In this blog, I am going to start a series of blogs looking at interesting topics (well interesting to me at least!) and look at some of the evidence around them. Most of the topics will be around areas that are relevant to the patients that we see as physiotherapists and there will be some links in each of the blogs to point you towards some resources that might help. Today we will have a brief look at hip arthritis and the thorny question of when it is appropriate to consider surgery. This article was prompted by reading a report in our physiotherapy magazine Frontline in which there were a series of revealing statistics about hip replacements, the ages at which patients have hip replacements and how common revisions (having another hip replacement on the same hip) are. The whole article can be accessed here: http://www.csp.org.uk/frontline/article/hip-replacement-pros-cons-early-surgery

Hip replacements are the most common joint replacement and also by far the most successful (in terms of patient satisfaction) joint replacement. In general, patients that have a hip replacement seem to do very well (this is certainly my experience as a physiotherapist), it tends to cure their pain, often returns them to high levels of mobility and although the initial month or so is very painful, patients tend to recover very well and make excellent progress with their physiotherapy. It is generally used for patients with significant hip pain from osteoarthritis (wear and tear) or for patients who have broken their hip. To make things simple this article will just look at its usage for help with osteoarthritis. So, if it is so great, why doesn’t everyone just have their hip replaced when they get some pain from arthritis. Surely if it’s so successful we should just get a new one and be done with it? Well firstly surgery is always risky and you really don’t want to have a major operation if you can avoid one - infection or an error in the operation are always a risk. Secondly the NHS is unlikely ever to be able to afford to replace everyone's hip that hurts from arthritis. Thirdly pain from osteoarthritis tends to come and go and is often manageable with the right strategy and so although it may hurt one day or week then next it may be perfectly fine, so it makes sense to try to wait a bit.

So, who should have an operation and when and are there any problems with the current trends? Well, as ever things are not black and white and who should have a hip replacement is not easily decided by a mathematical formula and yes there do seem to be some issues with current trends in terms of who is having a hip replacement. It used to be the case that only elderly patients (over 70yrs) would be having hip replacements due to wear and tear in the joint. So, these patients tended to have reasonably low requirements in terms of performance from the joint and also by the time the joint was wearing out or needed revising (in say 15 - 20yrs) the majority were dead! However this has dramatically changed with many more younger patients (a third are under the age of 60) now having hip replacements, these patients tend to have much higher demands from the joint (e.g. they want to do a lot of exercise) and they are now living well past the time that the hip will have worn out by and so will often need a revision (e.g. a second surgery/hip replacement). Patients tend to be unwilling to have their lives disrupted by pain and discomfort in a hip joint and often nowadays are much more willing to have surgery than in the past. Now, this isn’t exactly a problem as long as these patients really understand the implications of having a joint replacement early in life and that they will almost certainly need a revision at some point. Revisions sound easy but in fact they are major open surgery with all the risks that entails and are often not as successful as the initial hip replacement. Also, there is a tendency that if a patient has hip pain and they have an x-ray which shows arthritis or a clear problem such as a cam deformity then they will be referred for surgery (obviously this doesn’t always happen) especially if they are very active and are demanding that their hip be “fixed”. The problem with this approach is that very often these symptoms come and go and that often the patient has not exhausted all conservative options such as physiotherapy, stretching, strengthening, exercise, rest and anti-inflammatories.

So, to attempt to answer the earlier question: When should you consider a hip replacement? Firstly age is certainly a component here, if you are much older e.g. 80, have been getting longstanding hip/groin pain that is reducing your mobility rapidly and you have clear arthritis in the joint – well this seems an easy decision and you most likely need to see a surgeon for their opinion about a hip replacement. The answer becomes less clear in a younger population and by that I mean anyone under 60, personally my experience (and this is the clear recommendation from NICE https://www.nice.org.uk/guidance/cg177) is that patients should have tried all conservative management options for a significant period before (probably a minimum of a year) before considering surgery. So, what do I mean by conservative options? Firstly physiotherapy: this would include a programme of stretching and strengthening and general building up of activity aimed at strengthening the muscles of the legs and hips. Next the use of some general management strategies such as resting the hip if it hurts too much but generally keeping active with it. Anti-inflammatories can also help manage symptoms during flare ups. Finally for patients that are overweight – the main answer is simply weight loss! My experience is that many patients have not tried enough of these alternatives before they jump to surgery.

Just to be clear, I am not anti-hip replacement surgery – in fact it is by far the most successful joint replacement and is also one of the most successful surgeries in terms of patient satisfaction full stop. In the right person and patient a hip replacement can be truly life transforming, stopping their pain and allowing them to have a good quality of life. However I really do think that before surgery patients should have absolutely exhausted all other options (not just tried for a few weeks and given up).

If you or anyone you know needs help with hip pain or recovery post hip replacement then please get in touch to have a chat about how we might be able to help with physiotherapy. We can be contacted via email: enquiries@threespiresphysiotherapy.co.uk or phone: 07884281623