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Hip surgery lying on the back

12 December 2016

Spire Cardiff Hospital Consultant Marci Maheson talks to the Daily Mail about a new technique of operating with the patient lying on his back rather than his side, which dramatically reduces patient recovery time.

How lying on your back for a hip operation can offer thousands a quick recovery: New technique replaces joints while causing minimal damage

  • Many over-50s have hip arthritis, caused by cracked and fragmented cartilage
  • When Neil was in his 40s, shooting pains in his legs would wake him every night
  • The new procedure had him walking without crutches after no less than six days

Thousands of Britons have hip replacements each year, but now there's a new technique where joints can be replaced with less damage to surrounding tissue.

Neil Cox, 51, a TV cameraman from Cardiff, had the operation, as he tells CAROL DAVIS.

THE PATIENT

When I was in my 40s, I started to feel shooting pains down my legs all through the day — it was like a needle stabbing me.
I had to get on with things at work and lift heavy boxes: I tried not to let it stop me getting on with life.

But over time it got worse, and six years ago my GP referred me to a specialist clinic to try chiropractic exercises.

There, an X-ray showed I was developing arthritis in my left hip. The specialists said I might need a hip replacement at some point, but I was worried about the surgery.

So instead I did lots of exercises, which seemed to help.

But, three years ago, the shooting pains returned and this time they were constant and chronic.

The pain would wake me several times a night, even though I took lots of painkillers and often went on long walks with my wife, Susie, to keep the muscles supporting my hip strong.

The pain was there all the time and I was noticeably limping. A GP friend recommended the hip surgeon Marci Maheson, who I saw privately in April 2013.

More X-rays confirmed that the cushioning cartilage tissue around the joint was wearing away, so bone was starting to grind on bone.

Mr Maheson said I needed a hip replacement because the damage to the joint was not repairable.

I decided to have this done on the NHS rather than paying privately and was referred.

I still didn't like the thought of a hip replacement, but serious pain was there all the time and getting worse so I didn't have much choice.

I was prescribed painkillers while I waited for the operation, but even on these I struggled to carry heavy kit upstairs, though my crew were great and left me the lighter boxes.

Five months later in June 2014, I returned to see Mr Maheson, who explained he was going to use a new technique that meant a smaller incision with no damage to muscles — so it was less invasive and recovery was faster.

Basically, I would be lying on my back during the operation instead of my side, which, together with improved equipment, gives the surgeon more control over the implant.

I had to postpone it due to work, but finally had the two-hour operation under general anaesthetic in June last year. I was back on the ward by lunchtime feeling fine.

Susie took me home the next day with painkillers. I recovered very quickly — two days later I walked 400m on crutches and six days after I was walking around without crutches. It was remarkable.

I stopped using them completely after three weeks and went back to work six weeks later. Now I can carry the heaviest boxes and go on long hill walks without pain.

THE SURGEON

Marci Maheson is a consultant orthopaedic surgeon at Cardiff and Vale University Health Board and Spire Cardiff Hospital.
Around 90,000 hip replacement operations are performed in Britain annually.

People can start developing hip arthritis from around the age of 50, as the smooth cartilage that lines the joint becomes cracked and fragmented, meaning bone grinds on bone — causing pain.

While we don't fully understand what causes this, in most cases it is the result of wear and tear as we age.

Patients can exercise to strengthen muscles and lose weight, as this can put undue pressure on joints, and we can also prescribe painkillers or give steroid injections into the hip to reduce symptoms, but these are temporary measures.

When pain starts to interfere with a patient's sleep and everyday activities, we offer a hip replacement.

One of the most common techniques involves operating with the patient on their side, getting into the joint either from the side or the back of the hip.

This requires a 10-20cm incision and leads to muscle and connecting tissue damage as we cut through these to get to the joint.
Patients spend three to five days in hospital and take up to three months to fully recover.

We have now developed a technique called the direct anterior approach, where we can fit the hip replacement with the patient lying on their back.

This means they are more stable than lying on their side, so we can better control where we place the implant.

It also means better access to the joint since we can work between the muscles instead of having to cut them — we use the natural divide between the muscles to part them.

Doing this ensures a quicker recovery for the patient as they don't have to wait for the muscles to reattach and heal.

The reason we can do it this way is that we now have specialised instruments that work around corners — we make the incision at the front of the thigh and then have to turn a right angle into the thigh bone to access the joint.

We also now have better imaging technology to use during surgery, which means we can see the entire bone — even areas inside the thigh bone and joint that are hidden to the eye.

Plus, we use an X-ray and special scan during the operation to help us navigate around the joint and make the replacement more accurate, which lowers the risk of dislocation — it's just 0.3 per cent compared with the 3-5 per cent in those who go for the conventional approach.

It also stops us needing to cut through neighbouring tissue.

This technique is suitable for most patients and is now available at NHS hospitals.

A recent study in the Journal of Arthroplasty showed there was no increased risk to patients in surgeons learning this new approach.

Lying on their back, the patient has a general anaesthetic or spinal block with sedation for the 90 to 120-minute operation.

I make an 8cm incision over the front of the upper thigh, parting muscles with a scalpel to reach the hip joint.

I open the capsule that envelopes the joint and cut away the head of the thigh bone. Then, using angled reamers, which work in a similar way to a cheese grater, I shape the socket and place the synthetic ball into it. Next, I put the pin of the implant into the thigh bone, checking its positioning with the X-ray.

Then I close the capsule and sew up the skin incision using dissolvable stitches.

The patient usually goes home late the next day. Their recovery is quicker, they often get back on their feet (with crutches) within 36 hours compared with three to five days with the conventional technique, and, like Neil, they can become active more quickly without pain.

The operation costs around £12,000-13,000 both privately and to the NHS.

Source: published in the Daily Mail 12 December 2016