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RADIO SCIENCE UNIT
CASE NOTES 8. - Joint Replacements
RADIO 4
TUESDAY 01/02/05 2100-2130
PRESENTER:
MARK PORTER
REPORTER: TRISHA MACNAIR
CONTRIBUTORS:
TIM BRIGGS
ROB MOOTS
AILSA BOSWORTH
AINSLIE HARRIOT
SUE KING
JANE HARRISON
BARRY PARKER
RICHARD FIELD
PRODUCERS: GERALDINE FITZGERALD
PAULINE MACGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about joint replacements, and we are going to be concentrating on the hip and the knee. Both are routine procedures - particularly hip replacement, which is now one of the most commonly performed surgical operations in the UK - around 70,000 are done every year.
Despite advances in materials and techniques artificial hips still have a limited life - particularly in younger, more active people. I'll be finding out about an alternative technique that's been increasingly used in younger patients - including one of the country's favourite chefs.
AINSLIE CLIP
It must have been about four or five years ago at least that I started to get slight pain in the hip, it's like - especially when I was playing sport it just started to irritate me and I thought oh something's wrong and continued to play my normal three sets of tennis. But things started to change - instead of winning six-two, six-three, six-four I started losing. Oh you've got to blame something you know.
PORTER
Trisha Macnair visits a centre dedicated to replacing joints - 3,000 patients will be treated by the team at the South West London Elective Orthopaedic Centre over the next year. Are dedicated surgical centres like this the way forward for the NHS?
But first the recent scare about the safety of anti-inflammatories. Surgery isn't the only way of dealing with arthritic joints - indeed it's invariably the last option after lifestyle changes - such as exercise and weight loss - physiotherapy, and medication - in particular the pain killing family of drugs known as non-steroidal anti-inflammatories or NSAIDs.
Nearly everyone with arthritis will have taken anti-inflammatory drugs like ibuprofen or diclofenac at some time. They work well, but occasionally can have potentially lethal side effects. They can irritate the lining of the stomach, and cause ulcers and catastrophic bleeds. At least 2,000 people die every year in the UK from anti-inflammatory induced stomach haemorrhages.
Coxibs - or COX 2 inhibitors - were hailed as a new generation of anti-inflammatories that had a powerful effect on the joints, but were gentle on the stomach. Hundreds of thousands of patients were switched to them, and most did extremely well - but, as is often the case with new drugs, an unexpected side effect turned up.
In September last year Vioxx - a coxib taken by around 400,000 people in the UK - was withdrawn from the market following research that showed patients taking the drug long term, were more likely to have a heart attack or stroke.
Vioxx is no longer available, but what about the other coxibs still on the market - drugs like Celebrex which many concerned doctors have tarred with same brush and stopped using altogether - reverting back to the older generation anti-inflammatories.
Ailsa Bosworth has arthritis, is Chief Executive of the National Rheumatoid Arthritis Society, and was one of the many people who were happy on coxibs.
BOSWORTH
I went on to COX 2 inhibitors a number of years ago and it was my GP who introduced me at that stage to them and I was very glad to go onto them because I liked the idea that they would not impact on my stomach and my gastrointestinal tract as much as the traditional NSAIDs. There were no risks identified to me at the time I went on to the drugs and it also means that you don't have to take a proton pump inhibitor, which you have to take with conventional NSAIDs, which coats your stomach and helps to mitigate some of the damage that is done by the conventional NSAIDs. I was on this particular COX 2 for a number of years and then got gradually more concerned as things started to come out in the press about cardiovascular risk and increased risk of stroke and so on. And so after a period of time I decided to come off that drug and in fact five weeks after that this drug was withdrawn from the market at the end of last year. So I then went on to another COX 2, because there are several different brands, and within a matter of weeks we were starting to get information in the press about cardiovascular risk with this particular drug and even though the second drug that I have been on hasn't been withdrawn from the market my GP's surgery has stopped prescribing it, so I've had to go back on to conventional NSAIDs and the PPI, which I'm not too happy about.
PORTER
Rob Moots is Professor of Rheumatology at the University of Liverpool.
