Zoe Andrews

Hello, and I hope you're all well. My name is Zoe and I’m the Matron for Surgery at Benenden Hospital.

I’d like to welcome you all to our webinar on hip replacement surgery. The presenter today is Mr Raj Shrivastava, our Consultant Orthopaedic surgeon. His presentation will be followed by a Q&A session and, if you'd like to ask a question, please do so by the Q&A icon which is at the top right-hand side of your screen. This can be done with or without giving your name. Just to remind you that this webinar is being recorded although other attendees won't know that you're attending unless you give your name when asking a question. Now is your opportunity to leave if you'd prefer not to be part of the recording.

I’ll hand over now to Mr Shrivastava and you'll hear from me again shortly. Enjoy the presentation and if you think of a question while you're watching, please add it in the text box.

Mr Shrivastava

Thank you very much Zoe. Good morning everybody and thank you very much for joining us today for this webinar. In the next half an hour to 40 minutes, I’m going to cover some general information about total hip replacement, which I think will be helpful to you if you are having any hip problems or considering a hip replacement in the near future

So, first of all, it is fair to mention that it is a very common procedure. UK-wide there are more than 75,000 hip replacements performed every year. And this number is creeping up every year. It is also fair to say that it is one of the most successful operations in the history of orthopaedics.

Just to give you some idea, this concept about Quality Adjustment Life Years applies to most of the surgical interventions where, in relation to that intervention, scientists measure how much improvement in the quality of life happens and how long it lasts. And on that criteria, of all the major surgical interventions hip replacement gives the best value - even better than coronary artery bypass grafting.

Now survival of the hip prosthesis is getting better and better. Looking at the figures of the hips which were done more than 10-15 years ago (it is already crossing 15 years!) and I’m almost sure that what we are doing today will give even a longer life to the prosthesis in due course. And patient satisfaction after hip replacement is really very high; it is more than 95 percent.

I’ll take you through a brief history about total hip replacement. Before the 1960s everything was very primitive; the first sincere attempt to replace the hip was documented in 1891, where an ivory prosthesis was used, then it was fixed in the hip with some metal work. Many more attempts were made. The first metallic hip was done in 1941 in America. Most of these attempts failed because of the primitive technique, and there wasn't enough understanding about the biomechanics of the hip joint and infection was a major issue and the commonest outcome was a failure of the prosthesis.

 Now the revolution took place in the 1960s when - and it is all due to Sir John Charnley. He was an Orthopedic surgeon in Writington Hospital, near Liverpool. And if you want to remember one surgeon in relation to total hip replacement it is Sir John Charnley. He is the person who established all the principles of modern total hip replacement and total hip replacement became a common surgical procedure. He established the materials, surgical technique as well as the infection control during these procedures. And all these techniques, at least in principle, are still valid today.

After the 1960s there has been further evolution and there has been better technology. As far as materials are concerned there is highly cross-linked polyethylene available, which lasts longer; ceramic surfaces also increase the life of the processes. We have improved our surgical techniques significantly and, most importantly in the last 10-15 years, rehabilitation has become much more aggressive as well as more standardised.

Most of the hospitals follow a rapid recovery program. That means that patients have minimum disturbance to their physiology during total hip replacement, and we expect them to return back to normality as quickly as possible after the surgical intervention.

Another very big development has been monitoring of total hip replacements and, you can imagine, as I mentioned there are more than 75,000 procedures performed every year. There are more than 300 hospitals which perform total hip replacement and there are more than a thousand hip surgeons in the United Kingdom. There are companies which provide different type of hip prostheses. If you put all these data together, you can see that monitoring of the situation is a nightmare. But thanks to the National Joint Registry, which was established about 15 years ago, that monitoring is a very well-established procedure now in the United Kingdom. And I’ll come back to this later on in my presentation.

Now coming to the indication for the total hip replacement. It is very simple. It is just to control the pain from a diseased hip. And, if you control the pain, you’re also restoring the function from that hip joint. In practical terms, the pain and dysfunction is associated mostly due to osteoarthritis and osteoarthritis is the commonest indication for total hip replacement in more than 90 percent of the patients. Then come other type of arthritis like rheumatoid arthritis, sero-negative arthritis arthritis associated with psoriasis, arthritis associated with previous trauma etc.

