Are you experiencing a lot of groin, thigh or knee pain, stiffness, limping and general slowing up? This could mean you have severe osteoarthritis of the hip. I asked Stuart Edwards, a consultant orthopaedic surgeon who has been practising in Co Kilkenny’s Aut Even hospital for the past six years, how to assess if your condition is serious enough to warrant a hip replacement operation.“The main indicator is pain,” he says. “Patients can get sounds like grinding or clicking and stiffness, but pain is the strongest indicator for surgery. Everyone feels pain differently, however, and it’s often about marrying the X-ray appearance with reported levels of pain, but I usually ask patients these five telling questions:
Are you experiencing a lot of groin, thigh or knee pain, stiffness, limping and general slowing up? This could mean you have severe osteoarthritis of the hip. I asked Stuart Edwards, a consultant orthopaedic surgeon who has been practising in Co Kilkenny’s Aut Even hospital for the past six years, how to assess if your condition is serious enough to warrant a hip replacement operation.
“The main indicator is pain,” he says. “Patients can get sounds like grinding or clicking and stiffness, but pain is the strongest indicator for surgery. Everyone feels pain differently, however, and it’s often about marrying the X-ray appearance with reported levels of pain, but I usually ask patients these five telling questions:
1. Do you have pain every day?2. Does it disturb your sleep at night?3. Are you taking painkillers regularly?4. Is walking a mile difficult for you?5. Is what you’re experiencing a misery rather than a nuisance? If the answers are yes, it usually means that a hip replacement operation would benefit the patient. The most serious of those is the night pain, because if you can’t sleep at night your day is destroyed and this seriously affects your life.
When it comes down to it, no one should have to suffer agony.
There are always risks involved, but there is a 90-95% success rate with this operation, which is phenomenal.
Q&A
Margaret Hawkins: “What about a situation where a person says they are in great pain, but the X-ray doesn’t show huge damage?”Stuart Edwards: “In situations like this, it’s important to emphasise that it is the patient we are treating, not the X-ray. I usually suggest what I call a diagnostic and therapeutic hip injection. If this eradicates their pain over six to eight weeks it would be a stronger indication for them to have a hip replacement operation. I would also send them for an MRI scan as it will emphasise any wear and tear to the hip, but X-rays are generally the gold standard for showing osteoarthritis damage.” MH: “How long will the hip replacement last?”SE: “About 15 years and maybe longer, as the technology is improving all the time.” MH: “What’s the most common age to have one done?”SE: “The most common age is the early to mid-60s. Over the last decade, the age of having such operations has reduced because technology has improved and patients’ expectations have increased.” MH: “What are the risk factors for osteoarthritis of the hip?”SE: “Obesity is a factor, but a family history of osteoarthritis can be a bigger one. There is also a congenital condition called dysplasia, where the socket didn’t form properly, and approximately 40% of women under 50 who have arthritis have a degree of dysplasia.” MH: “What occupations are affected the most?”SE: “It’s either young sportsmen, who have had lots of knocks and groin strains over the years and then develop problems in their mid-30s or 40s, or people like farmers, whose work has involved heavy daily lifting which has led to a repetitive stress injury of the hip joint.” MH: “Are there different types of hip replacements?”SE: “Yes, cemented and uncemented. With the cemented hip, a titanium stem is inserted into the thigh bone and fixed using an acrylic cement. That’s the type of operation mostly done in northern Europe, but the uncemented type, more common in the US, is now becoming more popular. The idea behind the uncemented procedure is that the bone grows into parts of the [titanium] stem that’s inserted into the thigh bone, so it seems to be more biological. It’s also a slightly quicker operation. I do both kinds of operations. I use cemented hips in the more elderly population that have wider thigh bones, as it is easier to get a complete fit. The uncemented approach I use in younger patients in the hope that, biologically, it may last them longer.”
Nuts and bolts
But what’s actually done?
“An incision of about 15cm is made, your hip is dislocated from the socket, the femoral [thigh bone] head is removed, the socket is exposed, the circumference of it is cleaned and it is then shaped into a hemisphere so that the new socket can fit snugly.
“The worn cartilage is then removed in order to get down to good-quality bone. In the uncemented operation, the hole the surgeon makes is 1mm smaller than the trial shell.
