Hip Replacement Surgery: How It Improves Quality of Life and Why It’s on the Rise

Introduction to Joint Replacement and Infection Risks

[00:00] Any joint replacement surgery you have assessed about infection? Infection. Okay? And this happens in less than 1% but it is a disaster and it can happen. But I tell you this, at the moment it's just a marketing tool. Infection point of view. As I said, as surgeons we really try to do our best to avoid any

[00:20] risk even if it was a minor risk eventually if you have repeated can destroy the cartilage. It also if you're coming up for a knee and hip replacement it may actually make it worse. Before you offer me surgery like PRP stem cells. Your physio will say no I think this is the one we need. I hope I can say that for every surgeon. You have knee pain.

[00:40] People used to think I should exercise more, but they shouldn't, is it? Any joint replacement surgery you've ever obsessed about infection. The one thing that does seem to work is to think of hyaluronic acid. What are the immediate complications that we can face? Post-surgery, physiotherapy. Not really. And literature also, they mentioned that you have full recovery, which is getting back to your normal self is six months to one year. Is that old literature? Yeah, that must be it.

[01:00] I want to ask you a very, very important and important question here. So if I'm 55 and I have the surgery, if I'm lucky enough to live till 85, now I'm 30 years down the line, I have a hip replacement, I have a prosthesis inside, how long I expect it to last? If you say a hip fracture in an elderly is a death sentence.

[01:20] Dr. Paul, welcome to Scrubs and Suits. Thank you so much. It's really a delight to be here. You know, you have the distinction of being the first orthopedic surgeon on this podcast. Yes, of course I am. Of course. So before we jump into the actual nitty-gritty of this podcast, just tell us about yourself. I know you're a hip and knee surgeon.

[01:40] But tell us what you do. What brought you to Dubai in the first place? Well at my wife actually I was in the we were in the Middle East She's very fascinated about coming to other parts of the world You know as well as I do we were in this NHS comfort blanket where you've got a job for life and you can have a certain amount of salary and you can have a certain way of living and Then she throws it all up at the end of my training says you can go to

Journey into Orthopedics: Why Choose Hip and Knee Surgery

[02:00] out in and see the rest of the world and how everyone else lives. And I go, no, I really just want to be in my comfort blanket. So really I've got my wife to thank, blame, whatever. Okay. Is she adopted as well? No, absolutely not. She did. I wrote it, she read a book about meeting women and all this sort of stuff. So I had my wife to thank for that. We had very small kids as well. And we only had one at the time.

[02:20] We had small babies. So it's a good time before they go to school to really kind of get out there and see things. So we had a very short career. So let's go. I mean, probably a couple of decades or 15 years back when you decided to start orthopedic surgery as your career. Why? Why did you choose orthopedics? Well, it's always been my aim. In fact, it's probably started about 17. I went to see some orthopedic surgery where my mother's from in Calais.

[02:40] in France and I went to a clinic there and I followed an orthopedic surgeon around. I remember seeing an arthroscopy and you know that it's pretty bloodless, right, but I remember feeling quite... Is it 17 years ago? No, no, when I was 17 years old. 17 years old? Yeah, yeah. 17 years old. So maybe when I was, you know, maybe 35, 40 years ago and I just managed, in those days,

[03:00] go to theatre with a surgeon. I don't know if you could do that as a work experience A level student now. But I went in and I remember looking at these TV screens. There was no blood, but feeling very queasy in this kind of strange environment of theatre, you know, with washing your hands and all that. And yeah, it was just kind of a fascinating place. Well that should put you away from it, isn't it? Yeah, it feels

[03:20] So yeah, no, it was just but it was just a it was a very sacred place almost You know and it still is actually when I think about it or just washing hands and these rituals that you go through and all this sort of stuff So yeah, it was it was something that I had never really experienced before. But why did you then make hip and knee surgery or bread and butter? Why did you choose that? That's very straightforward because it works

[03:40] works. You mean nothing else works in antibiotics? No, I think what is it, 150 years ago people rightly didn't trust their doctors when they were doing leeches and all sorts of stuff, but really this one really seemed to work and it works very, very quickly, particularly hip replacements. So it was kind of very attractive. If you want a quick time buzz as an doctor