Avascular necrosis is a condition where the blood supply to the head of the femur gets compromised and there are so many reasons for that. Avascular necrosis is an indication for total hip replacement, and it is significant because this happens mostly in relatively young people. So, this is one of the common causes of hip replacement in a relatively young population.

Fracture neck of femur has become an increasingly frequent indication for total hip replacement. Previously most of these patients after fracture neck of femur used to get only partial replacement, with very poor function. And quite a lot of these patients required another surgery to revise them to total hip replacement. And the message has been very loud and clear, that if anybody who is relatively fit and active sustains fracture neck of femur, then it is better to do a total hip replacement.

I’ll show you some examples on an x-ray. Osteoarthritis comes in various sizes and shapes. I have chosen a somewhat severely affected hip so that you can see it clearly. The left hip, which is this one; you can see it is a ball and socket joint and the joint space is quite smooth, and the surface of the hip joint is quite rounded and regular.

Now if you compare this with the right hip, you can't see any gap there; it is quite irregular. There are osteophyte formations, which are this bony growth on the edges of the socket.

Now, the next indication is avascular necrosis. This is an MRI scan of avascular necrosis, and on the left-hand side you can see a triangular segment of damaged bone in the hip, and that is where the blood supply to the hip has been cut off. On the right side you can also see a crescent of damaged bone on the top of the ball of the hip joint, and that is again due to avascular necrosis.

This is the x-ray of the same patient, and you can see the damage to the top of the hip on the left side, and there is more or less a separate fragment lying there. This is an example of fracture neck of femur. On the right-hand side there is an intact femur and on the left-hand side the neck of the femur is broken, which is just here. There that's the fracture neck of femur.

Now coming to the commonest indication, and that is the osteoarthritis of the hip joint. So let's go into somewhat more detail about the pain one gets in arthritis of the hip.

The typical hip, following osteoarthritis in the hip, is in the groin and it is at the top of the thigh and then it goes towards the knee joint. It is very common to have activity-related pain and you get good days and bad days. Sometimes you get pain during the night as well, and this night pain is usually associated with a change of movement, change of position in the bed and related to relaxation of the muscles as we fall asleep.

Quite a lot of patients report that weather is an important factor for them, and whenever it is wet and windy, they get more pain and it is also quite scientific. There is scientific explanation for that - that whenever atmospheric pressure is high then most arthritic conditions are more painful.

In association with the pain, stiffness is also a common problem. And this stiffness manifests in difficulty in negotiating stairs, difficulty in cutting toenails and while most patients can drive all right, it is difficult to get in and out of the car. And if you talk to these patients, they adapt what they do; they sit first on the chair and then they swing their legs in and out of the car.

Now let's hope you are going to see a hip specialist and the first consultation will be about 20-30  minutes and it is expected that, by the time you see the specialist, the diagnosis is already established, you already had an x-ray and diagnosis has been confirmed.

However, if the situation has changed and your symptoms are different - are much worse than before - then you will be advised to have another x-ray. During this consultation you will be given quite a lot of information by your specialist, but he will tell you what he wants to tell you and it might not be the same as what you want to know.

So, it is advisable that, before you go to see the specialist, make a list of points you want to ask; your worries and anything particular in your situation you want to discuss with the specialist. Make a written list of it. It is also a very good idea to take somebody with you; your partner or somebody from your family who will be able to retain more information for you and will be able to tell you later on if you haven't been able to retain that information.

Before a hip replacement, it is always a good idea to try simpler things. First, after all, total hip replacement is a pain-relieving operation and, if you can relieve that pain by other, simpler measures then it is worth a try.

There are various ways to control the pain; by having painkillers, trying anti-inflammatories and having some physiotherapy. As I mentioned earlier, pain is related to activity and hence activity modification has also got a place. So, suppose you are having a good day, then you take less painkillers and do more activities. If somebody is having a bad day, then you slow down on that day and take more painkillers.

