Events

Cherona

Once again, good evening and a very warm welcome to our webinar on knee osteoarthritis treatment. My name is Cherona, and I'm hosting this evening's session.

I'm delighted to be joined by our expert speaker, Mr Matthew Oliver, consultant trauma and orthopaedic surgeon.

Tonight's session will begin with a presentation from Mr Oliver, followed by a live Q&A. If you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen. You're welcome to ask anonymously or include your name. Just a quick note that the session is being recorded, so any names shared may be visible in the recording.

To help us get through as many as possible, keep please keep your questions brief.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

Over to you.

Mr Matthew Oliver

Good evening, everyone. Thank you for the invitation to come to speak to you all via this webinar tonight. I'm going to talk to you about osteoarthritis of the knee, what it is and its treatment.

So, let's move on. A little bit about myself. My name is Mr Matthew Oliver. I'm a consultant orthopaedic surgeon. I've been working here at Benenden Hospital since 2012. I trained in London at St George's in the late 90s and did my higher surgical training in the southeast Thames region, mainly in Kent and Sussex.

I've also spent a period of about 18 months in academic medicine, learning and studying the human knee joint, carrying out various basic science clinical studies and bioengineering studies on different knee replacements.

Following this, I went to Canada for a year and did an adult hip and knee reconstruction fellowship, working for six very eminent orthopaedic surgeons, rotating in blocks of four months and working with them in pairs.

It was a fantastic experience working in a different healthcare system and I learned a lot and some of, well, quite a lot of the things I learned in Calgary I brought to my NHS and private practice and use the techniques to this day.

I'm a hip and knee surgeon and got appointed to my local trust in East Kent in 2010, and I consider myself a relatively high volume hip and knee surgeon. I perform three times the national average of hip and knee replacements compared to my peers.

So, included in this session are seven sections. First, the consultation, followed by the problem, talking to you about osteoarthritis of the knee, then the treatment options, the risks of surgery, what the hospital stay is like and the recovery following a knee replacement, and then we'll talk a little bit about what's available out there to help you make the right decision for whom and where you should have your knee replaced and then we'll follow up with a question and answer session.

So here's a picture of my colleague, Mr Chipperfield, the medical director. He's examining a patient in clinic. It looks like he's assessing them for an anterior cruciate ligament injury.

So, basically the consultation is all about making sure that we know what the problem is for a thorough medical history taking session.

Making a note of the symptoms and signs, followed by a full clinical examination, not only assessing the knee joint, but also the joint above and below: the hip and the ankle.

Along with that, the neurological function of the limb will be assessed along with the blood supply or the vascularity of the limb.

We sometimes require X-rays and if we're fortunate enough, these will be available on the day they would have been image linked across from wherever you've had them taken.

But sometimes we have to send you off for an X-ray and on a few occasions, more specialist images are required such as MRI scans. And of course we can't get these quite on the day just yet, but you'll have an appointment quite rapidly for one of these and we should hopefully see you with the results within two to four weeks.

Whilst we're assessing you, we're also triaging you for your fitness for anaesthetic.

If you're going to have any operations here at Benenden Hospital, the most common technique, anaesthetic technique, is to perform a spinal anaesthetic with sedation, certainly for the big ops like hips and knee replacements.

Some of the smaller ops, such as a knee arthroscopy, are carried out under general anaesthetic.

It's important that we assess your fitness for anaesthesia thoroughly because we are a small hospital with not that much medical backup in the countryside of Kent, so we have to be cautious about who is safe to proceed with an operation here.

So, what is osteoarthritis of the knee? It is essentially a disease process of wear and tear. It is incurable, and it presents very insidiously throughout our life. It gradually comes on us.

And it normally presents initially with just a little bit of pain on activity. You might just get a bit of a twinge and a little bit of an ache where the joint is wearing out. So it may be on the medial side or the inside of your knee. It may be at the front of your knee if it's the kneecap that's wearing out

You may also notice the knee feels a bit stiff, certainly first thing in the morning.

As the problem progresses, your walking distance will gradually reduce, and you may notice it swell up a little bit from time to time. Eventually, it will start to cause problems with your more enjoyable activities, such as playing golf, going for a walk, playing racquet sports, etc. As the problem progresses, the pain unfortunately is there 24/7. Painkillers don't really help, and you have disturbed sleep at night. It will ache at the end of the day if you've been standing on your feet a lot. Also, you may notice the shape of your knee changing.

One of the things that you'll first notice is that you won't be able to fully extend the joint. That means laying out flat on the bed. It will be a little bit bent in fixed flexion.

You may also notice it becomes a bit knock-kneed or bow-legged as parts of the joint wear out faster than other parts. The causes of osteoarthritis of the knee can really be broken down into three or four.

Firstly, it's a condition that is idiopathic, in the sense that it's just part of getting older, unfortunately. All of us will have to go through that phase, and it begins in our 40s, when the menisci, or the shock absorbers in the knee, start to degenerate and perish like washers on a tap. They start to have little micro-tears that all join together and form a larger tear and therefore become ineffective at dealing with the shock between the joint surfaces.

And when there's too much shock or too much load, the articular cartilage starts to break down. That's the actual cartilage that lines the joints. Initially, it shows up as little fissures or cracks, and then it breaks off in chunks, leaving bare areas of bone denuded of cartilage.

When you get to that stage, which is in the latter parts of the disease process, it is almost like having bone on bone. And you can see that on a weight-bearing X-ray of the knee joint.

