Two hours ago this man was having revolutionary hip surgery … Now he’s back on an exercise bike – and pain-free at last
The scene is as ordinary as it is remarkable – a young man begins to pedal, cautiously, on an exercise bike. His expression of absolute concentration is quickly replaced by complete surprise. Then a broad smile breaks across his face.
‘It doesn’t hurt!’ he announces, clearly amazed. ‘It’s a bit stiff and sore. But it doesn’t hurt any more.’
We are in the physiotherapy gym at the Hospital of St Cross, Rugby. And what makes this moment so astonishing is that just two hours earlier, 33-year-old Ben Wilkins had undergone surgery on his right hip.
The procedure – femoroacetabular arthroscopy, more commonly known as hip preservation surgery – is set to transform the world of orthopaedics. The ground-breaking surgical technique is yielding incredible results in curing hip pain where all other treatments have failed.
And some experts believe it could eventually halve the number of hip-replacement operations. Last year around 50,000 were carried out by the NHS and 10,000 in the private sector, at a cost of up to £9,000 per hip.
Ben first started having problems 18 months ago when he thought he had strained a muscle playing football.
‘I began waking up in the middle of the night in agony,’ he recalls. ‘It felt like a stabbing, burning pain inside my right hip. I had to give up sport and my job as a security guard. It was so bad I couldn’t even take my seven-year-old son Brandon to the park to play football, which was extremely depressing.’
In October 2009, Ben’s GP referred him to orthopaedic surgeon Professor Damian Griffin, a specialist in hip-preservation surgery.
Recent advances in scanning techniques allow surgeons to create highly detailed computer images of the hip joint‘s surface, and surgically correct minor malformations or repair damage that is causing pain.
‘There would once have been little we could do to help patients like Ben who were experiencing severe, inexplicable hip pain,’ says Prof Griffin. ‘At best he would have been given painkillers and told to manage. His pain would have gradually got worse.
‘In ten years he would probably have developed arthritis and needed a hip replacement.
‘And hip replacements need replacing. If they last 20 years we think it is very good going, and they wear out faster in younger, active patients. He would probably have to have another hip replacement, if not two, in his lifetime – with all the painful months of rehabilitation each operation entails.
‘Now, thanks to this new procedure, I can say with confidence that he will be pain-free and back to doing everything he enjoyed within a couple of months.’
The hip-preservation process begins during a first consultation, where specialised scanners similar to X-rays are used to produce accurate threedimensional computer images of the surface of the bones in the hip joint.
‘The scans revealed that many patients experiencing pain, like Ben, had abnormalities on the surface of their hip bones,’ explains Prof Griffin.
The hip is made up of a rounded ball at the head of the thigh-bone (the femoral head), which inserts into a socket (the acetabulum) in the pelvis. Both surfaces are covered by cartilage, allowing smooth movement. The joint is surrounded by ligaments and a tough, fibrous capsule which provides further support.
‘The femoral head should be an evenly rounded ball, but in some individuals there is a bulge that rubs against the cartilage lining of the acetabulum. In other cases the abnormality is in the rim of the acetabulum, or in both parts of the joint. The result is extra friction that can lead to wearing away or tears in the cartilage, causing pain and inflammation.
‘The symptoms are usually first brought on by exercise or physical work, or while sitting for long periods, such as in a car seat.
‘In Ben’s case, we discovered that the problem was a malformed femoral head. It was just millimetres of bone, but the pain it was causing was immense,’ says Prof Griffin.
Ben was suffering from the common condition femoroacetabular impingement (FAI). ‘We don’t know why it happens, but it is believed that the abnormalities occur when the bones grow during adolescence,’ he says. ‘Quite apart from the immediate discomfort and disability this causes, if left untreated it is likely the patient will eventually develop osteoarthritis.’
A condition affecting around 8.5million in the UK, osteoarthritis occurs in a joint when the cartilage becomes worn and uneven. Injury or trauma such as an operation, obesity and even genetics mean the cartilage does not repair itself as well or as quickly as it should.
As a result the underlying bone thickens, causing permanent deformity. This uneven surface hinders smooth movement, causing further damage, and the joint becomes stiff and swollen.
Many experts believe that FAI could be a major risk factor in the development of this kind of joint disease. There is no cure and the condition can be disabling. For many, joint replacement is the only option. Prof Griffin estimates that around half of all hip-replacement patients suffer from FAI.
