Hip and Knee Surgery An Overview – Mr Gavin McHugh

Good Evening ladies and gentlemen, Gavin McHugh is my name, I am an orthopaedic surgeon based at the UPMC Sports Surgery Clinic, I also work in Beaumont and Cappagh hospitals as well. I have been invited along this evening to talk about a few problems regarding the hip and knee and hopefully, I can shed some light on these issues, find out simple advice as to what you can do with certain things and we will also have a bit of a chat about what’s involved with going ahead with things like surgery in terms of joint replacements and the recovery process and how to know when and how to go with the problem.

We will start of with the hip and again it’s going to be really quite simple in terms of breaking down the problems that we see and the first problem that I would see, probably about ten times a week is an issue called bursitis off `the hip, so a lot of people think they have arthritis in their hip and they come to me and they point out over the side of almost the buttock area, so its out over right out on the outside and the first thing to say is that hip pain is actually right In the groin area, so often times when people have arthritis in the groin they have arthritis, they think they have a groin strain initially and that’s often that bursitis presents as a pain over the side of the hip so and classically patients come to me and say they’re having trouble sleeping at night, whenever they roll over on to their right side they get a pain out over the outside, generally they don’t have problems with things like moving the hip but going up things like up and down the stairs that involves quite a bit of hip movement can re-create that pain over the outside shall we say off the thigh area as well, sometimes it radiates down to the side of the leg as well, but quite often it’s just a localized pain and you know what straight away clinically is when you over the thigh area, patients generally hop and yell that’s really sore. I say it quite frequently the vast majority of times it can be settled down with some sort of physiotherapy to help strengthen the glutes abductors and posterior chain is generally and quite frequently I’ll also inject it as well and a lot of times GPs will be willing to inject this as well if not sports medicine physicians will often inject it as well. There are plenty of options there in terms of who to go with and who to deal with that. Quite often find it takes a second or even a third injection to knock it for six but generally we’ll be able to get that to settle down without an operation as such.

Straight on to the next problem which is just arthritis in your hip and how do you know when you’re getting arthritis in your hip. I suppose it’s a good question because a lot of the time, arthritis creeps up on people slowly and subtly over years and years and it can start with a little bit of an ache right in the groin area, and sometimes it comes on after say a couple of miles of walk initially, sometimes people notice that they’re having a little bit more trouble getting their shoes and socks on things like that. It’s usually only later in the process that they’ll get a lot of pain at night time and where it’s often waking people from sleep and so as I say it often comes on quite subtly initially. What to do initially, not a lot is the answer, simple allergies just taking paracetamol can often help, anti-inflammatory are usually the most effective painkiller for any musculoskeletal issues in general but obviously, they come with the risk regarding your tummy in terms of potential for ulcers and a small risk of other things like cardiac issues and stuff so, That has to be offset but at the same time you can’t be going around in pain all the time. What I often say to people is if you know you’re going for a long walk or if you know you’re going to be playing a game of tennis or golf or whatever you do, you might just take an anti-inflammatory just before that and quite often people can get through in a couple of years, before moving on to the next level. In terms of physiotherapy for arthritis in your hip, absolutely in terms of strengthening issues but I often find that people who put a lot of into deep stretching to try and improve the movement will frequently exacerbate the problem and I think that’s just where were basically what you’re causing is an actual pinch in the hip itself so part of the arthritis process involves more bone being formed around the ball itself and to try and force that movement as I say frequently just aggravates things rather than improving it. I tend to say to people to work really within their comfort zone in terms of the range and not to push those ends and movements too much.

