Mr Alex Chipperfield
Good evening and welcome.
My name's Alex Chipperfield, I am Consultant Orthopaedic Surgeon here at Benenden Hospital, and welcome to our webinar.
Today, we're going to be talking about all things related to knee arthritis treatment, for knee arthritis, and up to and including knee replacement surgery.
So the basic structure of this talk will be that I will go through a set number of things, so we'll talk about consultation and assessment.
We'll talk about the findings, the signs, the symptoms of knee arthritis.
I'll take you through a ladder of treatment, going from, from conservative through minor to surgical, and at the end, there'll be plenty of time to answer your questions, which is probably the most interesting part of this.
You'll see there's a question box on your screen, if you type in a question during tonight's presentation, that will pop up on my screen.
If there are any that are particularly pertinent and relevant to what I'm talking about at the time, I will stop my lecture and answer that question straight away.
If not, at the end of the talk, we will take some time, I'll go through the questions, and I'll answer as many as I can in the time allotted.
It's important to know that this session is recorded, and it will be put up on our website afterwards, so if you're using your name, just be aware that your name will be broadcast.
So you can you don't have to put your name in, or just use a first name, if you don't want it to be recognisable.
So, a little bit about me, first of all, like I said, I'm a consultant hip and knee surgeon here at Benenden.
I have, I qualified as a doctor 30 years ago, and I've been working mainly in the southeast of England, although I did spend a couple of years over in Australia working there as well.
I've been a consultant for the last, 16 years, and for the last 14 of those, I've been working here at Benenden.
I used to work within the NHS as well, but 3 years ago I left the NHS, so now I exclusively work in the independent sector, mainly focusing on hip and knee replacement surgery.
So that's me.
As I've said, that's the structure of what we're going to talk about.
So we'll start with what happens, at the initial consultation.
So if you have a problem with your knee and you'd like to speak to someone about it, then you can book an appointment to come and see me or one of my colleagues here at Benenden Hospital.
Quite often, it's good to go through your GP, to get your GP to refer you, because they will give us all the your past medical history and at that consultation we will talk about the reason that you're there.
We'll talk about the signs and the symptoms of the problems that you're experiencing with your knee.
We'll make a physical assessment of your muscle strength, of your range of movement, of the stability and overall function of your knee.
We'll look at your knee both there and then, but also with, special tests, such as x-rays or MRI scans, depending on what we what's deemed appropriate at the time. and with that, all that information together, so with your history, with your examination findings, and with your special tests, we'll come up with a diagnosis and treatment options that are available to you.
At the same time, if we're thinking about surgical intervention, then it's an opportunity to assess your general medical health to see whether or not you are fit and healthy enough or suitable for surgery.
Sorry, forgive me, my mouth's a bit dry.
So, what is knee osteoarthritis?
Well, arthritis of the knee is a general term, really, for a group of problems in and around your knee joint.
Your knee joint is made up of lots of different structures.
I've got one in front of me here.
Here's a knee joint.
So, what makes up the knee joint? Well, you've got the bones and the ligaments and tendons that support the knee.
Inside the knee itself, you've got the articular cartilage, which is the smooth surface on the ends of the bones. and you've got this blue stuff, which is the meniscus, the cartilage that acts like a shock absorber in between the bones.
So you've got lots of moving parts, lots of variables here, and all of these things are affected by arthritis.
Arthritis is typically a degenerative condition that tends to be more age-related, and what you tend to see is a slow deterioration in the quality and substance of all of those structures that make up your knee.
Some or all of them can be affected, and depending on which one is affected at which
Stage will, determine what kind of cluster of symptoms you may develop.
Essentially, though, the common theme here is pain, is loss of function of the joint, and by loss of function, I mean loss of movement, but also loss of stability, or the ability to perform certain specialist movements.
Such as, it tends to be, typically, pivoting and twisting tend to be the first movements that you may lose in an arthritic knee. and, like I said, the causes of that are basically, a breakdown in the cartilage of the joint, whether that's the articular cartilage on the ends of the bones, or the meniscus cartilage that sits between the bones.
Cartilage degenerates with age, it becomes less soft and springy and forgiving, it becomes more hard and brittle, and it can fragment and start to disintegrate, and that tends to give you the problems.
So you have a picture where you've got where your the normal structure of your knee on the left-hand side of the screen there, showing normal, healthy components of your knee.
With a picture of an arthritic knee on the right, you can see that the lining, the knee itself, gets angry and inflamed.
The structures themselves start to disintegrate, wear, and get rough instead of smooth and mobile.
Treatment options, like I said, I would take you through a ladder of treatment options, starting small and building up and that typically tends to be what you do, the method, the approach to dealing with knee arthritis is that you start with the lower impact stuff, and build up from there.
So the first kind of options, and they tend to be kind of options that have already been done by the time you would come and see someone like me, is what we call conservative options, or non-surgical options.
So, things that will take the pressure off your worn-out knee.