[04:00] You really want to get into this stuff. I mean and it's not chronic. Okay, I know medicine has its intellectual challenges and all that and if you're a psychiatrist These would be also challenges in on a certain level But the thing is you get such a dramatic change with orthopedic. How long you've been doing these now? Well from my sort of training that's 20 years

[04:20] Before then I was in SHO for a good six or seven years before then. You've been a part of it obviously. Yeah and then obviously as a medical student I knew pretty early on probably about third or fourth year that this is really where I wanted to be. Let's start off with the normal anatomy of a hip because we're going to talk about hip first and then move to the knee. So let's talk about the normal anatomy of

[04:40] Maybe you can show to my audience what a hip looks like. So this is a pelvis. And obviously we have two hips. This is the right-sided hip where the cup sits and this is the left-sided one here. In and around the pelvis we have various muscles and most famously we have the gluteal muscles or the buttock muscles around there.

Understanding Hip Anatomy and Common Causes for Hip Replacement

[05:00] There are various gluteus that fill in around that. In and around that, the hip joint, we have the femur, the long leg bone or the shin bone. So Paul, when we talk about normal hip anatomy, hip is supposed to be the largest joint in the body, is that true?

[05:20] And if I'm getting older and with age, obviously the first joint or the most common joint to be affected with osteoarthritis is my hip, right? It could be the hip or the knee. Or the knee. It could be either. In fact, in this part of the world, it's more likely to be the knee. We're not really sure why, but it's definitely probably the population is definitely more knee dependent.

[05:40] So we know for a fact that arthritis with age obviously requires hip replacement at some point. What are the other reasons why people might need a replacement of the hip? Okay, so most commoners say wear and tear, getting a little bit older. But I suppose the two other main ones would be avascular necrosis within the hip, which is basically a starving of

[06:00] blood supply. Now there's at least 200 causes of that. But if I can remember a few, first of all, sometimes you never find the cause. So half the time you never find that cause. But sometimes it can be other things, steroids. Now someone is sticking steroids for a long time. Not even that long actually. So you could have like

[06:20] two or three shots. People have been explained to me that they put it down to one or two flu shots. They've had something put into them once or twice. And whether that's true or not, because as we know, patients sometimes attribute symptoms to things that may not be related. But they really can't think of other causes. You know, the other causes being particularly where I'm from alcohol.

[06:40] Then we have things like sickle cell and then most importantly trauma. Okay, so if we have trauma within the hip from a road accident high energy trauma Yeah, but the first case of a hip replacement I did in this country was a 14 year old boy. Okay, it got written up in the Gulf News He'd had a trauma road accident where

[07:00] when he was about 12 or 13 and he's a Q80 boy and he came to see me and my pediatric orthopedic colleague who they can do all sorts of clever cuts with the pelvis as I've just shown could not do anything because the hip joint was absolutely destroyed. The only option he had was a hip replacement. So when you see a vascular necrosis as the word suggests reduce blood supply to the

[07:20] bone and that leads to the bone being completely crumpled up. So there are various stages in that and so in the early stages it could just be salvageable by essentially just drilling the hip. Now my experience with that isn't great but it's probably worth a go in the early stages in stage one and two. Now the idea is you're basically giving your

[07:40] own body's stem cells, if you like, a chance to repair the area. It's minimal whether it works. It certainly doesn't work when there's been collapse within the femoral head, when things are getting quite serious and the cartilage is starting to break out and delaminate and then when the head is actually starting to flatten out. We've got to remember when the

The Evolution of Hip Replacement Surgery and Advancements Over Time

[08:00] vascular necrosis as well, it's only in the femoral head. There isn't a problem on the cup side. So it's quite often you just see the collapse in the head but you never see it actually in the cup unlike arthritis which is both sides. So now let me make it easy for the audience. So if you have 10 patients coming to you for hip replacement, how many of those are because of regular osteoarthritis with age and how many are the

[08:20] These are the weird and wonderful ones that they are.

[08:40] Okay, all these, right. But there might be one in the 40 to 50 year age bracket. Now those are the ones regularly that I see here. They've done something. They've played rugby. They've had some trauma in their life. They may have taken the ulcer steroid. I get those one out of those four that are seen in the UK that would be on a standard basis.

