Gold standard for hip replacement

I treat a number of foreign patients in my practice.

Their most common reason for coming to Singapore for treatment is that they believe Singapore has well-trained doctors with up-to-date facilities and equipment. This has allowed Singapore to develop into a respected, regional medical hub over the past decade.

Three months ago, Mrs A and her daughter from Russia came to visit my clinic. I noticed that she was limping in pain and using a walking stick.

She had been living with hip pain for the past two years. During this time, the pain became increasingly severe and she had to take painkillers regularly.

Her daughter noticed she was no longer able to walk outside for extended periods. As a result, she had less contact with her friends and became more withdrawn.

When I examined Mrs A, I noticed she had a stiff hip joint with associated shortening of her leg.

X-rays which had been ordered by a previous doctor demonstrated advanced osteoarthritis of the hip joint.

In the hip and knee joints, the ends of the bones are covered with a layer of cartilage. This cartilage allows the joints to move smoothly.

If the cartilage is damaged or thinned out over time, then rubbing or friction between the bones occurs with movement.

This friction can lead to pain and swelling of the hip or knee. An advanced stage of this process is termed osteoarthritis.

As the hip and knee joints take on the load of the body weight, they are more likely to develop osteoarthritis than other joints.

I discussed with Mrs A early treatment measures such as exercising to lose weight, going for physiotherapy, using a walking stick and taking painkillers.

Unfortunately, she was unable to lose much weight as she was in too much pain to be able to exercise or have physiotherapy.

She was already using a stick and taking painkillers but these were ineffective.

She told me that she had searched the Internet and read about hip resurfacing surgery, which involved implanting a pair of matching metal caps into the hip joint. One cap would fit over the top of the femur (thigh bone) and the other, over the pelvis socket that the femur meets to form the hip joint.

Unlike this "metal-on-metal" implant, conventional hip replacement implants are made of metal and plastic.

Various websites displayed flashy pictures of the hip resurfacing implant showing how small its parts were compared to those of the conventional hip replacement implant, she recalled.

The websites also featured testimonies from patients about the speedy recovery they made after surgery and how they could return to doing strenuous sports.

Listening to her, I remembered how we had a similar situation in Singapore.

I recounted to her the events surrounding the use of a certain hip resurfacing implant in Singapore, which had occurred in the last two years.

Some doctors had used the implant for patients with hip pain and osteoarthritis.

Orthopaedic surgeons gave talks to family doctors and the public, extolling the benefits of the implant.

However, after a few years, these implants loosened and each patient had to undergo repeat surgery to remove the hip resurfacing implant and replace it with a conventional hip implant.

Eventually, the Health Sciences Authority recalled the implant, thus preventing its further use.

Doctors can be easily caught up in the latest medical breakthroughs.

Unfortunately, many times, these types of treatment turn out to be just temporary fads.

Our priority as doctors should be to do the best for our patients and to help them make an informed choice.

This should entail educating our patients about the accepted gold standard treatment of their condition and the alternative types of treatment, which may include newer medical devices or developments.

However, our discussion should be based on evidence and should explain the comparative outcome of the various types of treatment.

If no research has been published on a particular form of treatment, then we have an obligation to explain this to our patients and notify them of the lack of published results.

With this in mind, I offered Mrs A surgery using a conventional total hip replacement implant which is still considered the gold standard around the world.

It has a proven track record of over 95 per cent longevity at 15 years, which is difficult to improve upon.

Mrs A went ahead with the hip replacement operation and recovered well.

Her pain was resolved, her leg lengths were equalised and she was able to walk without the use of a walking stick. Her mental state became positive and happy.

As I was saying farewell to her at the end of her last visit, she told me excitedly: "Finally, I can wear my high heels again."

Dr Andrew Quoc Dutton is an orthopaedic surgeon at Raffles Orthopaedic Centre at Raffles Hospital. His clinical interests lie in minimally invasive surgery for the knees and hips, cartilage regeneration and stem cell therapy.