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At the heart of general practice since 1960

Maybe GP should take action over this frivolous complaint

Miss Eleanor Sproson and Mr Chris Moran outline six recent developments in their field

1. Minimally invasive hip replacement surgery

The concept of minimally invasive hip surgery has been introduced to reduce the surgical trauma associated with total hip replacement and for a more rapid recovery and a shorter hospital stay. There are two basic approaches.

Single-incision surgery

This involves a traditional surgical approach using special instruments and light sources. This has enabled surgeons to insert tried and trusted hip replacements through incisions of

9-13cm, dependent on the body shape. The procedure requires experience and is not always possible.

Dual-incision surgery

This has required the development of new surgical approaches. The approach, pioneered in the US, involves a small incision in the groin, through which the acetabular cup is inserted and a second small incision, over the side of the hip, through which the femoral component is implanted. As has been reported in the media, this procedure can allow patients to walk within a few hours and be discharged within 24 hours of surgery.

This is a technically challenging procedure and should only be performed by surgeons after specific training. Results are in the early stages and have been promising. Unfortunately, the well-established joint replacements cannot be used with this technique and there are no medium-term results for the new implants that have been developed for this purpose.

The potential complications are similar to standard surgery but may prove to be more common. For the present, we would recommend some caution. A hip replacement is for life and the longevity of the hip is highly dependent upon the technical skill of the surgeon: the hip must be inserted correctly.

The short-term gains from minimally invasive surgery may not be worth the long-term risks if the joint replacement does not last as long.

2. Hip resurfacing

Surgeons from Birmingham have pioneered a technique that has led to resurgence of interest in hip resurfacing. The surgery involves a traditional approach to the hip with a cemented metal cap on the arthritic head of femur and the insertion of an uncemented, metal acetabular cup.

This provides a 'metal against metal' bearing-surface and avoids the removal of a large amount of bone, but this is still an option if/when a more traditional hip replacement is needed at a later date.

The operation is primarily aimed at young patients with painful arthritis. These patients would not be suitable for a more traditional type of total hip replacement due to age and their desired level of activity. The operation has been performed for around eight years and the results, so far, are promising. Good pain relief is reported, with excellent mobility, including a return to some active sports (such as tennis doubles) and work.

Hip resurfacing is no less of an operation than a total hip replacement. The scar is the same length and the risks are similar. Patients should be warned of the risk of infection, thromboembolism, fracture and dislocation.

Contraindications include osteoporosis and collapse of the femoral head due to avascular necrosis. The hope is that these hips will last

10-20 years but young patients must be aware that the hip will eventually wear out and further complex surgery will be needed. Long-term follow-up for these patients is mandatory.

Resurfacing hip surgery is now more widely available. The surgery itself is specialised and should be undertaken by surgeons with a specific interest and training. Most large orthopaedic units will now have specialists in this field and you should contact your local department to find which consultants offer this service.

3. NICE issues guidance on osteoporosis drugs

In January this year NICE published its guidance on the treatment of osteoporotic fragility fractures in postmenopausal women, summarised as follows:

· Those women with low dietary calcium levels and the risk of vitamin D deficiency need calcium and vitamin D supplements.

· Bisphosphonates (alendronate, etidronate, risedronate) in women aged >75 without the need for a dual energy X-ray absorptiometry (DEXA).

· Bisphosphonates (alendronate, etidronate, risedronate) in women aged 65 to75 if osteoporosis is confirmed on DEXA scan.

· Bisphosphonates (alendronate, etidronate, risedronate) in women aged <65 if="" they="" are="" at="" approximately="" doubled="" risk*="" of="">

· Raloxifene second-line treatment for those in whom bisphosphonates are contraindicated.

· Teriparatide should be given to women >65 who have an inadequate treatment response (another fracture despite full adherence to treatment for two-three years).

*Doubled risk defined as: a very low bone mineral density (T score -3.2 standard deviations or below) or a low bone mineral density (T score -2.5 standard deviations or below) and one or more independent risk factor.

Independent risk factors: body mass index <19; current="" smoking;="" family="" history="" of="" maternal="" hip="" fracture;="" long-term="" corticosteroids;="" conditions="" affecting="" bone="">

4. Osteoporosis pathway for trauma patients

Osteoporosis care pathways for trauma patients are now being introduced throughout the country after being pioneered in Glasgow. These services are led by a specialist nurse who co-ordinates care and liaises between the trauma team, osteoporosis specialist and GPs.

The aim is to make an early assessment of female patients aged over 50, and male patients over 60, with fragility fractures. These fractures are caused by falls from standing height or less. The patients are broadly divided into two groups:

·Hip fracture patients who are admitted to hospital and assessed on the ward according to an agreed protocol

·Other fractures that are assessed in a fracture clinic.

