Mr Bridle specializes in hip and knee replacement surgery. As well as performing a large number of primary replacements, including complex cases, he has an interest in revision surgery following implant failure and in particular the treatment of infected hip and knee replacements.
When an area of the body is in pain or discomfort many people will naturally try to ease off exercising for fear of making the problem worse. However, stopping regular exercise in order to alleviate pain or to help counteract reduced mobility is actually contradictory to what experts recommend.
For those with hip osteoarthritis, the advice from medical professionals is that exercising is still critical to ensure that the joint is still being used regularly and that the body is not put under other stresses and strains brought on by a reduction in exercise.
Gentle forms of exercise such as walking and swimming are particularly good for those suffering from osteoarthritis. Although strenuous walks, hiking and walks involving steep gradients may not be ideal, short walks on a relatively flat plain that ensure that you are getting out and about and allowing your joints to flex are essential for making sure that the joint is not deteriorate faster than it is already doing.
Over half of those with hip osteoarthritis (53%) were not choosing to walk as a form of exercise
Two thirds (66%) were walking, but for less than the recommended 90 minutes per week
Just under one quarter (23%) were walking enough to meet the current recommended level of at least 150 minutes per week
According to research published in the Osteoarthritis and Cartilage journal, walking and gentle exercise is actually critical for helping to prevent joint cartilage from deteriorating. The analysis, undertaken by Queen Mary University of London, looked at “the benefits of exercise on the tissues that form our joints and how this is down to tiny hair-like structures called primary cilia found on living cells.”
Researchers found that exercise acted as a natural anti-inflammatory for the joint cartilage, helping counteract some of the deterioration. Exercise actually encourages the production of a protein called HDAC6, which is important for the generation of primary cilia cells.
A greater understanding of how the protein and the cells interact means that experts could develop therapeutic ‘mechano-medicine’ for arthritis patients. This means that the benefits of exercise can be replicated and used as part of a wider treatment programme.
These findings are interesting and important for the development of new treatments for people suffering from joint osteoarthritis. The condition affects many thousands of people in the UK, so the development of new treatments such as this are welcomed by medical professionals looking to find the best way to treat their patients.
Hip replacement operations are popular and common practice with around 175,000 hip operations being conducted every year in the United Kingdom. Over time, people’s bone density and joints deteriorate for a number of reasons and some they are referred for hip replacement treatment whereby some (or all) of the joint is replaced. The aim of the operation is to increase mobility and to reduce pain and discomfort.
A common cause of hip joint deterioration is osteoarthritis which is deterioration of the cartilage around the joints. This means the ball and socket joint rub together causing unnatural amounts of friction which can cause problems with mobility, pain and discomfort when walking, sitting, standing or doing any form of exercise.
Extensive new joint replacement study revealed
For the first time, the performance of different kinds of hip and knee prosthetic implants have been assessed on a massive scale by researchers at the University of Bristol. The study – the first of its kind in size and scope – has yielded some very interesting findings, with significant differences in the performance of the different materials used for the joint replacement components and subsequently the proportion of patients who require revision surgery after their initial operation.
These results were published in the BMJ Open journal in April this year and have been compiled from data from the National Joint Registry for England Wales Northern Ireland and the Isle of Man.
The study analysed data from more than 1.7 million patients who had undergone joint replacement between April 2003 and December 2016. Specifically, the data came from nearly 4,500 hip implants that were used in almost 800,000 hip replacements and just under 450 different types of knee implants used in just under 950,000 knee replacements. This equates to.
All orthopaedic surgeons have preferences in terms of the approach to hip and knee replacement surgeries; the way the operation is conducted and the materials used for the prophetic joints. The possible combinations of the available implants are enormous; depending on the patient’s individual circumstances a surgical strategy is discussed with the patient. Encouragingly, the results yield some very positive findings overall, with “the vast majority of implants used by the health service – 89 per cent of knees and 96 per cent of hips – perform better than standard.”
The cemented Exeter stem features in a number of the best performing combinations, with various different acetabular components, which suggests that this component performs well in a number of different clinical settings, with many different surgeons using this component. London Hip Surgeon Mr Simon Bridle recommends this implant for the majority of his patients.
