Published by Devon Life Magazine

The Exeter Hip

The Exeter Hip isn’t a dance – although dancing is very much on the cards, as Malcolm Twigg finds out

There’s one striking thing about the Princess Elizabeth Orthopaedic Centre at the RD&E immediately apparent when you visit, and that’s the air of tranquility. The waiting area  has none of that nail-chewing-edge-of-seat atmosphere that seems to come with the territory in other medical waiting areas. As a patient-friendly environment it would be hard to beat but that’s something we have come to expect at the RD&E during the course of this series of articles. What is not immediately apparent, except amongst those who know, is that behind the scenes at the Princess Elizabeth there is a high-profile team which is quietly leading the world in hip joint replacement. And in ‘leading the world’ we are talking about something like 80% of hip joint replacements in places like Sweden, Australia, and New Zealand being performed using the Exeter Hip and, according to John Timperley, one of the consultant surgeons on the hip replacement team, it is the most widely implanted hip replacement in the United Kingdom.

Graham Gie is one of the three consultants in this remarkable team, although he wasn’t around when we went to find out about the phenomenally successful Exeter Hip, so his colleagues, John Timperley and Matthew Hubble, did the honours on his behalf. And it’s a success story without equal – both as a medical process and an example of collaboration between the hospital and the university. Real credit for the Exeter Hip has to go to the two men who originally developed it in the late 1960s: Professor R S M Ling, at that time an orthopaedic surgeon at the hospital (later made honorary professor in biomedical engineering as a consequence of his work in hip replacement), and Dr Clive Lee, then of the Department of Engineering Science at Exeter University (now the School of Engineering). Hip replacement entails the fitting of an artificial ball and socket to take the place of worn cartilage and bone, thus returning mobility to the patient.

In the late 1960s there were three designs of artificial joint available, all of which, for various reasons, had problems associated with their use. It was clear at this stage, however, that hip replacement generally was becoming one of the most successful major surgical procedures ever to be carried out. Enlisting the expertise of Dr Lee, Professor Ling then set about designing a new hip system in a bid to overcome some of the problems associated with the other available types of replacement. That saw the start of what was to become known throughout the world as ‘The Exeter Hip’, a radically new stem design and cementing technique, bringing long-term relief to thousands of patients. Today, both Professor Ling and Dr Lee are semi-retired, although they still give lectures on the procedure many times a year. Successful though the Exeter Hip is, it is still under constant development. The joint itself is manufactured by Stryker Howmedica Osteonics, a multinational company based in America, although the hip prostheses themselves are actually forged in France.

              
Matthew Hubble                           John Timperley

Professor Robin Ling

Dr Clive Lee

Graham Gie

Ros Sculpher, who looks after data collection, is another long-serving member and has been in the Unit for fourteen years. “I make sure that all the data on people who have had operations goes  into the computer. We can then pullout the results of groups of patients to look at for various research projects.” Assisting her is Sandy Wraight, whose official title is Research Assistant, and who, amongst other things, digitises the x-rays for storage on the computer. “We keep a record of every hip that has ever been put in at the Orthopaedic Centre. And we keep track of them, even if the patient moves away, and bring their profiles up to date.”  

Sandy Wraight & Ros Sculpher (seated)

A significant amount of money is ploughed back into the hospital by industry to fund ongoing research work at the hospital. Professor Ling was quick to set up a research unit at the Princess Elizabeth Centre and there are now four dedicated research staff recording and monitoring patient data and continuing research programmes to further improve the success rate of hip replacement. It’s a close-knit team of long standing. First point of contact for patients and someone to whom they can always turn for advice is Nita Wendover, a senior chartered physiotherapist, who has worked at the Centre for nine years. “I also run some clinics on behalf of the surgeons before and after surgery and carry out a lot of data collection and research.

Nita Wendover

It’s that latter aspect that is such an integral part on the ongoing development process here. The more information on past patients that can be retrieved and analysed, the better  the performance characteristics of the Exeter Hip can be appreciated and any improvements put in hand. Another member of the research team, Patrick Hourigan, also a chartered physiotherapist although not working in that capacity, runs several randomised controlled clinical trials where they are trying to improve the long-term survival of the artificial hip joints. “We use a system called RSA (Stereoradiology), where we implant minute tantalum balls in the joint which can then be x-rayed against a grid over the years to trace any movement or degradation in the joint. “We are one of the few places in the UK that actually keeps information on hip replacements in this way. We never discharge patients. We constantly collect information about the outcomes of surgery,” John Timperley told me. “There is no central register of hip replacements in the UK, although discussions are currently taking place at government level. Consequently there is no bank of analysis available nationally on which to base future decisions about the use of implants and the techniques that should be used during implantation, and all that is available to us is what we collect here.” It’s a different situation in Sweden, where the Exeter Hip is very widely used in hip operations. There, a wealth of information is available, analysing the likelihood of further operations being necessary in the event of failure of the primary operation when all types of implant are used. The results of the Exeter femoral component have recently been published in the orthopaedic literature, and, in the group of patients analysed, there was no failure of the stem for loosening at twelve years’ follow-up.  The Princess Elizabeth Orthopaedic Hospital pioneered bone grafting in the femur in hip replacement therapy The Exeter Hip is a remarkable success story  This is the other world-leading aspect of the operation here – the revision procedures, which are operations where, for whatever reason, artificial hips have to be replaced a second or even a third time and one where pioneering work was carried out in Exeter.  Results of the Centre are known for over 30 years now and loosening of this stem is rare. Mechanical loosening can, however, occur and there are failures of other implants which are revised at the Princess Elizabeth Orthopaedic Centre. Revisions are a much more complicated process than the primary operation. Whereas the initial operation at the RD&E takes as little as an hour, revision procedures can take up to three times as long. The Princess Elizabeth Orthopaedic Centre have set up their own bone bank run by Sarah Lunniss, the bone bank manager, and the bone donated by patients at their primary procedure is carefully checked following national guidelines and can then be used at revision procedures as a scaffold to restore bonestock in those patients who require it. The Exeter team is attempting to perfect a technique using bone from the bone bank, which is then used in patients who have compromised bonestock at the time of their revision operation. It’s a process that has reinforced the Princess Elizabeth Orthopaedic Centre’s claim to world leadership in the field of hip replacement and draws attention from surgeons worldwide.