Now a walking stick is a very scientific way to share the weight from your hip joint. Although most patients do not like it, it is a very scientific way (and highly recommended way) to improve your walking while you are suffering from arthritis - especially before your operation.

Now before considering hip replacement, it’s also a very good idea to optimise your health. After all it is a major surgical intervention and you should be in the best of health. Hence if you have got any co-morbidities, like hypertension, heart failure or anything else, make sure that all these conditions are under control.

Anaemia has got a special mention because, if you are anaemic before your operation, then your risk of requiring a transfusion is significantly higher - and transfusion affects your recovery. So, it is a good idea to make sure that your anaemia is under control.

Now coming to weight management. Weight management is quite an emotive issue for patients, and I understand it is a very difficult situation. If you've got arthritic, painful joints you can't exercise, and you do tend to put on more weight. But - at the same time - the scientific aspect of this is that if you are quite heavy, and especially if you are morbidly obese with a BMI of more than 40, then your chances of having post-operative complications is significantly higher. And another big disadvantage is that the life of the prosthesis you are going to have is significantly compromised. So, a sincere attempt has to be made to control your weight if you are morbidly obese, before considering hip replacement.

My personal experience is that I do see these patients. Every time I see such patients, I start running late in my clinic because I have to spend more time. But I can tell you that more than 90% of the time this advice is taken, there is a light at the end of the tunnel and most of the patients manage their weight successfully. And then they come back, and I replace their hip successfully with lesser risk.

I’m sorry about this spelling mistake here, it should be pre-habilitation.

And if you have got some weakness around your joints or muscle weakness due to inactivity, it is a good idea to have some physiotherapy beforehand to make sure that your muscles and everything else is functioning.

Now before your operation you will have a pre-assessment, where you will be thoroughly assessed medically, and you will be prepared for your operation. You will spend two to four hours in hospital, you will be seen by a team of health professionals which will involve a pre-anaesthetic nurse. You will be seen by a physiotherapist and, if necessary, by an occupational therapist. And if there are significant co-morbidities then a Consultant Anaesthetist will be assessing you as well.

This pre-assessment usually takes place about two to four weeks before the operation. There will be quite a lot of information given to you and every aspect of your hospital stay will be explained to you.

And another important aspect is the discharge planning. If there are any issues when you go home, then these will be addressed during this pre-assessment.

Anaesthesia. Quite a lot of patients worry about the anaesthetic aspect of their care. There are two distinct type of anaesthesia available for total hip replacement. The commonest and the best one is either spinal or epidural. This procedure involves an injection in the back, and it is the method of choice because it improves your pain management immediately after the operation. Blood loss is less and risk of blood clots in the legs is also less after this technique. However, if you have got a spinal condition, or you’ve had spinal operations, then it might be difficult.

The second choice is general anaesthetic which requires putting some sort of tube in the throat and it obviously is not suitable for patients who have got pre-existing chest conditions - and post-operative pain management is also a bit more challenging after general anaesthesia. Sometimes it could be a combination of both; you can have general anaesthetic first and under general anaesthetic you can have a spinal to get all the advantages of a spinal technique, like reduced blood loss and better pain management afterwards.

Now our Anaesthetist will talk to you in detail before taking any decision about what to do, and either you have a preference - you can mention it - or you can leave it to your specialist Anaesthetist to decide on your behalf.  Now this is my favourite slide. Ralph used to be an Anaesthesiologist but a long, long, long time ago and he's not been in service for a very long time now - our anaesthesia is very, very safe.

Coming to the approaches to hip replacement. There are quite a lot of different approaches which have been used. The posterior approach, where we approach the hip joint from the buttock, is the commonest and has been in use the longest.

After that, it is the lateral approach where we approach the hip joint from the side. This has been in use since 1960s, and it is the second most frequent approach.

Anterior approach, where we approach the hip joint from the front, is less damaging to the muscles. It has been in use for the last ten years, but there are some disadvantages of this approach as well, and it has not caught up as much as we would have liked.

