Your questions on surgery and arthritis

Q) Can an old (10 years) replacement hip joint be successfully replaced?

Susan, via email - 2015

A) Yes, replacement joints can be replaced, but the surgery is more complicated each time it's done. That said, 10 years wouldn’t be considered that old for a replacement hip joint given that 80% of replacements last for over 20 years.

If you're experiencing increased symptoms from the hip joint it's worth getting it checked out by your GP to establish where the symptoms are coming from. Sometimes pain felt in the hip region can be coming from other places such as the lower back.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) Looking ahead it's likely I'm going to need a second knee replacement and replacement of each of my hips. So, I wonder, has a knee and hip replacement ever been done at the same time? That would cut operations in half! Would it be possible, theoretically or practically?

Rosemary, Poole - 2017

A) In theory it's possible to have both operations done at the same time (or at least in the same hospital stay), but there are a few things you’ll need to consider. Firstly, having two fairly large surgeries together will mean your recovery is likely to take longer, though it would probably still be shorter than total recovery time for having one surgery and full recovery followed by another.

Importantly, if you need both a hip and a knee replacement, and you're worried about how you’ll cope with your rehabilitation, most surgeons will recommend having surgery on the hip first. Recovery after hip surgery doesn't require as much rehab, so a painful knee won't interfere too much with your recovery. If you do well after a hip replacement, you're also more likely to cope successfully with the more intensive rehab required after knee surgery.

Another thing to bear in mind is that pain from the hip can spread to the knee, so replacing the hip joint may improve the pain in the knee or at least give a clearer idea of how much of the knee pain is coming from osteoarthritis in the knee.

The final consideration is a logistical one. Nowadays, orthopaedic surgeons usually specialise in either hip or knee replacements, so there would also be the question of whether it would be possible to co-ordinate surgeons.

This answer was provided by Dr Tom Margham in 2017, and was correct at the time of publication.

Q) I’m 57, not overweight and don’t smoke. I need a total hip replacement and have been told it’s my choice when to have it.

Can I ask what your opinion is on people having a replacement hip then continuing to do martial arts, specifically karate? Any kicks I do are to a maximum of waist height. I've put off the surgery for the last three years as I have been advised not to train ever again afterwards. Although, apparently it’s OK to play tennis and badminton, which I would have thought involve significantly greater impact than karate. I'd be interested in your opinion.

Ruth - 2018

A) The main risk of doing karate or other martial arts that involve kicking after a hip replacement would be dislocation of the joint, rather than the impact. It’s the twisting movements involved in martial arts kicks that are different from racquet sports.

That said, it seems like quite a sweeping statement to be advised to never train again. You're clearly someone who will demand a high level of function from any joint replacement, so it might help to see an orthopaedic surgeon with expertise in surgical management of hip osteoarthritis in sportspeople. They'd be able to advise you on the specifics of treatment and rehabilitation, and on what the full range of options are available to you, not just a total hip replacement.

It’s worth doing some research online about your local surgeons and their areas of expertise. Your GP should then be able to refer you.

This answer was provided by Dr Tom Margham in 2018, and was correct at the time of publication.

Q) As a 66-year old, I've been playing non-competitive indoor and outdoor football at my university once a week (occasionally twice a week) for decades with colleagues and their sons. I was diagnosed with avascular necrosis in my hip around 1992 after I'd finished playing local league football, and was told I'd need a new hip within 10 years. But since suffering virtually no pain, only stiffness, for a few days after football, I've not had the operation. My question is: is there any case of a person receiving a new hip and resuming football thereafter? I presume orthopaedic surgeons would be aghast at the thought, given football is a contact sport with sudden movements and changes of direction (it's not golf or bowls, after all). But maybe I’m wrong? 

