Monday - Friday 09:00-16:00Saturday and Sunday - CLOSED+441614476762info@manchesterhipclinic.comSpire Hospital, 170 Barlow Moor Road, Didsbury, Manchester M20 2AF
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Total hip replacement is one of the most successful operations that you can have. A successful one can literally be transformational. It can take a patient who is living with constant pain, dependent on strong pain killers, with very limited mobility and overnight, cure their pain and allow them to lead a fulfilling life. Because of the National Joint Registry, here in the UK, we can track patients after their surgery and see how long the implants last. We know that on average, if you have a well-designed implant (such as an Exeter), over 96% will still be in place and functioning well at 14 years. It is reasonable to predict that those implants will last 20 to 30 years. However, we know that if the components are not put in correctly or if the leg length or soft-tissue balance is not right, it can have a significant impact on the complication rate or how well the implant functions. This has led to the development of robotic hips.

 

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Mako robot

Recently, some work has been done on what people are doing with their hip replacements after surgery. One paper published in 2019 showed that while all their patients returned to activity, there was a general move from high to low impact exercise. Another showed that after 10 years, 89% remained active but again there was a significant decrease in high impact sport. What is not clear is was that because patients were told to reduce their activity by their doctor/surgeon or was it because they themselves did not want to wear the new joint out? Perhaps by improving the accuracy of surgery and the muscle balance, we can have the confidence to enable people to maintain their desired level of activity?

 

The market leader by far in robotic assisted hip surgery is Stryker and the MAKO robot. They have well in excess of 500 machines around the world and over 20 in the UK. At the Manchester Hip Clinic,  we started doing MAKO procedures in 2018 and are now one of the highest volume centres in the UK. Essentially, what MAKO does, is use CT scans to accurately map the shape of the patients own hip so that the new artificial one mirrors it exactly and then the robotic element ensures that the surgeon puts it in perfectly. Recent publications have shown that when using this technology, there is increased accuracy, improved patient function and quicker recovery.

 

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Mako surgical planning

The use of MAKO has transformed how we do hip replacements. We see a lot of younger patients who have abnormally shaped hips that would previously have been very challenging to replace. With MAKO, we now have the confidence to know that we are choosing the correct implant and putting it in in the best possible position. That confidence allows us to encourage patients to return to sport and a range of different activities. If I was having a hip or knee replacement, I would definitely have it done using MAKO!

Understand more about MAKO…click HERE

Hear Oshors story…click HERE

 

 

 

 

 


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Modern Hip resurfacing was introduced in 1997 by a Birmingham surgeon called Derek McMinn, who basically looked at two old prostheses, the Judet hip from the 1950s, and the McKee-Farrar metal-on-metal hip replacement of the 1960s and combined the two to make the modern hip resurfacing. It is still a hip replacement, but unlike “traditional” replacements, it consisted of a metal cup in the pelvis and a metal cap on the head of the thigh bone. It is sometimes referred to as a partial hip replacement but in reality, it is a complete hip replacement.

A resurfacing is a ‘metal-on-metal’ (MOM) implant. This refers to the two surfaces that rub against each other when the joint moves. Historically, for its time, the McKee-Farrar had very good survivorship, and so the idea was that metal bearings would last much longer than the other bearings of the time (metal-on-plastic or ceramic). Resurfacing tends to be more stable as the head which goes on the femur is very large, so the risk of ‘dislocation’ was less. This reduced wear and increased stability opened up the option of hip replacements to younger active patients, as the feeling at the time was that this type of implant would reduce the need for revision or repeat surgery, which is more complex, higher risk and likely to have a poorer result than a first-time replacement. What was not appreciated, was that the neck (which is much wider than the neck of a standard hip replacement) could still catch against the cup and cause damage, which is essentially what happens with hip impingement.

Significant numbers were implanted in the late 1990s and early 2000s. Other companies saw they were missing out and so all the major implant manufacturers released a version (but all had to be slightly different due to patents). The original Birmingham hip resurfacing has done the best of all the various versions but unfortunately, some of these new designs did very badly. Actually, compared with standard hip replacements, they all had worse long-term results. This was because the metal-on-metal bearing actually wasn’t as safe as thought. Back in the 1960s, patients were not as active as now, and were in much worse condition prior to their hip replacement (which at the time was considered ‘major’ surgery) and so the issues with MOM didn’t really occur. Over time, it became clear that while the resurfacing did not produce as much wear as the traditional types, it did produce large amounts of very small metal particles which could cause very significant soft-tissue reactions and damage.

