The cutting edge of hip replacement surgery

Consultant Hip Surgeon, Mr Hugh Apthorp shares the attention to detail required in every aspect of hip replacement surgery and how he pioneered the rapid recovery programme used throughout the UK today.

What are the various approaches to hip replacement?

Surgeons may approach the hip from the front (anterior), back (posterior), or side (laterally). Most importantly, you want your surgeon to have performed their selected approach, thousands of times. But some approaches can further minimise trauma.

I call my approach the ‘Direct Superior Approach’. It combines the advantages of an anterior approach with the safety of a mini posterior approach, whilst reducing the common complications of these approaches. The day I combined these techniques, my patients started doing even better.

Can you replace both hips in one surgery?

The results from the Direct Superior Approach, along with rapid mobilisation were so encouraging, I was able to operate on patients requiring both hips to be replaced in the same surgery. What we call a bilateral replacement. In the right patients, and those needing both hips replaced, this means one operation, two to three days in hospital, one recovery period - and enjoying normal life in half the time it would otherwise take.

If you get it right through meticulous surgical skills, early mobilisation and rapid recovery, patients quickly get back to enjoying a life without pain.

How can surgeons and clinical teams optimise and speed up recovery?

Another significant advance in hip replacement surgery was the introduction of rapid recovery programmes. In the early 2000’s when length of hospital stay for hip replacement was often over a week, I rewrote a new system for the NHS in the South of England. Beginning with pre-assessment, we train patients to use crutches before their operation, and prepare them practically and psychologically for their recovery. We explain how they’ll be up walking within hours of surgery, and how we'll manage any ‘to be expected’ discomfort.

The whole team is engaged in delivering a rapid recovery - where a patient’s discharge is planned around a two night stay. Surgeon, anaesthetist, ward staff, physiotherapists, occupational therapists, pain and infection control nurses all play their part. The objective is to vastly improve patients’ short, and thereby longer term recovery. Think of it like this, ‘start as you mean to go on’.

How does getting patients moving within hours of surgery help?

Essential to the recovery process is early mobilisation - walking. This pumps blood back to the heart, helps prevent joint stiffness and blood pressure issues as well as complications such as not being able to urinate. Whilst it may sound simple and obvious, the cumulative changes driven by rapid recovery programmes reaped exciting rewards.

What is the role of anaesthetics and pain relief in improving recovery?

Typically, anaesthesia for a hip replacement would be a general anaesthetic and a spinal injection, normally consisting of morphine and local anaesthetic. But now we just use the spinal (local) injection, removing the morphine element which can cause itching, nausea, vomiting and problems with people’s blood pressure - potentially making patients sicker at a time when we need them to be as healthy as possible for their recovery.

We also give a local anaesthetic to numb the leg in seven positions around the hip joint. And because we’re doing the surgery in an efficient, minimally invasive manner, we can reduce the spinal anaesthesia so that numbness is wearing off by the end of the operation.

Crucially, as there’s less trauma due to the minimally invasive surgical approach, we’re able to get on top of pain relief, preemptively managing it by giving patients pain medication such as intravenous paracetamol before the anaesthetic has worn off. So, patients can walk almost immediately.

In summary, how can patients improve the likelihood of the very best surgical outcomes?

If I was an orthopaedic patient, I’d put myself in the hands of a high volume, sub-specialised surgeon; one performing hundreds of hip replacements a year, with low revision rates. I’d also want to be in a hospital with experienced clinical teams used to anticipating both orthopaedic and other less common complications, as well as being well versed in rapid recovery protocols.

Many surgeons claim to perform minimally invasive hip surgery, but the question remains whether beneath the scar, there has been excessive trauma due to the added complexity of access through smaller incisions. If you get it right through meticulous surgical skills, early mobilisation and rapid recovery programmes - supported by optimised anaesthesia and pain medication - patients can achieve a substantially earlier return to full functionality and psychological well-being, quickly getting back to enjoying a life without pain.

Mr Hugh Apthorp has among the best Patient Reported Outcome Measures (PROMS) for hip replacement surgery in the country, based on National Joint Registry data. Compare my Care can provide success rates and satisfaction figures for Mr Apthorp on request, demonstrating significantly above average PROMS just six months after hip replacement surgery.