Next up we have Dr Razvan Stoita a highly experienced fellowship

trained orthopedic hip and knee surgeon.

He routinely uses 3D computer analysis in the assessment and management of knee

and patella deformities and failed hip and knee replacements.

Today, Dr. Stoeter will be talking about osteoarthritis of the hip.

Thank you. Thanks, Mike.

Hey, good morning, everyone. Thank you.

So today, I'm just going to talk about mainly the treatment of hip osteoarthritis.

I was going to speak a bit about non-replacement options, the non-operative

management, but Sam has already touched on that, and they would have been exactly

similar what Sam said. I'm only going to show a slide anyway.

And mostly, we're going to talk about the hip replacement.

I've chosen to show a few interesting cases rather than just being just the

standard hip osteoarthritis.

But the problems that we encounter in some different patients that may have

a hip replacement for a different diagnosis than osteoarthritis.

And we'll see whether we can talk a bit about the ERAS model.

So as disclosure, I do have a company-sponsored fellow, and some of the implants

used here have been manufactured by the company, and I do have a financial interest

in the Orthopedic Institute.

So when we look at the non-operative treatment of hip osteoarthritis,

Sam showed you what the College of General Practitioners recommend,

and then I looked at a different body, which is the Osteoarthritis Research

Society International,

and they all essentially do the same things.

They look at the evidence available, they set some criterias,

and they make some recommendations.

And the same, the main treatment for arthritis for this society is the education

and land-based exercises.

So we can get them to do strengthening. They're encouraged to do them themselves.

And cardio or low-impact activities are what's most recommended.

So walking, cycling, swimming. That's what we want them to do.

As a conditional recommendation, in patients where the...

Risk or the complications associated with the treatment is not significant,

then yes, we can give them some non-steroidals, walking aids,

and injections, really, they are only recommended on a short-term basis.

But there is a lot of modalities that are not recommended.

We don't have enough evidence. They make no difference. And you see there, the paracetamol.

It's actually, I know that Sam, in the College of General Practitioner, they put weight loss.

But in the Osteoarthritis Research Society, weight loss is not really recommended.

If they've got a BMI more than 40, then yes, then they're recommended for general health.

But they haven't shown. There's not enough evidence to show that it does make

a difference in hip arthritis. Whereas if we look at the knee osteoarthritis,

then losing weight makes a big difference to their symptoms, yeah?

And I would just avoid all of those massages, thermotherapy, whatever.

It's just shown no evidence at all for it to provide any long-term relief of symptoms.

So if we're looking at the surgical treatment, really, it's the hip replacement that it is.

Whether we do a resurfacing in a young, big, active males or just the standard

hip replacement, There's no other treatment that has shown benefit.

We've moved away from doing fusions in the hip because the function is really

poor, even in the youngest of patients.

So the question is, when are we going to offer somebody a hip replacement?

So for me, it's really, they've got to have pain or they've got to have a functional deficit.

Would their quality of life need to be impaired? So I'm not looking really at the x-rays.

I just want them, they need to have some sort of disability,

either pain, some patients may not have pain but

they could have a lot of functional disability they could have a lot of stiffness

can't get to their feet can't get in a car and

so on the x-ray it's really to confirm the diagnosis it's not it doesn't guide

me with respect to treatment I could have a patient that might have a really

bad x-ray with significant joint space loss but if they've got no pain no functional

deficit I'm not going to offer it to them.

And same as Sam was using the HIP score, I used the HOOS score,

which is, again, a patient-reported score.

And it looks at the pain. It looks at their stiffness.

It looks at their function. The function with respect to daily activities,

function with respect to sporting activities, and also their quality of life.

And I want them to score in this right side of the page, the severe and the

extreme. I want them to be really disabled with it.

I don't want to offer somebody a hip replacement if they've got hardly any symptoms or mild symptoms.

Those patients, if we educate them about what it is and how to cope with it, they can still carry on.

