I'd like to introduce you to Mr. Rishi Chana who is a hip preservationist/surgeon in the UK. He is extremely committed to supporting patients and preserving their hips! He agreed to answer several questions for inquiring minds on all sides of the pond.
Note: Some of the options provided from his perspective in the UK may not be available in the country where you live. This may be due to insurance company limitations, data collection or governmental agency requirements/restrictions.
What are some of the most important questions that patients should ask of their prospective surgeon prior to agreeing to surgery?
Have we tried everything short of surgery to get the hip better?
How confident are we that it is all my hip and what do you think a realistic goal for recovery looks like?
What can I do to make sure we achieve our agreed plan?
When picking a PT for post-op rehab, what types of questions should a patient ask a prospective PT?
Again experience, confidence and expertise is vital here. Preferably someone who knows and understands your surgeon’s philosophy and what they have done will improve your recovery.
If you, the surgeon and PT are all on the same page about understanding what has happened, how your body is going to react and a good mindful approach of listening to your body; not pushing too far and knowing when to step it back or up, through your recovery will result in a good outcome.
What type of surgeon training should patients look for when choosing a surgeon?
If you are familiar with [more medical] terms used [than] your surgeon, walk away!
Expertise and knowledge in knowing when the joint can or cannot be saved is key here. Ask your surgeon what they offer for labral defects, how many labral repair, cartilage defects and pincer takedowns they have done. Experience in this field takes over 150 cases to get up to expert level. Your surgeon should also know their own outcomes and should show you this data. Doing a higher volume of this surgery keeps the skills needed at a high level, your surgeon should be doing at least 70 cases a year. They must be fellowship qualified and be an upstanding member of the International Society of Hip Preservation (ISHA).
When would you do a labral debridement versus repair versus reconstruction?
Never. I always will repair or reconstruct with good results. I think the joint dynamics are badly altered with a debridement. The seal of the ball and socket is lost.
How can a patient contribute to the success or failure of their results?
Be in good health and shape prior to surgery. This includes core strength and condition.
Listen to your PT and surgeon and your body. Be patient. The body heals at a natural rate that cannot be rushed so work alongside this clock.
There are some drugs that may help: Your surgeon can take you through these options for pain relief, anti-inflammatory and cartilage promoting growth agents to enhance success.
What have you noted as the biggest changes in hip preservation in the last 5-10 years?
I think the whole concept has moved from hip ‘arthroscopy or keyhole,’ to hip preservation. This to me is a significant change in mindset of the therapists and surgeons.
I strongly feel that my philosophy of ‘Biological reconstruction of the hip’ embraces this ideal from several different angles, allowing us to use an aggregate of marginal gains that results in an exponential sum gain outcome.
Do the Surgery Well: This means doing the basics well, recognising the pincer and cam pathology and addressing them on an individual basis. Being prepared in every case to go the whole hog and do a labral repair or reconstruction if needed.
Orthobiologics and Stem Cells: Addressing any cartilage defects within the hip joint with biological collagen scaffolds and bone marrow or lipo-derived stem cells is a vital part of this reconstruction. The aim is to keep your natural joint, stronger for longer!
I offer all my patients an individualised package that will address all the above issues that cause poor hip function and early failure.
Accelerated Recovery: The hard part from the patient's perspective comes into play immediately after surgery: how do I get back to normal function and ensure I have a great recovery. What does this look like? Again, this can be quite different depending on your own circumstances. The one key factor here is how good or poor your core gluteal and abductor condition is pre-op. If there is nothing there to start with then the road is a longer and harder one as we have to build your muscle, strength, stamina and endurance from scratch. Good core pre-op condition will allow a faster recovery.
What are some exciting innovations coming down the pike in hip preservation that you would like to see further research on or to be implemented worldwide?
Orthobiologics scaffolds or fillers that are made of animal based Type 1 & 3 collagen (ChondroGide), or hyaluronic acid scaffolds that are vegan (HyalolFast), are now available for filling in cartilage defects. This is called AMIC (Autologous Matrix-Induced Chondrogenesis). These can then be augmented with your own stem cells that come from bone marrow or lipotissue. This is analogous to returfing a dead patch of lawn in your garden: The old dead area is dug up and refreshed, the scaffold is a sponge or compost that is then laid down into the defect and we re-seed the area with stem cells. This has good data in the hip now showing excellent outcomes and stability of the new cartilage cushion up to 8 years after, with better results compared to microfracture, which has a 30% failure rate. (See DiGirolamo’s paper of AMIC vs Microfracture). I am in the process of publishing my own data of AMIC+BMAC which is an evolutionary step forward towards natural hip preservation.
More developments of medications that can alter cartilage growth factors will improve on the already promising results.
What are you most proud of as far as your contribution to the field of hip preservation?
AMIC+BMAC study vs Microfracture presented at the International Society of Hip Arthroscopy/Preservation in Madrid, 2019. This confirms a 100% success of Biological reconstruction vs microfracture failure of 35% in patients up to 55 years old. The return to function was also better in Bio Recon at 96% vs 66% Micro#. I am publishing the next paper on Labral reconstruction without the use of human tissue allograft next year.
What are the main differences in practice in the UK as compared to the US?
Not sure, probably licensing of FDA approved items. I think the whole stem cell market there is a free for all, be wary there are a lot of fake stem cell clinics out there who do not offer the full package. Injections will not remove and repair damaged bone and labral defects on their own.
How do you see hip preservation being practiced in the UK as compared to other countries? What do you see as the reason for the increase in hip arthroscopy?
This is still a very limited and specialised field despite a 7 fold increase in operative numbers. Lots of surgeons now understand the pathology and want to treat this challenging condition. The NHRA registry will ensure good quality data is kept with outliers identified and good practice confirmed. Even fewer people offer the full Biological Reconstruction package as this is technically very demanding and takes years of training and practice.
Are there varied post-op protocols ie weight bearing status, ROM restrictions etc. in the UK like there are in the U.S?
I tend to weight bear as pain allows and get rid of crutches over two weeks if I don’t do a big AMIC+BMAC defect repair.
Accelerated Recovery can mean return to 90% function within 6 weeks. My philosophy here is:
Stage 1: Week 1; Wake up the core: glutes and abductors, avoid overdoing the psoas hip flexors.
Stage 2: Week 2; Get rid of the crutches and start to work on balance, muscle control and hip adductor stretches and strength.
Stage 3: Week 3; Stamina and endurance phase starting slow then increasing to 90% by week 6.
How could a patient contact you for further information?
If you have any questions for Mr. Chana, you can follow him on
Instagram@londhipsurgeon
LinkedIn: Mr. Rishi Chana
Or check out other ways to contact him: