‘What is Hip Arthritis?’
Mr Paul Magill

My name is Paul Magill I’m a consultant orthopaedic surgeon working in UPMC Sports Surgery Clinic in Santry.  I specialize in hip replacements and knee replacements and this evening I’ll be discussing ‘Hip Arthritis’.

Pauline was a previous patient of mine and I went on a journey with Pauline through her hip arthritis Journey. So, Pauline came to see me early in her diagnosis and we went through a certain period of managing her problem without surgery and then it came a point where she could no longer manage, so Pauline decided to go ahead and have hip replacement she was petrified but thankfully the procedure went well and she made a great recovery and for her this whole journey was so momentous that she decided to celebrate it by renting out her local Social Club inviting all of her friends for her new hip party. It just illustrates nicely that hip arthritis is a journey and I suppose that’s the theme of this talk. I’m going to bring you through the different steps of that journey and I hope by doing so I will answer the most commonly asked questions that I get in the clinic.

So, starting with what is hip arthritis and how do I know I have hip arthritis is there anything that I can do to stop it or reverse it or if I ignore it am I doing more harm. We can talk about injections and we can talk about the optimum time to get a hip replacement, we can then talk about with the different types and the different nuances of hip replacements and then finally, recovery what does recovery entail? Can I play sports and why am I not recovering at the same speed as the person down the road?

To begin with what is hip arthritis? Hip arthritis simply means that the shock absorber in your hip is worn away. This is an x-ray of a patient who has hip arthritis on one side and a healthy hip on the other side, as we are looking at the screen on our right-hand side is their healthy hip, so the hip is a ball and socket joint so that’s the ball formed by the femoral head and that’s the socket which is formed by the acetabulum which is part of the pelvic bone and you can see that there’s a gap between that ball and socket, that gap is a positive finding, that gap is filled with cartilage which is your shock absorber. In comparison as we look at the screen on our left the patient’s right hip there’s the ball there’s the socket and you can see in this case there’s no gap between the ball and the socket so this patient’s hip cartilage is completely eroded away on their right-hand side, so they have bone touching bone so that is arthritis there are lots of causes for arthritis. It could be a childhood injury, it could be a previous infection, it could be a road traffic accident, it could be a disease such as rheumatoid or psoriasis or gout, but more often than not we label it as osteoarthritis and osteoarthritis simply means we don’t really know what’s caused it and more than likely it’s a genetic predisposition. In any case when it reaches this stage when it reaches bone touching bone, there’s no surgery that I can do to reopen that space, there’s no injection that I can put in there to reopen that space and unfortunately there’s no supplement that you as the patient can take to reopen that space. When the cartilage is gone it’s gone and the bone on bone contact will remain until we do hip replacement.

How do you know if you have hip arthritis? So, the two most common symptoms are pain and stiffness but these can be very variable so if you have any concerns at all the best thing you can do is see an orthopaedic surgeon and the diagnosis of hip arthritis is usually very quick and easy with an x-ray and an examination. The most common description of pain is groin pain but it can be thigh, it can be lower back, it could be knee. The most common description of stiffness is a difficulty putting on your socks but again it can be very variable so if you have any concerns please come and see one of us.

The first port of call once you have a diagnosis of hip arthritis is to manage it as best you can without surgery. Now I know a lot of you logging on tonight are probably in the middle of that journey already and many patients come to see me already halfway along that journey where they have been managing their arthritis for many years without any intervention the key to managing arthritis is to remain active. I appreciate this is difficult how can you remain active if you have a sore hip but the key is to identify activities that you can tolerate or that your hip can tolerate and do plenty of those and to identify the activities that you cannot tolerate or your hip gets really angry after and to avoid those activities. For example, if you’re a runner it might be time to cut back on the running and take up more cycling, if you’re a farmer and you got a really busy life maybe try and cut down your work and get some help on the farm and somebody else to take up the slack a little bit, simple things like that can get a few more years out of your hip. In conjunction with that is weight loss again easier said than done I appreciate that but if you are able to manage weight loss it will reduce a significant amount of burden from your hip. Thirdly and lastly are painkillers, so painkillers are not the answer there’s certainly part of the toolbox but they’re best used intermittently and it’s best if you can stick to the more simple type of painkillers, it’s best if you can avoid if it all possible morphine-based painkillers because after a while they don’t work but painkillers are certainly a useful party of the tool box, especially if they mean you can remain active. If you need to take a painkiller to remain active to get it right for that big long walk by all means take it it’s better to take the painkiller and remain active.