How do you know it’s time to go ahead with something more substantial? In terms of arthritis and the hip the only real option is a hip replacement, Injections for the odd person can give some temporary relief but in comparison to knee problems, I find it’s often quite short-lived, it is not something that I would recommend a lot. Ultimately for me, all it comes down to is it is time or a joint replacement or not. It’s time for a joint replacement when you have pain daily that is significantly interfering with your day to day activities so if you find that you play golf or you play tennis or something and you’re saying no frequently to this because you know you’re going to end up in pain afterward and you pay that price for the rest of the evening or the following day and you’ve stopped and done well that’s when this time as far as I’m concerned to start to consider something more like a joint replacement. It’s not to say that it is still a significant operation and it’s an operation that comes with risks, why am I then so happy to recommend it? Well we know that patients with moderate symptoms shall we say are the group that ends up benefiting the most following the joint replacement surgery so it’s not the most severe group, the most severe group I often Say t people it’s almost nearly like the ship has already sailed whereas if you got moderate symptoms and you’re still just about clinging on to being able to do all the activities you want but that very easily you can get that back again after the surgery.

In the recovery process after hip replacement, in general, most people are back to see me in about six weeks and most are doing very well at that stage either of crutches completely or just using one walking stick or one crutch but it depends and varies from person to person. Overall by three months the vast majority of people are more or less completely recovered at that stage. In terms of hips, is there anything else? What I often get asked about is people who come with both hips and its something I have moved more and more towards over the years in terms of replacing both hips at the same time a few years ago it sort of came as a real shock to people that this could be done and its now something I would be a strong advocate for. If both hips where one is bad as the other, then as far as I’m concerned as long as your fit it, it’s an absolute no-brainer. You get to recover both at the same time. The risks of surgery that risks of having both hips replaced at the same time are lower than if you had one done followed by one done a few months later and there is evidence to show this.

Then if I just move on then to a few issues with regards to the knee. So first of all just in terms, which we see again all the time is meniscal tears or tears in the cartilage that people will talk about. Quite often patients in their 40s and 50s, they’re out walking or sometimes there getting up from a sleeping position and they feel a relatively sudden onset of pain in the knee usually associated with my swelling in the knee and uncomfortable over a localized area, most common in the inside knuckle of the knee. The vast majority of the time this will settle down with painkillers as we talked about, over time if it’s not settling down then it’s time to get the ball rolling in terms of going to see your GP and potentially getting more organized.

The first I usually do is to inject the knee, injections in the hip don’t often give lasting relief. Injections for cartilage in the knee will often give a few months of relief.  Then moving on overtime the knee shock absorber has been damaged and this over time leads to arthritis. From the arthritis point of view, pretty similar to the hip what goes well things like injections can work well to give you some temporary relief and there are plenty of injection options. In terms of more definitive treatment, you’re moving up into the replacement territory. In terms of replacement, I am a fan of partial knee replacement rather than full knee replacements. A full knee replacement is a significant surgery and day out of searching for what’s involved and the recovery. The recovery is 6 months, it’s certainly 3-4 months until you are back on track. A partial knee replacement, you just replace one knuckle on the knee, it’s a much smaller implant, and up to 50% are suitable for partial knee replacement, where the pain is localized to one area. It’s a smaller operation, smaller implant, and a lower risk of clots and injections, heart attacks, and DMTs. Reduced risks of almost a 1/3 in comparison to full knee replacements. It feels more like your old knee compared to a full knee replacement you can feel the replacement. They last almost as full as full knee replacement, almost as the remaining part of the knee can deteriorate over time but it’s only 2% over ten years.

In terms of what’s involved in the recovery, from the knee and hip, well here at the UPMC Sports Surgery Clinic you’re talking a 2-3 night stay after your surgery. When do you go home after a joint replacement? Well, you go home when your pain is controlled and you are safe and mobile. If that’s the following day perfect, if it’s 2-3 days later then that’s fine as well, everyone has their own pace. The partial knee is usually the day after or two. You give crutches when your here and you wean yourself off after a few weeks, some people that are 6 weeks other 2-3 weeks, you can do this by increasing your mobility around the house and then venturing yourself out. You are much better at taking your time instead of limping around. In terms of the recovery in general, Hips tend to find it easier, knees find it every bit as hard as they were expecting even more so. Quite frequently than with the last one that leads me to the point of both knees at the same time.

