Professor Joe Queally is a Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic in Santry Dublin who specialises in the hip and knee.
Good evening, everyone. Joe Queally here, one of the Orthopaedic Consultants at the UPMC Sports Surgery Clinic. I’m also an associate professor at Trinity College Dublin.
My talk this evening is five common questions that patients ask me about hip replacements. The idea is that I will try and give you answers based on the most recent evidence and scientific literature that’s available.
Asking questions about hip replacements, in general – it’s important to ask your surgeon whoever he or she may be as to how successful it is. And these are questions that would include how long would it last? What type of hip replacement is being used? Questions that are particularly relevant to your personal situation – what do you want to be able to do after the hip replacement? Also, to take into account what medical problems you might have, such as having diabetes or being overweight, how this might affect your hip replacement, and what you can do to help optimize and make sure that you have the best outcome possible.
It is good to have answers that are based on the most up to date, available evidence as possible, because in medicine facts and evidence, change all the time and it’s important to have the most accurate and up to date information when you’re when you’re making a decision about going ahead with a total hip replacement.
Before we get into these questions I’m just going to, in a very simple way, discuss how we measure success after a total hip replacement.
There are two basic ways that we measure success: the first we look at is implant survivorship – by that I mean is, how long does the joint replacement last. That’s really important because you want your hip replacement to last for as long as possible.
The second question that we look at is how well does your hip replacement work. So we want it to last really long, and we want it to work really well. In terms of how well it works, we’re interested in, particularly how quickly patients can get back to function – to walking into doing things that they would like to do.
We’re also interested in seeing how long this good function lasts. We would hope that your input, along with lasting a long time, would also work very well for a long time. When we’re deciding what type of hip replacement to use and how to put it in. These are the two basic questions that we look at.
How do we gather evidence on hip replacements?
There are a few basic ways that we can gather evidence. The first is that surgeons record how well their patients did. They publish their work in an academic paper and a simple example of this is a surgeon might say I did 50 hip replacements – I asked him questions about how well they’re recovered and I found that they could all walk without crutches, by eight weeks after their surgery.
This generally limits the amount of patients to relatively smaller numbers.
The second way that we can try and figure out which is the best type of hip replacement, or the best type of technique is we can compare two different treatments.
So, a surgeon can set up a study where he does, or she does 25 replacements using one technique, and then does 25 hip replacements, compared to a different technique, and they can say that the ‘x’ technique resulted in a better hip replacement, because it lasted for 10 years longer than the ‘y’ hip replacement.
The third way we have of looking at how well joint replacements do in general and this is becoming more common, is that in most countries all surgeons have to report on how well their patients did to a national body, so you have to submit data, saying what type of hip replacement that you have done, and the data is subsequently gathered on how long your hip replacements last, and how well they work.
This is a really powerful tool, because it gathers information on hundreds of thousands of hip replacements, over prolonged periods of time and it gives really good evidence on which replacements work best and as care and techniques evolve, which techniques are better than others.
So that’s just a backdrop for how we figure out how joint replacements work well.
When I’m answering the five most common questions, this is the type of evidence studies that I will be discussing.
So the first question and the most obvious question is what is a hip replacement?
A hip replacement is where somebody’s hip joint, which is this circle here, is removed in its entirety, due to a problem with it. and an implant which we can see here on the right is put in its place.
The implant mimics your natural hip and that it’s a ball and socket type of implant. So the socket part here goes into the pelvis and into the thigh bone here, there is a stem with a bald part attached. The actual joint then is this ball and socket baring here, which the idea is that it mimics your own native hip joint.
So when do we do it?
The most common reason for doing hip replacement is for arthritis of the hip.
What is arthritis?
So a normal hip joint, as we can see here on the left, the ball and socket part of the joint is lined with cartilage which is a very smooth structure that allows your joints to move like a bearing and it allows it to move in a smooth and friction-free way.
What happens with arthritis is that this cartilage lining gets worn out, or gets destroyed for a variety of different reasons.
Because of that, your hip joint is no longer able to move in a smooth and pain-free way.