[09:00] But are the other three still age-related here, even in Dubai? Probably not. Most of my patients are still in that 40s, 50s and 60s age bracket. They're just coming a bit earlier. But that could represent the general population makeup of Dubai, right? That's exactly right. As I say, the expat population is mainly the ones, not the locals so much.

[09:20] Generally, they are the working age population that generally are here and they have it done a bit earlier. It is the case that most hip replacements around the world are coming a lot earlier now. The reason for that is we think that we can put these in and they're going to last a lot longer. So there used to be this old adage that you'd see your family doctor and say, you'd be in your kind

[09:40] early 40s, you're too young for that, you have to sweat it out and suffer. We as joint replacement surgeons discount that really completely. If you suffer, you will not be able to live a full and active life. As a 42 year old, for example, if you wanted to go hiking at the weekends but you knew you couldn't because the pain would be so bad on a Monday,

[10:00] Then you need a hip replacement. Yeah. Okay, we don't wait anymore. Yeah, but do you think overall these surgeries are on a rise now? Definitely. Yeah, definitely more awareness among people in the fact. Yeah, definitely. There's more awareness of that and maybe hopefully eventually the thing that's really stopping the most people getting one around the world is the cost.

[10:20] It's still a very expensive operation anywhere in the world. It's hit in Dubai, but in the US and even in the UK, this would be a very expensive operation. But is it expensive because you are expensive to just think or is it the equipment that goes into it? Yes, both. It's both. But the implants and the fees and all that around it. I mean, obviously, you can go to certain parts of the world and they can do it a lot cheaper.

[10:40] And hopefully they can do it well. But you know that doesn't always, as we know, equate as much. But the alcohol, it should come down. I mean, you know, I've had LASIK surgery. It used to be really quite expensive 10 years ago when I was looking at the price. I've done it just down the road here a few years ago. And it's fairly cheap. So hopefully this would be a dream to bring people in and do it. So just let's talk about before we go

[11:00] into the surgery per se. Let's talk about the history. So when was the first hip replacement surgery done? Yeah, so the first one we know about that we know that really started working with a guy called Sir John Charnley, British guy, very proud of that. It's non-American because they seem to think that they claim everything. Okay, and basically I don't know whether hip replacement will be invented now because he was just knocking up

[11:20] these things in the shed in the back of a hospital. And then he was getting some sterilization and he didn't have to go to lots of DHA and FDA approvals and then he was just putting them in. Now he was very very lucky because he had a dental surgical friend and the problem was how you got these cups to stick.

[11:40] It was the cup that was failing and he still is to this day how the cup fails. He just happened to have a dental mate who was using filler to put dentures in. So he was a surgeon I hope. He was a surgeon. So he knew how to cut open in size and get into the joint. Well he did but I think again that has been perfected and that technique has come. People came on after

Decision-Making for Hip Replacement: When to Consider Surgery

[12:00] For example, he was a genius and a real pioneer.

[12:20] price because it was that good and what he's done for people around the world, millions of people around the world was amazing and he had that forethought but most importantly like all good investors you got to get lucky and I say this dental friend he had he was able to put this cup in and stick the cup without it getting loose and this was the problem they were having problems with. They could put these things in but they didn't know how

[12:40] really get the glue and fix it. In the last decade or 20 years how has it evolved? I know the material has but what else has happened in the field of hyperbic? Yeah so people think the innovation has been the material not necessarily so much. So there has been this shift particularly what we call unsemmented and cemented hips so you can put these

[13:00] things in without that special dental pace or cement now and you can stick and the bone will stick and grow into it. Okay. This is a kind of a revolutionary thing, but that's been around for a fair few years now, at least 30 years with that. Okay. I think what's really changed is the things around the operation. Okay. So the

[13:20] pre-op care, the understanding from the patient. So you're very, very keen to talk to the patient and understand what their expectations are. You will be coming onto it step by step. So before I was just talking about the evolution and we're seeing how this has evolved. So the technique has evolved, right? Yeah, oh, definitely. Yeah, just the sort of approaches that people use. For example, in

[13:40] In the past you used to cut a bit of the bone off the main thigh bone and then wire it back on. That would have been a childly technique. Now we try and avoid that. We try and either split muscle or just part muscle away without actually having to cut it very much. So those are the innovations in that. The implants are such not really because as I explained

[14:00] You want an implant that is tried and tested. You don't want anything too new and fancy because sometimes these things can fail quite quickly. Right, Dr. Paul, let's start with the first point, which is decision making. So imagine I am 55, I'm almost there, but 55 and I am now thinking, okay, I've got a hip pain and my doctor has said you're developing osteoarthritis.

