when performed by experienced surgeons in specialist centres’.

If you would like to discuss this in more detail, please contact us.

If we used this information in isolation when choosing the right implant for a particular patient, we would probably use something like a cemented Charnley stem and a cemented polyethylene cup. This hip replacement would almost certainly give excellent pain relief for most patients. However if you are under 65, have complex anatomy or want to do anything other than potter about, it might not fit the bill. The plastic socket will wear out in time, causing pain, instability and loosening of the implants. Joint replacement surgeons want to provide their patients with implants that will allow them to work, play some sports and return to as normal a life as possible. In order to this we use materials such as ceramics and chrome/cobalt/molybdenum which are durable and wear resistant. Hip replacements using thes materials haven’t been around for as long as the more traditional systems, and as a result they might at first glance might not appear to be as good as the older hips. However there is ample evidence in the literature to show that ‘conventional’ hip replacements in younger patients are more likely to fail in their lifetime than in older patients. Most of the joint replacement surgeons that I know spend a lot of time trying to work out which operations and implants are best for their patients. We use the information that is available to us to help inform our decisions, but ultimately rely on our training, experience and judgment to the do the best we can, as often as we can. If you want to find out which type of hip replacement might be best for you, speak to an experienced hip surgeon who will help you decide.

If you would like to discuss your hip problem with me, ask your GP for a referral.