Gerry, Canterbury - 2014

A) If you are a regular reader of this column you will know that I am a strong advocate of exercise. I have a friend who, despite osteoarthritis, exercises every day to his limit. He can’t run 30 miles over the hills any more but he can at least still get out. I do support your continued efforts and while it would not be my chosen sport it is obviously the right one for you. My advice would be to see to a sympathetic doctor or physiotherapist who can give you a measured opinion on your hip. There is no point having the operation just for the sake of it. As for playing with a new hip – well, you are right in your presumption but I can tell you that patients do things with their new joints that would shock their surgeons. However, you don’t want to end up dislocating it, or needing a revision operation too soon, so I would advise against this form of exercise if you do go down that route.

This answer was provided by Dr Philip Helliwell in 2014, and was correct at the time of publication.

Q) What's your advice regarding swimming breaststroke following a hip replacement? I've heard various opinions. Personally I do a modified version, i.e. not the whole movement of the hip/leg. Originally I was informed by my excellent orthopaedic surgeon, 'Yes, it’s ok to do this,' but they added, 'the physios don’t like it'. I attend aquacise classes regularly and asked the instructor’s advice, but she doesn’t know either. We're both keen to hear your verdict.

Gillian, Ipswich - 2009

A) I think any exercise for people with arthritis is good, and that includes people who've had joint replacements. Swimming is a particularly good exercise as it doesn't stress your leg joints in the same way as walking or running. However, certain ways of swimming are discouraged. Swimming breaststroke is thought to be bad for the knees, including replacement knees. There's mixed opinion on this topic following hip replacement and some healthcare professionals will advise against it. I think it's likely that timing may be the problem. I'd advise avoiding breaststroke until the hip is healed and recovered fully – probably about six months after the operation. I'd also give the following advice. You need to exercise to keep fit, keep your weight down and reduce your chance of heart disease. Any form of aerobic exercise (exercise that makes you out of breath) is good, including swimming. Try and swim so that you don’t feel any pain in the hip and swim a relaxed, normal breaststroke without exaggerated movement of the leg joints. Do also keep up with the ‘dry land’ exercises you were taught after the operation.

This answer was provided by Dr Philip Helliwell in 2009, and was correct at the time of publication.

Q) My husband (aged 75) has just been told that he can have a replacement hip in two months’ time. Have you any hints on how I can help him prepare for the operation and aid his rehabilitation afterwards? For example, do you have information on exercises, aids, rest and nutrition? His life has changed drastically during the last year and so we look forward to him having his mobility back. Thanks for any tips!

Esme, Stafford - 2011

A) It's not uncommon for some hospitals to arrange pre-op physiotherapy for people undergoing joint replacement. This is to strengthen the muscles around the joint, making the recovery process much easier. Have a look at our hip replacement information, which contains useful advice on preparing for surgery and some post-op exercises. You can also contact your local physiotherapy department as they may have a leaflet or be able to offer you an appointment before the operation.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) I’m 85 and have painful hip osteoarthritis. I have to make a decision on whether to have replacement. The latest report from the National Joint Registry gives a death rate of 1.17% within 30 days of the operation for men aged 80+. This is out of 18,918 in this group, who a month earlier were presumably declared medically fit enough for a major elective operation. I find this very daunting. I wouldn’t fly an aircraft type which had a record of one crash in 100 flights, no matter how idyllic the destination! Any comments please, or have I misunderstood the statistics?

G K, Hatfield - 2013

A) Try looking at it a different way – there is a 99% chance of surviving the operation for people of your age. Any operation carries a risk of death whatever the operation and whatever the age. Major operations, such as replacement of a hip, carry a higher risk, and increasing age carries a higher risk, no matter how fit you are beforehand. Having said that the statistic you quote is for all cases, and some people will have more risk than others, and some operations are not as smooth as others (those done in an emergency, after a hip fracture for example). But they are lumped together statistically. Your surgeon will consult the anaesthetist if there is any doubt about your fitness for the operation. And if there are other problems, such as lung or heart disease, they may not operate, or operate under spinal anaesthesia to minimise the risks. Some people are put off by the surgeon spelling out the potential risks, but it all has to be put in context – how much improvement in quality of life will you gain by having the operation?

