👍 Amanda’s YES / NO decision 👎

LIFETIME HIP & KNEE

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#032: Amanda’s YES / NO decision

(name changed to protect the innocent)

A hip injection took away Amanda's pain
BUT only for 3 weeks...

Recap in Newsletter #031.

Could Amanda have another one?

We talked about it.

The 1st hip injection generally works well.
The 2nd injection, not so well.
The 3rd injection, a waste of time.

Repeated hip injection WOULD make both of us feel like we were doing something.

BUT it is not the best approach. Even in the medium term.
For starters, 3 weeks of pain relief is not a good return on investment.

AND there's some recent evidence points against hip injection...
...a small study showing injection accelerated joint arthritis.

We talked about other non-operative options and about joint replacement.
A similar discussion to every other conversion we'd had.
BUT added emphasis on replacing that joint.

We talked about:

The risk-benefit of hip replacement.
Amanda's relatively young age.
Amanda's perhaps 1 in 5 lifetime risk of revision

That's the risk of needing 2nd time joint replacement. Lifetime risk if that is covered here...

The pain relief from the joint replacement...
...would be the same as the hip injection.
BUT the pain relief would be ongoing.

Weigh up a small chance of second time surgery AND a few small risks...

AGAINST being out of pain NOW.
And I can see why people opt for joint replacement.

For me, now that we knew where Amanda’s pain was coming from.
The key question for her was…

Was the pain interfering with everyday life?

And it was a simple ‘YES’.

And that is how I find this person...
...this patient, with back, hip, knee and ankle pain...
...lying anaesthetised on the operating table in front of me.

The hip is...
- prepped,
- draped,
- incised,
- approached
(via the back)
- and dislocated.

The leg is twisted so that the foot points up to the ceiling. That position...

If you lie on your side.
And bend your knees up.
Almost rolling yourself into a ball.
With your top knee bent to 90 degrees.
Rotate your top foot so that your lower leg points vertically

(I hope you can't do this!)

..that's the position that dislocates the hip out the back of the joint.

I'm looking at an abnormal femoral head
BUT the cartilage isn’t that bad.
NOT the worst hip I’ve ever seen :/

Why is this hip painful?

Amanda is 89 kg (BMI 33)
Typical of the average person undergoing hip replacement.

Amanda is classed as obese.
Like most people on the operating table undergoing hip replacement.

The upper limit of ‘overweight’ for Amanda is 81 kg (BMI 30)
The upper limit of ‘normal’ is 67 kg (BMI 25).

So, an 8 kg weight loss or 1.25 stones would scrape into the overweight category.

Multiply kg by 2.2 to get pounds.
Divide kg by 6.4 to get stones.

A 22 kg weight loss or 3.4 stones would just about give normal bodyweight.

These are daunting numbers. And so IMPORTANT...

5x Bodyweight

5x Bodyweight passes through our lower limb joints with every step we take.

That extra 22 kg (or 3.4 stones) is an extra 110 kg (or 17 stones) of force.

Extra force that hammers through each lower limb joint
...with every step that Amanda takes.

And we take somewhere between 1 and 3 MILLION steps every year.
That is a LOT of extra force.

Our joints are not naturally designed to take it.
It's like hitting each joint with a 110kg hammer over a million times per year.

It’s no surprise then that the extra force contributes to joint inflammation.

It’s no surprise that that Amanda’s joints are painful.

So Amanda underwent hip replacement.
And she now continues to do in her words... 'okay'.

Her hip joint pain has gone.
Her muscle pain is manageable
Her trapped nerve pain comes and goes.

BUT I still agonise over whether hip replacement was the right answer.
Why couldn't we have done more to optimise Amanda's bodyweight first?

And by 'we' I mean...
- Amanda
- But I also mean 'me'
- And I also mean the healthcare system
(and if we're not stopping there)
- I also mean society as a whole.

Society as a whole is NOT able to eat well or move enough.

IF society's 'norm' was to eat well
IF healthy food was more readily available
IF Amanda could have maintained a more healthy weight.

Perhaps giving Amanda 40 years of healthy weight..

Perhaps 80 million steps of healthy weight...

Could she have...
- moved more,
- stayed strong,
- avoided hip replacement?

That combination of excess bodyweight + low muscle strength...

...is my best sense of why Amanda's pain was bad.
BUT her hip was NOT that bad.

--

Right, thanks, as always, for reading this far. It's the real-world outcomes of excess bodyweight next.

Back to the evidence. Sounds a bit dry?
Maybe. BUT the real-world evidence is the combined stories of people like Amanda.

The numbers tell the stories of 1000s of people.
And at the same time point the way forward.
All we have to do is listen.

--

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