What happens after a while is that bone starts to grind on bone. This causes severe hip pain and consequent reduced ability to walk or to do things like, play golf, gardening, or hiking.
So really osteoarthritis is damaged cartilage around the lining of both the ball and the socket part of the hip joint.
This is an example here on an X-ray of a normal hip, over here on the left side. We can see space between the ball and socket part of the hip joint.
This is where the cartilage sits, which I’ve just mentioned earlier. When we look at the right here there’s no space between the bones. This is because the cartilage has been damaged or worn away. What’s happening here on the right side is that bone is grinding on bone.
It’s a bit like a rusty hinge – it doesn’t move in a smooth manner, it causes pain, because of that patients can’t walk properly, and they can’t do activities, such as, as I said, such as such as playing golf or even dressing themselves, or even getting in and out of a car can be difficult.
This is a patient who has had arthritis in both hips. He’s had both hips replaced as we can see here.
So the second question that I get asked quite commonly is how long would my hip replacement last?
Again this is a really important question because we want hip replacements to last for as long as possible. Because sometimes we need to do hip replacements a second time around, and that’s called a revision hip replacement.
Revision hip replacements are a harder operation both for patients to recover from and also for the surgeon to carry out. They are best avoided for as long as possible.
That’s why we tend to avoid doing hip replacements in younger patients because we want to avoid having to do a second hip replacement, and some patients they need three and four and in very rare cases even up to five hip replacements over a prolonged period.
How long can we say that hip replacements last in general?
This is a paper published in 2019 in The Lancet, which is one of the leading medical journals – the author’s looked at a huge number of hip replacements that were reported in the scientific literature – so they looked at all surgeons who reported how other hip replacements were doing, and they also looked at joint registries in countries such as the UK, New Zealand, Australia and the Scandinavian countries, who have been recording all hip replacements that are done in their countries and how long they last.
They added all the hips together to try and come up with a figure of how long does the average hip replacement last for.
The number of hips that they included in the study was 228,888 hips, which is a huge number. This is really good because the more numbers in a study, the more accurate the data is.
So what did they find?
|They found that 85% of patients can expect for hip replacements last 15 years, 75% of patients can expect for hip replacements last 20 years, and 58% of patients can expect her hip replacements to last 25 years.|
So roughly over half of patients who have a hip replacement can expect it to last 25 years which is a good outcome – this says these figures have slowly improved over the past 30 to 40 years.
Obviously the other side to this is 40% of patients, their hip replacement won’t last 25 years, and these patients often need to have their hip replacement done a second time, which is called a revision hip replacement.
The average age at which patients in the study have a hip replacement is 67. The majority were women at 55%, and the vast majority of hip replacements were carried out for osteoarthritis.
Other causes for hip replacements apart from arthritis, will be for patients who have damaged their hip really badly after an accident who have a really bad hip fracture, patients who have had infections in their hip which is unusual but sometimes happens, or patients who have had childhood hip disease – who have had an issue with their hips since birth, where their hips haven’t quite formed properly.
Another question I get asked all the time in my clinic is which surgical approach is best?
By which surgical approach I mean is – what is the best way to put in a hip replacement, and the best way to get in and around the muscles to put the replacement in?
There is three basic ways to do this:
One is the anterior approach – this is where the hip replacement is put in from the front of your hip. There is what’s called the anterolateral approach, where the hip replacement is put in from the side. And then there is the posterior approach, where the hip replacement is put in from the back of your hip, and they are the three main ways that we put hip replacements in at the minute. Patients often ask which is which of these three is the best way to do it?
The posterior approach, which is the approach that I use, is the most commonly used and this is where the hip replacement is put in via dissection through the muscles of the back of the hip. This is a good approach because it gives you a very good view of the hip joint itself and it allows the hip replacement to be put in a really good position. There’s a theoretical disadvantage that there might be a higher risk of dislocation.