Two very common questions I get at this stage are can I stop it or reverse the process? unfortunately not, there are a lot of supplements out there like glucosamine, hyaluronic acid, turmeric all of these things are good and they do no harm and some people find that they’re great so by all means you should try them but unfortunately there is no evidence if you look at the data objectively there’s no evidence that they will make any difference to your arthritis in the long term. Probably most importantly if I ignore am I doing more harm? The answer to that is categorically no, I can reassure anybody who has hip arthritis the best thing you can do is remain active, it does not benefit from rest. Activity is really important because it maintains the muscle bulk around your hip and if your muscle bulk around your hip is strong it will act in some way as an external shock absorber but also if you eventually do go towards hip replacement the stronger your muscles are going into the operation the more predictable your positive outcome will be post operatively so you are not doing more harm. Find whatever way you can to remain active.

There will come a point however where there will be a decision whether or not to operate. So, because we’re using the theme of a journey in this talk let’s bring it back to roads so I would ask you which of these three roads would you consider repairing or resurfacing? I certainly don’t think anybody would argue that the road on the right-hand side of our screen is in disrepair and needs fix to repaired but what about the road on our left it’s a little bit cracked but it’s certainly workable, I guess we could resurface that if it’s a very busy road but if it wasn’t a very busy road we could leave it alone. What about the one in the middle well it’s progressed to potholes not a very good road but it’s still workable if it wasn’t a busy road.

Well the same applies to hips I think the hip on the right you can argue there’s no hope for that hip and of course that patient would definitely benefit from hip replacement. Whereas the one on the left it’s just about bone touching bone and it’s only in one side so you may get a few more years out of this hip yet, whereas in the one in the middle it’s kind of somewhere between the two the patient has both hips affected you can see there’s bone touching bone on both hips but it’s certainly not as bad as the one on the right. The problem is though the patients are not roads clearly there’s more nuance to managing patients than there is to managing roads so I have patients who coming to me with X-ray’s like the one on the right but they don’t want a hip replacement they’re able to manage their symptoms just fine likewise I have patients who come to me with the X-ray on the left and their pain is out of control. So, the decision to operate is not simply based on x-ray, and it’s simply not made by me but it’s a decision that we come to together and it’s largely based on your symptoms. It’s important to highlight obviously that hip replacement is a big operation and of course like every big operation it carries risks. It is a great operation, it’s successful in over 90% of people but if you’re one of the unlucky one’s statistics don’t matter so of course there are risks like nerve injury, dislocation, infection and it’s important that patients know this and this is an excerpt from my clinical letters so if you do have a hip replacement under my care this will be included in the letter which I post to you in preparation for your surgery. So, it’s important when you’re making the decision that you realize this is not just something you should be taking lightly hip replacement is a major undertaking.

If we do decide on surgery unfortunately there are no other options than total hip replacement. Keyhole surgery has no role if there’s already established arthritis likewise stem cell therapy has no role if there’s already established arthritis so the only show in town is total hip replacement. Thankfully that’s a great operation so much so that in 2007 the Lancet which is one of the most prestigious medical journals, it published a paper and the title of the paper was the operation of the century total hip replacement so it is a fantastic operation it and cataract surgery are comparable in terms of results, pretty much every other operation has a much poorer result than those two.

Hip replacement was invented by John Charley, served as an orthopaedic surgeon from Manchester in England and this was in the early 60s and in a lot of ways things have changed since the 1960s but in a lot of ways things haven’t changed the basic concept and the ingredients of a hip replacement are still pretty much the same today, our materials have improved we’re much more streamlining the way we do things but a lot of things are very much the same. One of the biggest changes I suppose is in the patients that we treat in the early 60s John Charley would have treated only patients who were in dire need. This is a video of a lady he treated, the same patient the left and the right and you can see this poor lady was struggling to walk her hips were so bad that they were contracted in a fixed crossed position she struggled to get from a to b. Clearly then you can see walking very well six months later but this lady would have spent weeks possibly up to six weeks lying in bed possibly with the broomstick between her legs to keep her hips apart while they healed so it would have been a very laborious and long recovery whereas now we’re performing hip replacements on people like this. Whilst this is amazing and whilst it’s a validation of Charley’s concepts it’s also a problem because we shouldn’t ignore the fact that the primary reason to do hip replacement is take away pain.  Patient expectations nowadays need to be managed much more carefully than they used to be back in the day of Charley.