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) I had a left hip replacement just over two years ago due to severe osteoarthritis. Since then I have struggled to regain normal walking ability, despite a lot of physiotherapy. My surgeon has put a great deal of effort to find out why I am still slow and stiff. From the scans he has done, he tells me that I have an ‘enthesopathy’ affecting the medial gluteal muscle. I am to have a guided steroid injection soon, as a last-ditch attempt to ease the stiffness and discomfort. I have not heard of this problem before. Can you tell me anything about this condition?

Clare, via email - 2014

A) The enthesis is the point where ligaments, tendons and muscles attach themselves to bone, and is a common cause of pain. The most common enthesopathies (that just means pathological abnormalities at the enthesis) are tennis elbow and plantar fasciitis (formerly called policeman’s heel, in the days when policemen used to walk their beat all day). Sometimes enthesopathies can be part of a more widespread inflammatory arthritis such as ankylosing spondylitis and psoriatic arthritis. And sometimes they can occur after surgery, as in your case. The symptoms are pain at the point of attachment and stiffness after rest. If there is inflammation then a steroid injection at the point of attachment will help, as will stretching exercises. Since the injection has to be given right at the point of inflammation, a guided approach is often used – the guide can be ultrasound or sometimes x-rays.

This answer was provided by Dr Philip Helliwell in 2014, and was correct at the time of publication.

Q) I had a knee replacement four months ago. The operation was successful and I can walk, drive and exercise, but I still have pain just below my knee when I stand and sit or try to go up and down stairs, even though I did all the exercises. Have I overdone the exercises or damaged my tendons/ligaments?

Pat - 2017

A) I know it can be disappointing not to quickly feel 100% after an operation, however some pain and swelling after a knee replacement is normal for several months as the body heals around the new joint. It sounds like you have been doing all the right things to look after your new knee, so it is unlikely you have damaged tendons or ligaments.

The fact that you still have pain on standing, sitting and going up and down stairs is perhaps not surprising as these are some of the movements that put the most strain through your knees.

So, don’t feel disheartened and continue with the sensible activities that you have been doing and see if the pain settles over the next couple of months. However, if you start getting pain when at rest, if the pain gets worse rather than gradually better or it does not settle down, then you should be going to see your GP to get this checked out.

This answer was provided by Dr Tom Margham in 2017, and was correct at the time of publication.

Q) In a letter to Arthritis Today a retired consultant surgeon stated that she'd had a meniscectomy 'which of course resulted in osteoarthritis of that knee'. I would like to know the reason for this. I had a menisectomy as part of an arthroscopic procedure three years ago, as I was already suffering from osteoarthritis of the knee. Despite extensive treatment the arthritis has now become, in the words of my consultant, 'end stage', and I shall be having a knee replacement later in the year. In light of the above-mentioned letter, I'm now wondering if this procedure caused the arthritis to become worse, or did the condition deteriorate over the passage of time (my general assumption).

Linda, Nuneaton - 2011

A) Good question. Some years ago it was found that having a menisectomy (removal of the knee menisci, or cartilages) predisposed that joint to osteoarthritis in later years. Not surprisingly, a tendency to develop osteoarthritis in other joints increased that risk. Now, that study was done when menisectomies were achieved by opening the knee joint and the procedure was much more extensive than today’s keyhole approach, so it may not now be the case that osteoarthritis is a certain consequence of this procedure. You do have to remember, of course, that the reason for the torn meniscus (cartilage) may also be the reason for the later development of osteoarthritis, that is injury to the knee. Nowadays, with the keyhole approach, many people with torn menisci are found to already have established osteoarthritis and the arthroscopy (and menisectomy) is just one stage on the way to having a knee replacement. One will follow the other but it may be many years in between the procedures.

This answer was provided by Dr Philip Helliwell in 2011, and was correct at the time of publication.