MOOTS
It's a very difficult situation because we're really faced with incomplete data. I think with one of the coxibs there clearly was a risk of having a problem if you were taking a high dose of it. With the other coxib, that's been raised as potentially have problems, the data's very conflicting. For example one big trial shows that there's a slight increase of getting heart disease or of stroke if you're taking it, whereas another big trial and indeed lots of other trials have suggested there's no problem. And I think really we have to be fairly pragmatic in this - we have to bear in mind that the type of chronic pain in arthritis can be really horrible and non-steroidal anti-inflammatory drugs are very, very helpful in treating this. So again we have to weigh up the pros and the cons. With regards to coxibs they're much safer on the bowel but there is a question mark in some that there may be a bit of an increased risk in heart disease or strokes. On the other hand the older fashioned anti-inflammatory drugs don't appear to have a risk of heart disease or strokes but do have a significant risk of bowel disease.
BOSWORTH
We don't know whether the increased risk that I'm now at - going back on to conventional NSAIDs - in terms of stomach bleed is more than the risk that I would have if I stayed on a COX 2 inhibitor for MI or cardiovascular risk of some kind.
MOOTS
I think when a patient goes to talk to their GP or their rheumatologist about the pros and cons of taking these coxibs there already will be the right amount of information to help make that decision. For example, patients will know whether or not they've had any significant heart problems or strokes and also the GPs in that type of patient at risk of that should be seeing them at regular intervals to check for risk factors. I think the first thing to bear in mind when one's thinking about anti-inflammatory drugs is do you really need them. In many situations, such as milder forms of arthritis, there's absolutely no need to take these drugs - just regular exercise, losing weight or taking over-the-counter preparations, such as paracetamol, are all that's needed. But on the other hand in the more severe forms of arthritis, such as rheumatoid arthritis, it's kind of hard to find an alternative that will work as well as these drugs.
PORTER
Professor Rob Moots. Coincidentally there has just been a study published comparing the anti-inflammatory ibuprofen to paracetamol in people with arthritis and there was no significant difference in pain relief between the two - so don't dismiss paracetamol, it's a much better drug than most of us give credit for, and, as long as you don't exceed the recommended dose, about as safe as modern pharmaceuticals get.
Now onto joint replacements. My guest today is Mr Tim Briggs, consultant surgeon at the Royal National Orthopaedic Hospital in Stanmore.
Tim, most listeners will be familiar with hip and knee ops - what other joints can we
replace?
BRIGGS
We can replace most joints in the upper limb - shoulder, elbow, wrist, fingers - and in the lower limb - the hip, the knee and the ankle. And even now people are starting to look at replacing lumbar discs in the lumbar spine, so quite extensive really.
PORTER
Hip replacement is probably the bread and butter replacement, talk me through what's involved.
BRIGGS
The patients are in hospital for usually four or five days. It's a major operation, I mean because people do so well from it I think people sometimes forget that this is a major procedure ...
PORTER
When I was an anaesthetist, I've seen what it's like and it's pretty major.
BRIGGS
Yes, it's a major procedure but patients recover extremely well from it. What you're actually doing is you're replacing the diseased arthritic ball and socket joint in the hip joint. And you can do that in a number of ways using a number of different materials and different types of prostheses. But the idea is to give you a hip that moves well and without the pain you had before surgery.
PORTER
How quickly do patients recover, if all goes well?
BRIGGS
If all goes well patients, as I say, are up within - usually about five days, we don't let them drive for about six weeks, especially the conventional type of hip replacement. But by six weeks most patients - the wounds are healed well, they're mobilising well with maybe one stick, they're walking around the house and then after six weeks you start - you let them drive and they can lie on their side and get back to a much more normal life.
PORTER
What can go wrong?
BRIGGS
The main ones in hip replacement is if you don't look after your hip within the first six weeks you increase the risk of it dislocating, which is a catastrophic effect if it happens on the patient. You're always worried about the risk of infection and infection rate in hip replacement should be no more than between 1 or 1½%. You're also concerned about deep vein thrombosis, we always hear about it now - people flying across the Atlantic ...
PORTER
Blood clots ...
BRIGGS
It can happen in hip replacement but the surgeon and the team that look after the patient should really take account of that and take precautions to prevent that happening.
PORTER
So looking at the success rate how do you judge whether something's been successful?
BRIGGS
By the patient's response, in terms of yes thank you very much I'm out of pain, they've got no complications and they're back leading a normal healthy life.