So, weight loss, modification of activity, that can have a big impact on the amount of pressure that you're putting through your damaged joint, and it can alleviate quite a lot of your symptoms.
Weight loss medication has been transformative, as far as knee arthritis goes.
Knee arthritis is very sensitive to weight, and the thing that used to stop people from being able to lose weight was the fact that they had a lot of pain in their knees.
Now, with help from weight loss injections, that weight loss, although never easy, is easier than it was before and that can allow people to lose weight, take the pressure off the knee joints, and that can help in itself.
Physiotherapy, things like, exercises to build up the strength, build up the move or maintain the movement that you have in your knee can be very useful.
If your knee joint itself is wearing out, then the keeping the muscles that support and move it as strong and healthy as possible, help a great deal and can take a lot of pressure off the inside part of the joint.
Strapping, braces, again, a lot of people don't get on with them, but some people find a great deal of benefit from having their knee strapped or wearing a brace.
It can certainly psychologically make your knee feel more stable, more supported, and more helped in many ways.
The next step up from those kind of interventions are the that's slightly more invasive, and that would be injection therapy.
There are a few different kinds of injections and, I'll talk about all of those, a little bit later on.
The headline one that we talk about most, and that most people who come and see me are more interested in talking about, is an injection called Arthrosamid®.
Now, if you look on the Benenden Hospital website, you'll see a talk that I gave about 3 or 4 weeks ago purely on Arthrosamid®.
So, I'll talk about it in some detail today, but if you want the extended version, please log on to our website, and you can see my old talk that goes through things in a lot more detail there.
After injections, the next step from that will be surgical intervention, and there are different levels of surgery that you can do.
There are smaller operations, like keyhole surgery, that can be appropriate in the earlier stages of arthritis.
There are slightly bigger operations that involve extra-articular surgery, so that would involve something called an osteotomy, which is when you break the bones to realign the joint, to take pressure off one particular part of the joint or the other.
There are experimental at the moment, but there are cartilage procedures that sometimes that you can do to move cartilage around inside the knee joint from a healthy area to a diseased area.
There are cartilage transplants that some specialist centers do.
We don't do that kind of surgery here, and it's rare that people are appropriate for it, but if needs be, we can point you in the right direction as far as that goes.
A level above that, we start talking about replacements, whether that be a partial knee replacement or a full knee replacement, and we offer both of those, types here at Benenden.
I said I would talk a little bit more about Arthrosamid®, so we've got a few slides on that.
First question, what is Arthrosamid®? Well, Arthrosamid® is, essentially, it's an injectable gel.
It's, polyacrylamide 2.5% for the scientists amongst you.
Essentially, it's an injectable implant, and what happens is that you inject this gel inside the knee joint. and it permanently binds with the lining of the knee joint.
The reason that's helpful is that like I said to you, the knee joint itself, there are lots of parts to the knee joint that can be affected by arthritis and one of the major parts is the lining of the knee joint. and when you get arthritis, the lining of that joint gets very angry, swollen, thick, inflamed, and painful.
Arthrosamid® binds with that lining to calm down the inflammation and to stop the pain and swelling that you get associated with an inflamed lining of the joint.
So you get decreased stiffness, you get reduced pain, and better movement as a result.
The way that Arthrosamid® differs from other injections is the longevity of the action.
Most injections before Arthrosamid® came along, you know, you'd get months, weeks or months of relief with other injections.
With Arthrosamid® that has moved from weeks and months to months and years.
The data that we that we've got at the moment, people who are noticing a benefit with Arthrosamid® are still noticing it noticing it 3, 4, 5 years later.
So, from that side of things, it's really helpful.
How does Arthrosamid® work, what's the process behind it? Well, it's, it's a day case procedure, but it is done we do it here in our operating theatre environment.
So, you come into hospital, it's a planned procedure that you come into hospital either for the morning or the afternoon.
You'll be in hospital for 3-4 hours.
You come along to the ward.
First thing you do is you get given some antibiotics.
We cover Arthrosamid® injections with antibiotics to minimize the risk of infection.
Those antibiotics we give you are tablets, and we like them to be in your system for about an hour before you have the injection.
So you'll come to the ward, you'll have your tablets.
Sit back and relax, and then about an hour or so later, we get you down to the operating theatre.
There, we'll clean and prepare your knee, and we use an ultrasound machine to guide a needle directly into your knee joint.
The first thing that happens with that needle is that I inject, anaesthetic, which will numb the inside of your knee.
If you have a very tense collection of fluid inside your knee, then we can drain off some of that fluid. and then after that, we will do the injection, injecting the Arthrosamid® into your knee joint.
Once that's completed, you go back up to the ward, have a cup of tea and a biscuit, and then you get to go home.
We advise that you take it easy for the first 48-72 hours, and then you can start to build up your activity again with a gradual rehab program that we provide.
I mentioned before about the longevity of Arthrosamid® effectiveness.