Other causes of osteoarthritis are if you have been unfortunate enough to have had an injury to your knee in your youth, such as an ACL rupture, say, from a skiing accident. It changes the biomechanics of how the knee works, and the knee becomes unstable and translates, rotates and flexes in a slightly wobbly way, putting extra load on the joint and therefore accelerating the wear and tear process.

This can be, to a certain extent, reduced if you were to have the anterior cruciate ligament reconstructed, and there's strong evidence to show that that is a worthwhile procedure to have done if you wish to remain an active, sporty person and try to return your knee to near-normal biomechanics.

Other causes are a little bit more rare, such as avascular necrosis or SONK, which is known as spontaneous osteonecrosis of the knee. That's when the blood supply to the knee joint is temporarily damaged and it doesn't always recover.

Therefore, the bone underneath the articular cartilage starts to break down, and the cartilage has no scaffold to support it, so it collapses, breaks off and acts as a nidus for the rest of the knee to wear out.

Probably the most important cause to mention in a webinar such as this is lifestyle issues, and that's obesity, really. Obesity is an absolute dead cert that you'll get an osteoarthritic knee. Lots of studies have proven this, and it's very closely correlated to what's known as your body mass index, which is a crude way of measuring your obesity.

Probably the most important cause to mention in a webinar such as this is lifestyle issues, and that's obesity, really. Obesity is an absolute dead cert that you'll get an osteoarthritic knee. Lots of studies have proven this

One of the figures that I've always remembered easily is the BMI of 40, which is classed as morbidly obese. In the morbidly obese range, there's a 40% greater risk, or 40 times relative risk, that you'll end up having an arthritic knee, so 40-40 makes it easy for me to remember. So it's absolutely essential that you bring your weight down to put less load through the knee joint.

A healthy knee and an arthritic knee are seen in these pictures here on my left, or the right of the screen, I think, for you, is the healthy knee. You can see the two collateral ligaments either side, the cruciate ligaments in the middle overlapping, and healthy-looking bone surfaces of the femur and the tibia. The menisci, or the shock absorbers, are not in this schematic diagram. Then, on the other side, you can see the fissuring and breaking down of the articular cartilage.

And the red wall sort of bony areas, that's a very basic way of describing what happens in an arthritic knee.

So the treatment options, non-surgical and surgical. The non-surgical ones are lifestyle advice, weight loss using a dietitian, joining a Weight Watchers or Slimming World initiative, perhaps using weight loss injections if you qualify for these, and, in some cases, bariatric surgery to bring weight down ready to have knee replacements.

Activity modifications certainly do work, but a lot of people find it difficult to understand that they should still do exercise and push their arthritic knee. There's lots of evidence to show that if you do light load-bearing exercise with an arthritic knee, yes, it will hurt, especially initially, but because you're building up the muscles around the knee, your knee will be more stable, and it'll be very grateful to you for doing this, because it's the instability in the knee and the jarring of the worn-out surfaces that contribute a lot to your pain. Building up the muscles around the knee is absolutely essential.

The articular cartilage, it relies solely on nutrition by diffusion from the synovial fluid. And if you don't move your knee, then these processes are not stimulated.

strapping and braces have a role. The off-loader braces, it can jack the joint out so the bones don't touch each other. These work for a while, but patients usually find them quite cumbersome and uncomfortable, and you can't always wear the clothing that you wish because they're quite bulky.

Other non-surgical treatments include steroid injections.

These are tried and tested, it's usually local anaesthetic and a steroid mixed together.

And these are carried out as an outpatient procedure in the clinic and will provide reasonable relief of discomfort for about 4 to 6 months. The more you have, though, the less effective they become and also having a steroid injection will preclude you from having a knee replacement for about six months because of the heightened risk of infection

There's also Durolane supplemental Viscosupplementation that is offered here at Benenden if you're a member. This is having a Castrol GTX-type injection of hyaluronic acid.

Basically, hyaluronic acid is a key component of your joints, but as we get older, the concentration of that acid declines, and that acid has a key role in lubricating the knee joint, so the Durolane offers a sort of a super boost of hyaluronic acid and again is quite effective for the mild to moderately arthritic knee.

For about 4 to 6 months, and it can be repeated.

The other injection offered here at Benenden is called arthrosamid, and I'll spend a bit of time talking about that in some detail in a few minutes' time.

The surgical solutions, you can have an osteotomy. That means reshaping the knee joint.

Not performed here at Benenden is quite a specialist procedure, and you have to catch the arthritic knee at a very early stage to make it worth your while.

People that have these operations are normally late 20s, 30s, and maybe 40s when the arthritis is a very early stage, and it's due to malalignment of the bones. So, there's point loading of one particular spot in the knee, and the bones are reshaped to offload that area.

and distribute the weight more evenly. And you can have an osteotomy of the tibia or the femur. It's quite a high morbidity operation having your legs snapped and reset and they need to be motivated and stick with it for several months while it all heals up.

But it's certainly an option. Arthroscopic techniques, very few indications for keyhole surgery with an arthritic knee. There are a few exceptions, such as a loose body or a bit of bone floating around causing mechanical issues of locking and giving way.

can very much be beneficial to fish this out, and the patients and mechanical issues go away, and they're just left with the usual arthritic pain that they may be able to tolerate.

And sometimes a meniscal tear in an arthritic knee is addressed through the keyhole, but we have to be very careful about this, because there's no point debriding a meniscal tear for the sake of it. It has to be an unstable tear.

that's causing a mechanical issue. Otherwise, all we're going to do is speed up the demise of the knee by taking out the cartilage.