PORTER
And how many of your patients out of a hundred would you expect to do that?
BRIGGS
I would expect in hip replacement certainly 98% of patients to be able to get back to that sort of situation.
PORTER
Now the other issue is how long these prostheses last, I mean they're quite high-tech alloys, using the likes of titanium and those sorts of things, but mother nature's very clever and the human hip lasts a lot longer, how long do we think that they last?
BRIGGS
If you have a conventional hip replacement, and by that I mean there's three gold standard hip replacements - the Charnley, which is used in the North of England, was used mainly at Wrightington; the Exeter hip replacement and then there's the Stanmore hip, and those three are the gold standard. And if you look at the main register in the world - the best register - which is the Swedish register those hips are lasting sort of - 90% - sort of about 12-13 years. So hip replacements will last well if a patient looks after it and provided they're put in properly.
PORTER
And all those different prostheses we're talking about and they're essentially the same thing - these are basically - this is the artificial ball and the spike that goes down into the shaft of the long bone - the thigh bone - and - have they all got artificial sockets as well in the pelvis?
BRIGGS
Yes I think that most - when - there is a group of patients that fall over and fracture their hip where you just use half a hip, but most people that have an osteoarthritic hip get the full monty, if you like, they get the ball and the socket.
PORTER
What about resurfacing - this is the technique that I've seen increasingly come through in patients in general practice relative recent, but it's not a new technique is it?
BRIGGS
No I mean resurfacing was used in the 1960s and in early '70s in a number of centres, both in ours and at the Royal London ...
PORTER
The difference being?
BRIGGS
Well it's - they were using metal or metal bearings with large sized heads...
PORTER
So you're not actually chopping the top off the hip you're just covering it with ...
BRIGGS
You're covering it - just covering the top, the ball part, you actually shave it down and you cover it with a metal ball. And the problem with the older type of - the older generation metal of metal on hips is that they failed and they failed because the hips were sort of ground - the hip and the socket were what we called using handlapped or made to fit very carefully so they were what we called the bed - the bearing surface was round the circumference and therefore they bound together and the cup came loose. The new generation is what we call apical bearing, so there's a little space and a little bit more sloppy, so you can get some fluid from the synovial fluid, which is the normal lining of the joint, goes in between, helps separate and helps lubricate the joint. And it seems, at the moment, to be doing very well.
PORTER
And they are being put forward in younger more active people, often people who you're a bit reluctant to do a hip replacement in.
BRIGGS
They are, I mean I see it in my practice young patients now won't accept just going away and living as they are with pain, they want something done about it and I can understand that because patients want quality of life. And we're using both hip and knee replacements in younger patients and I think that at the present time the metal on metal resurfacing seems to be doing well, we're only up to about seven years in terms of follow up and we need much more data to just make sure that what we're doing for patients is the right thing in the long term.
PORTER
Well one person who was convinced was chef Ainslie Harriot who had his arthritic left hip resurfaced last year.
At first anti-inflammatories kept his pain under control, but they didn't help his mobility - uncharacteristically he started losing at tennis, standing for long periods in the kitchen became a chore, and then the pain started to keep him awake at night.
In his 40s, and always on the go, Ainslie wasn't keen on a conventional hip replacement so, after doing a bit of research he opted for resurfacing.
HARRIOT
You know we're talking about Ainslie Harriot here ...
PORTER
Impossible to slow down.
HARRIOT
I'm like that, you know, if you met my father or you met my late mother we're an active family, we're buzzing, we're doing things all the time, we've always been like that. And I didn't really want to be restricted Mark, so I suddenly started looking at other options or reading up about other things and then I discovered the Birmingham Hip and I just liked the sound of it, I liked the idea of it.
PORTER
What did the actual operation involve, how quickly did you recover?
HARRIOT
Well the operation involved about a week of my time literally - I went in on the Tuesday, operated on the Wednesday morning and on Thursday I was up. I say literally - that quick - they get you up out of bed, yes it's painful, yes you're completely shocked and all the drugs are wearing off and stuff like that but they really try and get you up as quickly as possible. And by day three I was walking, albeit very, very slowly, and with crutches up and down.
PORTER
But afterwards I often find people who've had hip surgery they didn't realise quite how limited they were, because it's a very gradual onset, obviously it took you a while to recover but how long was it before you were back to normal?