This is a graph that shows the scientific evidence for that, it shows that in numerous different studies, people who have Arthrosamid® injection, their pain levels drop right down to a manageable level, and the important thing is that they stay there, and those lines are extending up to 5 years, and hopefully beyond that now, where you're getting sustained long-term relief from your symptoms.
As I've said, Arthrosamid® is one of lots of different types of injections that you could have.
The other ones that we provide here are it can break down into two different forms.
The bottom one there is a steroid injection, that's the classic injection.
You might call it a cortisone, or a steroid, or that kind of thing. and essentially, again, a steroid is a powerful anti-inflammatory agent that we inject directly into the knee joint.
That has, a very rapid effect on swollen, inflamed, angry knee joint.
Steroid injections are very good for dealing with an acutely painful swollen joint.
The bad thing about steroids is that, although they work rapidly, they can wear off pretty quickly as well, and it's common for people to have weeks or sometimes months of relief, but not much longer than that.
The problem with steroid injections, it would be okay if you could keep repeating them.
But steroids, if you have multiple high doses of steroid injections, that can be bad for your knee joint and for the rest of your body as well, so it's not something that we like to repeat too frequently.
So, in my practice, steroid injection is a good emergency treatment, if you've got an acutely painful knee, it's not a sustainable, feasible, long-term treatment for your knee problems.
The other type of injection, the top one there, is, is down there as a Duralane viscose supplementation.
Essentially, what that is, is a compound called hyaluronic acid, which is injected into the knee, comes under lots of different trade names.
Duralane is one of the trade names for it. and again, in the same way as a steroid, it has an anti-inflammatory impact on the lining of the joint.
Again, it's a temporary one, it gets absorbed into the body and only really sits in the knee for a few months.
But the good thing about hyaluronic acid as opposed to steroid is you have less in the way of systemic effects, so there's less side effects, so it is something that can be repeated more frequently with less danger of trouble with your knee.
Let's say you've gone down that pathway, and you've exhausted all other solutions.
Well, then you might be looking at knee replacement surgery.
Knee replacement is a very common procedure.
There are about 100,000 performed, in the UK every year.
Here at Benenden, we perform somewhere between 1,000 and 1,500 joint replacements here every year, so we do lots of them.
The average age for someone to have a knee replacement is in their mid to late 60s.
But what we've noticed over the years, and what I'm seeing on a daily basis, is that that age group that is getting younger.
I will frequently replace people's knees in their 50s and even younger than that, so it's becoming as modern techniques evolve, it's becoming more of a reliable option for the younger patient.
It tends to be slightly more women than men that end up having knee replacements. and I think that's mainly because women live longer than men, so there's more older women around than older men.
The idea behind a knee replacement is to help with the pain, it gets rid of the pain coming from a worn-out joint, and that can restore your previous levels of movement and activities.
It's also very good for correcting deformities.
Quite often, you'll get a deformity, either a bow-legged or a knock-kneed deformity, associated with your arthritic change, and knee replacement is very good at correcting that deformity.
Realigning the mechanical axis there, that's what it's called.
This is a picture of a knee replacement.
Essentially, there are 3 or 4 components to it, depending on whether or not you replace someone's kneecap.
On this picture, there are three components visible.
There is, here we go, there's a curved piece of metal that sits on the end of the thigh bone, and then you have a flat piece of metal that sits on the top of the shin bone that has a piece of plastic that attaches to it, and essentially they articulate with each other like that.
The kind of knee replacement that we use here, It's not quite as beaten up as this one is.
It's something called a Vanguard Knee Replacement, which is manufactured by a company called Zimmer Biomet.
The reason we use that knee replacement is that it has it's got a very good track record.
It's long-lasting, highly rated knee replacement that works well and performs well in the joint registries.
This is just a little animation that we'll have going on in the background.
If it starts to move, I always think it's not going to move, and then eventually it does.
Just when I give up all hope, here we go, starting to move.
What this is showing is it's showing a diseased knee joint here, with arthritis within the knee joint. and, hey, presto, you get a, there's the knee replacement.
Now, what happens is that we make cuts in the bone.
That reshaped the end of the thigh bone and the top of the shin bone.
Which then allows us to fit the new components in.
So you don't chop out the whole of the knee joint and throw that away.
Essentially, what you're doing is you're reshaping the ends of the bones to accommodate the combination of metal and plastic that you put inside the knee joint.
Now, that is a that's an illustration of a total knee replacement.
There are other options when it comes to knee replacement.
There are partial knee replacements as well, or what we call unicompartmental knee replacements.
So, if you are in a situation where the disease in your knee is isolated to one particular area of your knee.
The commonest for a partial knee replacement is the medial side, the inside part of your knee.
If you're in a situation where you have only arthritis in that part of your knee, and the rest of your knee is absolutely pristine.
Then you may be suitable for a unicompartmental or partial knee replacement.
So, whereas a total knee replacement replaces all of the end of the thigh bone, and all of the top of the shin bone.
A partial knee replacement just takes away the worn part of the bone, leaving, in this case, two-thirds of a natural knee. and one-third of a knee that's made of metal and plastic.