So, clear expectations for the patient are key, so both of these expectations on screen now are not correct so some patients have an expectation if I don’t have surgery I’m going to end up in a wheelchair well I would suggest that’s not correct very few people end up in a wheelchair. I can’t remember the last person I’ve met who’s ended up in a wheelchair because of hip arthritis most people are able to maintain some level of mobility no matter how bad their hip is on the other end of the spectrum it’s an incorrect expectation to think that you’re going to be a brilliant runner you’re going to be running like Usain Bolt after your hip replacement of course you’re not so both of these expectations are incorrect and it’s important that that’s clear and that sign posted prior to hip replacement.

The best thing that I can signpost for any patient going into hip replacement placement is if you have a hip replacement there is an over 90% chance possibly even as high as 95% chance that you will no longer have pain in your hip, everything else is secondary. Can I play sports after my hip replacement? Maybe, maybe not even if you can do things like skiing, playing tennis, running marathons of course we, all know people who have done this after hip replacements, the bigger question is should they be doing those things and I would argue they shouldn’t. If you’re doing these things you’re placing yourself either in a risky position where you could be doing damage to your hip or you’re going to were out the artificial hip sooner than you should be. Having a hip replacement comes with some sense of responsibility so if we did hip replacements and only Andy Murray’s in the world our results would not be as positive.

After you’ve made the decision to go for hip replacement the other factors surrounding hip replacement should be discussed with your surgeon and that’s because the answers to those questions are specific to you the patient and specific to the surgeon. So, there’s a lot of things we can discuss there’s an implant shape, there’s a type of fixation, do we use cement or not, there’s materials that we use in the hip replacement, there’s a surgical approach we can put the hip in from the front or we can put it in from the back so the front is called bikini incision, the back is called a posterior approach and there’s reasons why each surgeon chooses that approach and there’s patient factors and surgeon factors for that. There’s articulating surfaces so that’s probably the most important thing to consider so most hips these days we use a ceramic ball and a plastic liner, there’s the concept of the hip replacement is a total hip replacement or resurfacing hip replacement. Some surgeons like myself applicate for day case surgery I think there’s a lot of positives for that for the right person. Robotics are advocated by some surgeons and some surgeons advocate for doing both hips at the same time if both hips are bad enough but it’s difficult to say as globalized talk, the answers to all of these questions this is something you need to discuss with your surgeon after you’ve made a decision for surgery. These shouldn’t affect whether or not you’re going for surgery but they can be teased out with your particular surgeon.

Recovery is said to take about six weeks and part of that is true so this is a graph of data from my own patients so if you have had a hip replacement under my care, I log you onto an app and I invite you to submit your surgical scores both preoperatively and postoperatively. So, you can see surgical scores pre-operatively are poor and that the scores make a significant improvement and that improvement is most marked within the first six weeks but you can see that the improvement continues right up to six months, one year and beyond so recovery really does take one year by all means the first six weeks are the most important and that’s when you have the most contact with me and the physiotherapist in terms of information but recovery will continue for up to a year, so it really is a journey.

Lastly you shouldn’t compare yourself to others so we are all different we all recover at different speeds so don’t worry if you’re not off your crutches at six weeks, don’t worry if the old man up the street is recovering much quicker than you, paradoxically younger people often do recover slower than older people and that’s because probably they have higher muscle mass so it takes longer to heal and secondly expectations are different. So, it’s dangerous to compare yourself to others but of course if you think you have a problem contact your surgeon.

So just to reiterate hip arthritis is a journey, like any journey it has its highs and lows it has its challenges. Hip replacement is not the pinnacle, hip replacement is part of that journey and recovery can take up to a year afterwards.