HARRIOT
I don't think I'm certainly back to normal yet. Of course I'm walking around, I was playing tennis two nights ago and I'm going skiing in a few weeks time, that's okay, in terms of sort of how you can get about but back to normal - no can't get down and dance like Wilson Picket and like James Brown, I can't do that anymore, that's frustrating. [LAUGHTER] Get up back, get on up.
PORTER
But are you sleeping though?
HARRIOT
Yeah I'm sleeping.
PORTER
Are you winning your tennis again?
HARRIOT
I'm winning my tennis. It's great, it's put me suddenly in a position I can cross over my legs quite comfortably, I know this just sounds like the average person, it's something you'd normally do, but when you've got arthritis in your hip it's quite a difficult task, as soon as you do it you kind of unlock your legs straightaway, you think ooh that hurts. So I can do that, I can just squat down and do things quite easily, bending over - it's been quite a remarkable achievement.
PORTER
What were you told about how long this hip's going to last?
HARRIOT
Well I think the materials they use - it's like a scooped out metal tennis ball that fits over the joint - and what was quite interesting, you need to do this operation quite early, in the sense that - sounds a bit gory this but they actually file down the bone and they use this scooped out metal ball to sort of cap the joint, which seems logical to me, instead of waiting until it completely wears out and there's nothing for the cap to fit onto, to grip onto. The idea of that means that it should last for 20, 30 years, it could last the rest of my life, we don't know yet. I know that this is the second design that they've come up with, when I was reading up about it, but the first person had the hip, the resurfacing hip, about 15 years ago. So let's say so far we know that it lasts 15 years but the later edition has only been going for about 9 or 10 years. My operation's not even a year old yet but I certainly feel that it's moved me on immensely and it's made me a lot more active and a lot more confident.
PORTER
Have you got to be careful about certain things - were you warned not to do things or can you return to a normal life?
HARRIOT
No, no sort of massive impact sports like rugby - too old for that anyway. Or no bungee jumping - the hip may pop out [LAUGHTER].
PORTER
Ainslie Harriot.
Your listening to Case Notes, I'm Dr Mark Porter and I discussing joint replacements with my guest, orthopaedic surgeon Tim Briggs.
Tim - Ainslie there obviously happy with his surgery. But we don't know an awful lot about the long term outlook for resurfaced hips do we?
BRIGGS
We don't at the moment. I mean like all hip replacements, doesn't matter which type of design patients have, but for the majority of patients the relief of the pain they had before surgery is immediate and they get back to normal life. But the trouble is we need to know the data of follow up, not at one year but at 15, 16 years for the next generations of the population coming along. And this is why the British Orthopaedic Association set up this joint register and we have that now in the UK, which is - we should have had it years ago but it's now been running for two years and really all hip replacements and knee replacements should go into this registry so that in 5, 10, 15 years time we will have meaningful data to be able to demonstrate to patients where to go for their hip replacement, what sort of hip replacement to have, which hips are lasting and which ones are failing.
PORTER
What happens if a resurfaced hip does fail prematurely, let's say at six years or something, presumably you have to remove the whole thing and give them a normal hip?
BRIGGS
Yes, you take out the resurfacing component and you convert it to a standardised hip replacement where you have a hip going down the shaft of the femur.
PORTER
Do you think there's a problem with people with resurfacing that's being sold as something that they can carry on with their normal activity - I mean Ainslie, for instance, he's a big guy and very active, 6' 3", that hip's going to take a lot of bashing?
BRIGGS
It is but the articulating surface is metal, so it should be able to take the - withstand the battering, but I think we've got to wait for outcome and I think the outcome's going to be crucial.
PORTER
What about knees? We've talked about hips, but knees basically are a form of resurfacing aren't they.
BRIGGS
Yes, I mean knee replacements again were developed initially in the sort of '50s and '60s and they were in those days a fixed hinge, so you basically chopped out part of the end of the thigh bone and part of the shin bone and you put in a component which was a fixed hinge and constrained. Now they're resurfaced, you have a metal sort of resurfacing device on the end of the thigh bone, plastic on the top of the shin bone ...
PORTER
So the joint is plastic on metal.
BRIGGS
Yeah, and the great thing about it is it's the patient's own ligaments and tendons that hold the whole construct together and that's why now it does so well and lasts so well.