In the last three to four years there has been another approach, where the hip is approached from the top of the hip. Now there is quite a lot of mention in literature about minimally invasive hip replacement, and the patient gets quite attracted to this technique. But there is no proof that any of these techniques – whichever minimally invasive technique you use - improves your chances of recovery, except that minimally invasive gives a smaller surgical scar. So, in summary, every approach has got pros and cons.

There is no proven advantage of any of the approaches and, at three months, results are equally effective with every approach. So, it is best to leave it to the surgeon's choice because, after all, he's trained in certain aspects of an approach - and it is better to leave it to him.

Now coming to the types of hip replacement. There are many varieties of hip replacement prostheses available, I’ll describe a couple of aspects of these prostheses. First one is the method of fixation of the prosthesis in the bone, whether it is with cement or without cement (and it can be a combination of both where one component is cemented, and one component is uncemented) and that is known as the hybrid method.

I’ll give you an example. This is the cemented hip replacement, and you can see a white area around the metallic hip. And that is the bone cement which has been used to fill the gap between the prosthesis and the bone. This technique is much more commonly used in elderly patients, where the bone is a bit osteoporotic - and you don't want to be too energetic in preparing the bone and risk breaking the bone.

The second common technique is cementless hip and here there is no cement. The bone has been prepared in such a way that the prosthesis snugly fits into the bone directly, and it stays there because there is no space for it to move. Most of these prostheses have got a special lining on them, which we call hydroxyapatite which is chemically similar to our own bone, and it attracts bone. So in about six weeks’ time this type of prosthesis gets joined together with the bone.

There is another way of describing hip replacement types and that is according to the articular surfaces. The commonest one is metal on plastic, where your socket articulating surfaces are plastic and the head is metal; that is the most frequently used combination.

The second one is a plastic socket with a ceramic head. The ceramic head in general is used in younger patients because it improves the life of the prosthesis and the wear of the prosthesis is less, making it last longer. However, the disadvantage of ceramic is that at the moment it is somewhat costlier than the metal prosthesis, and also it is much more fragile as well.

And because of the fragility if both the components are ceramic - that is the third one, ceramic on ceramic - then there is a risk that the prosthesis might squeak, and it might break.

So about 15 years ago, it was very popular technique to give metal on metal hips and most of us thought “We are doing a good job, and prosthesis will last longer”. It was only partly true. Most of the successfully done metal on metal hip replacement have lasted a very long time and they are still surviving, but in a small number of patients there has been a significant problem with metal particles, and this technique has been completely abandoned nowadays.

This is a picture of the articulating surface; the pink stuff you see is ceramic, the white is plastic, and the grey is metal. So, the right-hand picture is showing you ceramic on ceramic, the middle one is plastic on ceramic, whereas the left one is plastic on metal.

Now what will happen after the operation? After all it is a major procedure so you will spend about half an hour to one hour in recovery where you will be monitored very closely, your vital signs, pain management - everything will be looked after. The next few days, again there will be plenty of pain management issues which will be addressed, depending on how severe it is. But I want to reassure everybody that you are not left in pain. There are quite a lot of pain management techniques available and you will be kept comfortable one way or another.

Sickness can be an issue for the first couple of days after the operation and hence there will be quite a lot of medicine and help available for sickness management.

Wound care is an important aspect; your dressing will be checked regularly. Because we’ll be giving you anticoagulant to reduce the risk of blood clots, there is a tendency that a small number of patients will have oozing from the wound and hence it will require some attention. But it happens only in a small number of patients.

Coming onto mobilisation. As I mentioned earlier on, most of us we follow rapid recovery programmes and mobilisation happens as soon as possible. So, the basic principle is that as soon as you’ve recovered from the anaesthetic - your vital signs are stable - you are ready to get up and walk. In principle, for most patients who have their operation in the morning – we’d expect them to sit up and start walking in the afternoon.

If your operation is late in the evening, then perhaps we will be kind to you and let you take a rest during the night and you will start getting up the next day. Within the next couple of days, before your discharge, you will have an x-ray to check the position of the prosthesis, and for any future reference as well.

Now this is all very good, but every operation carries some risks and it is better to mention all these potential risks. First of all, to reassure everybody, risks are not common. As I said, 95 percent of patients do not come across any problems and we make sure that risk to the patient is as low as possible.

