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Hip replacement: the pros and cons of early surgery

More people are having hip replacement surgery before they reach the age of 60. Some physiotherapy experts favour another approach, as Gill Hitchcock reports.

Hip hip hooray
Should we care that more and more younger people are having hip replacements? Almost a third of those given new hips are aged below 60, according to a report by the Medical Technology Group of research charities, medical device manufacturers and patients.
 
The Keep Britain Working document cites this as an economic success. It includes data showing that 60 per cent of working-age people who had a hip replacement in 2016 returned to work. Getting these 18,500 people back on the job saved the UK £70.5 million in Job Seeker’s Allowance alone.
 
Talk to physiotherapists and other clinicians about the upward trend in replacements for those aged under 60, however, and you get a less sanguine view. For instance, the National Joint Registry’s medical director, Martyn Porter, warns about the higher risk of revision surgery for younger patients. His data shows that people in general who have a new hip, have a 6.8 per cent risk of revision within 13 years. But for women under 55, the 13-year revision rate is 13.5 per cent and in men under 55 it’s 10 per cent. 
 
While Dr Porter says that younger patients shouldn’t be denied potentially life-changing surgery, he believes they should be fully aware of the revision risk, which he attributes to greater physical activity in this age group.
 
Jonathan Quicke, clinical academic physiotherapist at Keele University, says: ‘Clearly people who are younger are more likely to have a revision sooner so it’s important that they weigh up the benefits and costs of having an early joint replacement and are offered optimum non-surgical treatment.’
 
Many patients demand surgery, however. Karen Barker, professor of physiotherapy at the University of Oxford, says they are more aware of their condition because of better diagnostic tests, which pick up cam lesions and arthritis early. And they are ‘not prepared to put up with the level of symptoms that patients in previous years would’.
 
Osteoarthritis, the most common reason for hip replacement, was once considered the unavoidable result of longevity but research shows it is a complex condition with many causes. Symptoms are episodic and, as Dr Quicke says, people should understand their condition and have strategies to manage it.
 
The National Institute for Health and Care Excellence (NICE) recommends education, exercise and weight loss as gold standard treatments for hip osteoarthritis. And there is high-quality evidence for the benefits of conservative management, including the fact that strengthening and aerobic exercises, such as cycling and walking, can improve pain and mobility (Uthman et al 2013, Fransen et al 2014). See here and DOI: 10.1002/14651858.CD007912.pub2.
 
Despite this, Professor Barker believes there is poor awareness among clinicians – physiotherapists and GPs included – about the proven benefits of conservative management. ‘The moment clinicians see clear evidence of arthritis on x-ray, they have a tendency to presume that someone needs a joint replacement, rather than spending enough time following a conservative strategy,’ she says.
 
‘Without getting overly political, the current commissioning model for primary care physiotherapy is increasingly weighted to fewer sessions, rather than managing a long-term condition. But it is hard to be effective if you are only seeing someone for a couple of sessions, and it is less likely that that in itself is going to make a big enough difference. I sometimes think physiotherapy is unfairly labelled as not effective when it hasn’t been delivered with sufficient intensity and duration. It’s a commissioning problem.’
 
Toby Smith, senior researcher in rehabilitation at the University of Oxford, identifies two barriers to conservative management. First, getting patients to engage: ‘Physiotherapy is great, but only when people actually do it. And particularly for osteoarthritis of the hip, it’s really difficult to change the behaviour of patients who have painful hips which stop them doing so much.’ 
 
Second, despite evidence for the benefits of programmes incorporating exercise and behaviour change, trusts baulk at the cost. ‘There is no quick fix,’ he says. ‘Often these programmes run between six and 12 sessions. Having said that, if this group of patients can be managed within 12 sessions, it could make a big difference to follow-ups, prevent a burden on NHS services and – most importantly – improve the quality of life for patients. 

Focus on physiotherapy

‘It’s such a widespread condition and it is so challenging to change the mindset, not just of patients, but of clinicians and commissioners,’ says Dr Smith.
 
There are pockets of good practice. Professor Barker says some parts of the country do follow the full NICE guidance and first exhaust conservative treatment strategies of weight loss, non-steroidal anti-inflammatories and physiotherapy. She says there are others, where they have ‘interface hubs’ to triage patients and tend to be better at filtering the right patients through to surgery.
 
CSP research shows that physiotherapists in Suffolk working as first points of contact in primary care have reduced referrals for hip and knee replacements by 20 per cent. ‘As long as the first contact physiotherapist has the support and experience to make the judgment, they should know which person is a good candidate for physiotherapy and which a good surgical candidate,’ says Dr Smith. ‘It has to work both ways.’
 
Meanwhile, Dr Quicke has set up a pilot physiotherapy osteoarthritis service at a general practice in Leek, Staffordshire. For the past nine months, it has been helping people to understand and manage their condition through education, exercise and behaviour change to manage weight. This spring, he will evaluate the service against NICE quality standards and explore its impact on referrals for imaging and to orthopaedics.
 
As Keeping Britain Working acknowledges, the NHS is under pressure to do more with less money. And as demand for services continues to outstrip increases in funding, avoiding deterioration and unnecessary surgery for people with hip osteoarthritis will be better for patients and NHS coffers.
 
In future, Professor Barker wants the health service to commission good quality, conservative packages of care before referring patients for surgery. ‘That means physiotherapy,’ she says. ‘It’s not the only answer – we still need other conservative strategies, such as weight-loss management and physical activity – but it’s a major part of it.’ 
 

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