It's although it's still a big, irreversible operation, it is a lesser operation than a full knee replacement. and it can give you can end up in a position where your knee feels a bit more natural, a bit more like your own, whereas a total knee replacement, your knee can feel slightly artificial afterwards.
So, it's useful to have, it's a good option for selected patients.
But it's not appropriate for everyone, doesn't work for everyone but it's certainly an option that we could offer.
Another thing that we can offer is ROSA.
ROSA stands for Robotic Surgical Assistant, and what this is, is this is a, this is a tool that I use, this ROSA machine is a tool, a robotic tool that I use in the operating theatre to help me make those cuts in the bone that you've seen on the last video, make those cuts, as accurately and precisely as possible to try and get the best result of the knee replacement that you're having.
Essentially what that means to you is that your knee replacement is in the optimum position to give you the best results in the long term.
It tends to translate in people, getting over their operation a little bit more quickly, and being able to get the maximum amount of function that they possibly can out of their knee replacement.
The way it works is that, we attach sensors.
The robot comes in two parts.
I'm leaning on one part, which is the mechanical arm, which you can see folded at this stage.
There's another part of the machine, which is a separate console, which is has cameras on.
So it's the eyes of the robot and the arm of the robot.
The eyes, look we attach sensors to your leg, so the eyes of the robot know exactly where your leg is in real time.
From that, what we do in the first instance is we map out the movement, the stability, and the three-dimensional anatomy of your knee, using those sensors and using the robot.
Or then generate a surgical plan based on the software that the robot provides. and then the robotic system will then move the mechanical arm into position to allow me to make the cuts in the bone precisely according to the plan.
There's an animation, there's a video that will explain that probably more coherently.
ROSA Knee is a robotic surgical assistant for total knee replacement.
Your surgeon is specially trained to use the robot.
ROSA knee does not operate on its own.
Your surgeon is in the operating room the entire time, and making decisions throughout your surgery.
Your surgeon creates a plan for your surgery based on your unique anatomy.
The bot helps to ensure the plan is executed as intended.
ROSA Knee uses a camera and optical trackers to know where your leg is in space.
If your leg moves, the robot can tell and adjusts accordingly.
ROSA Knee provides your surgeon with data about your knee.
This helps to personalize your surgery based on your unique anatomy.
There we go, a lovely video about ROSA.
Updates, as before, since that video has been made, there is now a ROSA option for partial knee replacements as well, so if you are suitable for partial knee replacements, we can then we can now use the ROSA system, to help with that surgery.
We've got the risks of joint replacement on the screen at the moment.
Before we go on to that, I'll just talk about my experience with ROSA knees.
We have been doing them for over a year now, I think, and there are five surgeons of us five of us here who use the ROSA knee.
I have done half of the robotic cases here, the other guys have done the other half, so we're all we're all experienced in it and all of us have noticed that the ROSA system, robotic surgery.
We were all a little bit sceptical, we thought that it was a bit of a gimmick more than anything else.
I've certainly noticed, and my colleagues would agree, that we do we do find it helpful, beneficial.
Like I said, particularly in the early stages, we see people hitting their milestones more quickly, we see people in less pain with more movement at an earlier stage.
Whether that translates into longevity of the implants, only time will tell.
But at the moment, it's very promising.
It's something that I would certainly maintain in my practice and plan to expand to other parts of the body as the technology and equipment becomes available over time.
So, I've gone from being a sceptic to a convert, and if I was to have my knee replaced, I would choose a surgeon who has experience in robotic surgery.
Risks of joint replacement.
You've probably had a chance to read that while I've been talking, but, there are risks.
It is a big operation, and it's not 100% guaranteed to be perfect.
There are things that can go wrong, either during or after an operation.
Most of the problems that you can get with knee replacement, we anticipate and avoid without you knowing anything about it, because everything that we do is tailored to minimizing the risk for you during the operation.
But having said that, sometimes bad things can happen.
You can have injuries during the operation, you can have problems afterwards, you can develop infections, you can develop blood clots, you can get a lot of swelling and stiffness and pain.
Artificial joints can eventually wear out as well.
So, there are lots of things that can go wrong and do go wrong.
Fortunately, in a hospital like Benenden, our complication rate is incredibly low, our infection rate is incredibly low as well but it's not zero.
There are still sometimes bad things happen on balance, the majority of people, you know, the risks of surgery are massively outweighed by the benefits that you get from it.
Talking more about your hospital stay, well, you'll be in hospital, normally one or two nights following a knee replacement.
Depending on what time of day you have your operation, depends on whether or not you'll be up and about the same day.
If you have your knee replacement in the morning, we'll have you walking in the afternoon.
If you're last on the operating list, we might give you the night off, and then you start being chased around the ward the next day.
You will be able to put all your weight through it straight away, but you will be given crutches in the early stages to help you get around.
Most people will be discharged home on crutches, and you'll get rid of those crutches as you feel comfortable over the next few weeks.
