As a young student nurse training in the Royal Air Force in the late 1970s, I worked in the operating theatre. I had already spent some time on the male orthopaedic ward which comprised predominantly young servicemen, who were on ‘traction’ for various back problems, and older men, some of whom had suffered fractures and undergone surgery for joint replacements.
While on the orthopaedic ward I cared for these patients and watched as older men who were admitted with severe pain and impaired mobility underwent a transformation following joint replacements during their two or three week stay as in-patients. I understood the mechanics and biology of joint replacements and the nursing care they needed, but it was not until I began a student placement in theatres that I really appreciated the sheer complexity of having an artificial hip.
In the late 1970s I remember being fascinated by the array of surgical instruments that were used in hip replacements; two large trays of instruments and a few supplementary extras depending on their specific surgical requirements. In place of the delicate and fine surgical instruments that I had seen used in other surgical procedures was a set of tools not dissimilar to those of my father’s tool-shed or carpentry box.
The amount of physical activity that was required by the surgical team to replace a hip with what seemed to me an inordinal amount of pushing and tugging, surprised me. Frequently asked to ‘hold up the leg while it’s prepped’, I supported countless legs and discovered how heavy they were and how difficult it was to keep them steady while qualified theatre staff washed and draped the leg in preparation for the procedure. Then I watched fascinated as the hip was replaced. The recovery period was relatively long. I would often see post-operative patients walking accompanied up and down the wards or in wheelchairs on their way to the physiotherapist. Patients spent approximately two or three weeks as in-patients, only mobilising out of bed on the third or fourth day after the procedure.
Overall, the procedure was largely effective with improved mobility and a reduction in pain. Since that time healthcare, surgery and postoperative care has changed significantly. The trays of surgical instruments can be as many as 25 and the choice of available replacement joints is vast. New and more robust materials continue to evolve, reducing wear and tear, thus prolonging the life of the prosthesis and allowing for better mobility. Joints that no longer require cement are constantly being improved and minimal invasive surgery is being used to reduce the size of the surgical incision needed. Computer-aided surgery to allow greater visibility and precision, once a rarity, is increasingly more common.
Contemporary patient care is more likely to be based on research evidence than the surgeon’s personal preference or on ‘the way we have always done it’. Consequently, fit patients may be out of bed on the day of the operation and discharged from hospital within three days, thus avoiding the complications, such as deep vein thrombosis, known to result from inactivity. Overall, surgical care has much improved since the late 1970s. With the expectation that hip replacements are the norm, an aging population can continue to enjoy mobility without pain.
In recent times, two particular constraints have impacted significantly on the overall ability to achieve this aim and improve outcomes for hip replacement patients.
First, the growing problem of obesity, since the number of obese adults in the UK has nearly tripled since 1980. However, while research demonstrates that obese people undergoing hip replacements have similar outcomes and recovery times to those who are not, research also shows that obese people are more likely to require hip replacements at a significantly younger age; approximately seven years sooner.
Second, in the UK life expectancy has improved considerably. More people are living longer and they expect to be able to access what they need to help them manage their health and wellbeing, including any relevant surgery.
According to the National institute of Clinical Excellence (NICE), hip replacements must be able to withstand at least 10 years’ wear and tear before needing replacement. Generally, unless there is a specific clinical reason, surgeons adhere to this advice but with an ageing population more hips will need to be replaced. These 2nd replacements are more complex, more time consuming and more expensive. This leaves society with a number of uncomfortable questions.
Should we ration the amount of surgery that an individual is entitled to, not on the grounds of obesity or other discriminatory factors, but purely on a pro-rata basis, perhaps two replacements per person? This is counter to Bevan’s original concept of the NHS as being ‘free healthcare for all at the point of care’. The issues relating to hip replacements are indicative of the whole debate around the fact that the healthier we become, the longer we live, and the longer we live the more we are likely to need the NHS to help keep us healthy.
Might the relative efficiently of the NHS in keeping the population generally more healthy and increasing longevity make it impossible to sustain a system that is not rationed for an ever-increasing and older population?
What do you think?
- Andrew JG, Palan J, Kurup HV, Gibson P, Murray DW, Beard DJ. (2008) Obesity in total hip replacement, Journal of Bone Joint Surgery British Volume, Apr 90 (4), 424-9.
- NHS Information Centre (2010) Statistics on obesity, physical activity and diet: England, 2010.
- National Institute for Clinical Excellence (2000) Guidance on the Selection of Prostheses for Primary Total Hip Replacement. Issued: April 2000 NICE