So, the first risk is that of excessive bleeding. And if it is too much during, or immediately after, the operation then you might end up having a blood transfusion. The risk of requiring a blood transfusion at the moment is less than five percent after a straightforward total hip replacement. As I mentioned earlier on, if you are anaemic to begin with before your operation, then your risk of requiring a blood transfusion is significantly higher.

Now during the operation - after all it is a highly technical operation - we use various types of instruments and there is a slight risk of perforating the bone or even cracking the bone, especially if we are doing a cementless technique, where the preparation has to be very accurate. And the risk of having a fracture in the bone or perforation is about five to ten percent. But most of the time it is managed during the operation and it is hardly ever that it changes rehabilitation after the operation.

We can change the leg length; we can make the leg longer or shorter during hip replacement but there is a good 95 per cent chance that you will not feel any difference in your leg lengths.

There is a very slight risk of sciatic nerve injury which will give rise to foot drop and some loss of sensation in the leg. Usually it is temporary but sometimes it can be permanent and certain approaches to the hip are more prone to get sciatic nerve injury than others. But in all the risk of having sciatic nerve problems is again less than one percent.

Now I have put this ‘during recovery’ and ‘late complication’ together but, because there is quite a lot of overlap here, infection appears prominently. An infection is one of the serious risks after hip replacement. The risk in most of the hospitals you will see is kept under one percent and anybody who’s even slightly higher risk will be flagged up straight away.

There are so many things which are done in the hospital atmosphere where we do hip replacement routinely to reduce the risk of infection; antisepsis will be observed thoroughly during each and every aspect of patient care, our theatres are special theatres with laminar air flow - which are proven to reduce the risk of infection – and antibiotics are routinely given immediately before we make the cut for hip replacement.

And these are all the measures to reduce the risk of infection. If unfortunately, somebody gets an infection, then it is a serious condition. Initially we can try and control the infection by aggressive antibiotic treatment, but it is not uncommon to require more operations to either change the prosthesis or deprive the wound. But if there is infection, then it is a serious condition. But just to reassure everybody again, the risk of having significant infection after hip replacement requiring any treatment is less than 0.5 percent at the moment.

Blood clots in the leg and blood clots in the lung, DVT and pulmonary embolism; these are relatively common. Blood clots in the leg can happen commonly, but we do so many things to control this risk. Your risk will be assessed during pre-assessment and then you will be given anti-coagulant to thin your blood for five weeks and that reduces the risk of blood clots significantly. Another very important aspect of a preventative measure to reduce this risk will be to get you up and going quickly. You get blood clots when you're not walking, you're in pain, lying miserably in bed, but once you are walking up and about then the risk of having a blood clot is really very, very low.

Dislocation. Most patients worry quite a lot about dislocation but, in reality, it is extremely rare. I do not want to boast, but again I can't remember when I saw a dislocation after a straightforward primary hip replacement.

Limping is common. Most patients have limping before their operation, but we expect that limps should go away quickly after successful hip replacement. But about one in five hundred patients will limp, despite having a total hip replacement - and that is due to the failure of soft tissues which fail to heal up after the operation.

In late complications we worry about loosening up the implant, which becomes separated from the bone or the implant gets worn out - especially the plastic bit - and then you need to have another operation to change those relevant implants.

Now I have promised that I’ll talk to you about the National Joint Registry. This has been the biggest development in the total hip replacement area. It was established in 2003 in the United Kingdom; there are about 35 national registries worldwide, but the UK's national joint registry is one of the world’s leading and it was established in 2003, and it was the very first one to be established actually.

And it has got a huge, big database and it was on the back of very high-profile implant failures. So, you can see the scenario again; that's 75,000 hips, 300 hospitals, thousands of hip surgeons and 50 types of hip replacements happening. So, you can see that things can go wrong, so we need a very strong monitoring system, and this is where the National Joint Registry fits in.