Whilst you're in hospital, you'll be given lots of painkillers, because in the early stages, it's that pain and swelling that tends to be the limiting factor.
So we need to get on top of that, and if we can do that, then things will feel a lot better.
You'll see the physiotherapist, and they'll give you tips on getting going straight away, and also guidance through the early weeks of your surgery.
The first couple of weeks, you will be needing to take lots of painkillers, and I'd also advise that you take that you, have access to ice, because that will help hugely with the swelling and bruising that you will get after the operation. and you'll go through physiotherapy, and a gradual return to feeling normal.
Most people, after 6 weeks, have turned a corner and feel a lot better.
They tend to be back, thinking about driving, walking, doing more and more independently. and it's a gradual healing process over that over a period of time, over that first three to six months, where people get back to, more and more normal activities.
I mentioned that I'm not the only one here, this is, these are the people here, including myself, who perform knee replacement surgery.
All a good bunch of guys, and I'm sure you'd have a good experience with any of them.
How do you decide who to go, where to go?
Well, there's lots of lots of help out there on the internet.
There's lots of, review sites.
One of the biggest in the UK is a site called Doctify, and Doctify has really taken off in the last few years, and it's a it's a feedback service.
All doctors will be mentioned on it, and all patients are invited and encouraged to give feedback.
Not only are doctors rated, but also institutions are rated as well, so you can look at the hospital as well as the person.
This is me, my Doctify.
I can't see my box is in the wrong place.
I can't see how many, there we go, just moved.
Okay, that's a week or so ago.
I've got more than 331 reviews now, but of the 331 reviews, my rate is 4.99 out of 5.
That's pretty good.
The other guys are almost as good as me as far as feedback goes, so, like I said, we're all we're all very good.
Another way to look at people is you can look at, their performance, their activity on something called the National Joint Registry.
In the UK, every joint replacement that is performed is logged on the NJR and monitored over the years, and you can look at individual surgeons, you can look at their activity, you can look at their mortality and revision rates as well. and so you can see how they compare to the national average.
That kind of data is freely available, if you know where to look. and I've just told you, so something to worth looking at.
It's important that you choose a surgeon that you're comfortable with.
that you see other patients have been comfortable with, and also someone that performs a decent amount of operations.
You don't want your operation performed by someone?
Who does it once in a blue moon? You want people who do it regularly, day in, day out.
The other thing that you can find on the National Joint Registry is, data on joint replacements, and you can really go into great detail about the demographics and the indications and performance of all sorts of different joints, you can get nice infographics that are formed there.
So there's lots of online resources and forums out there that you can look at when it comes to joint replacement.
However, most people find that the best thing to do if you're considering joint replacement surgery, and if you've got questions or want to know if it's the right thing for you, come along, come and have a chat, go through that process, let us look at your knee, take a full history, examine you, put it in context of your greater medical picture and functional picture, see how it's affecting your life, and from that, we'll be able to come to a shared decision to decide whether or not, surgery would be appropriate and the right thing or the right time for you.
Those are the prices for various different treatments that are available, and it's worth knowing that if you are a Benenden member, then you get a 10% discount on the self-pay prices.
As with all of these webinars, there is a there's a there's an offer attached to it, and the offer is that you can get 50% off your consultation if you book, off the back of this webinar, there's the special code up there.
There will be people available until 8pm tonight, and the helpline is available Monday to Friday, 8am to 6pm, if you want to book something there.
Also, if you've registered and given your details online for the talk today, one of the advisors will follow things up later on with you, so if you want to take things further, you always can.
There are lots of other webinars coming up over the weeks ahead.
If you're not truly sick of the sound of my voice or my face, I'm doing another one of these this time next week, for hip replacements, and you're very welcome to come along and listen to me and watch me talk about hip replacement surgery.
We've got other things such as varicose veins and gynaecology, urology, ENT, migraines, all of these things.
There's a rolling rotor of webinars, so please look on the hospital website if there's something that catches your interest.
Either tune into one live, or look at the archive of previous events that we've got, you'll find that quite useful.
I'm just going to go back to the prices and leave them up there for people to look at. and now I'm going to go through,
For the next 15-20 minutes, I'll do my best to whiz through lots of questions that we've got on the screen, see if I can, try and answer as many as possible.
So very top one, anonymous attendee.
Can I have a knee replacement if I'm on prednisolone for polymyalgia rheumatica?
The short answer to that question is, yes, you can.
Polymyalgia rheumatica, for those who don't know, is a generalized condition where you get pain and inflammation that affects lots of muscles that move you around, and it can be quite debilitating.
The mainstay of treatment for that it's a burst of steroids, which you appear to be on and what you try and do is, after you've been on steroids for a while, is to try and taper them down slowly.
Ideally, if you're planning to have surgery, it would be good if you've reached the end of your taper, or if you're at a stable level of steroid intake.