The problems associated with the MOM bearing became apparent around 2006 and as a result most companies dropped it and versions of it around 2007-8. The numbers of replacements implanted in the UK fell significantly.

 

Numbers of hip replacements implanted in UK by type

The current scenario is that a lot of NHS and private hospitals will not allow any form of MOM hip replacements (resurfacing or otherwise) to be performed. There are a few surgeons who still perform them as they believe that the failure rate is associated with the implantation technique, which is true to an extent but not wholly so. This situation continued until Andy Murray had his resurfacing early last year, which led to an increase in interest once again.

Technology has moved on since 1997, there are now far better contemporary styles of hip replacement which have all of the benefits of a resurfacing without the downsides and so the indications for resurfacing over anything else have essentially gone away. We specialise in hip replacements (with ceramic on highly cross-linked polyethylene) using robotics as I believe that technology produces the best outcome with the least complications and longest survival. For comparison, the revision risk of the type of implants we use at 14 years ranges from 3.77 to 5.28% compared to 14.78% for all ages of resurfacings, which rises to 22% in those under 55 years (see NJR).

At the Manchester Hip Clinic, we use either Accolade 2 uncemented stems or Exeter cemented stems (depending on age or bone shape) with Tritanium cups, all of which are made by Stryker, one of the big global orthopaedic companies. The bearing surfaces are ceramic on polyethylene, which has the least wear and best long-term survival on the National Joint Registry and we use Mako robotics to make sure they go in perfectly which gives excellent muscle balance and allows early return to function.

Most patients are in 2-3 days and off crutches by 2-4 weeks, exercise bike by 2 weeks and gradual increase in activity over 6-12 weeks. The dislocation risk is highest until at least 12 weeks but the hip will continue to improve for 10-12 months post-surgery. The fitter and stronger you are pre-surgery has a big effect on your recovery afterwards. We treat a lot of high-level athletes for both arthroscopy and replacement, so we are very pro-active with rehabilitation. It is important for us to liaise with your physio locally so we can monitor your recovery. If that is not possible, we can arrange physio supervision over Skype with our own team or one of our partner practices.

For more information see our UK national guidelines, the national joint registry report

and some information on our website…click HERE

 

By Prof Max Fehily and Mr Giles Stafford, London Hip Surgeon (click HERE)


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The demands on any sportsperson in the groin region is huge but particularly so in football given the volume of change of direction work involved. The fact that there are 45 muscles which attach to the pelvis in a variety of directions gives us a snap shot of the different forces involved in this region and why groin injuries are so common.

One thing that we used to frequently discover in football and the same in clinic now is that whenever people seemed to have pain or pathology in the hip and groin, there would be some kind of muscular weakness. There is strong evidence to suggest that reduced adductor strength is related to the incidence of groin pain and the development of groin injuries and yet people generally take the approach of stretching and releasing muscles (which may be relevant but not always) rather than combining this with a strength programme.

A nice simple way to strengthen your adductors can be to follow the “Copenhagen Protocol” which has been shown to significantly improve the strength in the adductors (even when performed during mid season competition). This would start with 2 sets of 6 in week 1 done twice per week and volume increase weekly very gradually. By 8 weeks you should be competent to perform 3 x 15 twice per week. To perform the exercise, adopt the position shown below and bring the lower leg towards your weight bearing leg and lower it back down again. If this is too hard then just hold the position to start the strengthening process.

 

This is of course only one dimension to a complex region of the body which quite often requires a more detailed assessment and rehabilitation programme.

 

Dave Williams, physiotherapist of Harris & Ross Physiotherapy at Wilmslow and Wigan clinics following 8 years working in elite sport at the Manchester City F.C Academy. During his time at MCFC, he was lead Physio for the hugely successful Youth team boasting players such as Phil Foden, Jadon Sancho and Kieran Trippier amongst many others.



Who does this affect?
Labral tears usually occur in patients who have femero-acetabular impingement. These patients have either an abnormal bump on their femoral neck or an overhanging pelvic cup. In both these cases, the soft cartilaginous cup rim (labrum) gets damaged (figure 1) as the hip bends up. Initially the rim is simply peeled back but eventually it becomes torn and occasionally shredded. Patients are typically younger and very active, often taking part in sports such as running, kick-boxing, mountain biking and horse riding. Occasionally it can occur due to a severe and traumatic injury e.g. hip dislocation while playing rugby.