Cartilage transplantation, not performed at Benenden, super specialist, been around for about 25, 30 years, and this is where they take non-weight-bearing cartilage from the knee and transplant it into the worn-out weight-bearing area.

The area that can be transplanted is very small, it's about 1cm squared, and maybe slightly bigger, and is normally reserved for very isolated patches of where the inclusion criteria to be selected for this is very tight indeed, and the fact that it's being practiced for 30 years informs you that it isn't quite 100% successful, but we're getting there, and certainly it is an option that is gaining momentum.

This is joint preservation surgery to try and keep hold of your natural knee for as long as possible, and then moving on, we've got the different forms of knee replacement, the partial knee replacements where you just have part of the knee removed and replaced.

such as the medial compartment or the patellofemoral compartment, and then the total knee replacement where all three compartments of the knee are replaced. Usually, that's the patellofemoral and lateral and medial compartments.

So, Arthrosamid: this is a novel research injection that hasn't quite got through all of the NHS National Institute for Health and Care Excellence approval hoops yet, but it's certainly tried and tested throughout Europe and is gaining momentum as a validated, reliable alternative to having invasive surgery.

So, what is it? It's a permanent implant that is injected into your knee.

It's made of mostly water and a very clever chemical called polyacrylamide.

It's non-biodegradable, so it's there forever and it works by integrating itself into the synovial lining of your knee joint over a period of weeks to months.

When it's doing that, it alters the function of the lining and stops it from making some of the inflammatory chemicals that irritate your knee. And also, it makes the synovial tissue more elastic, and therefore helps reduce the joint stiffness.

And, reduces some pain and enhances function. It's really important to emphasize it is not a magic bullet. You will still have an osteoarthritic knee after this injection, and it will still gradually get worse.

However, in quite a few cases, it does seem to make living with an arthritic knee a lot more manageable for people. And there are several testimonials on the Benenden website to validate this.

And in my own practice, I've had some quite miraculous reversals where people have become a lot more active and participated in long walks, joined their rambling group again, got back to the golf course and so on and so forth.

There have been a few patients where their expectations haven't been met, and it is difficult to know for certain whether one will respond to this injection. The majority are responding, but there are percentages that aren't. On that note, it's interesting when people have bilateral injections: one knee might respond slightly more than the other. There is no rhyme or reason for that. It certainly seems to work well for knees that are mildly to moderately arthritic and also where they have patellofemoral arthritis.

Those people seem to benefit the most. That said, some people with quite advanced arthritis who are either too sick to have a knee replacement due to other comorbidities.

Or just don't want the hassle of a major operation. These people have opted to have this injection, and quite a few of them have come back being quite happy with some reduction in pain and better function.

As I say, it takes a few weeks to work, up to 3 months, and in a few cases, there have been a few late bloomers, where it's actually taken 4 to 5 months to kick in.

The manufacturers in their studies that they publish on their website have had results now up to about four to five years with maintained pain relief. We've only been using it here at Benenden Hospital for a couple of years.

So we'll have to wait and see.

It's a day case. It's carried out in the main operating theatre here at the moment. You come a few hours before the procedure to have antibiotics given orally, by mouth, and when you come down to the operating theatre, your knee is cleaned with antiseptic, and then local anaesthetic is used to numb the injection site.

While that's kicking in, an ultrasound is used to ensure that the needle is placed within the suprapatellar pouch, which is in the knee joint.

If there is some fluid on the knee, then it is drained. If there's not, then 6 little 1 millilitre syringes are injected into the knee through the initial same needle used to administer the local anaesthetic. So essentially, it's just one needle prick.

Once that's done, the needle is removed, a plaster is placed on the knee and it's best to have a restful 24 to 48 hours or so, and avoid strenuous activity for a couple of weeks.

There is a dedicated rehab program to follow as well, which is beneficial.

The main risks of the injection are infection, that's why you have the antibiotics, and also you can have some increased stiffness in the knee for the first few weeks.

And the final risk is that you don't respond.

The y-axis is the pain level and the x-axis is the timeline.

So at the top of the graph, that's the injection going in, and you can see over a period of four weeks the pain is coming down, and it reaches its zenith of effectivity around the 12 to 13 week mark.

That dashed line is the threshold it needs to get past to make it clinically a viable solution.

You know, to use for this purpose. And then, as you can see in all of the studies, there is prolonged relief of discomfort for quite a long while

I've spoken about the Durolane already. That's the super booster of hyaluronic acid.

And that reduces some pain for 4 to 6 months, and it can be repeated. There are no real nasty chemicals in this, but again, it's probably worth waiting about 4 to 6 months if you're going to have a knee replacement following this.

And I've mentioned local anaesthetics and steroid injections. The only two important things are that you have to wait up to six months for your knee replacement and, if you have too many, it's actually counterproductive. It corrodes the cartilage.

So knee replacement surgery, there's some stats there saying that over 100,000 have been performed in the UK in 2023.

I think it's about 140-odd thousand now. I've performed, I think that's the 2025 figures.

And the average age is about 69. Most of the patients, just over 55%, seem to be ladies. The average body mass index is about 30.9 as well, which is in the overweight/obese category.

95% of the time, the main indication for the operation is osteoarthritis

The aims of the knee replacement are to reduce the pain and restore your function and mobility and to realign the mechanical axis of the leg if you've got a very bowed leg or a very knocked knee

It gives us an opportunity to straighten things out for you, which in itself improves your quality of life.