[14:20] 30 years ago people just used to live with it. They live with the pain, it will affect their quality of life, their limb might shorten and they'll just live and eventually suck them and die after that. So the quality of life, you might live 30 years, you might live 40 years, maybe 10 years, you don't know from 55. But then those years you will suffer. Now things have started moving on and people have realised that I can

[14:40] do something about this. So the number of people coming to you and saying, okay, I am 55, I need my hip replaced because I've got 30 years to go for sure if I remain alive and I want good quality of life. So that first decision about balancing your morbidity to actual surgery, it's not very easy, isn't it? How do you sit with a patient and experience

[15:00] explain this to them?

[15:20] sorely a miss. 55-year-olds should go hiking to keep their health, their well-being, their mentally, physically up to speed. So it's a very easy decision for my world. And to explain the ... first of all, you have to be in enough pain, so you need to have it. You need to have the

[15:40] right symptoms. It is the case that people come to me saying they've been told they need a hip replacement and actually their x-rays look okay. And I've said, well look, wait it out, do some physio, take some anti-inflammatories and sure enough some of the best kind of reviews I get and some other things. Thanks very much, Doc. You were right. For the conservative management. Yeah, exactly. And that's where we should

Pre-Surgery Preparation: Fitness, BMI, and Anesthesia Options

[16:00] always be heading for this stuff. Okay, that's the first thing. But then if you do have bone-on-bone arthritis and the cartilage is completely worn down and you're suffering and you've tried everything and most importantly for a British trained surgeon, nighttime symptoms, you have tried everything to go to sleep and you can't. And we know when we've had small children and

[16:20] all that just how cranky that sends you and how you can't function in your daily living if you can't sleep. But then of course there's all the other things like the stiffness and the walking distance. You know you may be limited to even just getting to the car from the car park. You know putting your shoes on, cutting your toenails, all these things like that you know the effect equality of

[16:40] So it's a very easy decision. And now if you ask me how I persuade patients, well first of all, I just show them videos now. After surgery? No, no, no, patients. Before and after. Yeah, yeah. Particularly the after bit where they're worried about the surgery. So I say, look, but this is my patient four days in his garden and he's basically 18.

[17:00] exercise. He's lifting his leg up. He's walking. Okay. You can see a little bit of swelling, but his wound is dry. You can see within six weeks they don't even know if they've had it. You know, I have patients telling me forgetting even at six weeks, which side did I know? Can I see your scar? And they in six weeks? Yeah. Yeah. They go. Oh, yeah. Yeah. This one. Okay. It is like that. Right.

[17:20] For hips. For what needs, if I'm honest? For knees, it's not quite there yet. For hips, really. So you decide, okay, I'm your patient, you decide, okay, my right hip needs replacement. What is the preparation before surgery? I need to be fit enough to undergo that surgery first. What are the parameters? I think that's where the innovation is actually. So I would like patients

[17:40] patients to optimize all their healthy stuff first. So quitting their smoking, keeping their alcohol down obviously, I would like them to eat and drink. Now I think there's a lot of research still needing to be done about optimizing patients from the nutrition point of view. So if you have good nutrition, probably good gut flora if you've taken some providers, there's no great evidence

[18:00] at the moment, but I think this is where things should start heading, like optimizing the patient's pressure. And then of course, particularly if they have weak muscles, particularly if they've had it for a fair few years, their gluteals may have wasted, it might be worth going to see a physio. First, to try and build the muscles up, but also to understand the instructions if very occasionally they need physio

[18:20] afterwards for their general mobility. It's very rare that patients actually need physio, but if they've had it for a long time, then maybe. So imagine, okay, so I'm the patient, so my BMI is 40. Now what do I do? Yeah. Well, am I okay still to go ahead with it? You know, I've done people way more than that. Right. Okay. I would tell them, we used to have this contract with patients if they had a high BMI.