Symptoms
Patients with labral tears present with deep sharp groin pain, which may only occur on full hip bending. They may or may not be an associated deep click, which can be either due to the torn labrum, or more commonly, an inflamed tendon running over the front of the hip. If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or infammation of tendons in front of the hip (sartorius tendonitis).

Investigations
All patients undergo specialised x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). The MR arthrogram involves injecting dye into the hip joint prior to the scan. This allows identification of the torn cartilage. CT scans are used to accurately map out the bony deformity. This is very important when planning the surgery.

Non-surgical Treatment
Not everyone needs surgery so we initially treat patients with physiotherapy, painkillers, anti-inflammatory drugs and modification of activity. However, if they have a proven labral tear and physiotherapy has not cured their symptoms, then it is recommended that they undergo key-hole hip surgery (hip arthroscopy) first to address both the torn cartilage and bony abnormality, then undergo our specialist rehabilitation afterwards. A patient who has a painful hip and a proven tear is unlikely to settle without surgical intervention.

Surgical Treatment
The treatment of choice is hip arthroscopy. This allows access to both the true hip joint itself and the front of the femoral head where the bony abnormality is often located. Most patients do not have frank labral tears, rather the labrum is peeled back from the acetabular rim. In those patients where there is a gross tear, there is good evidence to show that patients do better long term if the tear is repaired. Occasionally the labrum is frayed and is simply debrided back until it is stable. Once that is carried out, the rest of the joint surfaces are inspected and treated as required. If the joint surface is damaged, it can be trimmed back if minor or if more severe, then specialist techniques can be carried out to encourage new cartilage growth, such as stem cell grafting.

If there is an underlying bony abnormality on either the femoral head or the bony pelvic cup, then that is also addressed at this stage. This is technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehily’s own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In these cases the operation is done using an open technique and the labral tear can be addressed at the same time. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, all patients are different and advantages and disadvantages of the various treatment options can be discussed at the time of your consultation with Professor Fehily.


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A painful hip can be through a one off injury but more commonly in clinic at Altius Healthcare we see pain that has come on gradually over a period of months and got worse. Patients describe a deep pain in either their groin or buttock or both and don’t recount a particular event. Their pain tends to vary in severity and is aggravated by certain movements that compress the joint surfaces including prolonged sitting. Combining physical therapy with other avenues can help people deal with the pain in a better manner. Medical marijuana has been known to aid in pain relief and depending on how you consume it, you can go and look at pipes and bongs online to find the best one for you.

Often these patients are scanned and the results of the imaging don’t match their pain presentation. Some have a large amount of damage in their hip but are relatively pain free and others are very painful with little to report on the scan.
The majority of patients (regardless of their scan results) have muscular inhibition, as a result of the pain they are in and which we can address with home exercises which almost always helps them with their pain.

Patients with painful hips tend to keep going on them until they have picked up a poor movement pattern (limp) which sets off a cascade of events that if you don’t address with treatment and rehabilitation they continue to gradually get worse.

Once you are feeling pain the important thing to do initially is to identify the things that aggravate your pain and avoid them. This may sound like common sense but you would be surprised how many people try to push through the pain only to make it worse. For instance, if prolonged sitting is a problem, record how long it takes in sitting for you to get to 4/10 severity and then use this a s a guide to make sure that you don’t exceed this pain threshold in any one day.

Do take medication as well. People will not take medication because they think it will numb them so they do not know when they are making things worse. Once you know that without medication you can only sit for 40 mins then once you are taking medication stick to this rule of not sitting for longer than 40 mins for 3 days and then reassess your progress.

A person who has had hip pain for a month or longer will normally always have inhibition in their gluteal muscles (buttocks) and adductors (groins). In clinic, we would normally always prescribe exercises to help wake these muscles up. I often suggest a single leg bridge and a ball squeeze as a good place to start. Patients with hip pain also tend to have poor trunk strength, often worse on their painful side so we would also teach a modified plank exercise in three positions to strengthen the natural corset which is so important in stabilising the spine on the pelvis and off-loading the hips.

At the same time as addressing muscular inhibition, we also encourage patients to work on their spasm. We often find in clinic if the gluteals and adductors aren’t working properly, their default is to go into spasm to stop you moving which causes you more pain. We find teaching you deep pressure techniques with a foam roller can reduce spasm and pain and be a great thing to do before you do your strengthening rehab.