The second approach is anterolateral – this is where the hip is put in from the side. This involves going through muscles at the side of the hip, and the potential disadvantage of this is that there may be a slight risk of limp after this approach, due to disrupting the muscles at the side of your hip
The third approach is the anterior approach which is a newer approach, where the hip replacement is put in from the front of the hip.
Muscle sparing means that instead of cutting through muscles, the hip replacement is put in between muscles.
The assumed advantage of this is that you may get back quicker to doing activities such as walking. The disadvantage of this is that there might be a slight increased risk of problems afterwards, such as fracture when putting the hip replacement in, or injuring nerves at the front of your hip.
Obviously, for surgeons and for patients, we all want to know which of these three approaches is the best and which one should I have for my particular situation.
The answer needs to be found in the evidence and what studies show to be the difference between the three approaches.
I just picked one very recent paper which was published in June last year, which has come from Boston and Copenhagen. These surgeons looked at 93 patients in two different groups.
In one patient they use the anterior approach and in the 2nd 93 patients to use the posterior approach.
What they looked at was how well do the hip replacements function from six weeks, up to to five years. They are wondering which approach – the anterior approach from the front or the posterior approach from the back, results in the best hip function from very early on to, to the five year mark.
They found that both approaches resulted in a significant improvement in function by asking patients questions such as, how far can you walk? What activities of daily living can you do? They found that there was no difference between the two approaches in scores at six weeks, one year or five year.
They found for hip function it doesn’t really matter which approach is used. There is no difference.
The next paper I’m going to look at is, as I mentioned at the beginning, is how long does a hip replacement last when it’s done via the anterior, from the front, from the side or from the back?
This is a study from one of the Scandinavian registries, and they looked at over 20,000 patients that had each of these three approaches either again from the front, from the side, or from the back. They looked at the implant survival as two and five years.
They found no difference between the approaches in terms of survivorship (98% at five years). They concluded that how long a hip replacement lasts is not linked to which approach is used.
So in terms of which approach to recommend to patients: The scientific evidence does not show benefit of one approach over another, in terms of how long the implant lasts, how well it works, or how quick the patients have returned to walking.
So even though I use the posterior approach, because it’s the approach that I have been trained in but I can’t say that that’s any better than the other two approaches, and vice versa.
So, moving on to question number four, this is ‘what about hip resurfacing instead of hip replacement?’
So what is hip resurfacing? It is a form of hip replacement where instead of taking you out to hold the hip joint as we see here on the right -much of the hip joint, particularly the ball part of the hip joint is retained, and the metal cap is put on the top of the ball part.
So what it means is that just less of your hip joint removed and the potential advantages to this are that it kind of preserves more of your natural hip joint. So in theory could result, potentially in better hip movements and better hip function. It’s also less likely to dislocate and this is due to the size of the cap that is put on the top of the ball part.
The big problem with this metal cap was that the baring that was being used was metal on metal and this led to big problems with metal ions.
Most hip replacements have a metal on plastic baring or ceramic on plastic bearing which we’ll see in a minute. But this resurfacing type of hip replacement has to use a metal on metal bearing. As a lot of people are probably aware, this caused major problems with early failure of a lot of patients who had hip resurfacing.
This was due to a problem called metallosis. Here on the left we see what a standard hip replacement bearing is like, whether it’s a metal head and a plastic liner in the socket. With resurfacing, there is a metal cap and a metal liner in the socket.
This resulted in the production of metal debris or wear in the hip joint, and this is demonstrated here in this black material, and it resulted in early failure of hip replacements, but up to 25% of hip replacements failing at the five-year mark, when this should be 6%.
This resulted in a product recall, where all these procedures were stopped, and all the previous resurfacing had to be investigated and some of them had to be replaced and because that hip resurfacing essentially died out and become a procedure that was no longer performed.
Until, 2019, when Andy Murray, a tennis player famously had a Birmingham, which is a type of hip resurfacing procedure, carried out.
It has started to reappear in a very small subgroup or selection of patients. There is an argument that there may be a role again now for resurfacing in some patients, there may be better implants where this metal wear is less likely to happen, and it may be better for younger patients who are young and active and want to continue to have a very active sporting life in particular.