PORTER
Tell me do you actually cut those or do you go - do you divide them, do you pull them apart?
BRIGGS
No you pull them apart and the major ligaments on the inside and outside of the knee are kept and one of the major ligaments inside the knee, called the cruciate, is kept and the patient is then able to function extremely well and that's why the knee's now doing so well.
PORTER
Yeah I mean I get the impression as a GP that they are better than they used to be but they still seem to take quite a lot longer to recover than hips.
BRIGGS
Well they do and the reason for that I think is because when you've had a knee replacement you've got to start bending the knees, sort of 24, 48 hours after the operation, that's uncomfortable because you're bending through the scar. Whereas with a hip replacement the scar's usually on the outer side of the thigh so when you start bending the hip you're bending through virgin tissue. And therefore it does take a while to get going but if you look at the quality of life index in terms of which operations across every specialty are the best operations that we can do - cataract, hip and knee replacements are the top three.
PORTER
Tim, I want to talk a bit more about the type of prosthesis used a bit later and which are best. But first, there is more to a good recovery than opting for the right bit of metalwork - the skill and experience of the surgeon, and his or her team, are paramount too.
The South West London Elective Orthopaedic Centre at Epsom is a new initiative designed to pool expertise and improve outcomes. Three thousand people will have their operations there this year, mostly new hips and knees, making it the biggest such centre in the UK, and the second biggest in the world. Tricia Macnair paid them a visit.
ACTUALITY - PHYSIOTHERAPY SESSION
HARRISON
So it's good leg up first, then the bad leg and the crutches, crutches down, operated leg - bad leg - and good leg. Well done that was excellent.
Mr Proctor's been on crutches before, so this isn't entirely a new experience for him.
PROCTOR
No I feel very comfortable actually.
MACNAIR
It's three days since Alan Proctor's operation, and with the help of Jane Harrison and the rest of the team, he is well on the way to recovery.
The centre's been very carefully designed with orthopaedic patients in mind. A lot of attention has also been given to preparing patients carefully before they even come in for surgery. So they begin their journey through treatment with a visit to the pre-assessment clinic. Sue King, director of nursing showed me round.
KING
The clinic here basically is nurse led by advanced nurse practitioners. Patients all attend about an hour and a half education class where we actually talk through their whole pathway with them. So that patients know exactly what is going to happen to them from the time they come into the centre to the time they go home. They're also seen by discharge coordinators and their home situation is assessed and their discharge is actually planned before they actually come in.
MACNAIR
Patients have the chance to ask questions and explore any particular concerns they have. They may also be given advice and exercises by the physiotherapist to help prepare, before they return, on the day of operation, for surgery. Mr Barry Parker is a hip and knee surgeon, and medical director of the centre.
PARKER
The patients will come in here on the day of surgery already prepared, knowing exactly what's going to happen.
MACNAIR
There's a quite calm and peaceful air.
PARKER
Well they're prepared for it you see, they've had it explained to them.
MACNAIR
Before the operation a nurse will take a sample of blood in case a transfusion is needed. But that rarely happens. Particular care is taken with blood loss during the operation, this means that the centre has one of the lowest transfusion rates in the country for this sort of surgery. This is one of several factors which enables the centre to offer surgery to people who might be deemed unfit by other treatment centres. Another factor is the use, wherever possible, of regional anaesthesia techniques rather than a general anaesthetic.
PARKER
Very few of our patients, it's well less than 10%, have general anaesthetic, so they're nearly all done under spinal or epidural anaesthesia. And that means that they have good pain control afterwards, it's easy to keep their medical condition stable, it also means that we're able to treat patients that reflect the whole range of patients requiring this type of surgery. So we'll treat sick patients, people with serious medical conditions.
MACNAIR
After the operation, carried out in one of four state of the art theatres, patients don't go straight back to the ward, instead they're taken to a special post-anaesthetic care unit.
ACTUALITY - CARE UNIT
We've got two beds which are spec-ed up to a high dependency level and we have two that are spec-ed up to an intensive care level. So which is why we can deal with any patient.
PARKER
There is no junior medical staff providing day-to-day care for the patients at all, it is directly done by the consultants and the nursing staff. Here though we have a roster of intensive care doctors, 24 hours a day, seven days a week, providing cover for these patients here.