Regarding how much and how often. Obviously most patients are busy people and struggle to get anything done regularly just as some patients can over do it and aggravate things further. Therefore finding a balance is important and listening to your hip and how it is feeling, is of up most importance. I always suggest doing rehab Monday, Wednesday and Friday is a good place to start. The body needs to rest and recover from the strengthening you are doing and normally I say if you are sore (less than 4/10) during the exercises and and/or afterwards, that needs to be monitored and if you haven’t recovered by the next day and you are still 4/10 pain then you are doing too much of the wrong thing for you at that stage. During each rehab session I ask people to repeat each exercise three times until fatigue with a minutes rest between sets.

Catching hip pain early and treating it aggressively before you pick up a poor movement pattern is essential for a speedy recovery. Do not leave things for a month before you do something about it. Early intervention is key in managing any injury.
So in summary, the devil is in the detail. We see many patients who make fantastic recoveries from severe hip pain with a huge amount of damage on a scan. The patients who do best are those who catch the pain early and make time to do the rehab properly and listen to their symptoms and don’t train with too much pain.

If in doubt and before you start doing the wrong thing it is important to get an accurate diagnosis. You should always get in to see an experienced physio or specialist sports medicine doctor with a special interest in the hip and groin as it is a specialist area and requires often a multi-centred approach.

If you would like further information or would like to send us a question please feel free to get in touch and we will help you as much as we can.

Douglas Jones
Director, Altius Healthcare
www.altiushealthcare.co.uk


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Both adults and children alike find that their level and intensity of exercise peaks and troughs throughout the year. The body has the most amazing capacity to adapt to any stress or load placed on it providing that it has time to do so. If we ask more of the body both bone and muscles can get stronger. The problems start when we have a sudden spike in a new activity or we do more sport at a greater intensity following a period of rest such as following the summer holidays and Christmas. When we then resume our sport with renewed vigor in a determination to regain any lost fitness the sudden spike in activity results in tissue overload and pain. Transitions between the sporting seasons such as the end of the football season and beginning of the cricket season pose problems with double the demand on the body. This is a particular issue with teenagers who are going through a growth spurt at the same time, which puts the muscles in more danger. Problems can occur in any part of the body, but back issues like spondylolisthesis caused by hyperextension of the back due to rigorous sports are common among teenagers. Luckily, such issues can be confronted by treatment from places like Medical City Kids Orthopedics, along with many other sports-related injuries faced by young or old athletes.

In growing athletes, there are two common types of overuse injuries, those affecting the bone and those affecting the insertion of the tendon on to the bone. Excessive, repetitive and sudden loading of young bones can cause bone bruising which often causes pain. With adequate rest, this will settle but if the symptoms are ignored, the child becomes at risk of a hairline fracture in the bone known as a stress fracture. These types of injuries tend to affect cricketers, swimmers and gymnasts who repeatedly arch their lower back stressing the bones in the lower back. They also are prevalent in the shin and foot bones especially in young runners. Recent thinking is that, in addition to excessive load there may also be a link to low levels of Vitamin D and it is worth considering supplementing the diet of children who live in northern England and those involved in indoor sports such as swimming and gymnastics.

In adults, we see many overuse injuries in tendons such as the rotator cuff tendon in the shoulder caused by a sudden spike in activities such as hedge cutting and is known as a tendinopathy. However, in children the area of bone where the tendon attaches to the bone is weaker than the tendon itself and loading the tendon in the same way results in a growth plate injury to the bone. These injuries are commonly found in the heel where the Achilles’ tendon attaches (Sever’s disease), the quadriceps attachment at the knee (Osgood Schlatters disease) and can occur in any area where muscles attach to young immature bones.

Traditionally the advice for overload injuries was rest. With careful management compete rest may not be necessary if the young athlete is given the correct early advice. There are guidelines within certain sports such as in cricket to limit the number of balls that young crickets can bowl in any one session and accumulated over the week. Many experts have used graphs such as this one to help us understand what is too much or too little (the “Goldilocks principle”) and it varies from child to child. The important factor is giving the growing body time to adapt and become stronger. The England Cricket Board adopt a recipe of no more than 2 consecutive days of fast bowling with no more than 4 days of play in every 7-day period.