So, each and every patient who has a hip replacement, the data will be put in the joint registry. You will be given information during your pre-assessment and you will be asked to sign a consent form. If you sign the consent form your personal data will go to the joint registry. If you do not sign the consent form, then your data will go anonymously. And what will happen with this data is that if there is any problem with this implant, or patient, subsequently anywhere in the United Kingdom then it will be linked with the previous data available in the joint registry.

It has been a huge, big development; believe me it is one of the best things which has happened to joint replacement surgery in the United Kingdom. We monitor all the implants so if there are any implants which is not performing as well as expected, then it will be flagged straight away.

Surgeons get monitored every year when we do our appraisal, which is mandatory nowadays, then we have to put our annual surgeon level report in our appraisal. And if any surgeon is showing less than ideal results in national joint registry, then it will reflect to the hospital as well. So, you cannot have an outlying surgeon without the knowledge of the hospital. And, similarly, there are hospital level performance data available so that the hospital can look at their own personal figures, and if there are any hospital level problems then this can be addressed as well.

In the last five years, NJR or National Joint Registry has also included PROM data. These are the patient-reported outcome measures, and you will be given some forms to fill in and you’ll send those to the NJR and then the NJR will put them on your behalf in the system.

And all these measures are so important to monitor every aspect of patient care following hip replacement surgery. Now, just to give you some examples, when I was preparing this talk only about ten days ago, this was the snapshot about Benenden Hospital. I just put ‘Benenden Hospital’ and all this data is available in public domain. You can log on to the NJR site and ask for data for any surgeon you want, or any hospital you want to look at.

So, this was the data about Benenden Hospital, and you can see all those things which are highlighted here, and this is the detailed information that there have been 281 hip replacements, 368 primary knee replacements. In total 682 joint replacements have been done during that period. And at the same time you can compare this with the national average as well, so all this information is in the public domain and it is very difficult to underperform nowadays and you cannot hide, which is excellent news from the patient care point of view.

Now this is the very first slide I showed to you and I’m showing it again to you just to remind ourselves that, as I said in this talk, total hip replacement is a common procedure. It is a safe procedure, it is an effective procedure and the commonest outcome we expect after this procedure is a pain-free hip which lasts for a long time, and a happy patient.

This is the end of my talk. Thank you very much indeed and I’ll hand it over to Zoe now.

Zoe Andrews

Thank you, Mr Shrivastava, that was really interesting. Okay so we've got some great questions now. I’m going to start off with a question from Maureen, and Maureen's asking:

How long will it be before I can see a Consultant and then how long after can I expect to have my operation?

Mr Shivastrava

Okay, good morning, Zoe. The answer to your question is that once you are booked into hospital you will be given an appointment for a Consultant within two weeks. So, you’ll see a specialist within two to three weeks’ time and then, depending on your care pathway, you will be given a date for your operation.

It all depends on your funding stream, etc, your medical conditions, when can we arrange your pre-assessment etc. So, there are so many variables, but as far as seeing a specialist is concerned it is within two to three weeks of your referral.

Zoe Andrews

Great, thank you. So, we've got a couple of questions now from Victor. So, first of all he's asking about the different types of prosthesis available, which I think we've pretty much covered in the presentation but come back to us Victor if you'd like a little bit more information.

Victor's then asking about how we decide on which process and which prosthesis we use for the patient, and then lastly, he's asking about blood thinning medication, and do we provide this for the period of time after the operation?

Mr Shivastrava

Hello Victor, good morning to you.  Yes, the simplest answer is that as far as the choice of prosthesis is concerned, it is somewhat surgeon-driven but, at the same time, patients are free to challenge surgeons if they want to have something specific.

My choice of selection of prosthesis - my criteria basically -- is that I want to use something which is time tested, which has got a very good track record and which I know can reliably give long term benefits to the patient. So, at Benenden Hospital we have a choice of two prostheses, two systems available and both of them have got a very good proven track record.

The minor variation will be about what articulating surface to use, and this is for personal discussion between you and your specialist. But all the types of prostheses which are used here - I can reassure everybody - these are very well tested. We have got very good long-term track record and we are not using any outliers, or anything suspicious which has not been tested for a number of years and which do not have a proven track record.