It’s something I do quite often. I have a very low threshold of doing both partial knees at the same, for both full knees and total knee replacement is a significant undertaking for people, but I would describe it as really grabbing the bull by the horn in terms of this is someone who rents to get themselves sorted and get recovered again. I always ask everyone that has both knees replaced was it easy, they say no it was horrendous, Then I ask do they regret having them both done at the same time and they say not as I wouldn’t have come back for the second one. With that sort of semi not so pleasant thought, they do end up coming back but another couple of years later when they have deteriorated, even more, it’s the reason I have come more around to it in fixing the problem as quickly as we can to get people back and the sooner we get people back fit and active, the better it is in so many ways in their overall health and the pain relief they get. If you are struggling every day it is time to get something done about it. Get it fixed back on track because there is no sense in sliding down that slope as such in terms of deteriorating further and further. I hope I raised a few issues today and I hope you found it interesting. Thank you so much for listening today.

It isn’t ideal to go ahead with a joint replacement in your 40’s or even 30’s or 20’s if necessary, but occasionally that is the case we find ourselves in but it just really just comes down to weighing up the potential benefits and the relief what you are potentially setting someone up for in the future all right.

If someone is in their early 40’s are they looking at having a joint replacement revised again in their 60’s or late 70’s. If you are in your 50’s there is a 30% chance roughly that you are going to end up having a revision done at some stage in your lifetime. In your 40’s that may rise to a 50 / 50 chance of having it done again. If you’re in your 30’s you almost certainly going to end up having something again. It just weighs down and boils down to sort of weighing that up with the potential benefits and how bad someone is. If someone is experiencing night pain and it is waking you up every night from sleep multiple times and it is holding you back from the things that you like to do day to day then potentially then you’re shifting towards having something done about it.

I would look at a joint replacement as in general an opportunity to get back doing things and the only sort of reservation that I would place on a hip replacement or even a knee replacement to a lesser extent is not going back for significant road runs and by that I mean it’s fine if you’re in the gym doing a kilometre warm-up or something on a treadmill but if you’re someone that loves going out for 3-10 mile runs per week then you know I would say pick up, cycling something like that.

Aside from that I mean I’m happy for people to go back playing tennis, I’m happy for people to go back playing indoor soccer, I’m happy for them to go back riding a motorbike absolutely and playing with the kids, that’s the whole point of getting a joint that you are able to do that after. In general, the answer is yes rather than no to activities like that for me.

It depends on what you define by out of action. The rehab starts that day quite often and you’re up to taking a few steps the day of the surgery by the time you’re going home which is 2-3 days later, you’re independently mobile right and I’ll often encourage people to get off crutches around the house one to weeks, not everyone is able to do that for a lot of people they might still require even one crutch at six weeks, they might still be using two crutches for 4-5 weeks when out and about.

As a guide it really depends, you’re not going to be lifting big lumps of children around the place, you could be talking around 4 weeks. People going back to office work, a couple of weeks is quite possible if you are self-employed but don’t make the mistake of selling yourself short. The most important thing is your own recovery, you have to say I’m going to be out of action for 6-8 weeks pending review and get it right as this is the most important thing.

It’s not essential by any means but you do certainly see some knees in particularly if people have been quite reliant on anti-inflammatories for a good period of time before surgery, I think they almost need to wean themselves of them and if they get a little bit of rebound inflammation, so yeah not frequently you’ll get someone who might need to take one every other day for a period of time but it’s just modulated by the swelling and in the joint, if it feels good then absolutely not, but if it is a bit inflamed then potentially yes.

Yes is the answer to that but actually, quite marginally so, the way I explain that to people is that you’re leaving 2/3 of the knee behind, so obviously there’s a chance that can deteriorate. If you look at the UK joint registry the figures for the 10-year survival for a total knee, an average for a total knee is 96 percent, for a partial knee which is the zookas that is the phrase that I use but I just have to compare it with something it’s 94 percent. So a 2 percent difference for keeping 2/3 of your knee. I’d often say to people even if that figure was 10 percent, I would take it tonight because the benefits more than outweigh those risks. Marginal but yes is the answer.