Follow-up after Hip Replacement

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Once implanted, joint replacements should be periodically followed-up.  This follow-up includes taking x-rays to assess the implants.  The minimum recommended follow-up for implants with a known good track record involves review at 1 year and then at 5 year intervals.  Personally we believe that after 15 years closer follow-up is a good idea with review every 2 years as problems can begin to appear around this time in some cases.

It has been suggested that this follow-up could be performed by general practitioners and Mr Sood and his team investigated this and published a paper on this topic.  GP’s rely on reports of x-rays taken in local hospitals and do not see the x-rays themselves.  We found that such reports did not always spot problems with the replacements and so potential problems could be inadvertently missed.  We concluded that follow-up of joint replacements should only be performed by specialists, ideally hip surgeons but also possibly by other suitably trained staff.

 

Should primary care physicians perform routine long-term Follow-up of total hip arthroplasty patients?  MC Nogaro, M Wijeratna, M Sood.  Journal of Arthroscopy & Joint Surgery 1 (2014) 27-31

Dislocating Hip Replacements Cured

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Mr Sood and his team presented work at The annual Meeting of the British Hip Society in Exeter on the difficult problem of dislocating hip replacements.  Mr Sood specialises in re-do hip replacements and is often referred patients who are suffering repeated hip dislocations.  This is a distressing complication that can occur soon after a hip replacement or some years later.  Analysis of the results of Mr Sood’s series showed that in 95% of cases a single procedure prevented dislocations.  In one case a further procedure was required to prevent further dislocations.

These results are amongst the best reported for this sort of surgery but are only achievable with meticulous assessment and the use of a variety of different implants to achieve hip stability.

Treatments for Cartilage Damage

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Mr Sood’s article in Vantage Magazine explains the available options to deal with articular cartilage damage and early arthritis.  Such damage is often related to sporting injuries.  The treatments aim to restore the damaged cartilage where possible and this is knee joint preservation.  Such treatment also helps to relieve pain and to prevent further deterioration of the joint.

The full text of the article appears below.

 

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Consultant Orthopaedic Surgeon, Mr Manoj Sood discusses the options available for joint preserving knee surgery

Every year, many people are diagnosed with cartilage damage, often as a result of injury.  Articular cartilage is located at the ends of the bones that make joints in the body.  When damaged, the cartilage does not heal and, in the knee, can progress to arthritis which can lead ultimately to the need for a knee replacement.  More than 90,000 knee-replacement operations are performed every year in the UK.

As a result of this, there is a growing interest in joint-preserving options in a bid to repair damaged articular cartilage, relieve pain and delay the need for knee-replacement surgery.
What causes damaged cartilage?

When healthy, articular cartilage allows smooth movement of the joint. When damaged through injury, a cartilage defect occurs which may involve either part or the whole thickness of the cartilage with the underlying bone becoming exposed. These cartilage defects cause the surface to become rough, damaging the joint further which may progress to painful arthritis. A number of techniques to repair cartilage are available, with this area of medicine developing rapidly as the focus shifts to prevent or delay the need for knee replacement.

If you suspect that you may have sustained cartilage damage or any problems with your joints, you should arrange an appointment with your GP or specialist, as soon as possible.  Ignoring the problem could result in the injury becoming much worse and more difficult to treat.

What is joint preservation?

Joint preservation is a fairly new concept involving highly specialised treatments for preventing knee pain. It aims to restore normal and pain-free joint function involving treatments that aim to prevent cartilage injuries progressing to arthritis, as well as non-replacement treatments for established arthritis. There are a variety of ways in which joint preservation can be performed including lifestyle changes, medication and surgery.

Which treatment options are available to me if I have damaged cartilage?

Prior to any treatment options being offered, your specialist will perform some diagnostic tests to determine the best care plan for you. Some surgical options you may be offered include:

Chondroplasty

Although not a cartilage repair technique, this can help relieve pain and also allow you to start exercising and strengthening the knee in preparation for future surgery. This procedure is carried out through key-hole surgery (arthroscopy) and any loose cartilage that is irritating the joint is removed.

Microfracture (MF)

By creating small holes in the exposed bone in the base of a full-thickness defect, this allows marrow stem cells into the defect which then form fibrocartilage. This method is most suitable for smaller cartilage defects and can be very effective.

Autologous matrix induced chondrogenesis (AMIC)

MF is performed and then a gel or membrane matrix is placed in the defect as a ‘scaffold’ to help the stem cells to form cartilage. This technique is showing great promise.

Osteochondral autograft transfer / Mosaicplasty

Cylindrical plugs of healthy bone with its overlying cartilage are transferred from a non-load bearing area of the same knee into a cartilage defect in the load-bearing area, recreating a smooth surface.  It is an effective technique, but is limited by the number of cylinders that can be taken from the ‘donor’ site.

Autologous chondrocyte implantation (ACI)

This involves two stages and can be used to treat larger cartilage defects, especially in younger patients. The first stage involves an arthroscopy to harvest a small piece of cartilage from a non-load bearing part of the knee.  This is sent to a tissue lab where cartilage cells are grown and then implanted into the defect during an open, second-stage operation, around six weeks later.