For instance, the New Zealand ‘twang’ has been very much in evidence in the Unit over the past year. Tony Lamberton is currently working as one of two clinical Fellows on the team and came to the Unit to learn more about the revision procedure. He will be exporting that knowledge back to New Zealand with him when he returns in about six months’ time. “The Exeter Hip is already the most popular replacement in New Zealand anyway.

Tony Lamberton

I came specifically to learn about the revision procedure because it was developed here – you can’t just pick it up by reading a book or watching a video.” For such a seemingly big operation, hip replacement is remarkably cheap for the NHS. It is estimated that the NHS cost for a joint replacement is approximately £4,500 per patient because of the economies of scale that the NHS produces. The limitations on the number of operations that the Unit can carry out are due to funding issues, availability of theatre time, bed availability and staffing levels, both in theatre and on the wards. The three surgeons on the Hip Unit and their teams currently carry out about 450 primary hip operations per year and 150 revision hip operations, and that is without counting the knee replacements and revision knee replacements which are also carried out on the Unit. Hip replacement is a relatively new treatment, developed during the 1960s, and the Exeter Hip has been right there at the forefront, almost since the inception of the procedure. It’s quite a remarkable story, but the success in acclaim and professional kudos is as nothing compared to the benefits passed on to the thousands of patients who have been the recipients of the treatment over the years. More than 8,000 patients are recorded in the Research Unit as having been treated at the hospital, but this is a fraction of the number worldwide who are now walking around, unaided, with a little piece of the Princess Elizabeth Orthopaedic Centre tucked away inside their bodies. But, perhaps the last word should come from the patients themselves.

Anne McMillan, now living in Cardiff, was resident in Torquay back in the 60s and, although she is now a healthy and active having developed ankylosing spondylitis. She was coping with a small baby and having to get round on walking sticks. The pain became so bad, Mrs McMillan admitted that she “could have committed suicide tomorrow”. She lived with the condition for three-and-a-half years since hip replacement therapy was then in its infancy and the doctors were reluctant to carry out such radical surgery on someone so young, and they were also concerned about how long the treatment would be effective in someone of Mrs McMillan’s age. But eventually they agreed, and the Hip replacement is a relatively new treatment, developed during the 1960’s.

9th July 1971 is a date now implanted indelibly on Mrs McMillan’s memory, which is when Professor Ling carried out the operation on her left hip, followed by the right hip two years later. In fact, despite the need for revision of one of the sockets some years later, Mrs McMillan’s hips are still going strong. She was able to return to full-time nursing for thirteen years afterwards, played some friendly tennis and went swimming in her younger years and, despite some residual problems with her spine caused by the ankylosing spondylitis, Mrs McMillan is in no doubt what effect the hip replacement had on her life. “I can’t praise Mr Ling enough,” she said.

Beverley Gravett is another patient who has good reason to be grateful for the expertise of the staff at the RD&E – and another young woman at the time that she had her first hip operation. Beverley lives in West Sussex and, as a seventeen-year-old, she broke her hip in a car accident. Problems with the damaged hip gradually became worse and eventually she was forced to have a hip replacement at a local hospital. It was never entirely successful, however. Following the birth of her children, she had to have the hip revised. “I could feel it moving around inside. One day my leg would be longer, the next day it would be shorter.” The problem was that the bone around the joint was crumbling and she needed a bone graft along with her revision operation. The necessary treatment was not available at her local hospital so, more than ten years ago, she was transferred to Exeter, where this pioneering bone grafting revision operation was available under the care of Mr Gie. Since the grafting was carried out she has suffered no further problems and is effusive about the effect it had on her life. “And my kids’ lives,” she said. “I could do much more with them than I ever had before.”

Fact file

• Hip joint replacement, or arthroplasty, is one of the most successful surgical procedures ever, characterised by a high success rate and long-term benefits
• Hip arthroplasty is most often used when conditions like arthritis have damaged the joint between the femur (thigh bone) and pelvis
• Arthritis wears away cartilage protecting the ends of the bone, causing severe pain and loss of function. Arthroplasty (joint replacement) is a technique to replace the damaged joint by using artificial materials such as plastics, metals or ceramic
• There are approximately 45,000 primary hip replacements performed in the UK per year
• Some patients have both hips replaced
• Arthroplasty is most commonly used in the elderly, although younger patients have benefited
• Artificial hips can have a life of over 20 years and often last for the remainder of the lives of their elderly recipients
• A primary operation to replace a hip usually takes between one and one-and-a-half hours
• Improved mobility is noticeable within a few days of the operation
• Use of crutches may be required for up to six weeks after the  Operation
• Patients are usually able to return to all the normal activities of daily living