The study also identifies joint replacement implant combinations which are performing less well. Although this is important information, this does need to be considered with a bit of caution as there are many factors which may be influencing this. Mr Bridle feels that a surgeon needs to think carefully before using these seemingly less well-performing implants.
Martyn Porter, an orthopaedic surgeon and former president of the British Orthopaedic Association, believes that opening the channels of debate about which prosthetic joints are best for which patients are empowering for the patient and helps them understand more about the treatment they are about to receive. He summarises: “The data produced by this study is very powerful. Whilst the rate of revision is only one of the metrics by which the success of joint replacement is judged, it is one that is often important to patients. This data is the beginning of a discussion that patients can have with their surgeon around the type of joint replacement that they might have.”
To discuss your joint replacement in more detail, including the type of implant used and the results you can expect, call 020 8947 9524 to arrange a consultation with Mr Bridle.
Dislocation of a new hip joint is one of the things that patients are usually most concerned about and is something that surgeons will be very careful to warn about when advising patients about how to approach their post-operative recovery.
Interestingly, according to the results of a new study, depending on the type of surgery they have had, low-risk patients do not need to be as concerned about the risk of dislocation as their level of risk to this group is extremely low. The research, carried out by the Hospital for Special Surgery (HSS) in New York, reports that “low-risk patients undergoing a total hip replacement with a posterior approach can skip the standard hip precautions currently recommended for post-surgical recovery.”
Posterior approach: This involves surgeons making an incision through the side or the buttocks. The incision is small; the main gluteal muscle is split and small muscles are taken off the back of the hip and repaired at the end of the surgery.
Anterior approach: By comparison, surgeons using this approach will make their incision through the front of the hip. The incision starts at the top of the pelvic bone and continues down towards the top of the thigh. The surgery is done by opening the space between different muscle groups.
Both approaches have a very low chance of their new joint dislocating.
Authors of the new report suggest that if the guidance is not adapted to reflect the nature of the surgery, then low-risk patients could be scared unnecessarily about their risk of dislocation, when in fact they are at very low risk of this occurring. Peter Sculco, one of the report authors, says that if not handled properly “the precautions can be limiting and cause fear in patients.”
By way of an example, for patients who have had traditional posterior approach surgery, the “standard precautions include not flexing your hip past 90 degrees, not internally rotating your hip more than 10 degrees, using an elevated seat cushion at all times, and sleeping on your back for six weeks.”
This level of precaution is not required if the muscles are repaired with a posterior approach, or with an anterior approach, as the muscles have not been affected in the same way. The important take away from this new research is that a ‘one size for all approach’ is not appropriate for designing a recovery plan for the two different kinds of surgery, and that guidance for the post-operative days, weeks and months should be designed and tailored according to the nature of the surgery. The traditional ‘hip precautions’ are just not required in most patients having hip replacements and patients are allowed to use the hip as comfort allows from the very early post-operative stages.
According to findings from a new US study into recovery from joint replacement surgery, there is no heightened risk to patients if their stay in hospital is shortened and they are encouraged to go home and take a more active role in their own rehabilitation.
The findings, explained by surgeon Michael P. Ast of the Hospital for Special Surgery in New York, suggest that “there is a massive shift taking place toward more ambulatory hip and knee replacement surgeries that allow that patients go home on the same day of their operations.” This follows a growing trend across many areas of medical practice, whereby care is encouraged outside of the primary medical setting.
There are many factors which affect the shift towards same-day hip replacement. Over the years, medical processes have improved significantly. Hip replacement operations have been undertaken for decades, so surgeons have the benefit of many, many years of medical data to help improve practices. The design and materials used for the implant materials have also evolved and improved, plus we know more now about managing pain relief through a variety of different approaches.
This philosophy is reflected in the enhanced recovery programme that is run by the Fortius Clinic in London. The ethos at the Fortius Joint Replacement Centre (FJRC) at the BUPA Cromwell Hospital, is to encourage an Enhanced Recovery Pathway (ERP); there are many benefits to this approach accelerating patients’ recovery.