Now as far as blood thinners are concerned, the duration of blood thinning is after hip replacement. The guideline is for five weeks. To be honest with you, if somebody is very young and fit and very active then it has a lesser role, and there is some evidence available that in these patients you can get away with two weeks of anticoagulation. But, most of the time, we rely on the safety aspect and it is safer to say that for five weeks anticoagulation is effective and safe.

Zoe Andrews

Thank you for those questions Victor. So, the next question is from somebody that's asking they're in remission with vasculitis affecting the kidney. Now does this cause an issue with having a hip replacement?

Mr Shrivastava

I mean, it is one of the comorbidities so it will be decided after your thorough pre-assessment. And if there is any problem (it depends on the level of the kidney function), if provided your kidney function is quite reasonable, then it should not be a major issue.

It is just that you have to be careful in using certain medications like anticoagulants etc. But it all depends on your detailed assessment, so do not make up your mind just now. If you have got hip problems, and you have got other conditions, then go and see the specialist, have the pre-assessment before deciding finally how to take it further.

Zoe Andrews

Great, thank you. This question kind of leads on from there. This is from Tony and he's asking about pre-assessment and he's asking how long will I have to wait following my pre-assessment until I can have my operation?

Mr Shrivastava

As I mentioned in my talk, pre-assessment is done about two to four weeks before the operation. Most of the time, by the time you have your pre-assessment, there will be a date pencilled in the diary for you.

It all depends; if you are coming from far away for your operation, then we will try and do your pre-assessment on the day of your consultation with the specialist. But again, there is quite a lot of individual variation in these things and it all depends on logistics of the department and it will be individually discussed with you - and whatever you prefer, that will be taken into consideration as well.

Zoe Andrews

Thank you. Now the next question is from Barbara. Now Barbara's asking about exercise while waiting for a hip replacement. So, she says she's still playing tennis, but she does suffer more pain the following evening after she's been playing. So, while waiting for the hip replacement is she actually doing more harm than good by this exercising?

Mr Shrivastava

Hello Barbara. No, you are not doing any harm. My advice would be to keep yourself active, keep enjoying tennis. My only advice will be to take some painkillers to control the pain. Remember pain is a protective reflex in the body, so don't go to the extent where pain is getting worse and worse. Provided your pain is manageable and provided you can manage it by taking some simple painkillers, there is no harm in continuing with your activities.

Zoe Andrews

Thank you. So, we've got another member here, Glynis, who's also asking about exercising and it says: how can I avoid hip deterioration? She's also exercising after a DEXA scan warning. Should I be thinking about diet or more exercise?

Mr Shrivastava

Good morning Glynis. To be honest with you, a DEXA scan is for osteoporosis. It is not relevant to osteoarthritis, so as such I do not see any problem. And osteoporosis is an entirely different condition and it has to be managed by different medications.

Exercising is not harmful. As far as osteoporosis is concerned, exercise is one of the ways to reduce the risk of osteoporosis or any complications of osteoporosis

Zoe Andrews

Thank you. Now Angela has been told that at 54, she's possibly too young to have a hip replacement at the moment. She also has osteopenia. My Consultant is proposing a platelet-rich plasma treatment in the first instance, is this something that we can use as a treatment and that we can offer.

Mr Shrivastava

Good morning to you. It's a very interesting question actually. I personally do not have any experience with platelet-rich plasma. My personal feeling is that whatever we do on the NHS, we should do it elsewhere as well.

Platelet-rich plasma therapy is not available on the NHS and the literature is very variable about it. Some papers have claimed very good results and there is other literature available which shows that it does not give any lasting benefit. So, the jury is still open about platelet-rich plasma. But if you believe in it, if your specialist believes in it, then there is no harm in trying it. It is another way of postponing your ultimate total hip replacement.

As far as your relatively young age is concerned, everything is relative. You don't want to compromise your present too much to secure your future. Yes, at the age of 55, if you have your hip replacement you will have another procedure subsequently in about 15-20 years’ time. But at the same time, it all depends on the amount of arthritis and amount of compromise it is creating for your life.

Zoe Andrews

Thank you. Another question about exercise here. It's great to see that so many of the people on the webinar are very fit and active. So, Maureen's asking after her hip replacement can she still play sports like badminton?