This is a sensible approach to most sports giving the body a day to recover allowing minor stresses to be heal and repair and more tissue can be laid down in case the load recurs. Many young athletes can pack an enormous amount in to a week with some children doing several sports a day and no days off to repair. It is not only the muscles and bones in these very active children that are at risk. These children are often exhausted and susceptible to a condition called overtraining syndrome with recurrent sore throats and fatigue. Ensuring children get adequate sleep is paramount as this is when the body can repair.

The better conditioned a young athlete becomes, the stronger level of protection against injury. Learning to move correctly is critical to a child’s development and just like they must become literate in Maths and English, it is essential that they learn correct movement patterns and become physically literate. Movements such as lunging, crawling, squatting and deadlifts form the basis of many sports and should be taught at an early age but are often missing from the current physical education curriculum.

Physiofit specialises in the development of young athletes and can provide guidance on how to create strong and robust athletes who learn to monitor their workload and safely learn how to do age appropriate strength and conditioning in a 1:1 or class environment in our rehabilitation centre in Wilmslow.

Angela Jackson MCSP AACP ACPSM – www.physiofit.co.uk
Angela established Physiofit in 1992. She has been involved in treating people in sports at all levels both in the UK and Canada for the last 28 years. She has worked with the England Volleyball team, Cheshire Hockey, National league hockey clubs and is the Consultant Physio to all the Cheshire Cricket teams. Her major interest is in prevention of injuries especially in children. She now lectures on courses to share her expertise on developing athletes and gives regular talks in schools and clubs on injury prevention.
?She launched the Physiofit screening programme 20 years ago to identify how to prevent injuries and enhance performance and has helped many young athletes realise their sporting dreams in representing their country including her own two children. Her areas of expertise are in knee injuries, the sporty child, hockey, golf, running, cricket and nordic walking.
In the last few years she has become a dedicated running physio training with The Running School and with Blaise DuBois from the Running Clinic in Canada. She has extensive knowledge in golf strength and conditioning and screening having trained with TPI, Ramsay McMaster and Golf Biodynamics.


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They say prevention is better than cure and that is certainly true in hips! Having said that you can’t change your genetics. Some people have a certain shape to their hip which seems to predispose to early hip osteoarthritis. These ‘CAM’ and ‘Pincer’ shaped hips predispose to pinching (impingement) of the hip against its socket, leading to damaged cartilage and eventually arthritis. Hip Arthroscopy surgery can be used to reshape the hip and may prevent early arthritis progressing to advanced stages.

The most important modifiable risk factors for arthritis is your weight and activity level. Being even slightly overweight leads to increased load on the hip joint. Over time the hip can be squashed down and change shape permanently. The increased angle leads to more pinching and the hip wears down more quickly. Losing weight can slow the whole process down. Other people have illnesses in childhood such as Hip Dysplasia (the hip and socket are too shallow, having not formed properly), Perthes disease (the blood supply to the hip gets cut off in childhood), or Slipped capital femoral epiphysis (the growth plate of the bone slips out of place). All of these conditions need to be spotted in childhood so something can be done about it and potentially prevent adult hip osteoarthritis.

Early hip OA is much easier to fix than advanced OA. Sometimes X-rays can miss the early features, MRI or CT scans are more reliable. If you are sure that you have hip or groin pain, but the X-ray is normal, you will need to speak to your doctor about a specialist opinion or scan.

Sometimes a steroid injection done under X-ray guidance can give temporary relief, and provide clarification around whether pain in the groin or buttock area is truly coming from the hip joint, however, they generally wear off after 2-3 months, so it is not a long-term option. Another alternative to steroid injections that have been known to offer short term, yet effective pain relief, are the taking of certain strains of medical marijuana. But only if it is legal to do so in your area. Places similar to Leaf2Go, (visit this website here) offer a choice of the best strains that can help with pain and other physical or mental ailments, but again, this may not be a long term solution. Other substances such as hyaluronic acid (an artificial version of your natural joint fluid) and PRP are also being used but need to be further evaluated to see if they have long-term benefit.

It is important to do regular strengthening exercise (such as core stability and pilates) and maintain a healthy weight, if hip pain is becoming intrusive, ask to see one of our specialists.

Dr Leon Creaney
www.sportandexercisemedicine.co.uk


The Manchester Hip Clinic is committed to helping all kinds of people with hip problems to be free from pain and often to resume near-normal levels of physical activity – even those who may have thought that such relief would never be possible.

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