Partial Resurfacing

This is a new technique currently being used in patients with large defects, as part of a trial.  It involves using a metal implant with an overlying artificial plastic cartilage that is placed into the defect; restoring the smooth joint surface. It has the advantage of not requiring any biological repair to occur, and represents a mini-replacement of only the damaged cartilage area.

The future

Stem cell-based treatments have already appeared and will be refined. Tissue-engineered articular cartilage, rather than fibro-cartilage that can be grown in the knee is the ‘Holy Grail’.  Much research is underway to try to find the best way to repair and, hopefully, regenerate articular cartilage.  In parallel with this, cartilage substitutes are being tested.

 

Mr Manoj Sood BSc MB.BS, FRSC, FRCS (Tr. & Orth.)

Mr Sood is a Consultant Orthopaedic Surgeon specialising in hip, knee and sports surgery.  He has a particular interest in joint preservation surgery,  joint replacement surgery and sports injuries

Joint Preservation in Knee Arthritis

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Mr Sood’s article in Practice Matters magazine describes the joint-preserving options that are available for people suffering from knee arthritis. This will be of interest to those patients who are keen to avoid or to delay knee replacement surgery but who wish to explore other pain relieving options.

The full-text of the article appears below.

If you would prefer to read the article in the magazine click here.

Joint preservation options in knee arthritis

Although the treatment for established knee arthritis is joint replacement,  joint preservation as an alternative has evolved in recent years.

 

Medical interventions

These aim to preserve joint function for as long as possible, without recourse to surgery.  As no medical treatments are currently available to slow down or reverse cartilage degeneration, surgical treatment may eventually be required.

 

Physiotherapy & Dietary supplements

There is good evidence that structured physiotherapy can help relieve some of the symptoms of arthritis, making this an important first step in treatment.

Glucosamine and chondroitin sulphate are constituents of normal cartilage matrix and although some patients who take these experience significant improvement in knee pain, clinical evidence for their effectiveness is mixed.

 

Injections

Steroid injections in patients with significant arthritis can have detrimental effects if a subsequent replacement becomes necessary, and rarely provide long-term benefit. Viscosupplementation injections, comprising hyaluronic acid (which occurs normally in the knee) can give pain relief. They normalise the chemical environment in the arthritic knee. Some have improvement in their symptoms for many months and are happy to have this simple injection repeated, periodically.  Platelet -rich plasma (PRP) injections, where healing cells from the patient’s blood are injected into the knee, can also help improve pain, although more evidence is needed before these can be routinely recommended.

 

Surgical interventions

As knee replacements have a finite lifespan, especially in younger and active patient, the aim in joint preservation surgery is to eliminate or delay the need for such surgery.

 

Arthroscopic debridement

This can help relieve the pain of arthritis and is carried out through key-hole surgery (arthroscopy). It involves smoothing over loose cartilage, resecting bony osteophytes and trimming meniscal tears. Although a little controversial in arthritis, leading knee surgeon Steadman has described a very specific and detailed debridement procedure (‘the package’), which resulted in a number of his patients delaying the need for replacement surgery, for a significant period of time.

 

Re-alignment osteotomy

In arthritis confined to one side of the knee, this established technique can take the load off the painful arthritic side and place it on the opposite normal side. This involves incompletely dividing the bone, realigning it, and securing in this new position with a plate. In appropriate cases, osteotomy can delay the need for joint replacement surgery by 8-10 years.

 

Kinespring device

A new and novel device that is being evaluated in appropriate patients with isolated medial compartment arthritis. The device is a mechanical load absorber placed on the inner side of the knee to offload this part of the joint, and relieve pain. It lies outside the joint and the procedure involves no bone resection and is not a joint replacement so future options of partial replacement or osteotomy are not compromised.

 

Partial resurfacing

This is a new technique being used in patients with large cartilage defects or localised arthritic areas. Through a mini-incision or arthroscopically-assisted technique, a metal implant with an overlying artificial plastic cartilage is inserted, restoring the smooth joint surface. There is minimal bone loss and this represents a ‘mini replacement’ of the damaged cartilage area.

 

Thus, a variety of treatment options are available as an alternative to joint replacement.  Joint preservation is an exciting and continuously evolving field.

Leg-length in Hip Replacement

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Mr Sood and his team presented work at the European Hip Society in Stockholm on the topic of how to make sure that patients leg length is restored correctly after total hip replacement.  After hip replacement the operated leg can be lengthened and patients can find this difficult.  Shortening can also occur but this is less common.

We use a special protocol during every hip replacement that we perform to monitor leg-length closely to ensure that leg-length problems do not arise.  We looked at 100 consecutive patients managed in this way and found that the results that we achieved were amongst the best reported results in the published literature for leg-length and offset.

 

Soft-tissue balancing in Total Hip Arthroplasty: Results in 100 consecutive patients

M Sood, A Memarzadeh and D Arvinte. 11th European Hip Society Congress Stockholm 2014