The ERP at Fortius is designed to give more control to patients to help steer their recovery and empower them to push themselves to full rehabilitation. The programme involves patients more collaboratively in the design of their recovery and encourages them to get a support network in place to help manage their rehabilitation. They are also encouraged to get out of bed at the earliest opportunity and begin testing the new joint. This is proven to help kick start the healing process – both mentally and physically – and is a big step forward compared with the previous recommendation of more prolonged bed rest following operations such as this.
What are the benefits of an ERP?
Typically, patients who follow the ERP approach can expect to stay in hospital for a shorter amount of time, at the moment typically around three days. As this report confirms, shorter length of stay can be achieved in suitable patients, with an appropriate home environment. The type of anaesthetic is important; we use largely spinal anaesthetic, which is proven to have many advantages over general anaesthetic. In addition pain control, including local anaesthetic techniques around the surgical wound, are very important in patients early recovery and we have well-established protocols to manage this.
Patients can enjoy a quicker recovery in the early days following their operation and can begin to see a greater range of motion and movement returning faster. Patients tend to find the recovery more comfortable as the medical support equipment is removed earlier – this includes apparatus such as bladder catheters, oxygen tubes and wound drains. These are all removed before the patient returns home, assuming the patient’s health and general state of recovery allow for this. The approach also tends to yield less post-operative complications.
A promising outlook for hip replacement patients
These findings are very encouraging for medical practitioners and patients. Although a quick discharge via an ERP won’t be suitable for everyone, for patients who are in a good state of general health, who have a support network to give assistance at home and who do not have any other underlying, serious medical conditions (such as heart disease, history of blood clots), this approach is proven to yield a faster and better recovery and can enable patients to get back to feeling normal and mobile much quicker.
You’ve probably heard the phrase ‘failing to prepare is preparing to fail’ – this is applicable to most things in life, including recovering from surgery. There are a number of things that patients and their surgeons can do to ensure that patients are fully prepared for their surgery and the recovery period. Adhering to these steps can have a marked impact on how quickly and how successfully you recover from surgery.
Hip replacement surgery is a major operation, so it is important to ensure that the necessary plans are put in place in advance. The first stage of prep is called pre-operative planning and this is the responsibility of your hip surgeon.
The hip surgeon’s to-do list
They will need to conduct a full anatomical assessment of the patient and design a bespoke treatment plan that takes into account the specific sizing of the components required for the artificial joint to accurately restore biomechanics. With conventional hip replacement surgery, this is done using X-rays, although in very complex cases a CT scan might be required.
Mr Simon Bridle now offers his patients the option of MAKO robotic hip replacement surgery, which has made the pre-operative planning stage much more precise and tailored to the individual patient. Prior to surgery, a CT scan is performed and that information fed into the MAKO software. A CT scan analyses the joint in multi-dimensions and a 3D model is produced which will be used by Mr Bridle as a guide during surgery.
The patient’s to-do list
Embrace healthy living
One recommendation for patients who are preparing for surgery is to ensure that you get in good shape physically before your operation. Smokers are advised to cut down (or ideally quit, if possible) as smoking hampers the body’s ability to heal. The reason that smokers experience more complications in healing from surgery is because smoking affects how well blood is circulated around the body.
Eat well before and after your surgery
Making sure you’re eating a well balanced and healthy diet will also help your body be in the best possible shape before surgery. Ensuring you’re getting a balanced intake of vitamins and minerals will help your body heal. If you are able to exercise gently (depending on how much mobility your current hip joint will allow) then this is also a good idea as it will help keep your weight stable. Gaining weight before an operation such as this is not advised as excess weight can put undue pressure on your recovering joint(s).
Get your house in order
Another job to do beforehand is to make your home ready for your return. Have a look around and reposition important household items so they are at a low level so that you can reach these easily. This could include things like the phone and remote control, but also things you will need in the kitchen which might be too heavy or awkward to lift down from higher cupboards. With the kitchen in mind, it is also sensible to batch cook some fresh meals that you can freeze and then prepare easily when you are recovering.