If things are fluctuating greatly, then that can be a problem with surgery, but if you're on a stable dose, or you've come off them altogether, then that shouldn't be a problem when it comes to surgery.
There are particular considerations that we have to take into account.
The best person to discuss that with would be the anaesthetist at the time of your pre-assessment, there are compensations that we make to adjust for the steroid levels in your body, but it does not mean that you can't have a knee replacement.
We need to be aware, and we make adjustments accordingly, but it wouldn't be a particular problem.
Graham writes, after an MRI, I have something loose in my knee joint, possibly bone or something else.
Currently not of concern, but should it be removed? If so, how the first thing to say is that, you know, if it was me, I'd like to know what it was, rather than being told it's possibly A or B.
I think getting a firm diagnosis of what it is would be useful, and I'd suggest,
coming along for an appointment so we could review your scan, the images, and talk about what it could possibly be.
You say it's currently not of concern? Well, if it's not of concern, as in, if it's not bothering you, or you're not getting any symptoms from it, then generally, the advice would be leave things well alone.
If you develop symptoms from a loose body inside your knee, and typically the kind of symptoms that you could develop at that stage, would be feelings of locking or instability, so you get mechanical kind of problems inside your knee.
If you start to become symptomatic, then it can be possible to remove the loose body.
Ideally, you want to remove it by doing the least amount of damage to the person as possible, so we tend to remove most loose bodies through keyhole surgery.
As long as it's small enough to fit through the keyhole, then it can be done that way.
But the first thing I would suggest is find out exactly what it is.
If it starts to bother you, then we could talk about removal.
It would be a simple keyhole procedure on the whole.
Marcus asks, how is the knee replacement stable without cruciate ligaments, please?
Let me get my model, this one.
So when you have a knee replacement, like I said, we've got this knee here, and we've got these orangey things are the ligaments around the front, sides, back. and deep inside the knee that support the knee.
All of those ligaments work in combination to make your knee stable.
When you have a knee replacement, you do have to sacrifice this ligament, the ACL, the cruciate ligament, right in the middle of the knee joint.
Now, most people, by the time their knee is worn out enough that they're talking about a full knee replacement, the anterior cruciate ligament, the ACL, is a fairly sorry-looking structure anyway, because that too undergoes degenerative change.
You cut away what's left of the ACL when you do the surgery.
But, all the other ligaments inside your knee, the ones at the front, the ones at the sides, the ones at the back are all still there.
So the support structures around your knee, including all the ligaments and muscles, are still there, and you rely on them for stability after the operation.
The knee replacement itself, the design of the knee replacement, the contours of the articular surfaces are designed to replicate the stability that losing a cruciate ligament will give.
So, the answer to your question is, you won't miss it, because the stability is made up by a combination of the design of the implant and the remaining structures around your knee.
There have been Patricia asks, there have been reports in the media about Zimmer Biomet implants failing sooner than expected.
Can you comment on this, please?
Yes, I can.
There are every now and again, there will be a report about a particular implant that is failing, in the same way that every now and again, there will be a report on a recall on car safety, or aeroplanes crashing.
Boeing was the most recent one who had design faults.
So, there are multiple different manufacturers, different companies that make orthopaedic implants, and Zimmer Biomet is one of those companies.
Other ones are Dupree, Johnson & Johnson, Smith & Nephew, Stryker.
These are all big, multinational implant companies.
Much the same way as car companies like Audi, Mercedes, BMW.
These different companies make different models of implants. and there are some old models, and some new models, and some that there are different designs in their portfolio.
There was an implant that was manufactured by Zimmer Biomet Company called the NextGen implant.
That NextGen was very popular about 15, 20 years ago.
There were, until recently, there were still some institutions that would use a NextGen implant.
On occasion, but the majority of modern facilities, the next gen has kind of been superseded by other implants as a natural evolution process.
Example would be a Ford Cortina.
Or a Ford Escort.
An old model that used to be very reliable, but it's no longer made.
The next-gen implant by Zimmer Biomet in certain patients were showing signs of wearing out or failing, loosening sooner than the average implant would do and so, very rightly, it was picked up by the big registry called the National Joint Registry, which looks at how implants perform over the years.
If they see an abnormality, that is flagged and highlighted, and as a result, publicized.
You may remember 10, 15 years ago, there was a lot of headlines about a certain type of hip replacement called a Birmingham hip replacement.
These metal-on-metal hip replacements that were initially performed well, but were found over a period of time to cause trouble, to cause damage. and be toxic in people, and so they were picked up again in the National Joint Registry, highlighted, withdrawn, and, no longer a major problem.
The same is true with the Zimmer Biomet NextGen implant.
It's not something that we use here at Benenden.
It's manufactured by the company that we use, but that's not, we don't use it.
There's been no signs of any problems with the Vanguard knee replacement over the years, and like I said, it performs incredibly well in the joint registry.
So, hopefully, bit of background, and hopefully reassurance that what we use, although it's made by a company that's had a problem with a different implant, all of the companies have had different problems with different implants over the years.