“If there is a tight fit, the definitive shell, which is made of titanium, is inserted. This shell has a very rough surface on the back of it, which allows bone to grow into it. Then the shell is checked for stability. Sometimes screws are used to make the socket more stable. After this, a liner made of plastic or ceramic, with a self-locking mechanism, is put inside this [socket] shell.
“The surgeon next concentrates on the femoral [the thigh bone] side. A series of increasing sized broaches are inserted into the thigh bone.
“A sleeve is then put on top of the broach and a ball on top of that and the hip is then put back into the joint.
“If the hip is stable and the soft tissue tension is correct, the definitive implants are selected and inserted. The different layers of the wound are then sewn up and the patient is transferred to the recovery room.”
Aftercare
“Four to five days is the normal length of time in hospital with the patient up and about the day after the operation. A pair of crutches is used for three to four weeks and a single crutch for three weeks after that.
“Home instructions include the use of an extended grabber to pick up things so that the person does not bend down. This is to reduce the risk of dislocating the hip. A raised toilet seat is also necessary.
“Exercises are recommended and the patient told not to drive for six weeks.” CL
WHAT HAPPENS IN HOSPITAL
If you were to have a hip replacement operation what would happen? This is the patient pathway:
• You are admitted on the morning of the operation.• You usually walk to theatre (to create a feeling of wellness).• You receive a spinal anaesthetic. You don’t feel anything and only wake after the operation is over. The operation generally takes about one hour.Useful websites;www.arthritisireland.iewww.autevenhospital.ieCase study
Marian O’Shaughnessy
Limerick native and retired primary school teacher, Marian O’Shaughnessy, had a hip operation in October 2012. She first experienced pain when she was 49 and initially thought that it was due to stress, but it worsened over time. She feels that she should have had a hip replacement operation earlier.
“I would advise people to get a second opinion as there are so many degrees of wellness,” she says.
“I had bouts of pain and this was put down to sciatica, but my muscles were wasting all the time due to lack of exercise. This can happen if you’ve been very active and then you stop. Because my hip was bad, even going from under me sometimes, I moved to resource teaching which was easier than standing in the classroom all day.
“At the time, I found it difficult to get an overall diagnosis of what was wrong with my hip and back. I had the operation in Co Limerick in October 2012 and the care was excellent.
“After the operation, I felt that I needed head-to-toe physiotherapy, however, not just exercises for the new hip, as my whole body had gone askew from walking incorrectly for so long. If you’re limping your whole body is out of alignment. I got the real benefit of the hip operation after I had that, as all my muscles were strengthened then.
“My advice to anyone facing the operation is to find a good physiotherapist. Aftercare could also be improved in this country. It would be good to have someone call over and help you with the exercises in the first couple of weeks after the operation, especially if you live on your own.
“People can be isolated and need support after an operation like this, even for simple things, like someone to drive them to physio appointments, for example, when they can’t drive themselves for six weeks. Taxis aren’t available in rural Ireland or would be too expensive if you live a long distance from a hospital.”
Cara Cunningham
Cara Cunningham is from Ballymore, Co Westmeath. She is the chairperson of the Westmeath branch of Arthritis Ireland. She had a hip replacement in February 2009 and is due to have a second one soon.
She experienced pain in her thigh only. Being only in her early 40s, she didn’t expect to need such an operation so soon.
“I laughed when the surgeon said I needed a hip replacement, but prior to that I was hardly able to put a shoe on my left foot and I was using a sock aid as well. I literally wasn’t able to do anything much on the left side at all. I could manage at work as it was mostly office work, but it was causing me mobility problems.
“Initially, I put my hip problems down to incorrect lifting when I was caring for my mother, but eventually I knew it wasn’t that. Even though there was a history of arthritis in the family too, I still felt I was a bit young for it at the time.
“I talked to people about the operation, some had good stories and some not so good, but I was glad to be put on the waiting list in the end and it was a relief when it happened. Within 24 hours of the operation it was a whole new lease of life for me. The pain was gone and I could move more easily. I did the recommended exercises after coming out of hospital religiously. I always say to people: ‘Do what you’re told by the hospital and you’ll do well’.
“The replacement is still going well, but I need the right one done now because it was supporting the left one when it was bad for so long.”
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