Get booked into ‘pre-hab’
Patients can also benefit a great deal from a bit of ‘pre-habilitation’. This essentially means that they can be prescribed a series of exercise that can help strengthen core and gluteal muscles, which is helpful in speeding recovery. The Fortius Joint Replacement Centre at Bupa Cromwell Hospital offers a Joint School where patients can be seen by a physiotherapist who can assess them and provide them with suitable exercises to undertake in the weeks leading up to surgery. A good stint of pre-hab exercises can work wonders in terms of getting your body ready for surgery and setting it up nicely for your recovery.
For more information on how best to prepare for hip replacement surgery, call 020 8947 9524 to arrange a consultation with Mr Simon Bridle.
When a patient has been recommended for a total hip arthroplasty (THA, also known as a total hip replacement) one of the most common complications in the years following the surgery is hip dislocation. The NHS reports that this happens in around 10% of cases. This is a frustrating complication for all involved and it is not always immediately obvious what the cause of dislocation is.
Hip replacement dislocation: the patient has had a lumbar fusion
A lumbar fusion is an operation designed to help patients who have spinal problems, specifically it fuses together two or more of the tiny bones in the spine, the vertebrae, so that they work together as one fused bone.
The aim of this is to stop the movement between these bones in cases where their natural alignment is causing the patient pain and impaired mobility. In a huge study conducted using patient data gathered between 2005 and 2012, the Bone and Joint Journal reports “patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their THA than age- and gender-matched patients without a lumbar spinal fusion.”
More research is required to establish what can be done to reduce the risk of dislocation following THA in patients who require or have had a lumbar fusion. Patients requiring either surgery will no doubt be in serious discomfort, with limited or no other options to fix the problem, other than via these methods.
Hip replacement dislocation: the patient has decreased spinopelvic motion
According to a report published recently in the Journal of Bone and Joint Surgery, dislocation following THA is also much more common in patients who have a spinopelvic imbalance – in layman’s terms, the tilt of the pelvis and the angle of the spine are misaligned, causing unnatural wear and tear on hip joints. This issue is exacerbated if coupled with either cup malposition or soft-tissue abnormalities.
The results came from a 20-patient study where all had suffered dislocation following a THA and, as such, data was examined to understand what factors could have caused the joint to dislocate.
Looking to understand hip replacement dislocation more clearly
Whatever the cause of the dislocation, hip replacement surgeons will welcome more research into this issue as when it does occur it will often require revision surgery (surgical intervention to replace or fix the joint again). Typically, dislocations of this nature occur between 10 and 15 years after the initial operation, but in rare cases, this can happen very soon after surgery. If you have undergone a THA and have any concerns, then consulting your hip surgeon quickly will ensure you are in the best hands to assess the problem and to agree the most suitable course of action.
Revision hip surgery is much more challenging than the initial procedure; Mr Simon Bridle combines surgical expertise with clinical experience and specialist training to deal with complex revision cases and has performed many of these procedures over the years.
If you’re a tennis fan then it will not have escaped your notice that Andy Murray has been having some difficulties recently, and these are being caused by repeated injuries to his hip joint which have finally developed into osteoarthritis.
Murray has been suffering with the build-up of this condition for around a decade, and although he has been able to make some adjustments to his game to mitigate the pain, it has reached a point where the pain is now debilitating. This painful condition has caused the former tennis ace to scale things right back and announce his retirement from professional sport and decide to have a hip resurfacing procedure.
This is an interesting course of action, as the feeling of London hip surgery expert Mr Simon Bridle is that although this technique is widely available, it is largely unproven in terms of the benefits it brings. Here we look at some of the reasons people may opt for hip resurfacing, and some of the challenges associated with it.
What is hip resurfacing?
The technique involves identifying where the bone is rubbing together, as this is what is causing the severe pain. The surface of the bone is then replaced with metal on both surfaces, so that the metal rubs together, not the bone. An article published in the New Scientist explains the theory: “Rather than bone rubbing against bone, causing severe pain, metal rubs against metal – while a significant amount of the patient’s original bones around the hip area remain intact.” The technique became very popular in the early 2000s, especially in younger patients. However, some implant designs performed poorly and this led to a high revision rate and far fewer of these procedures being done.