Q) Following an arthroscopy, I was referred for total joint replacement of both knees. My right knee joint was replaced in November 2008, and since then I've had more pain than before the operation. The problems of my left knee – awaiting surgery – have faded in comparison. I do have a good range of movement and observers tell me that my gait is freer and more natural, and my surgeon and GP tell me that sometimes these things take time. But I'm constantly meeting people who've made a full recovery after three months. Do you think further investigation is called for or is this normal and will eventually improve?

Jo, Hatfield - 2010

A) Obviously no two people are the same. I tell my patients that it may take up to a year to get over a major joint replacement but that the pain may never completely disappear. In your case it does seem to be taking a long time to recover. This may be due to several reasons. These include the amount of pain and damage before the operation, the difficulty of the procedure, and the presence of arthritis in other joints (such as the hip). I would continue to follow the advice of your GP, surgeon and physiotherapist, but if things don’t settle, you need to take this up with the surgeon. Very rarely the artificial joint may become loose or infected and it's possible to look into this with x-rays, blood tests and scans.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) I had a tibial osteotomy in my right knee in 1995, followed by my left knee in 1996. In 2002 I had a total knee replacement in my right knee, followed by my left knee in 2004. I was told that going up and down stairs was good exercise, which I have carried out diligently ever since. As I'm feeling slight intermittent pain in my left knee I went on the internet to find any information as to the length of time these replacements may be expected to last. I didn't find an answer, but what I did find was that climbing up and down stairs should be avoided. Could you comment please?

Sandra, Salisbury - 2009

A) I've discussed this question with physiotherapists and the consensus is that stair climbing is encouraged following the initial recovery period after total knee replacement. There may be exceptions to this when the situation is complicated by, for example, an infection in the knee after the operation, but in uncomplicated cases there's absolutely no reason for you to avoid such activities as they help build up those vital quadriceps muscles in the thighs.

This answer was provided by Dr Philip Helliwell in 2009, and was correct at the time of publication.

Q) I had a full right knee replacement 13 months ago. I then fell on this about a month later and a repair had to be done. Since then I have not been able to go out without crutches. It is not particularly painful and I feel the problem is psychological. Can you give me any practical solution to this? Any advice you can give me will be very warmly welcomed or if you can suggest a medical professional who might be able to help? I am 78.

Josie, via email - 2015

A) I’m sorry to hear of your predicament. New joints are always vulnerable to damage, and particularly so soon after being put in. The fall may have jeopardised the stability of the new joint but the surgery you had second time round should have corrected that. What you need now, I think, is some good physiotherapy to help you regain the function in your knee. You should perhaps check this with your surgeon but I am fairly confident that the situation can be improved. It may take a bit of time and some hard work.

This answer was provided by Dr Philip Helliwell in 2015, and was correct at the time of publication.

Q) Will it ever be possible for people who suffer from osteoarthritis of the knees to have cartilage transplants, instead of knee replacements? It would be far cheaper and not so invasive. Presumably, it would last much longer too.

Jackie - 2016

A) Stem cell transplants that grow new cartilage on the surface of joints are on the horizon. Studies funded by Versus Arthritis are at the forefront of research in this area.

That said, the treatment is still in its experimental phase and it's likely to be years before it's proven safe and effective and therefore made widely available as a treatment option for people with osteoarthritis. It'll also be an extremely expensive treatment, at least at first.

Osteoarthritis isn't just a disease of the cartilage. It affects the whole joint, causing muscle weakness and bone changes, as well as alterations to the way the brain processes pain messages over time. And we must remember we already have an effective treatment for osteoarthritis that helps the whole joint and the way that the brain deals with pain. It’s free, safe and helps your heart and lungs too. Yes, you guessed it: exercise.

Though it can feel counter-intuitive to move your joints when they feel sore, and exercise may be the very last thing you want to do, moving more really does work. Read our exercise and arthritis information for advice on choosing safe and effective exercise that works for you.

This answer was provided by Dr Tom Margham in 2016, and was correct at the time of publication.