Hip
Metal on metal (MoM) bearings in hip arthroplasty and resurfacing continues to dominate the headlines in both the orthopaedic literature and also the media at large. The degree of media interest has understandably caused considerable concern amongst the patient population who have had a MoM bearing hip arthroplasty or resurfacing. It is also of concern to patients who are awaiting surgery with some insisting that they do not have this type of implant. Clearly there are lessons to be learnt from MoM arthroplasty and resurfacing but are we in danger of throwing out the baby with the bath water? The fallout from the ASR has caused all hip resurfacings to be tarred with the same brush. Further tightening of the indications for MoM bearings and the identification of factors responsible for the early failure of implants will lead to clearer guidance for the hip surgeon. Indeed just last month the BHS issued further guidelines on stemmed, large diameter MoM hip replacements advising that bearings of 36mm or above should no longer be performed pending further information.
There have also been conflicting reports of a link between MoM hip replacements and bladder cancer. Despite the media coverage to the contrary, there is still no verified evidence linking MoM hip replacements and the risk of cancer. Patients who already have a MoM bearing implant should be followed up as suggested by the management guidelines published by the MHRA on the 28th February 2012 and recently endorsed by the BHS. This is a rapidly evolving situation and the BHS and BOA must be commended for keeping us up to date with current developments.
Hip arthroscopy continues to be taken up with considerable enthusiasm amongst surgeons across the country. As with any new procedure there is an inclination to push the envelope. One particular area of controversy is the role of arthroscopy in patients with hip dysplasia. Based on current evidence there is little support for performing a hip arthroscopy in isolation. It may be tempting to address a labral tear or a delaminated chondrolabral junction arthroscopically but to do this in isolation without planning for an operation to re-align the hip such as a peri-acetabular osteotomy risks early failure of the procedure. This point was highlighted in a case report in the recent edition of the Journal of Arthroscopy1 and it was also very well covered in the March edition of JBJS (Br) in the instructional review section.2
The publication of Patient Reported outcome Measures (PROMs) data over the past 2 years for hip and knee arthroplasty as well as varicose vein surgery and hernia repairs has highlighted the need for robust prospective data collection. With increased emphasis placed on the quality as well as the quantity of work performed within the NHS, adequate infrastructure is needed to support the collection of outcome data as well as information regarding patient demographics and case-mix. This is an enormous cultural change for some centres where retrospective data collection has been the norm. Times are changing and there is a considerable opportunity for clinicians to be involved in what type of data is collected and how it is presented. This may not always be the case.
We live and work in challenging times but now more than ever we need to retain the initiative before events overtake us. Data collection is pre-requisite for good clinical practice to confirm that the right patient is getting the right operation and that we are all achieving outcomes of a comparable standard.
Mr Chris Gooding, Locum Consultant Orthopaedic Surgeon, The Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
References.
1. Mei-Dan O, McConkey M, Brick M. Catastrophic failure of hip Arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Arthroscopy 2012; 28:3:440-5.
2. Jayakumar P, Ramachandran M, Youm T, Achan P. Arthroscopy of the hip for paediatric and adolescent disorders: current concepts. J Bone Joint Surg [Br] 2012;94-B:290–6.