At this hospital, since I've worked here, we've used the Vanguard knee replacement

My colleagues and I use this in our NHS practice as well. It's made by Zimmer Biomet, a large American orthopaedic company with a good reputation on the whole, and the knee replacement itself superseded the AGC knee, which was a very successful knee replacement made for 20-plus years. So this is the upgrade.

It's been around itself for about 20-odd years now, and in that time it's managed to become the highest-rated knee replacement out there on the ODEP rating. ODEP stands for Orthopaedic Data Evaluation Panel. It's an independent panel based in the UK that assesses all orthopaedic devices that are implanted into the human body, and 15A means that it's got 15-year survivorship of greater than 95%.

The 10-year survivorship figures of 96.4 must have been from a recent publication. It is usually cemented in place

And it can be performed with or without a patella resurfacing.

There are three types of orthopaedic knee surgeon. There's the person who resurfaces the patella every time. There's a selective resurface, who only resurfaces if it's worn out, and then there's the surgeon who doesn't resurface the patella, even though it's worn out.

There are three types of orthopaedic knee surgeon. There's the person that resurfaces the patella every time. There's a selective resurface only resurfaces if it's worn out, and then there's the surgeon that doesn't resurface the patella, even though it's worn out

The Vanguard knee is a very forgiving knee replacement for the patella because of its very shallow groove on the top of that femoral component

Myself, I'm a selective patella resurface. I couldn't bring myself to resurface a kneecap if it was only very mildly worn or pristine, but I certainly would resurface it if there is more wear, especially if the patient is relatively young, because I know that in 10 years' time that kneecap would have worn out and they would be back in pain again.

So here's a video showing you what an arthritic knee looks like. You can see the ulceration of the cartilage on the medial femoral condyle. That's that red blob there.

And then you can see what a knee replacement looks like. So essentially it's a resurfacing. It's not really a replacement in such, it's a resurfacing the worn out bony ends are removed and resurfaced with pristine brand new ends that are cemented in place.

And then the plastic bearing couple is connected between the two, and the knee is essentially balanced by her own natural ligaments.

A little bit about unicompartmental knee replacements. These are performed at Benenden and have been for many years. This is a good operation if the osteoarthritis is mainly isolated to one spot.

Usually the medial side of the knee, or the inside part of the knee.

It's quicker to recover from and less painful, and people say it has a more natural feel.

And they are able to get back to probably more robust activities following one of these.

The only caveat with this is that if you have any wear and tear elsewhere in the knee, that will come back and bite you on the nose at some point.

And if that arthritis takes hold, then the only way of getting rid of that and the pain is to have it revised to a total knee replacement.

So, thus the revision rates are slightly higher in the partial knee replacement compared to the total knee replacement. They are gaining momentum, though, about 15% of the knees performed in this country now are unicompartmental knee replacements but as I mentioned earlier, patient selection is absolutely paramount.

Talking about the Rosa knee system, there's Mr Chipperfield standing by the ROSA, which stands for robotic Orthopaedic Surgical Assistant. It's made by the company Zimmer Biomet.

It's been around a good few years now, but what's great about it is that, just like these modern cars, you can get software upgrades, and it's getting better and better.

The main benefits really are the perceived reduction in potential pain that someone gets because it's less invasive.

That usually leads to a slightly shorter length of stay in hospital and there's a reduced risk of any soft tissue injury.

It basically uses exactly the same instruments as a standard knee replacement. All the kits there as usual. The knee replacement itself is the standard one that I showed you in the video earlier that comes off the shelf.

The robot doesn't do the operation like some people think. It helps the surgeon to plan the operation and then carries out the bony cuts to the plan and validates it at every step. The surgeon, though, has to make all of the important decisions along the way.

It's also now possible to perform half or partial knee replacements using the ROSA.

So here's a video showing you what the ROSA is all about and how it works.

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 robot 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.

So, my own viewpoint on the ROSA Knee is that it's definitely an adjunct to improve the accuracy of performing a total knee replacement. At every stage of those bone cuts, we have to place the sensor back onto the bone cut and register it with the robot.

And if we're slightly out, the robot will not let us proceed to the next step. We have to cut again until it's bang on. When I say that, I mean it's within less than a millimetre or less than a degree.

So it's very, very accurate indeed. It also gives the surgeon the opportunity to see what the potential knee replacement is going to be like before it's actually happened, to make sure that the sizes are correct, that the implants are positioned how he or she wishes them to be, and that the knee itself is stable throughout a range of motion.

Once we're happy with that, we execute the plan. As I said earlier, it's validated at every step. We put the trial knee replacement in, and then we run another knee-state evaluation with the robot to check that it matches the plan that we had earlier on. Sometimes, we have to do a little bit of a tweak, such as a ligament release, or remove a little bit of extra bone to free things up, but most of the time, it provides a very stable platform, and the knee feels very good and stable throughout a range of motion, which is what the patient needs to have, so they feel confident on the stairs, confident when they crouch or squat, and they don't have any feelings of instability if they turn a corner, and so on and so forth.

I've experienced it. I'm about 51 years old now, so I've been around 16 years as a consultant. I trained before robots were on the scene, and I have experienced computer navigation. I've then experienced patient-specific instrumentation, which is when CT or MRI scans are done of patients' knees, and special moulds have been made, and the plan is tweaked in advance before the mould is made, and then the bony cuts are made. This is the next evolution on from that.

And I don't think robots are going to go anywhere. I think they're going to get better and more accurate. We don't know what the long-term data is yet. There are a few medium-term studies out there comparing what robot knee replacements are like compared to conventional knee replacements, but one thing is for sure: it's important to have a high-volume knee surgeon who knows how to do a standard knee replacement, because it is still art and science combined.