MACNAIR
Just along the corridor from the post-anaesthetic care unit another orthopaedic surgeon, Mr Richard Field, is working with colleagues to closely analyse the results of their work. In this way they aim to constantly hone their technique.
FIELD
What we're doing here is setting up our research programme, which is looking at the work we're doing, analysing the operations that are undertaken, so here, for example, are x-rays on which Aran who is in charge of our x-ray department has used his computer to put a whole load of visible lines, so that we can measure the geometry of the new joint and see whether we've matched the original geometry of the patient and therefore relate that to how effective and efficient the hip replacement is. And that allows us to provide the surgeons with feedback on their work, so that they can test themselves against the best possible standards and gradually improve their own work. We've also monitoring the long term outcome of all our joint replacement work for some years, so we know what normal levels of function are to achieve at different time points and when a patient is not achieving that we're alerted to it and we can arrange for them to see their surgeon in the clinic for an extra follow-up appointment to identify if there's a problem or sometimes there may be another joint that's wearing out that will also need some help.
MACNAIR
Each ward includes a small a small gym, which is essential for the intensive physiotherapy that plays such an important part in getting the patients active again. Here Jane Harrison and Alan Proctor are devising a programme of exercises which he will take home with him.
ACTUALITY - PHYSIOTHERAPY
HARRISON
Once the patients come in post-operatively they're really empowered to know what they're doing, they understand what we expect of them, they understand the typical things that are going to happen on each day following their surgery, what exercises to do, the speed at which we rehabilitate patients and that helps us get them on to their feet quickly, re-educate their walking and get them home safely.
PROCTOR
It's very comprehensive, it's really idiot proof, so it's very good. I'm probably their worst case scenario being overweight and maybe a bit of a nervous patient. They've relaxed me, things came along very well and you just sort of get confidence with who you're with and everything's worked very well.
PORTER
Tricia Macnair talking to Alan Proctor at the South West London Orthopaedic Centre in Epsom.
Tim, I must say that's somewhere I'd quite like to go and have my hip done, it sounds the right sort of place. But an interesting point about junior doctors - I can see the advantages of not having them there, no one wants to be practised on, but where does the next Mr Tim Briggs come from?
BRIGGS
I think you've got a very good point there, I mean there's no doubt that medical careers are undergoing significant modernisation. We're now going to train surgeons, like myself, in six years, proposals maybe to make that four years.
PORTER
And how long did it take you?
BRIGGS
Ten years from start to becoming a consultant at Stanmore. And my concern is that we're already shortening the training time, we've got the European working time directive and we're now going to take joint replacement where there's no junior staff, so my concern is where are these junior doctors going to get their training for when they become consultants?
PORTER
Tim, now I'm going to put you on the spot - assuming that somebody's not too young, not too old, not too - an average patient, let's say, resurfacing versus replacement for a hip, which would you opt for?
BRIGGS
I think at the moment it's difficult, I would hope in the next three of four years we'll get the answer to that and I think that's why we need the follow-up data for the resurfacing replacement to see what they're like at 10 years in these younger age groups.
PORTER
I get the feeling that you're erring on the side of the conventional one at the moment until we get more data on ...
BRIGGS
At the moment but it may change once we have adequate follow-up.
PORTER
And if you're going for a full replacement hip, which type of prostheses?
BRIGGS
Well I think that if you're over 60, 65, then you've got to go for one of the three gold standards I think - the Exeter, the Charnley or Stanmore. For the younger patients people are now talking about putting them in but we know more data before we can actually say with confidence that's the right thing to do.
PORTER
And briefly knees?
BRIGGS
I think with knees you want to ask you surgeon, quite rightly I think, about the type of knee he uses, the follow-up data it has, how successful in what sort of period of time and I think that the design of knee replacement is generally sorted.
PORTER
And Tim a lot of patients are scared about asking their surgeon questions but you don't mind.
BRIGGS
No, they've got to ask, people - you've surfed the net, they need to know how good we are and they should ask us the surgeon.
PORTER
I'm afraid we have to leave it there. Tim Briggs, thank you very much.
Next week's programme is all about wound healing - stitches, staples or glue - which works best, for what? And how diet influences how quickly you heal - and what you can do about it.
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