We don't use any that have shown any problems.
Oh, here we go.
Hello, I saw you a couple of years ago, and you told me that I needed a full knee replacement.
Do you know when you'll be able to perform a robotic full knee replacement? As I know they offer this in Australia. Many thanks.
Well that question was at 6.27, that might have been before I started talking about robotic knee replacements.
So hopefully, you'll have got the answer by now.
I recognize your name, I'm not going to say it out loud and broadcast it, but, nice to hear from you.
We do robotic knee replacements now, and I'd be more than happy to do that for you.
If you felt that was the right thing to do, the best thing to do is we'll arrange a consultation, we'll take a look at your knee now, see how things are looking, and we'll go from there.
Arthur asks, in what circumstance would you be would you advise going straight to a knee replacement instead of first starting with an Arthrosamid® injection?
Arthrosamid® injections are very good at dealing with inflammation wrapped around a worn-out knee.
Not everyone has a lot of inflammation around their knee.
Some people have very little inflammation around their knee, but very advanced arthritis in other ways.
When I see someone who's interested in Arthrosamid®, or when I see someone with arthritis in me in general, what you try and do is you try and figure out what the best treatment is for you.
If the problem that you are getting from the arthritis in your knee is one that Arthrosamid® cannot solve.
So if it's more of a deformity, or a problem from severe bone-on-bone arthritic change with little in the way of an inflammatory element around it.
Then I'm not sure that there'd be much value in spending money on an injection. and so, in that case, I would start I would say I would say those exact words.
I would assess your case, if there's something that Arthrosamid® can help with, and if we think that it is worthwhile enough, if it will give you value for money from that intervention, then we'll talk about it.
If I honestly don't think that it's not going to make any difference to you, I'll tell you.
Anonymous asks, is there a risk that the plastic between the two metal parts of the replacement knee will disintegrate?
Yes.
That is one of the ways that a knee replacement can fail.
Using the props a lot tonight.
One of the ways is that that plastic, this layer of plastic that sits between the two bits of metal.
Can eventually wear away and erode and, end up needing replacing.
In the old days, the first generation of knee replacements, the commonest reason to need further surgery on a knee replacement was exactly that, was because the plastic would wear out before, you know, before anything else failed.
Modern implants, modern plastic, modern metals, modern surgical techniques.
Have now reached a stage where the commonest reason for people to need redo surgery on their knee replacement is no longer the components wearing out.
It still can happen, eventually.
But most people, if you're if you have a knee replacement in your mid to late 60s onwards.
If you end up needing further surgery, it's more likely to be for a different problem, such as a broken bone, or a torn ligament, or an infection, or something else, or traumatic reason, rather than the implant itself wearing out.
So, yes, it's possible, it's less frequent than it used to be.
Obviously, the younger you are, the more likely it is that things will wear out, but it's by no means a certainty.
Follow-up, quick follow-up from Marcus.
Talking about ligaments, you have no PCL, would that be an issue for stability after replacement? The answer to that also is no.
The typical design of a knee replacement compensates for a lack of anterior cruciate ligament.
There are slight variations in the models that you can get, and you can get ones that are also compensate for insufficiency or lack of a posterior cruciate ligament as well. and most modern implants have an option to either be what we call a cruciate retaining or a cruciate sacrificing model, which involves cutting away the posterior cruciate as well.
There are some surgeons who routinely move remove the posterior cruciate ligament as part of their knee replacement surgery.
So yes.
It's, again, PCL, absence, loss, insufficiency, or poor function is not a contraindication to knee replacement, and would not require any super specialist equipment.
You were advised someone was advised that you would need a full knee replacement, but you should wait until you're 70. It's badly affecting my life. Can I have it now? I'm 66.
Yes, is the short answer.
The long answer is that although age is a factor when we're talking about knee replacement surgery, the most important thing is quality of life.
I see, like I said, I operate on people in their 50s.
I've replaced people's knees in their 20s, you know? If you're at the point where you can no longer enjoy your life because of your knee, then why should you be made to wake until a made-up time limit, you know?
Why should you have to wait until you're 70? There's no evidence to prove that.
Essentially, you should, if you're at the point where you can't live with your knee anymore, then it's time to have it done. and that, as long as you are aware of
The implications of that, it doesn't matter if you're 20, 30 or 100, you know? When the time is right, it's time to have it done.
If you've got a surgeon who's telling you that you can't have your knee replaced before you're 70, I would replace your surgeon as well as your knee.
Daryl asks, do they set off airport alarms?
The answer to that is sometimes they do and I think.
I shouldn't be saying this on camera.
I think that probably indicates that sometimes the machines in airports aren't switched on, like speed cameras that sometimes have cameras have filming and others don't.
You don't when you walk through the normal metal detector arch, it may not set things off.
It will be picked up on the new body scanners, where you stand in the airport and they scan you.
A knee replacement will show up on those kind of scanners, but again, the people that run their scanners will know that it's a knee replacement and not be concerned.