You know, you have to have a bit of a flair for it. It's about the feel and the look, and the innate ability of having done lots of knee replacements.

It amazes me, you know, the little tweaks that you have to make. That is through experience, and the robot doesn't have that empathy. It's a machine, whereas the human does knee into patient B, or, you know, it has to be custom-made to that patient, and doing it the standard way, or the robot way, that you'll always need that human touch.

So the risks of joint replacement.

During surgery, you can injure the bone. That's very rare, but you can have a fracture. You can certainly get nerve injury, foot drop and numbness, but again, very rare. You can bleed and sometimes need a blood transfusion.

There's a chance of a ligament or tendon injury, so we protect these with all the instruments

Afterwards, during the recovery phase your leg will be very bruised, and that's something that people don't get warned about enough. Your leg will go black, blue, green, orange, all the colours of the rainbow, and the bruising can be quite dramatic, all the way from the little toe up to the base of your spine. It's made worse by the blood thinners that you'll be put on to reduce the risk of deep vein thrombosis and pulmonary embolism.

You will have a limp, and you will have stiffness and swelling for several months. It's absolutely crucial that you do your exercise; otherwise, the knee will become a big clump of scar tissue, and your result will be very poor. It is no pain, no gain. The first six to eight weeks are hard graft, and it's important now more than ever that the focus is on prehabilitation to get you in the best fit state possible before you have your knee replaced, and your recovery will be much swifter and more manageable.

The late risk is implant failure; it does wear out.

The knees start to play up a bit from about 15 years onwards, so it's important to keep an eye on patients at that point. You can have a late fracture, it can dislocate if you have a heavy fall.

And also, you can get an infection. The wound infection can be dealt with antibiotics, usually, but a deep infection is a different kettle of fish. There's about a 1% chance of that happening in a hospital like Benenden

Probably less than 1%. It's very rare do we have infections here, fortunately, but it needs to be picked up early and most of the time it can be salvaged with very strong antibiotics and having the knee washed out and the implants exchanged, the ones that can be exchanged, and that's usually the plastic lining

Your hospital stay: a couple of nights in hospital mostly these days, sometimes one night. You'll be able to walk on the same day as your operation as long as the spinal anaesthetic has worn off.

You'll be uncomfortable, and you'll have to do those exercises as mentioned. I don't think you'll be back to normality within 6 weeks, as it says on that slide. I think that's a bit over-realistic

I think it'll take more like 3 months, but certainly life gets back to relative normality by 3 months, and you should be driving your car by about 6 weeks.

I mentioned about the bruising and the importance of the exercises in the first 6 weeks. You'll also come up for follow-up with us, where we'll check the wound, your range of motion, and the x-ray. If you're not getting enough bend in your knee, we'll read you the right act, and sometimes you might need to have a manipulation under anaesthesia if the bend is very poor

These are my colleagues. We all perform high volumes of hip and knee replacements, they've all worked together for many years.

The patient support tools, private healthcare information network or fin that's been around for about five, six years now. It's getting quite a lot of data. Not many people in the public domain know about it, but search it.

You can look me up and my colleagues, you'll see where we work, what our volumes of work are like, and you can also see validated feedback. We have to get at least 30 feedback reports submitted before they were published the results, but they're on there.

National Joint Registry, the Surgeon's profile. Again, you can Google us and hunt us down on there, and you can see where we work, how much operating we do, and the only other use and info on there is the mortality rate

Is that useful? Because an elective procedure and the mortality rate is hopefully going to be zero.

Then you've got Doctify, the patient review platform.

Benenden has endorsed this quite a lot over the last few years, and has gathered a lot of reviews. We've all signed up to it. It's validated and it's a very useful tool.

We can see how well we're doing, and it's nice to get feedback, good and bad, so we can tweak and improve our practice. The other one is top doctors, which is again very well used by patients when they're searching their surgeon.

What you need to do though is really look for a high volume surgeon with good reviews.

It's because they're the ones that usually provide the best outcomes.

Some stats. Knee replacements are in the blue, 134,000 in 2024. I've mentioned the average eight ages already in the BMI and the unicompartmental knees, 15% of them.

And you can see that most of the decision to operate is due to osteoarthritis. 98% of all knee replacements are performed on osteoarthritic knees.

So here's the lowdown of all the prices, and I think there is a promotion running with this webinar

So we're moving on shortly to the question and answer session. Yeah, thank you. Thank you, Mr Oliver. Very informative, and I agree, it is vital for patients to do some research ahead of conversations. We're really pleased to have so many of you with us today, and while we may not be able to answer all of your questions, we'll do our best to cover as many as we can.

On this slide, you will find information on arranging treatment

There's our telephone number, and moving straight into questions, we have Prakash, who asks, can PRP, stem cell, or arthrosamid injections help?

Mr Matthew Oliver

Certainly can. Arthrosamid is a proven, treatment now for the arthritic knee.

I've mentioned about that already. Stem cells, I don't have too much experience with those, but PRP is when someone has a sample of their blood taken, and then the blood is centrifuged, spun in a special machine, and all the goodness in the blood is kept and then injected in the knee, and it's supposed to, stimulate and improve the lubrication of the joint. The one commercially available that I'm aware of is called N-Stride, made by Zimmer Biomet.

I've never used it, So I can't really comment any further than that on that one.

Cherona

Thank you. We have a question that is brought up from a conversation on BBC's This Morning, where, research into research in Germany, discovered injecting tiny particles into the knee appears to be successful with pain management. Does that lead int the question that you've just answered?