So again, the rules are the same, we have to look at what is the evidence say as to whether hip resurfacing is a good idea or not.
In terms of how long they last – they last about 94% for 10 years which is similar to a total hip replacement, and what about how well they work this is a paper published in the BMJ which is another major medical journal.
In 2018, they looked at 60 patients who had hip resurfacing and 62 patients who had a standard total hip replacement. They found no difference in function at any stage, from six weeks to five years.
So where are we with hip resurfacing in 2020?
Is there a role for younger patients who are active, maybe patients who are aged 30 to 50? Is there improved implant technology where this metal wear effect is less?
I would say for most patients, there is no evidence to support this currently.
Hip resurfacing is generally to be avoided due to potential serious complications, as there’s no evidence at this current moment in time that these patients do any better than total hip replacement, in terms of how long it lasts, or how well it works.
So question number five is should I have a hip replacement if I am overweight or what does being overweight mean for me in terms of my hip replacement?
This is a study again another big study published in 2020. It looks at how being overweight affect having your hip replacement.
They divided patients up into three different groups based on their body mass index which is a measure of how overweight or obese you are based on your weight and your height.
For patients with a BMI less than 30 were considered non-obese – greater than 30 they were considered obese and a BMI greater than 40 they were considered morbidly obese.
This study is a great study because it looked at over 2 million patients, and looked at their outcomes after having a total hip replacement.
They found that being overweight and having hip replacement resulted in a slightly increased risk of complications or problems after your hip replacements.
These figures here represent how many times more likely you are to have a problem – so for infection, which can be a big problem in hip replacement surgery or any joint replacement surgery, if you were obese to the point your BMI is over 30 – you’re 2.7 times more likely to have a problem with infection afterwards. If you are morbidly obese, where the BMI is greater than 40 that rises to 3.69 times more likely to have a problem with infection.
In real terms, this changes maybe from about .5% to 1.5 or 2% of patients who have a hip replacement, but it is a significant number, and it is something that patients need to be aware of.
There is also slightly higher increased risk of dislocation and the need for having to have a second hip replacement.
So what does it mean being overweight and being significantly overweight does increase your risk of complication after total hip replacement. I don’t think it means that you can’t have a hip replacement, but it means for patients who are who are significantly overweight should consider a trial of weight loss or weight reduction to try and reduce and minimise the risk of having a problem after your hip replacement prior to having it.
It is important that patients are aware of the risks and that you are given an opportunity and help to lose weight, and to drop your BMI before surgery.
Just to summarize the talk, hip replacement involves replacing your hip joint with an implant to restore pain-free movement back into your hip and with that comes an improvement in your quality of life.
In terms of how long hip replacements last? Over half of patients can expect your hip replacement to last 25 years.
In terms of how hip replacements are put in? there’s no evidence to support one approach over the other at this moment in time.
For hip resurfacing, there is no role or minimal role for hip resurfacing at this current time, and being overweight increases the risk of complications slightly, and it’s best to try and reduce your weight prior to surgery.
Fiona Roche (FR) Business Development Manager at SSC put some of the audience’s questions to Professor Joe Queally (JQ).
FR: The first question is from Teresa and she’s asked: She’s got a hip impingement with severe cartilage damage, mobility is very restricted, high pain intensity – she’s only 56. Is a total hip replacement the best option? She was offered an injection but believes this is for short term pain relief, and she’s confused as to why she was offered an injection.
JQ: Given your age impingement is a common enough problem these days, and it can lead to arthritis or degeneration of your hip cartilage.
Really, many impingement patients or patients who want to live without arthritis do need a hip replacement. When you need a hip replacement really is decided by the severity of your symptoms. So when your symptoms are severe to the point where you have constant pain, where you can’t walk a reasonable distance or do the activities of daily living that you like to do, such as walking for example or playing golf and you are having difficulty sleeping at night – they are the general criteria for proceeding with a hip replacement.