Mr Shrivastava

Good morning Maureen. Yes, in principle you can, once you recover fully. I usually tell my patients that there is no restriction on you. The only disadvantage of playing sports like tennis or table tennis or badminton is that you do not know when you are going to twist and turn. These are very unpredictable moments; potentially it puts your hip at risk of coming out of the socket, but in practice I have hardly ever seen any patient coming to harm by doing these exercises.

So obviously it all depends on the happiness of your surgeon with your procedure. If he's very happy with your procedure and your hip is very, very stable then yes, by all means you can continue playing badminton. Otherwise perhaps you have to slow down a bit. So, I think it is something to be discussed after your operation with your specialist.

Zoe Andrews

Now we mentioned a little bit about the possibility of blood transfusion, post hip replacement, so Mark's asking: Are there any alternatives to having a blood transfusion?

Mr Shrivastava

Yes, there are in principle. There are alternatives but, Mark, first of all it is so rare to require a blood transfusion. Risk is less than five percent. Our last audit showed that only about three percent of patients required a blood transfusion in our practice.

And we can prevent it. How can we prevent it? First of all, by making sure that your haemoglobin is alright before doing the operation, and somebody is not anaemic. Second thing is that we are very careful nowadays with any surgical procedure and we use a substance we call tranexamic acid, which reduces the risk of blood loss from the wound.

Previously we used to put drains in the wound; nowadays we have stopped using drains. We have used re-infusion transfer. We used to take out all the blood which drains out and put it back in the patient. But nowadays it is completely unnecessary, so the need for blood transfusion - I can reassure patients - it is very, very rare. So, we should not worry about it.

If there is a special indication, suppose somebody has got some haematological problem and there is a significant risk of blood transfusion, then perhaps. If you do not want somebody else's blood, then some of the blood banks they have the facility to have your own blood taken from you a few weeks before your operation which can be given after the operation. But there are quite a lot of logistical difficulties in arranging them in most of the blood banks because it is not a common situation.

But once again to reassure you, the risk of requiring a blood transfusion is very, very low after the straightforward primary hip replacement.

Zoe Andrews

Thank you that's very reassuring. So, the next question is from a caller that's saying they have a torn meniscus in their left knee, and they require a hip replacement on their right hip. So which process would you recommend should be done first?

Mr Shrivastava

It's slightly challenging. Perhaps, before taking a final decision, I’d need some more information. If you have got just a torn meniscus, without any arthritis in the knee, then perhaps I would be keen to deal with the meniscus first. But in my experience, most of the tears in the meniscus are related to osteoarthritis in the knee, because the surface of the knee joint is rough and hence the tear in the meniscus.

And if it is part of arthritis in the knee, then I’d prefer to do the hip replacement first because - quite a lot of pain in the knee, which you might be attributing to your meniscus tear, might well be coming from the hip. So, it makes sense to do a hip replacement first, but obviously I need to know more about your meniscal tear.

Zoe Andrews

Thank you, and our last question for this morning is also around exercise. So, I’ve heard you have to do some exercise specifically before the operation; can you advise on anything?

Mr Shrivastava

I don't think there's any need to do any specific exercises. Best advice I can give you is to keep yourself active; gentle walking in most of patients in their 60s and 70s is a good enough exercise to keep yourself fit and active. That is the best exercise you can do yourself. There’s hardly any place for any specific exercise, unless and until there is any specific weakness in any of the muscle groups around the hip joint, which is very, very rare.

So, the message is - keep yourself active.

Zoe Andrews

Great, thank you and thank you all for joining in. So, you'll receive a short survey soon and we would be really grateful if you could just spare a few minutes to let us have your feedback on how today's webinar's been for you.

So, our next webinar here at Benenden is on Saturday the 23rd of January and we'll be talking about weight loss surgery with Mr Hamouda.

So, on behalf of Mr Shrivastava, myself and all the team at Benenden Hospital, I’d like to say thank you so much for joining us today and making it so interactive. We look forward to you joining us again very soon for our next webinar. And please all stay safe.