Mr Matthew Oliver

I am vaguely aware of that, but I don't know enough to be able to comment in detail. There are lots of novel, experimentative things being done at the moment in arthritic joints to see if we can stimulate new cartilage to grow and also to try and trick the knee into believing it's not arthritic. I'd have to go away and look into that for giving a more detailed answer.

Cherona

Thank you. From Karen, we have a question that asks, can you have arthrosamid injections in both knees at the same time?

Mr Matthew Oliver

You can do, yes.

Cherona

Lovely. Patricia asks or advises that she's been told she'll be having a nickel free knee replacement. Is the Vanguard the replacement that she will be having?

Mr Matthew Oliver

Yeah, so the Vanguard knee does come in a nickel free form. It's called the Niobium Vanguard-y. It's coated in this special metal alloy called niobium titanium. It looks very impressive. It's a gold implant gold in colour. Yeah, so a nickel-free option is available. It's expensive, but if you've got a significant nickel allergy, it's probably worthwhile the investment having it done, so you know that all bases are covered.

There was one question up there about Arthrosamid technique. I think that's important to mention. Are there cases where Arthrosamid technique is unsuitable? So there are some patients that you can't use Arthrosamid for, and those are patients who have inflammatory arthritis.

That's rheumatoid arthritis mainly. It's only licensed for osteoarthritis of the knee and just the knee joint, and that can be assessed during a patient's consultation. Absolutely.

Cherona

So, Steven posted a question earlier and has posted another one now. He wants to know if you need both knees replaced, do you need to have them done one at a time

Or both at once?

Mr Matthew Oliver

They both can be done at once. It's a big hit for the human body, and a few patients have had bilateral knee replacements performed here at Benenden over the years, but you'd have to be medically A1 for that, and they usually

But it would mean that you would be laid up on your back for four hours or so afterwards. You would be numb from the waist down for hours afterwards, and normally it's done as a day case, and you'd hopefully be on your way home within a couple of hours of having the procedure, whereas with spinal, that wouldn't be the case.

And it can be done under local anaesthetic. A few colleagues of mine over the years have done this. However, it is quite you have to have the injections significantly in advance, local has to be infiltrated in the knee

So it just slows the list up. And there are not that many advantages.

Cherona

Okay, thank you. Keith asks, his question is, if he has had a steroid injection, how long would he have to wait to have an Arthrosamid injection?

Mr Matthew Oliver

That's about four months, yeah. If the steroid hasn't worked, best to wait for four months, and then you can have Arthrosamid. They don't like it, the Arthrosamid team, if you administer it too quickly after a steroid, because they're worried about a flare-up of infection and so on and so forth. It's only theoretical. It probably won't happen, but it's just a safety measure.

Cherona

Right, thank you. Would you use Arthrosamid in medial knee osteoarthritis?

Mr Matthew Oliver

Yeah, sure, yeah.

Cherona

Lovely, thank you. Do you test for allergy to the replacement knee components? Would we test for that?

Mr Matthew Oliver

Not usually, but we do have allergy testing on site with the dermatologists here. They can test you for nickel

And over the years, I've had one patient who was allergic to plastic, and I had to get the polyethylene or plastic liner from the company, and she was giving them to take to her leg and to put in her mouth and to hold, and she didn't react to it at all okay. But they'd never heard of that in all of the years that they've been making knee replacements, so that was quite an interesting case

She is definitely allergic to plastic, though, because a plastic glass bottle would make her lips all blister. Goodness. But not the polyethylene that was used to make the liner, fortunately.

Cherona

Lovely, okay. Anna asks about collagen injection and supplements. Would that have any benefit on in knee pain?

Mr Matthew Oliver

There's no strong scientific evidence about collagen supplements and joint pain. However, anecdotally, it does seem to help, but there's no real science behind it, whether it's placebo effect or not, it's difficult to tell. I don't think it will do you any harm.

Cherona

Prakash asks, how many Arthrosamid injections can you have or time between the first one being taken? So how many can you have and then how long would you need to have between procedures?

Mr Matthew Oliver

There have been a few cases of top-up injections that I've been made aware of with colleagues here, because we've been doing it for a couple of years now.

But usually I don't think it should be necessary. If you haven't responded, there's no point having another one. And if you have responded, hopefully it will last for quite a while. However, the company says there's no harm in having a top-up if you want to have one

Certainly no point having it if you haven't responded, though.

Cherona

A very interesting question at the top is, can you kneel after a total knee replacement?

Mr Matthew Oliver

You can kneel, and it's not very comfortable, you should only kneel if absolutely necessary and pad the floor out

It's because you're putting all your weight through your kneecap onto your metal femur, so yeah, it'd be quite uncomfortable.

Cherona

It's not going to be very comfortable, is it?

Christine has severe osteoarthritis in her shoulder. Would Arthrosamid be a benefit? Probably not, no. And I think what she means probably is Arthrosamid rather than arthroscopic, but it's not licensed for any other joint at the moment other than the knee joint.

Arthroscopy in severe arthritis won't help you.

Cherona

Thank you. Do you know about Amisha operation? This patient or attendee, Lynn understands that it puts a pad between the bones of the knee joint.

Mr Matthew Oliver

I have never heard of it, actually, no.

Cherona

Thank you. Lynne, thank you.

This person has been given exercises to do. Will doing these stop that person from needing injections or replacement surgery? And is it okay to return to running or jogging a 5K distance circa 3 times a week?