Often we try and delay a hip replacement for patients who have lesser symptoms and a hip steroid injection is something that can be useful.
The reason for that is the average life span of a hip replacement for about 60% of patients now is about 20 years.
You may need a second hip replacement after that, and a steroid injection is used for patients with lesser symptoms, to try and delay a hip replacement. But there will come a time I’m sure when you may well need a hip replacement, and if the steroid injection doesn’t have much effect or starts to wear off, then that is generally the indicators that it’s time for a hip replacement.
FR: Thanks, Joe. Barry’s another one who says: he was told he needed a hip replacement 10 years ago, but he was too young. Is hip resurfacing or hip replacement with younger patients, and can minimally invasive hip surgery be performed on any patient?
He can function normally day to day and work with paracetamol but he’s edging closer to having surgery.
JQ: Yes again that just kind of feeds on to the previous answer. Really we do try to avoid if possible, hip replacements in younger patients, due to the lifespan of an average hip replacement.
It’s worth again pointing out that a revision hip replacement is a much more complex procedure for both us and for patients, in terms of recovery afterwards. The amount of function you have after revision total hip replacement tends to be less than your original hip replacement.
So I think if you have a reasonable level of function and you’re managing with paracetamol – again, you probably don’t hit those triggers or criteria that we have for proceeding with the hip replacement, and I am sure it will come with time.
Having hip replacements is like a lot of things it’s about getting the timing right. It’s the wrong thing to do to have it too early and it’s also a bad thing to have it too late. From a patient’s perspective, it’s about getting the timing right so that your symptoms haven’t progressed too severe.
You have reasonable hip flexibility so that you can recover after your hip replacement afterwards. But again, as I said, it’s important to avoid having you too early, so that you avoid having to have a revision hip replacement if at all possible.
FR: Thanks. Jeanette asked a very practical question there: could she still go horse riding after a hip replacement?
JQ: Yes, that’s a great question. I guess the best answer to that is maybe. There’s no reason why you can’t go horse riding. It depends on factors such as what your hip flexibility is like after your hip replacement, and that in turn will depend on your hip flexibility before your hip replacement.
So some patients have really stiff, hips before surgery due to arthritis. Whilst a hip replacement will bring back some flexibility in your hip, and may not bring back enough flexibility for horse riding and for getting on a horse and using a saddle.
You can certainly use aids to get onto the horse, like a stamp box. But spreading your knee’s on the saddle is the difficult part, it certainly is possible but you know, it depends on what your flexibility of muscles is like after your hip replacement.
I would say I have a written a recent article that you can access on my website for anybody who’s asked questions about what can you do when after a hip replacement? My website is www.joequealy.com.
On the news section, there is an article that goes through most sports – it’s based on a recent paper published in one of the leading national hip journals, and when it’s safe to go back to activities such as golf, cycling, even tennis, running and horse riding.
For horse riding, it’s generally at the six-month mark, if you have enough flexibility and range of movement after your surgery.
FR: That leads to Vivian’s question which is how soon, could you play golf after hip replacements?
JQ: Yeah again so golf, you can generally get back to Golf a little earlier. So generally I will say at the 12-week mark – some patients can get back a little earlier than that and again, your return to function after hip surgery – many things influence it, like what your flexibility is like after your hip replacement, which as I said, is influenced by your flexibility beforehand, your overall muscle strength and coordination will decide what type of activities you can do afterwards.
Again this feeds into the point I made there about not leaving it too late to get a hip replacement you know, if you wait until symptoms are very severe, which we sometimes see, then it’s hard to get good hip flexibility afterwards even with a hip replacement, that can limit your ability to return to any kind of higher functioning activity such as golf and so on.
FR: Mary asks: Which is the most common anaesthetic for a hip replacement general or epidural, and what are the advantages and disadvantages of both?
JQ: The most common anaesthetic by far is a spinal or epidural anaesthetic, which I would say in my practice is carried out for probably 96% of patients. This is really because it is the safest form of anesthesia for the majority of patients.