The protocols ensure osteoporosis treatment is either prescribed initially by the trauma service (and continued by the GP) or that the patient has appropriate investigations, such as a DEXA scan, and is then reviewed by the clinical specialist in osteoporosis (usually a consultant in health care of the elderly). Good communication between all three teams is essential.

An osteoporosis care pathway has been introduced in Nottingham over the past two years. A nurse specialist and assistant, together with consultants in health care of the elderly and orthopaedic trauma, run the service.

All hip fracture patients (750 a year) now receive appropriate osteoporosis treatment and more than 80 per cent of eligible fracture clinic patients now have a DEXA scan and treatment if required.

Patient satisfaction has been high and good communication with primary care has ensured that treatment is continued in the community. Obviously, the long-term effects of these interventions will take several years to show.

But the evidence so far suggests this early intervention will lead to a decreased incidence of second fragility fractures.

5. Unicompartment knee replacement

Unicompartment knee replacements are not new and have been used in a few centres for many years. But the number of surgeons now offering this procedure is increasing which makes it important that GPs know to refer appropriate patients.

For the majority of patients, osteoarthritis of the knee starts on the medial side, followed by the lateral side. The length of time between these two stages varies immensely from patient to patient. The prospect of replacing just the damaged (medial) side of the knee before the rest of the knee becomes arthritic is attractive.

There are several unicompartment knee prostheses available. The 'Oxford' prosthesis is used most widely. This has a metal femur and tibia with a plastic (polyethylene) spacer that provides a mobile bearing. It is used to replace the medial side of the knee. This operation should only be considered for patients with medial arthritis, no lateral or patellofemoral arthritis and a functioning anterior cruciate ligament.

Unicompartment knee replacements have several advantages: less blood loss; shorter operation; less costly prosthesis; shorter inpatient stay; quicker rehabilitation and much simpler revision.

Knee function is more normal with much better movement than total knee replacement. Failure rates are slightly higher than conventional knee replacement, which may be due to increased patient activity, wearing out the knee more rapidly.

When they fail, these knees can be revised to a total replacement with good results. They can therefore be considered for younger patients in the 40-60 age group.

6. Back pain pathways

In general, a multidisciplinary team including physiotherapists, occupational therapy, pain management and psychological support best manages back pain patients.

A surgical opinion should be available for the small number of patients who may benefit. Back pain care pathways aim to provide this service within a primary care setting.

In Nottingham a multidisciplinary team including physiotherapists, occupational therapists, nurses and a psychologist make up the Acute Back Pain Pathway. Patients after referral are assessed as to the type of pain they experience and how they feel about their pain.

Any patients with 'red flag' symptoms are referred to a spinal surgeon for assessment.

The treatment programmes then commence at a local leisure centre. The sessions each group attend are:

· How your spine works and pain theory

· Exercises

· Causes of back pain and solutions

· Pacing, planning and time management

· Work-related issues

· Posture

· Moving and handling

· Stress management

· Relaxation

· Swimming

· Fitness gym

· Communication

· Coping strategies

· Medication.

This programme of treatment has been very successful with participants ­ 83 per cent said their pain affected them less after doing the course.

And on its way... Mr Fares Haddad identifies five developments on the horizon

1Use of navigation and robotics to guide arthroplasty surgery

Hip and knee replacements will be increasingly inserted with the use of computerised navigation tools and constrained robotics so that the implants are inserted exactly where we would wish them to be. This would minimise surgical error and may allow more minimal incision/minimally invasive surgery techniques.

2Stem cell usage in the restoration of ligament and cartilage function

Novel biological scaffolds will allow stem cells to be harvested from patients ­ particularly from peripheral blood and bone marrow ­ in order to recreate tendon and ligament units. This may facilitate procedures such as ACL reconstruction.

3Intervertebral disc replacement

Management of disc disease has been fraught with problems and has very little evidence base behind it. Disc replacement, if successful, provides one very interesting avenue for the future in that regaining motion rather than restricting it with fusions may be a great advantage.

4Restoration of peripheral nerves

The repair and regeneration of peripheral nerves has always been a huge problem. It may be possible within five years to start to repair spinal cord lesions and at least peripheral nerve avulsions so that we restore some nerve function where previously this was not possible.

5Bone packing and bone graft substitutes

Novel techniques for the management of osteoporotic fractures will continue to increase, including bone packing with bone graft substitutes and the use of chemical stimulation such as bone morphogenic proteins to generate faster and more reproducible fracture healing in these cases. We may also have more information about which drugs to use after osteoporotic fractures to increase healing potential.

Fares Haddad is consultant orthopaedic and trauma surgeon at University College London Hospitals

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