Mr Matthew Oliver

Depends on the degree of wear and tear you have in your knees

But yeah, doing the exercises is a great way of keeping the muscles strong and the joints lubricated and with the appropriate nutrition. And it might indeed hold off the need for injections or replacement surgery

With regard to running, if your knees are quite arthritic and you've always ran 5K three times a week and your knees can handle it, then fair enough

Repetitive road running is probably not the best thing to do.

Cherona

Yeah. It's quite jarring, isn't it? Another question from Stephen Whiteley, who asked earlier about the functionality of full versus partial knee replacement and the ability to resume sport. Are you able to comment on that at all?

Mr Matthew Oliver

Yeah, for sure.

Partial knee replacement is a bit of a more of a natural feeling knee and people do get back to most sports, including skiing, running

Racket sports, cycling, golf, and so on. That said, so do people with full knee replacements, but with full knee replacements, it is a little bit more restricted with regard to the functionality.

It's harder to kneel down and to squat, and also can only get back to doubles tennis or doubles badminton. There's people that can ski with knee replacements and cycle. Thank you. So that answers Steven's initial question quite clearly, because he wanted to know about getting back to racquet sport and skiing

Cherona

And then our final question for the moment is from Graham, who would like to know whether you are awake during the operation?

Mr Matthew Oliver

You can be. You can be completely awake, chatting away to the anaesthetist, or you can

half-awake, or you can be completely asleep. It's under sedation, and it's turned up or down as per the patient's preference.

Cherona

Okay. Yeah.

Lovely. Thank you, Mr Oliver. Thank you, and thank you all for your questions and for being a part of this evening's session. If we have not covered your question and you have provided your name, we'll follow up with you via email.

Can we move to the final slide?

Thank you. As a thank you for attending this evening's session with us, we're pleased to offer

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If you'd like to speak to someone to book a consultation, our private patient team is on hand and available until 8pm this evening, and from 8am until 6pm Monday to Friday, you'll find the contact number for our team on your screen.

We also have upcoming webinars on a range of topics, including Arthrosamid

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Finally, a thank you from all of us here at Benenden Hospital for joining us. We hope to hear from you soon. Take care.

Mr Matthew Oliver

Thank you very much.

Damien

Okay, fantastic. Okay, so once again, thank you, and good evening, and a very warm welcome to you for our webinar tonight on hip replacement surgery. So, my name's Damien, and I'm your host for this session, and I'm delighted to be joined by our expert speaker, Mr Matthew Oliver, who's a consultant trauma and orthopaedic surgeon.

Now, tonight's session will be a presentation from Mr Oliver, followed by a live Q&A. If you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screens.

So you're welcome to ask anonymously or include your name. Just a quick note that the session is being recorded, so any names shared will be visible during the recording. To help us to get through as many questions as possible, please keep questions as brief as you can. If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

And I shall hand you over to Mr Oliver. Thank you.

Mr Matthew Oliver

Thank you, Damien. Good evening, everyone, and thank you very much for the opportunity to come and talk to you tonight. I'm grateful to Oli and Damien for the invite. It's nice to be back in the hot seat. So I'm here tonight to talk to you all about osteoarthritis of the hip, what it is, and how it's managed.

Just going to change the slide. There we go.

So, a little bit about me. As Damien said, I'm an orthopaedic surgeon. I qualified from St George's in Tooting in 1998, and I did my higher surgical training in the southeast Thames region, rotating through hospitals in Kent and Sussex.

I also spent a period of about 18 months in academic medicine studying the human knee joint, both with basic sciences and in a bioengineering lab at the University of Southampton.

Following that, I was fortunate to be lucky to be appointed to a senior joint reconstruction fellowship at the University of Calgary in Canada. I spent a year there working for six eminent hip and knee surgeons.

I learnt a considerable amount about hip and knee surgery but also what it was like to work in a different healthcare system from the NHS.

It was invaluable, and a lot of the stuff that I learned from that, both surgically and from the management perspective, I've used in my own practice to this present day.

I returned from Canada in 2010 and started as a consultant hip and knee surgeon at the William Harvey in Ashford, working for East Kent Hospitals' NHS Trust.

My practice has narrowed down in the last five or six years. When I was first appointed, I was really carrying out a lot of general orthopaedic operations, hand surgery, foot and ankle surgery, and hip and knee surgery, but as time has gone on, I've followed my passion for hip and knee surgery, and that's my prime elective activity these days.

general orthopaedic operations, hand surgery, foot and ankle surgery, and hip and knee surgery, but as time has gone on, I've followed my passion for hip and knee surgery, and that's my prime elective activity these days.

So I would consider myself a high-volume hip and knee surgeon. I do about three times the national average of hip and three times the national average of knee replacements compared to my peers in the UK.

Compared to my peers in the UK.

So, included in this session is what happens when you come to Benenden with pain around the hip region. I'll talk to you about the assessment, the investigations that are required, and the management plan.

I'll talk to you also about what osteoarthritis of the hips is all about, what causes it, and how it presents. We'll talk about treatment options, the risks of surgery, what your hospital stay will be like, and what to expect during the recovery period.

Finishing off, I'll spend some time talking about the various patient decision support tools that are available if you're undecided or need a little bit of help in deciding what to do. And then we'll finish off with a question-and-answer session.

So the consultation starts with a 20-minute slot with a person like myself. There are four colleagues of mine that do hip replacements here at Benenden, so five of us in total. We're all colleagues in the NHS who are all high-volume surgeons.

It'll start off with a medical history and a full examination.

The examination requires you to walk and to lie on a couch and have the hip joint and the knee joint examined, as well as the neurological status of the lower limbs.

