Hot topics

  1. Early Discharge programme- Recently there has been a huge emphasis in developing enhanced recovery or early discharge programmes in total hip replacement. We started out early discharge programme at Warwick Hospital in 2005 and We have based it entirely on clinical principles. Its success has undoubtedly improved the clinical journey for patients and incidentally has been of great financial benefit to the hospital. In developing our early discharge programme we wanted it to be inclusive of as many patients as possible and therefore it does not rely on any particular surgical or anaesthetic technique and the majority of patients can be accepted onto the programme even if they live alone.

    There are three important aspects to the programme

    Firstly, we have a robust pre-operative assessment this is a three step programme.  Firstly patients are given a DVD which follows a patient through the journey from consultation to discharge.  Secondly patients have to come to a lecture given by the physiotherapist which again goes through the journey they can expect.  Lastly, the patient is checked medically to ensure that he or she is ready for the major surgery ahead.  

The second aspect is that the Orthopaedic Team are extremely confident of the implants we use and the quality of the staff that are involved in looking after you, the patient. This should make your time in hospital a good experience.

The third aspect of the programme is what happens to the patient when they go home. I believe it is only possible to send people home early after surgery if the patient is supported appropriately in the home environment. We have developed a team of nurses and physiotherapists who visit the patient on a daily basis after the operation for as many days as necessary to ensure that the patient is managing at home and progressing as they should.


In 2011 Dr Foster, an independent hospital assessment, named the Warwick Hip Unit as the best NHS hip unit in the country based on our short length of stay, low rates of re-admission after surgery and a low revision rate within the first year.

  1. Metal on Metal hip replacements – The most well-known metal on metal hip replacement is the type of hip replacement known as a resurfacing. This was made popular following the success of the Birmingham hip replacement which has had good short and mid-term results. Other companies developed their own resurfacing replacements. The advantages of the resurfacing were a lower dislocation rate, increased range of movement with more normal gait patterns and less component wear resulting from a metal on metal articulation. In addition some companies made it possible to put the resurfacing head on a more conventional femoral stem to remove the risk of femoral neck fracture and failure due to collapse of the femoral head. These two failure mechanisms were concerns with a straightforward resurfacing hip replacement. By 2005 these types of hip replacements were gaining popularity. Concerns were raised about their success when groups of surgeons in Oxford and London reported seeing an increased number of failures. This resulted in the Medicines and Healthcare Products Regulatory Agency issuing a medical device alert on 22 April 2010. This suggested that all metal on metal hips should be followed annually for the first five years and that painful hips should be investigated with blood tests and imaging looking for evidence of high concentrations of metal ions in the blood or the formation of swellings around the hip. On 25 May 2010 a further alert was released reporting that a particular type of resurfacing, the ASR or ASR/XL implants were having a higher than anticipated revision rate. On 24 August 2010, DePuy the company that makes the ASR and ASR/XL total hip replacements, announced a voluntary recall of their implants. This was following the recognition in the National Joint Registry that the ASR had a revision rate of 12% at 5 years and the ASR/XL head, this is a resurfacing head on a stem femoral component, had a revision rate of 13% at 5 years. The advice from both the government and DePuy was that all patients with these hips implanted must be followed up regularly. Johnson & Johnson, the parent company of DePuy, supported this activity both with clinical support and financial support. The advantages of these hips seemed very attractive in improving the quality of the patients' lives following hip replacement. For many people this is true that the results have been very good. Unfortunately for a significant minority the situation has not been so good and they have required revision joint surgery. At present my revision rate runs at approximately 15% of all ASR or ASR/XL implants that I have put in. The failure mechanism is as yet not clearly determined although it is related to metal debris caused by wear which excites a response within the body which can be toxic to both bone and soft tissue. The long term outlook for resurfacing hips is not clear. There may still be a place for this surgery in young, fit men who seem to do very well with this type of replacement. It is becoming clear that some makes of hip resurfacing implants do better than others.

  1. Warwickshire Orthopaedics LLP- Several of the consultants at Warwick hospital have recently formed a group called Warwickshire Orthopaedics LLP.  This group works in conjunction with Warwick Hospital to help manage the NHS work load which can sometimes saturate the hospital facilities.  Warwickshire Orthopaedics can manage this demand: in addition it offers it services to the Warwickshire Nuffield Hospital who run a ‘choose and book’system .  Lastly it also offers its services to undertake orthopaedic work form further afield.

    Hip

  1. The Corail hip refers to the femoral or thigh side of the ball and socket joint that makes up the hip replacement. I have been using this type of hip since November 2001 and since the middle of 2002 I have used it virtually exclusively. It has been an exciting time from that initial implantation until the present time. When I first started using it I was only the second person in this country to have implanted it. It had been designed in France and was used in a few centres around the world. It was however not well-known. Over the last 9 years there has been a huge increase in its use. There have been now over 800,000 implantations made in all 5 continents of the world. It is still increasing in popularity and its success is perhaps reflected in the number of copies that have been made by other companies to try and reproduce the success of the Corail hip. I first learnt about the Corail hip at a small learning centre which took place in Annecy, France, where one of the designers of the operation would carry out surgery and discuss the results. Soon after I started using the hip I was lucky enough to be invited to join the faculty for the learning centre to add an English perspective to the meeting. Since that time we have had to move the learning centre from the small clinic to a large hotel within Annecy and the meeting is now run four times a year. Surgeons from all over the world come to learn how to implant the Corail hip. The initial designers based in and around Lyons in France, were known as the ARTRO group. Initially they were 7 in number although now have increased their number to 13.

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I was the first International speaker to talk at the Learning Centres but now the International Faculty has grown in number with speakers from as far afield as America and Australia talking at the meetings.

 

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There have been 3 important "spin-offs" for me. The Corail hip was designed in 1986 so celebrated its 25th birthday in 2011. I was invited to be one of 7 editors on a book that we published recently to celebrate the Corail's birthday.

 

The Corail has not changed its design over 25 years which is an important point when interpreting results. Technology however does move on and there have been important design changes in the instrumentation which allows the Corail hip to be put in. I was asked to be one of the developers of the new instrumentation.

 

Lastly within this country, I, with a colleague from Leeds, Martin Stone, have developed the Corail Registrar Training Programme. This is a programme that runs twice-yearly in Stratford-upon-Avon. It aims to give basic training in how to put in the Corail stem to young surgeons in England. It has now been running for over 5 years and we have a group of Consultant Surgeons from around the country who regularly use the Corail hip and who come and teach in this programme. We also have 2 international faculty members who contribute.

Obviously a hip can only be put in when there is something on the cup side as well as the stem side. This Corail teaching meeting has simply been extended to include the Pinnacle cup which is my preferred acetabular component to go with the Corail stem.