They tend not to set off metal detecting alarms, they do get picked up on scanners. There you go.
Here we go.
Oh, Patricia.
Can you kneel on a knee replacement?
Every now and again, I'll see someone who has been told at some point that they cannot kneel on knee replacements.
It's an apocryphal story that you hear every now and again.
There's no mechanical reason why you shouldn't be able to kneel on a knee replacement.
They are perfectly strong enough for you to kneel on.
The problem that that people can get is that in order to do a knee replacement, you end up with a cut right down the front of your knee.
That's the way we get in to put the knee replacement in.
So, after you've had your knee replaced, you'll have a scar right down the front of your knee, and that's the area that you put pressure on when you kneel.
In the early stages, when scars are healing, there can be a mixture of things, but they're generally they tend to be uncomfortable, they can be tender to pressure, they can be oversensitive, and at the same time, other patches of it can feel a bit numb.
So you're in a situation where you've got an area at the front of your knee that is painful, or numb, or both, to pressure. and if you try and kneel on that, particularly if you're kneeling on a hard surface it will be uncomfortable.
Once that healing process is fully gone, then you will be able to kneel on a knee replacement.
I've got plenty of patients who are who have to kneel on their knees as part of their jobs, who are plumbers or vicars, or carpet fitters, and in that situation, it might feel a bit funny to start with, it might be a little bit uncomfortable in the early days, but if it's something, like with anything, your body will get used to it if you do it often enough.
The structure underneath it is strong enough.
The sensation is odd to start with.
But most people get used to it, and yes, you will be able to kneel on your knee.
We've got lots of talk about ligaments today.
Deborah asks, do you always remove the ACL when doing a full or partial knee replacement?
With a full knee replacement, yes.
With a partial knee replacement, absolutely not.
In fact, one of the one of the prerequisites that you have to fulfil to be suitable for a partial knee replacement. is that you have to have your cruciate ligament intact.
So, on this model of the partial knee replacement, in the middle of the knee there, you've still got your ACL.
So, your partial knee replacement relies on the medial collateral ligament on the outside, and the anterior cruciate ligament on the inside part, it relies on that for stability and function of a partial replacement.
So, you don't cut through the ACL when you're doing a partial knee, and if you don't have an ACL, it's unlikely that you will be offered a partial knee replacement.
Last one, last question.
Tony I'm going for your question, Tony.
You had a patellectomy done in 1968, and now have arthritis in the knee. How does this affect treatment options, for example, Arthrosamid® or knee replacement?
Patellectomy I'm pleased to say is an operation that we don't do anymore, but I still see quite a few patients, over the years who've had patellectomies in the past.
What a patellectomy is, is it's an old-fashioned treatment for arthritis of the kneecap, or damage to the kneecap.
In the old days, if you damaged your kneecap, if you broke it badly enough, or if you developed arthritis in it.
The only option, apart from living with it, was for someone to take it away, remove it.
So, a patellectomy is when someone removes the kneecap, the front part of your knee.
As a salvage operation for a terrible injury it's alright, I suppose.
As a treatment for arthritis, like I said, it's been, it's an old-fashioned operation.
But I will still see people who, like Tony, will have had a patellectomy decades ago, and are living with the consequences of it.
How will it affect treatment options?
I've got plenty of patients with without kneecaps who have had multiple injections in the past.
So whether or not you have a kneecap.
If you're suitable, if you have a problem that an injection can help with, you can have an injection.
If you have developed arthritis in the rest of your knee, and the only option is a knee replacement, then having a knee replacement, having previously had a patellectomy is possible it requires assessment beforehand.
I need to make sure that although you don't have a patella, you still need to have an intact extensor mechanism, so something that allows you to bend and straighten your knee.
As long as you've still got that, then it is mechanically possible for you to have a knee replacement.
There are slight differences in the technique that we use for a knee replacement in a post-patellectomy case, but it's by no means impossible.
The results of surgery for knee replacement surgery following patellectomy aren't quite as good.
As knee replacement surgery in people who've never had a patellectomy but on the whole, it's still a hell of a lot better than living with a worn-out knee.
So, yes, it's possible, the conditions have to be right, the results aren't 100% as good as with a with a normal knee replacement, but certainly a lot of satisfied customers, so yeah.
Don't let it put you off.
We're past 7 o'clock now.
That's my lot, I'm afraid.
Hopefully you found that quite useful and interesting.
I certainly have, as far as the questions go, that's my favourite part, and I'm quite happy to sit and answer them all night, but everyone's got places to be, and so we'll leave it at that for the time being.
If you have any further questions that haven't been answered, we'll do our best to answer them, or make an appointment, come and see myself or one of my colleagues here, and
More than happy to talk to you in more detail about whatever you like.
That's it from me today like I said, tune in next week if you want to hear me talk about hip replacements.
Otherwise, it's been a pleasure, and hopefully that's been useful for you.
So, we're going to bring that to a close now.
Nice to see you all tonight.