But as Sam said, and I agree with him, once they get symptoms of hip arthritis,

their progression is guaranteed.

Those, compared to the knee arthritis, where they've got like a stepwise progression

where they get a bit worse, then they stabilize, then they function for a while, then again get worse.

These patients with hip arthritis, when they get symptoms, well,

those symptoms are going to get worse. There is no turning back for them.

So then we're looking at the hip replacement.

This is what a hip replacement looks like. And we've got, I've drawn a few lines

in through there because whenever we do a hip replacement, the longer the days

when we just turned up to theaters and asked, oh, so what are we doing today?

Oh, we're doing a hip replacement. Okay, no problem. Let's get it done.

Yeah, we do a lot of planning before we do that hip replacement because we want

to make sure that we restore the anatomy, will restore their leg length,

will restore their hip offset or the width of the hip.

Otherwise, if we make them long and with an increased hip offset, they get a lot of pain.

We want to protect their soft tissue. We want to make sure that we balance those

soft tissues, that they have an adequate liver arm through their abductor tendons

and they walk without a limb.

We want to choose the right implant for patients. and we're going to talk about

this in the elderly patients and how age affects the implant choice that we make.

We want to make sure we don't damage their soft tissue, make sure that the implants

we choose have got, they provide longevity.

And recently, well, not recently,

but a common example of this is the use of the newer polyethylene liners that

are highly cross-linked that have shown significant longevity compared to the

non-cross-linked polyethylene liners.

All of this to minimize the post-surgical

complication and get them their recovery as soon as possible.

So how we do prepare for a hip replacement. So first, we're going to need to

assess those patients and make sure that we've maximized their chronic comorbidities,

and then we correct whatever is modifiable.

And we heard Dr. Kotze talking about the opioids. Well, yeah,

we do want those preoperatively.

We want them to get off the opioids, at least to decrease them,

Because post-operative, if somebody comes on a large dose of pre-operative opiates,

then it's so much more difficult to control their post-operative pain.

We want them to get them out of bed pretty quickly. We want to make sure that

we control malnutrition and diabetes as they've got increased risk of an infection.

And we want them off their cigarettes for at least three weeks.

We can do some tests based on both urine and bloods to ensure that they have quit smoking.

Then we're doing a surgical planning, and I'm going to talk about this a little bit more.

We're deciding on how to do the hip replacement, what approach to use.

We can't use, for instance, the anterior approach really in every patient because

different patients have got different requirements and their anatomy are different

and we need to do different things.

What anesthesia we use, and again, Dr. Kotsi touched on that.

Yes, we do want to use a spinal anesthetic combined with regional blocks and

periarticular anesthetic.

And all of this is to try to minimize their pain in the first 24 to 48 hours,

which is really important to get them out of bed, get that recovery going.

We use intra-operative technology, and these are just some of the ways that

we use, and I use either a robot or computer navigation.

And then how do we manage them after their surgery?

So in the surgical planning all of my patients get their their standard x-rays

i look at their spine and the mobility of the spine and how this influences

their pelvic movement and we do a

CT scan and then we do a derived software image of what their hip movement is

what the implants are and all this in order to,

restored their bony anatomy, maximized their range of motion,

maximized their outcome.

So if we have a case study, so we've got, this is a young guy,

he's 41, and we look at his hip, so he's got obviously a problem with his left hip.

If we look at the right hip, he's got a bone and socket, a ball and socket,

but on the left side, he's got that mushroom-shaped femoral head,

He's got quite a shallow acetabulum, which is deficient up superiorly here.

We know that it doesn't have that round acetabulum. Even on the right is not

quite normal, but on the left is quite abnormal.

So this guy has had a purchase when he was young.

So again, we go through the planning.

We do a CT mainly to assess the bone defect where it is. we can see that the

anterior wall is not normal.

See how here on the opposite side is normal. And this is just a period of a

useless 3D image that we can't really make any decision on.

Mostly we look at the axial images to assess exactly what the bone anatomy is.