[18:40] eye say could you just try and lose a few kilos and that tells the surgeon this patient is willing to go ahead with the operation and it's kind of see how much dedicated his towards the contract between surgeon and patient yes the last thing a surgeon a good surgeon wants is to put something in and and it causes more harm okay so if they feel that there's some willingness on the patient

[19:00] Even if it's one or two kilos, I mean, BMI 40 is actually not that big, but it's not that big. It's more the fact that it's showing the surgeon, oh, this guy's got some oomph in him. He's got some willingness to understand the procedure and go for it. Because we're not just changing a car and putting your tires on. We have to have patients willing to be a bit up for it as well.

[19:20] Now what do you do? Again, this can be managed and controlled. I'd obviously speak to all my clever colleagues in the internal medicine department or my endocrinologist. They can fix all this stuff. So these are not absolute contraindications to undergo any of these? No, definitely not. And even the anesthesia from the lung point of view, because now everything is done with spinal, with small sedation. So you can have

[19:40] Patients come into that. So yeah, so my next step. Okay. I agree to do the surgery with you. You say okay, go and meet my anesthetist Yeah, what are the options I have what kind of anesthesia would they he my world? There isn't really that much option in terms of fact that you get a spinal spine. Maybe a local block. Okay, so I'm so I'm awake No, you're not awake. You can be sedated. Okay, so you can get a degree of circulation pressure

Surgical Procedure: Approaches, Techniques, and Prosthesis Types

[20:00] but you're not completely out like a general anaesthetic. That's an optional thing, right? If I want to be awake, I can. Yeah, you can. And that for a surgeon is great because then you will recover, you will get out of recovery and start moving quickly. And you also have to understand that again, you may have had a friend who had one 15, 20 years ago, they didn't get out of bed until for two to three days. If I do you at 8 o'clock in the morning, I'm excited.

[20:20] expecting you out of bed by midday. And that will… In four hours. Yeah. So if you talk about the innovation, it's within the anesthesia service more than it is with the… And it's a collaboration with the anesthesia and with the surgeon. And so I would say the biggest innovation in my time has been the communication with the

[20:40] Is this okay, so I come to a unit now and I've come to many units and I said I was using this and we were doing this and I'm not in these cysts But I saw my guys were doing that and I give them a pro forma now I don't mind if they adjust it completely or they just or they take a little bit or a lot of it as long as they've got a plan Like they get some rehab in the similar way, right?

[21:00] Spinal anesthesia, a little bit of sedation. With or without? Maybe with a block? Maybe not. Maybe with a block. And you're expecting the surgery to last how long? So straightforward surgery should be 60 minutes. 60 minutes, that's it. For unilateral replacement. If it's a revision or if it's a complex K, BMI, a little bit higher

[21:20] Maybe you could put another half an hour on that, just for closure. I know that different surgeons have different approaches, but there are few that you can take. What's your approach to get into the hip? Yeah, so people read a lot and they see a lot of stuff on Facebook and all that stuff. It is quite clear that for the poster approach,

[21:40] been fantastic. If you're going anything around the posterior approach, for example with the new anterior approach, you're really reinventing the wheel in my opinion. So when it's a posterior approach, it's through the glutes. Yeah, through the glutes. So it's kind of muscle splitting, it's not muscle cutting. There is some muscles deep within the hip, what we call the short external rotation

[22:00] cases that are cut, but you put them on a suture and then you tie them back to where they were afterwards and they heal up completely the same. The approach is fantastic because it doesn't drop the pelvis. You don't have to kind of get the glutes moving in again in say certain other approaches like the lateral approach. It's also

[22:20] Also, I think very importantly, avoiding the groin. The groin region. I think the new anterior approach is great. I think there may be room for that. But still, again, it's early days and I think operating around the groin is prone to trouble. There are more bugs in and around the groin and I think that the infection rates and people aren't saying that so much, are slightly higher.

[22:40] That's quite controversial. But I think anything that risks infection in my world is a big no-no. And until we're really certain, I'm not going to risk it. These things have to really, really be working well. And this is why I say it comes back to orthopedics. It's full of fads. It's full of new inventions, people reinventing wheels.

[23:00] And they turned out to be disasters. And sometimes disasters with a million people having gone through these things. So Paul, let's just talk about the action procedure now. So I mean, you brought your toys here. So can you explain to us how the hip replacement procedure happens and how the various you call them prosthesis or the development?