Myth busting hip resurfacing
Hip resurfacing is a smaller operation?
This is actually not the case. Although the work that is done to the existing hip bone is lesser, the surgery to put in the new metal surfaces involves the same amount of invasive surgery as a total hip replacement, as full access to the affected hip joint is still required. The procedure simply takes less of the bone away – in total hip replacement both the top of the thighbone and the socket it which is sits are replaced with artificial materials, whereas in hip resurfacing the head of the femur is typically smoothed down and covered with a metal cap and a layer of metal is placed in the pelvic socket.
There are fewer risks associated with hip resurfacing?
This is also a common misconception and not proven. The immediate operative risks are the same. The biggest concern with hip resurfacing remains the generation of metal debris, which can damage the bone and local soft tissues and also migrate into tissues throughout the body.
Hip resurfacing allows higher levels of function
There is little evidence that hip resurfacing performs any better than conventional hip replacements. Most surgeons will allow patients to return to similar levels of activity, no matter what type of hip has been put in and the type of hip seems to make little difference to the sporting activities which patients are able to return to.
Increased interest in hip resurfacing is inevitable
Nevertheless, the publicity associated with a high-profile sports star like Andy Murray choosing this treatment for his hip osteoarthritis means that awareness of hip resurfacing will grow again. If you are weighing up the decision of a hip replacement versus hip resurfacing, you can expect to find a plethora of information about Andy Murray’s experience and his decision to opt for hip resurfacing. We would strongly recommend speaking with a hip surgeon before making the final decision.
A common question asked during a knee or hip replacement consultation is how long will my artificial joint last. With growing numbers of younger, more active men and women presenting with joint pain and lack of mobility due to wear and tear, the potential hip replacement longevity has never been so important.
Previously thought to last 15 to 20 years, continuing development of implant materials, prosthesis design and improvement in surgical technique, means that your new hips and knees may last considerably longer. This has been confirmed by a large-scale study that has recently carried out by the University of Bristol.
Up till now, there has been limited data on the longevity of artificial joints, so London hip replacement expert Mr Simon Bridle welcomes this study. Its findings will help him provide more definitive data when assisting patients to make the decision as to whether to go ahead or not with surgery.
Hip replacement longevity examined
Published in the Lancet, the researchers analysed 25 years’ worth of operations, performed on over 500,000 patients. Lead study author and research fellow at Bristol Medical School, Dr Jonathan Evans said: “At best, the NHS has only been able to say how long replacements are designed to last, rather than referring to actual evidence from multiple patients’ experiences of joint replacement surgery.”
The study discovered the following:
Hip replacement: 89% lasted 15 years, 70% lasted 20 years and 58% lasted 25 years
Total knee replacements: 93% lasted 15 years, 90% lasted 20 years and 82% lasted 25 years
Partial knee replacements: 77% lasted 15 years, 72% lasted 20 years and 70% lasted 25 years
Interestingly, the UK joint replacement registry data didn’t go back far enough to be used in the study, so the researchers looked at data from Australia, Finland, New Zealand, Norway, Sweden and Denmark. However, they confirmed that their findings mirrored results from previous smaller-scale studies carried out in the UK.
Inevitably this data relates to the performance of joint replacements using older implants and materials. There have been considerable advances in implant technology over the years, in particular with bearings with a far lower wear rate, so there is every hope that hip and knee replacements put in today will do even better than this study suggests.
As the population ages and lives longer, combined with a growth in younger patients that are experiencing increased joint wear and tear, the news that our hip or knee replacements will last longer and require fewer repeat operations is great news.
Shocking figures illustrating the impact that the UK’s obesity crisis is having on the NHS were recently disclosed by an investigation carried out by the Sunday Times. The paper revealed that more than 41,000 obese people required hip or knee replacement operations last year – including seven teenagers.
The investigation found that the numbers of obese patients requiring joint replacement surgery had increased from 6,191 in the period 2009 to 2010 to a staggering 41, 671 in 2017 to 2018. This surge – amounting to a 575% increase – costs the NHS £200 million a year. It was found that obesity was the main or second most important factor for 25,577 of patients last year undergoing a joint replacement surgery. Another 16,184 patients had obesity as a primary or secondary diagnosis.