So the benefits to it are that it’s safer, as it protects your heart and lungs from having a general anaesthetic. It also allows you to recover a bit quicker afterwards.
Most of our hip replacement programs are now enhanced recovery, or fast-tracked hip replacement, where we aim to get people or patients walking, ideally within four to six hours of other hip replacements – so the same day of surgery typically in the afternoon.
We can do this because we use spinal or epidural anaesthesia that wears off. It is designed to wear off quickly. It’s designed to get patients walking and mobilizing as soon as possible which will speed up and enhance your recovery in general.
FR: After full hip replacement can you expect to get back to full rotation of the hip, for example getting the hip up to a 120-degree angle, I’m 60 have a full replacement after a fall seven months ago, and she runs and swims as well.
JQ: Again, this comes down to your range of movement of your hip is a function of two things really – one is your flexibility and the second is your muscle strength around your hip, and how much range of movement you have after your hip replacement is dependent to some degree on how flexible your hip was beforehand, as I’ve mentioned.
So if you’ve had good flexibility before your hip replacement, good muscle strength, and you’re quite active as you seem to be, then I would expect a good range of movement afterwards, whether you get up to 120 degrees of hip flexion, that’s hard to guarantee.
They certainly would expect a good enough range of movement to do you know most things such as cycling and swimming, and even playing tennis is possible, again after about six months after a hip replacement.
FR: Okay, that’s good and I’m just looking there was a question from Roisin White: she did have a hip replacement in 2013, and she’s had pain since then and she’s been told it’s been bursitis. She just wondered would it improve? because she does need the other hip done as well so she’s probably a bit nervous about that.
JQ: Yeah, so pain after a hip replacement does happen sometimes. The satisfaction rate from the scientific literature after a hip replacement is about somewhere between 90 to 95%.
So for most patients – it is probably the most successful operation of all time really, in terms of satisfaction after surgery, but the corollary of that is there is 5% of patients who have problems or difficulties. That is due to a variety of different reasons.
One of the more common causes of pain after hip replacement is bursitis on the outside of your hip, and it often causes pain on the outside of your hip. This is generally treatable with, generally with anti-inflammatories and physiotherapy to stretch the hip abductor muscles in that area in your hip – sometimes for your hip, a steroid injection into the bursa is required.
So in general for most patients, bursitis is generally treatable, but there are some patients who do have ongoing difficulties, I have to say. Does it mean that it would happen if you had another hip replacement? I would say not necessarily, but again, it would be hard to guarantee that it wouldn’t happen. But yes that’s bursitis after hip replacement.
FR: Someone asked: if you delayed a hip replacement will your muscles waste?
JQ: So it’s a good question, and again, it’s, you know, as I said, timing and hip replacement – it’s about getting the timing right really.
Those general triggers that I mentioned about having constant pain, pain at night time, and the inability to walk a reasonable distance. They’re generally the triggers that we use to proceed with the hip replacement.
Some patients may you know, for whatever reason, may have those symptoms for many years. And maybe avoiding surgery or they may not be aware of surgery or they may not be aware of the diagnosis, and often they’ve very stiff hips and recovery afterwards is not as good as if they had more flexible hips, before surgery.
So certainly about getting the timing right – not waiting too long with severe symptoms, to try and optimize and get the best possible outcome after your hip replacement, as I said though, going too early is also a bad idea. It’s about getting the timing right but for most patients that I meet, most patients do generally have a good sense of the right timing for their hip replacement.
FR: When you’re talking about the markers, she has just said: is limited movement, such as being unable to put on your socks and shoes – would that be an indication?
JQ: It would yes. Again it all depends on what your needs are really so and your age and your activities.
So, the classic difficulties that patients have, and again, that’s due to stiffness, is that they can’t walk a reasonable distance. They’ve difficulty putting on socks and shoes because their hips are stiff and they can’t bend or flex it. They have difficulties getting in and out of cars, again, because you can’t bend their hip properly are even using public transport.
When you start to hit those triggers, then it’s generally time to start at least have a discussion with somebody about is it time to go ahead with the hip replacement.