[23:20] access to the joint is all important. So we've already seen this joint before, we know it's the right side and we need to get access really to the clock face. The 360 clock face of the acetabulum. This is the skill because obviously there's a lot of muscle,

[23:40] issues and ligaments in and around and bone in and around it. So we've dislocated the hip. The hip is out of the joint and we want access to this 360 clock fat. So now you have an access? We have access. And that's really the skill of the orthopedic surgeon, the hip surgeon, to get really good access. And we use various retractors and all sorts

[24:00] Now with that, I want to put the cup in. Now as I said, for this example, we're going to demonstrate how that cup sticks. So this is a metal cup? This is the outer shell of metal and it's an uncemented one. Why is it uncemented? Because it has this rather rough surface here called high

[24:20] Phygoxyapatite now this stuff is like a it's a kind of bony calcium Composite that basically allows bone to grow into it, right? Okay, so it's a little bit warm because obviously this one has been in a patient Yeah, okay, but the principle is that you've got to put this thing in and obviously everyone has a different size Yeah, and everyone has so men and women

[24:40] This is almost certainly a man given he's this is a big bigger size and we ream the cup with these kind of cheese cheese reamers Yeah, okay, and then we size up and this is usually 1 millimeter bigger than the cheese and the same And we do what's called a press fit. Okay, it just so happens that this pelvis happens to fit

Post-Surgery Recovery: Pain Management and Mobility Timeline

[25:00] in this one. And the same principle, it sticks. Okay. And it just sticks into the cup. Now it sticks a lot more and there's a lot more force with it. There's usually a bigger hammer and but the same. So you hammer it in basically. We hammer it in with on a long spigot and yeah that's when sometimes patients can sometimes hear some banging. Okay if they're not if they're not that sedated. So I'm sedated.

[25:20] Don't worry about me. So this is very different to an uncemented hip by the way. So you never hear that banging you just put in around. But most of my young patients get this, especially in this part of the world. So there we are. We have this cup that's had an incompressible fit and within six weeks all the bone has grown into that. So it becomes part of you. But Paul, let me stop you there.

[25:40] There are no screws going into this. Some people put screws, but if you're an experienced hip surgeon, you try and avoid that because that's one thing that may need to come out later on if we need to do anything later on. So most of the time I don't need to put screws in. But if you don't put a screw, would it not just slip out? No, because it's press fitted in. Press fitted. Rather like this at the moment. If I bang this in hard enough, it would be press fit.

[26:00] Most of the time I don't need screws. Unless the bone was a bit parotidic or the patient was a bit elderly or something like that, I would probably put some screws. But most of the time, like in a guy like you, it would press fit very comfortably. Then the bone would glow into that as six weeks. And then it's part of you and it grows in. It's a really very beautiful concept.

[26:20] After that, this is a liner, an all-important liner. This is what we debate for many times when we go in our conferences with other hipsters which one is the best liner, which is the one in Vogue. This rather tasteful pink is ceramic. It's rather like the stuff you have on the fine pads. It's a hard surface. It does not

[26:40] throw off any particles and it's inert and it was thought to be the best liner you could get and essentially it fits in here like so, like that. Obviously this one has been worn down quite a bit but it still sticks in quite nicely. How does it stick in? Again it press fits in. This one's been worn

[27:00] but it's still actually fitting in. So this is a ceramic line. Now we then turn our attention to the femur. We cut the femoral head off and then we insert the stem down the femur. And everyone has a different size as well again, like men and women and also

[27:20] So how much bone you have in terms of the thickness of your bone? If you're a very athletic, active person, you might have very thick bone. And it may be quite difficult to get these things down. So you drill this into the long? Again, you use a hammer and it's on a spigot and you tap it down. OK, quite gently. Basically you're doing carpentry work. It is essentially that. Yeah.

[27:40] There's a lot of thinking and noise like carpentry. But the thing is when you do this for a long time you have to listen for the subtle signs because essentially this thing has got to press it into the bone and you're listening for a very subtle note change because if you're obviously over-sizing it you can break the femur. Now that's never happened.