Obesity and arthritis
Osteoarthritis is the result of wear and tear on our joints and, simply put, any excess weight adds more stress on our joints. Therefore, a common health condition relating to obesity is the development of arthritis.
Joint replacement surgery can be a highly effective way to relieve the symptoms of arthritis; joint pain and lack of mobility but, at the same time, obesity can raise the risk of complications relating to joint replacement surgery.
Obesity and hip replacements – the possible complications
A recent study carried out by the Mayo Clinic in the US concentrated on joint surgery-related complications and their relation to BMI or body mass index. Looking at data relating to 21,000 joint replacement procedures, they focused on revision surgery, whether that’s due to problems with the original implant, early dislocation or joint infection.
The researchers found that the risk of revision surgery increased in almost a linear fashion along with the patient’s BMI – each additional pound over the optimal weight for your height increased the risk of revision surgery.
The large scale study, published in the Journal of Bone and Joint Surgery, found that while obesity can increase the risk of complications associated with surgery, it shouldn’t necessarily be a deterrent when contemplating joint replacement surgery to relieve the symptoms of joint wear and tear. Function and pain were evaluated in over 5,000 patients, categorised as normal weight, overweight, obese, severely obese and morbidly obese. The more obese the patient, the worse pain and function were prior to surgery, yet after surgery, the pain scores were similar across all BMI levels.
So, some good news for those patients who are overweight and struggling with joint pain and lack of mobility to commit to an exercise regime. However, trying hard to lose weight in advance of surgery should always be the preferred option as this is likely to make surgery safer. In addition, of course, there is also a link between obesity and a whole host of health concerns, including diabetes, high blood pressure, heart disease and cancer, as well as the development of osteoarthritis.
Many people suffer from osteoarthritis and, contrary to popular misconceptions, it is not just a condition that affects older people. In fact, it is believed to affect between 12 and 15 per cent of the population who are aged between 25 and 74. It is much more prevalent in older people, but its presence in younger men and women as well means that there are a variety of causes which are not just explained by the natural ageing process and the inevitable wear and tear on joints as we get older.
According to a report published by the National Center for Biotechnology Information (NCBI) in the US, factors that affect patients’ likelihood to develop osteoarthritis are vast. These range from genetics and molecular structure, to what is described as environmental factors such as ‘biomechanical stress’. What this means is the stresses and strains that are put on people’s knee and hip joints through the lifestyles that they choose to live. Scientists are of the belief that biomedical stresses play a highly significant role in the likelihood of developing osteoarthritis.
The right balance needs to be struck
It is widely accepted that certain lifestyle activities can increase the chance of developing osteoarthritis in joints like the knees and hips. High impact sports, for example, especially those with very repetitive motions, have been linked with the development of the condition. It is a delicate balance that needs to be struck, though, as conditions such as obesity are also proven to be linked with the development of osteoarthritis.
Data that has contributed to this includes a study of 506 young female athletes in the US. The study looked at this group because their lifestyle choices suggested that they could be in a higher risk bracket for developing osteoarthritis. The results concluded that there were indeed patterns to be seen in the development of the condition in girls who had been impacted by ‘biomechanical stress’ on their joints, both during pre-puberty and when they were nearing adulthood.
Data such as this is particularly interesting to researchers, as it has been proven that women are at a greater risk than men of developing injuries to their knee and hip joints as a result of environmental factors, compared with men. The Journal of Orthopaedic and Sports Physical Therapy looks in detail at the factors that affect degeneration of the knee and hip joints and concludes that environment factors, coupled with gender, can be regarded as ‘red lights’ in terms of risk categories for those undertaking strenuous sports “the knee has been reported to be the most common site of overuse injuries in runners, 74 triathletes, 18 and military recruits ….. females sustain a higher number of traumatic and overuse knee injuries when compared to males.”
The benefits of understanding more about biomechanical stresses
Identifying these trends gives medical professionals the knowledge and statistics required to ensure that preventative steps to ensure that those in higher-risk categories are educated accordingly and advised of the risk associated with their lifestyles.