By treating this and a range of other similar conditions, he hopes the hip-preservation technique will, in these cases, stop arthritis from occurring, eradicating the need for joint-replacement surgery.
‘This operation could effectively halve the number of hip replacements carried out,’ he says.
The early corrective operations were carried out by Swiss doctors and involved making a 9in incision and complete dislocation of the hip joint. Although successful, recovery was arduous – there was a subsequent three-day hospital stay and patients were usually on crutches for three months.
For the past seven years Prof Griffin has pioneered a similar but minimally invasive keyhole procedure that can be carried out as a day case. Patients can begin physiotherapy within hours of the operation.
The procedure can last up to two hours, depending on the severity of the condition, and is carried out under general anaesthetic. First, the patient’s leg is placed under traction – held taut using a clamp on the foot and lower leg.
Using the clamp, the femoral head is then gently eased about a quarter of an inch out of its socket. Two or three keyhole incisions are made around the hip, through which a camera and surgical instruments are passed.
Once inside the hip joint, the surgeon then files down the abnormal surfaces of the bone, creating a smooth surface that new cartilage can grow over. Any damaged cartilage is either trimmed away, stitched or glued back into place. Finally, the leg is manipulated while the patient is still under anaesthetic to check ease of movement.
Post-operative physiotherapy sessions are given once a week for six weeks, with daily exercises to be practised at home, followed by a further six weeks of occasional sessions. Because the operation is a keyhole procedure, scarring is minimal. So far, Prof Griffin has treated 1,000 patients and 95 per cent of those who had suffered disabling pain were almost symptom-free a year after surgery. Just two per cent needed further treatment.
The technique was approved for NHS use in 2007, although the National Institute for Clinical Excellence, which produces guidelines for medics, acknowledges that more research is needed before it is recommended for widespread use.
Because of the highly specialised nature of the procedure, there are still few surgeons qualified to carry it out.
Although Prof Griffin is convinced of its potential, other experts are circumspect. Southampton-based consultant orthopaedic surgeon Douglas Dunlop carries out around 20 hip-preservation operations each year.
‘This surgery is helpful for some patients who are experiencing acute hip pain due to FAI,’ he says. ‘But it is still not clear whether it will solve the problem
in the long term. Some experts believe the abnormality – the lump on the bone surface – is caused by a misalignment in the joint. If this were the case, there is a likelihood that the lump may come back and the patient will need a hip replacement at some point anyway.’
One person who is certain about the benefits is 35-year-old Samantha Warden. The procurement specialist, who lives with her husband, Tim, 45, a project manager, in Stanwick, Northamptonshire, underwent the operation on her right hip in November 2008.
She had suffered debilitating pain since a flight back to the UK from South Africa in 2004. ‘I am a nervous flyer and had been prescribed sedatives,’ says Samantha. ‘I slept the whole way back and when I got up, my legs were in agony. After a few days the pain in my right leg had intensified to a sharp, stabbing sensation when I walked.’
Initially suspecting a deep-vein thrombosis – a blood clot that can form in the arteries of the leg after long periods of immobility – Samantha’s GP referred her for scans and X-rays, none of which revealed a cause.
‘I was on crutches and no one could tell me why I was in such pain,’ she says. ‘All the doctors could offer me was injections of powerful anti-inflammatory drugs into the joint, which helped but soon wore off.’
By chance, last year Samantha’s consultant read about Prof Griffin’s work and immediately referred her.
‘Samantha was suffering from FAI,’ says Prof Griffin. ‘The pain is often triggered by long periods of sitting, although this is not what causes the problem.’
Samantha says: ‘When he told me “We know what is wrong with you, and we can fix you” I burst into tears. I never thought I would hear those words. I believed I would be on crutches for the rest of my life.’
She underwent surgery to correct her FAI and was discharged from physiotherapy in April. ‘Almost immediately after the operation, on the exercise bike, I could feel the difference,’ she says. ‘I was achy but the stabbing pain had gone. Now I am back to the way I was before. I can even wear my favourite high heels again.’
This year Samantha plans to train for a 10km race – and she is eternally grateful to Prof Griffin. ‘I would walk over hot coals for that man. He helped me when I thought no one could.’
• http://www.hiparthroscopy clinic.co.uk
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