[28:00] to me, but you get to the point where you are listening for a very subtle note change. And it sounds very different when it's at the edges of the bone at the cortices than it is when it's going down easily. But then it's a very subtle kind of test to see that it's actually press-fitting in and it's not moving around too much.

[28:20] It's a feel, it's a kind of thing from the experience. There's no amount of robot that's going to tell you this at this stage in your life. We know we're still at the test of phase, we still need humans to actually figure this stuff out. Eventually the robots will sort all this stuff out, but they really aren't at the moment. In fact, robots in hips are not quite that useful. So now we have the

[28:40] have the hip. Yeah. Okay, this ball usually comes off but it doesn't. This one has been machined in. This again is a ceramic ball. Ceramic. Okay. Alright. And so this ceramic ball goes and wiggles around on a ceramic liner. Yes. Okay. Now that was kind of in vogue 20 years ago but 1% of these

[29:00] Out of every 100 squeaks. Okay. Alright. So this would be really annoying. Imagine every time you took a step you would squeak. Okay. And it's very annoying for the surgeon because obviously he has to put up with the patient complaining every three or four or six months he comes into the clinic. And sometimes they have to redo the surgery on that basis because of this continuous squeaking. So that one

[29:20] And if you're doing 300 years that equates to maybe three patients. Okay, so to avoid that they've ended up having to right at the moment We then we tend to put in a high dense polyethylene a kind of plastic hard lastly on the inner liner Yeah, and keep the ceramic right just to avoid this problem. Yes, okay

[29:40] The squeaking is taken out of the equation. But we think we're getting just as much longevity within the implant. So again, these are the kind of minor subtle alterations that have happened over the years. So Paul, just tell me about how have these processes evolved with time, the metal lender? In terms of the ally, I can't tell you.

Types of Hip Replacements: Total vs. Partial Hip Replacement

[30:00] structure. But these the old days, the Charlie time in the 1960s, these walls inserted with cement. Yeah, they were cemented in. Okay. And for an old patient, that may still be a good option. Because remember, old patients get eggshell bone, they get osteoporosis. Okay. And smashing one of these things in, in very fragile

[30:20] bone can affect effectively. Plus, we think that they have just as good, the cemented. Some countries like in Sweden, they'll give the cemented hips to the young people as well. So it's a philosophy in various countries. If you're in America, you only get uncemented.

[30:40] If you're in Sweden, you might even get exclusively cemented. If you're in the UK, it's about 50-50. We tend to give them to the younger patients. Why do we give them to the older one? Well, if you're in a government-based system, you're going to worry about cost. And cost of cemented here is five times less than one of these. Five times less. And there may not be that much.

[31:00] difference in terms of the efficacy. So if you are planning and if your population is over 70 and you're still getting 30 year results with a cemented hip, why not take a hip implant that's five times less? So what he just explained now was a total hip replacement right? Yes that's right. So what is partial hip replacement then? Well that's

[31:20] is kind of more for trauma I would say. Okay so if someone breaks the hip okay you may just then replace the ball and you may replace it with quite a big ball okay and it may be inside another ball okay what we call a hemiautoplasty. Okay it's a very straightforward operation to do because as I say the technical skill is getting

[31:40] exposure to the cup. So you don't need that. So the cup is fine. So you're not touching the cup. You're not touching the cup. But the problem with that is usually with elderly patients who have necafemorhactures, people who have broken their hip and you know they probably haven't got long left. And it's a quick operation to fix. You said the surgery takes about

Hospital Stay and Expected Recovery Timeline After Surgery

[32:00] Now the surgery is done. Now just explain the recovery in the first 24 hours. So I'm on my hospital bed, had my surgery. When do I expect to say the pain? How long would the pain be? Yeah, well the lovely thing about hip replacement is patients describe pain going off like a light. Okay, it's really that good. We have not got that same situation in the knee.

[32:20] So just having that implant in actually takes away quite a lot of pain. And as a result, you still need quite a lot of hydromethal and analgesia to actually figure out the cut that we've made. It almost goes very quickly. Your pain load goes quite quickly.

[32:40] And it's quite often the case within three days, you know, some of these high dose or high strength Morpheins can be minimized to just paracetamol and anti-inflammatories. But how long do you expect me to stay in the hospital? Yeah, no. So if you're young and fit guy like you now we're saying 24 hours.

[33:00] You