And then we do a plan and we consider the right hip here to be normal.

We try to match the left with the right. And this is where

the acetabulum would sit and we can see here well that

there is bone that's missing there that we're gonna

we're not going to have any bone support on

the superior part so we've got to do something there we've got

to replace it we know exactly what

stem we're using and then we know that at the end we're going to get the same

offset we're going to lengthen by 20 millimeters because that's what he's got

about 22 millimeters is shorter so so we do an x-ray we do we do the operation

and we get an x-ray and at the end we can see that.

There is the bone he has restored because I used part of his ephemeral head

to augment his acetabulum and I fixed it with some screws.

And the same, we can see it on the lateral end. This is, I think,

about a year or so after his surgery where all that bone graft is healed.

We've restored his leg length. We've restored his offset.

So in order to get to this, we need to think, well, how are we going to approach it?

What approach are we going to use? And the planning that we did before helps

us because the planning is telling us where,

so it tells us where the bone defect is, what we need to do to access that bone

defect to restore the bone anatomy.

So for this patient, because most of his bone defect was superior and anterior,

An anterior approach was appropriate. So this is what I did.

So I usually do anterior and posterior approaches.

Most of my patients do get an anterior approach

unless there are other factors that would make me choose a posterior approach, acetabulum.

When we look at the approach, we need to make sure that when we do an operation,

we can see what we're doing and we've got access to their joint.

We need to make sure that we can extend that approach if we run into trouble,

if we have a fracture that we can extend and expose that fracture,

fix it. We want to preserve the tissues.

We don't want to do an approach, cut all the muscles around and then we've got

a great looking x-ray at the end but the patients can't walk.

So, next we're going to look at the complex hip. So, I've got here two patients.

And we've got here the patient case A, it's a 60-year-old female.

It's got a problem with the right hip.

And we've got a case B, we've got a 28-year-old female. She's got a problem with the left hip.

So, can I just have by a show of hands, who thinks that the case A is a complex hip?

Nobody. So it's all good. So how about case B? Who thinks that this 28-year-old is a complex C?

Okay, so the majority of people think that the complex patient is the case B.

So let's go through the case A. Well, this is a 60-year-old, yeah?

At the age of two, she was diagnosed with juvenile polyarthritis.

She's had medications for it ever since. She's had systemic anti-inflammatories.

She's currently also on biologics. She's also got AF and she's on apixaban.

She's got multiple joints involved. She's had about 15 years ago,

she's had knee replacements, ankle surgery, elbows.

Her gait is pretty poor. Her mobility is pretty poor.

She's got a really bad airway in the way that her jaw is quite stiff.

She's got some instability in her cervical spine. But the x-rays are quite routine.

So who now thinks that this patient is still a simple patient? Yes.

Or it's not a simple patient. And these are patients that I worry about most

because I can't really control their AF. I can't really control their medications,

their arthritis medication.

We've got to stop those medications to do their surgery because they can get

the risk of infection, risk of post-operative hematomas.

So this is that patient. Now, the second patient, yeah, she's 28,

but she's got no significant medical comorbidities.

But she does have, she was born with a hypoplasia, so left lower limb hypoplasia.

You can see her pelvis is smaller, her acetabulum is smaller.

The femur is quite gracile if you compare the left femur to the right.

She's had, as a neonate, she had a septic arthritis of her hip.

You can see on the right, she's got a trochanter, greater trochanter.

There is no greater trochanter here. She's got no abductor function there.

She's had previous surgery, previous osteoromase, not completely healed.

Her sciatic nerve is not quite functioning. She's got a...

A partial foot drop. She's got abnormal sensation. So there is significant issues.

Then we're going to look at, well, we're going to still need to replace the hip.

This is what's slowing her down. She can't walk. She's 28, but we're going to

need to restore to try and give us some sort of hip that she's got similar to the other size.

So we're concerned a small size, trying to put appropriate implants,

implants that would restore her leg length.

She's got 14mm of leg length discrepancy and you're going to need to lengthen her by 14mm.

