A Less Clear Cut Story 🔎

LIFETIME HIP & KNEE

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#029: A Less Clear Cut Story

‘Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it’

Plato (428–348 BC)

Amanda is a 59-year-old woman lying on her side on the operating table in front of me.

Anaesthetised from the waist down.
Her right leg twisted 90 degrees inward.
Right foot pointing straight up at the ceiling.

I'm looking down at the ball of her dislocated hip joint. The femoral head.
And it doesn’t look THAT bad to me.

I mean, it’s abnormal. Worn in some places. BUT it’s NOT the worst hip I’ve ever seen.

The cartilage on the middle and lower parts of the ball are sparkling pristine. Glistening, super smooth under the operating theatre lights.

The tissues around the edges of the ball are red. Inflamed. 'Angry' looking. And the cartilage at the top of the hip is ragged. Worn away.

Worn away to bone over a small area. BUT only a small area.
Overall, the hip is not THAT bad.

Variation

Variation in cartilage damage between people who end up on the operating table fascinates me.

Could some of those people AVOID joint replacement?

Amanda has a ball and socket hip joint that doesn’t look that bad.
Compare her hip to the hips and knees of John, Mr Jones, George and Iain.

Each of the four men who hobbled into clinic on that grey autumn afternoon.

Each had completely destroyed a joint.

Each weighed over 120kg.

A clear cut reason why each of them had destroyed their joint.
But what about Amanda?

Why does the pain that she felt not correlate at all well with the damage in her joint??

Amanda’s story

I first met Amanda as a new patient in a similarly grey autumn afternoon clinic.
I saw her on 3x more occasions in clinic.

She had generalised pain right leg pain. Pain from her back, down her leg to her right foot. Pain in her hip and knee.

This 30 second video outlines how we start to break down where the pain is coming from...

Amanda's pain had been steadily getting worse. Getting in the way of everyday life.

And with it, she had become less active. Putting on extra bodyweight.

Looking back at her record, the pain could be coming from her hip joint.

And standing there at the operating table I’m as sure as I can be that hip replacement is the right next step. Excising her hip, and replacing it with a metal and plastic implant should help her.

However…

Usually, the picture is a bit clearer.
And usually I'm a bit more certain.

So, how did we get to this position?

Clinic assessments are snapshots in time.
Snapshots of a life lived in full motion.

Here’s what I found across several of those snapshots. Examination findings up first…

The Examination

When I bent and rotated Amanda’s hip there was pain in the groin and thigh.

Pain all the way down to her knee.
=> Points to pain coming from the hip joint.

Moving her knee was not painful.
=> Hip replacement should therefore help.

HOWEVER…

There was also tenderness where the muscle inserts into the outside of the hip.
=> Points to inflammation or a tear in that muscle.

A graduated exercise programme should help that.
=> Hip replacement would be the wrong thing to do.

AND…

There was also pain in her buttock.
And pain down the back of her leg.
Into her foot.

That pain got worse when I stretched the sciatic nerve.
=> MRI scan of the back can help rule out a trapped nerve causes that sort of 'sciatic' pain.

Most of the time, a clear picture emerges.
Tests are there only to confirm suspicions.

But the picture here remained UNCLEAR.

So, next , I’ll run through the tests.

The investigations that can help pin down the diagnosis...

The biomechanics and biochemistry of excess bodyweight are still at play here..

BUT it's not as clear cut as John, Mr Jones, George and Iain all hitting their joints with the equivalent of a 250kg mallet. Over ONE MILLION times per year.

I'll get to the evidence of how excess bodyweight dramatically effects hip and knee joint pain and outcomes.

BUT Amanda's less clear cut case shows how the role of excess bodyweight may not at first be that obvious.

Next week we'll take a look next at how her tests and investigations feed into a shared decision of hip joint replacement.

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Duchy Hospital
Truro
TR1 3UP
United Kingdom