Yeah good questions I’ll do with the second one first actually do cholesterol medications cause joint pains they can, they definitely can it’s not common everybody in the street is on a cholesterol medication but not everybody has joint pain but there are definitely incidences where if you’re not able to figure out the reason for the pain, if the x-rays don’t look too bad and the patient still has pain sometimes I will stop the cholesterol medications or ask the GP to stop the medications if it’s okay to do so and that in some cases can help the pain. If the x-rays show arthritis however it’s more than often the arthritis cause in the pain. The other question so injections are good in the right person at the right time. Plasma I believe is no better than steroid which is no better than hyaluronic acid which is no better than stem cells there are a lot of things you can have injected, if you look at the medical literature the evidence would suggest that they all work in the same way and that is they all have an anti-inflammatory effect. I think they all really pretty much do the same thing and again if you look at the literature they all seem to have the same level of effect. So yeah, I I’m happy that some patients get plasma injections but it has to be for the right patient at the right time they’re very rarely a cure for the problem but they can temporize things and give you a little bit longer out of your native hip prior to proceeding to surgery.

Yes, so that procedure the anterior approach has been in the news recently I’m aware of that. Anterior approach is not a new approach it’s been used for a very long-time and it really is surgeon preference, it’s really what the surgeon has been trained in so I have experience of doing the anterior approach during my training but I decided against it I personally use a posterior approach. Like everything there are positives and negatives to anything there’s no perfect solution so I felt that in my hands the posterior approach gives better results, it doesn’t result in any quicker recovery so personally I’ve done a lot of people day case procedures with the posterior approach and they recover just as correctly as somebody who does the anterior approach, both are good approaches, both have their positives, both have the negatives but it would be untrue to think that one results in a quicker recovery.

Yeah think you’re right there is a lot of people having hip and knee replacements these days. I don’t know if Ireland has a higher rate than any anywhere else. I don’t think so, I have trained abroad and certainly they’re equally busy in New Zealand and Australia where I have worked as well so I don’t think Ireland has a higher rate than anywhere else we do have a higher rate of hemochromatosis so that maybe something that we don’t fully appreciate but I don’t think so. Why does this happen why are so many people having hip replacements near I think its expectations, back in the olden days if your granny or granddad had arthritis they sat in the corner of the room beside the fire and they didn’t expect much. These days we as a society expect much more from ourselves and I think we intervene earlier and we’re more aggressive we know that hip replacements and knee replacements work, so we’re probably more aggressive in suggesting them for patients.

Yeah, I guess I can’t say for sure without seeing the imaging but what you have described there are you’re ticking a lot of boxes for why you should have a hip replacement. If you’ve no quality of life, if you can’t do the basics in life hip replacement is an excellent option for taking away pain as I said in my talk there’s an over 95% chance that hip replacement will take away your pain, so as long as your x-rays or your scans fit with your clinical picture. Certainly, from your clinical picture it sounds like you would benefit from a hip replacement even though you’re young if you’re in that much distress yeah you should speak to your surgeon about hip replacement for sure.

So similar to the anterior approach, robotic surgery is increasingly in the news and it’s a similar answer to the anterior approach it’s got positives and negatives robotic surgery can be extremely accurate you can cut one degree or 1 millimetre but that does not always translate into a better clinical outcome. Robotic probably has a role but I would encourage you to consider your surgeon more than the robot the best results we see over and over again are surgeons who do a lot of hip replacements or knee replacements it’s the volume which gets good results. If a surgeon is using a robot and only doing one or two cases I can guarantee you those results are not going to be as good as somebody who’s doing a lot and I think that’s probably the most important factor in choosing your surgeon and choosing your hospital.

Yeah 28 is very young, is it too young no I have operated on people in their 20s before. I never like doing it, no surgeon ever enjoys doing a hip replacement in somebody so young but again like the previous question if your life is so miserable, if you’re struggling to cope, then of course we can consider it as a last resort. Again, it’s hard for me to say for sure without seeing the imaging but the purpose of hip replacement is to take away pain and restore some quality of life and that’s applicable to any age, we do hip replacements in teenagers if there’s absolutely no resort left. It’s a big step but if it’s restoring some quality of life it can be considered.

Groin pain is typically hip related so by all means it doesn’t necessarily mean there’s hip arthritis, there can be lots of things in around the hip joint which giving you pain but by all means yes please get it checked out come and see us we can get you examined and scanned.