Now we know that her sciatic nerve is abnormal, so trying to lengthen her,

give her 14mm with an abnormal sciatic nerve can make that worse, can cause a foot drop.

In this patient, I would not really do this through an anterior approach,

so I've chosen a posterior approach for her because I I wanted to look at the

sighting nerve, free it up before I restore her leg lens.

And then at the end, we've done the x-rays.

We've done the hip replacement. So this is the case A, which was a simple technically,

but the patient is more complex medically.

And we've got the case B where we've done a hip replacement again,

where the technically is more difficult. However, the patient medically is well.

So when we think about a complex patient, it doesn't have to be just because

of their difficulty to do a

hip replacement, but we've got to also think about their medical history.

So then, what happens in the elderly patients? And the elderly patients are

those patients that are over the age of 75.

And the main reasons for, the main indications for hip replacement,

it's either osteoarthritis or they've got an intracapsular neck or femur fracture.

Now, these patients have got specific things that we look at.

And we look at because they can be osteopenia, their functional,

what their mobility is, their risk of falls, they can have cognitive impairment.

So we need to consider. And then you can see on that x-ray, this is a recent

patient who's had a pathological intracapsular femoral fracture on a background

of metastatic renal cell carcinoma.

I think she was 75 or 76.

So they do have a longer hospital admission. They're more likely to need inpatient rehab.

They've got a higher risk of blood transfusion.

And then when the Australian Joint Registry looked at the results and what's

better to do in elderly patients,

we know that the cementless or hybrid implants where we use a cemented femoral

stem have got better results,

particularly in those first three months,

compared to a cementless implant because there's a lower risk of intraoperative

fracture because of the osteopenia.

These patients are more likely to dislocate their hip, to have a periprosthetic

dislocation, particularly the subgroup of patients that have it done for a fracture.

And some 30% of the revisions in elderly patients done for a neck or femur fracture

are because of a dislocation.

For the first time last year,

the registry showed some benefit in doing an anterior hip replacement with respect

to the dislocation risk, which is lower compared to the posterior and the lateral approach.

And we can also use for this patient what's called a dual mobility liner where

we've got a small head within a big head.

And that's the patient from before. Or she's had a hybrid hip replacement with

a long femoral stem because she had a metastatic cancer in her femur.

So when we're looking at these patients, these elderly patients that fall over

and have periprosthetic fractures.

It's important that when we treat these patients, we treat them as well as we

can to restore their mobility straight away.

So these patients, if we've got somebody like it's eight-year-old who's got

a periprosthetic fracture, if you fix their femur and we don't allow them to

mobilize, their mobility will further diminish, will further decrease. so we'll have a problem.

So we need to revise it and revise it so they can straight away weight bear.

So that's one of the patients. And this is another patient, like an 87-year-old

male who's from home with a supportive wife, had a fall, fractured their femur.

And we can see that there is a fracture through the femoral shaft and through

the greater trochanter.

Now, this patient, And you've got to try to fix it and you've got to allow them,

you can't just stop them from weight bearing because their cognition is not

good enough to allow them to follow a non-weight bearing protocol.

So they get a revision hip replacement.

Again, this was done through a posterior approach, even though initially they

had their hip done anteriorly and they allowed them to weight bear straight away.

And then with respect to the ERAS model, which is the enhanced recovery after surgery,

it's essentially we're trying to get these patients through their operation,

out home, mobilizing as soon as possible, returning to their activities.

And this is shown to improve outcomes, improve patient satisfaction.

And there's different phases that we do with the patient education in the pre-operative

phase, What we do in the intraoperative phase with respect to anesthesia,

minimally invasive techniques, surgical blood loss management,

and the postoperative pages, getting them out of bed as soon as possible.

So this is some of the takeaways for the talk.

And again, education and physical therapy,

most important in the nonoperative management, look at their symptoms and function

before you recommend the hip replacement and choose carefully what you do in elderly patients.

Thanks.