Sometimes x-rays are required. If we're fortunate, then they'll be available for us via the GP, and they'll have been image-linked to the hospital, but sometimes we need to send you off for an x-ray of your pelvis and then catch up with you later in the morning to complete the consultation.

Occasionally, further, more detailed scans are required, like MRI scans. That's when the diagnosis is not clear-cut, as there are many causes of pain around the hip joint. It's not just an arthritic hip, and I'll allude to that in a bit more detail later.

Whilst we're getting to know you, we're developing the doctor-patient relationship, and in my practice, that's absolutely key, because it's a big deal that you feel that you're in safe hands and that you gain trust that, you know, we're going to do a major operation on you, potentially.

I don't like the idea of it being like a conveyor belt where you're seen, operated on, and discharged. It's important that there is a good rapport, and that's carried forward throughout the patient journey until we can conclude things with a successful outcome.

It being like a conveyor belt where you're seen, operated on, and discharged. It's important that there is a good rapport, and that's carried forward throughout the patient journey until we can conclude things with a successful outcome.

Again, while getting to know you, we're assessing your fitness for anaesthetic. That's key, here, because Benenden doesn't have that much medical backup. We're a private hospital in the Kent countryside. We do, however, have excellent resident medical officers who work on the wards.

that much medical backup. We're a private hospital in the Kent countryside. We do, however, have excellent resident medical officers who work on the wards.

And there is an on-call service that the anaesthetists staff for any medical concerns, but if it can't be controlled in-house, then patients very occasionally need to be transferred out to the local NHS hospital about half an hour up the road. That's very rare.

And to ensure that becomes very infrequent, the anaesthetists are very keen to ensure that anaesthetic fitness for surgery is primed.

very infrequent. The anaesthetists are very keen to ensure that anaesthetic fitness for surgery is primed.

So, what is osteoarthritis of the hip?

Essentially, it is thought of as a wear and tear phenomenon, where the joint gradually degrades over time, but it's actually a little bit more complicated than that.

It's fascinating to see when you operate on a patient's hip that's had a fracture, and they're in their 90s, and you have to replace it because it won't heal. It's broken, and when you remove the femoral head, you look at it, and it's absolutely pristine.

And you wonder why there's no sign whatsoever of any wear and tear, and the main reason for that is that they were fortunate enough to have been born with a very spherical femoral head. It's a perfect ball, and it fits in an almost perfect socket.

And they've looked after themselves, they've kept themselves active, and they've been fortunate to avoid significant injuries over the years.

And then, conversely, you can have a patient who's half that age, who's really struggling with a lot of pain.

Due to the wear and tear phenomenon, the hip is just worn out. And that's because there is still quite well, there is a significant genetic link with osteoarthritis of the hip.

And that predisposes people to early wear and tear. And that's because the hip joint isn't perfectly formed. And when it's not perfectly formed, it's labelled dysplastic. And there are various degrees of dysplasia. It can be very mild, and those hips don't normally, sort of.

cause a problem until a patient's in their 60s and 70s. Or it can be very dysplastic. Indeed, the patient could have been born with a dislocated hip that has had to be popped back into the socket, and as a consequence, the hip joint has never quite formed properly, and the femoral head has remained uncovered by the socket, and therefore increased wear has happened at a much more advanced rate. But on the whole, it is wear and tear.

popped back into the socket, and as a consequence, the hip joint has never quite formed properly, and the femoral head has remained uncovered by the socket, and therefore.

It presents with a gradual onset of pain anywhere in the hip region. It can be on the side, at the front, or in the buttock, and sometimes pain can be referred down to the knee.

That's because the hip and the knee share the same nerve pathways. And occasionally, we do see patients who have been referred in for knee pain, but the knee is actually fine. It's the hip that's really stiff and uncomfortable when it's examined.

As time progresses, stiffness really kicks in, and they have difficulty putting on shoes and socks, cutting their toenails, getting in and out of the car, and sitting in low-slung seats.

Sleep is disturbed every time one rolls over in bed, as the hip is stiff, and if you've been lying in any particular position for any longer than 15 or 20 minutes, it seizes up, and thus, when you roll over, it wakes you up.

If you leave things until it's a very late stage, then you may notice that your leg starts to shorten.

And a grating or grinding sound comes from the joint when you sit down in a chair or get up from a chair or, indeed, just walk around. That's because the hip is misshapen.

And there's no real lubrication or any cartilage left between the acetabulum and the femoral head.

So, I've talked about age-related wear and tear; we've talked about dysplasia where it hasn't formed quite right.

Other causes or risk factors include obesity, not so much when compared to knee osteoarthritis, where obesity is very strongly linked with developing arthritis of the knee. But it just makes sense that if you are significantly overweight, you're going to be putting more load through your hip joints.

Putting more stress on the muscles and tendons and ligaments that support the pelvis and the hip joint and, therefore, speed up the wear and tear process.

Joint injury. We talked earlier about fractures to the hip.

Sometimes these are able to be repaired with pins and plates, but the hip joint may still suffer because the blood supply to the femoral head may not fully recover, and the hip becomes necrotic and misshapen, and rapid arthritis kicks in. Other joint injury really refers to damage to the lining of the hip socket, which is known as the 'labrum'. This is a cartilaginous rubber-type ring that deepens the acetabular socket to prevent the femoral head from jumping out. But in some cases, the labrum can be damaged and torn.

With the invention of keyhole surgery to the hip, otherwise known as hip arthroscopy, some of the labral tears can now be repaired or trimmed away, which helps matters.

And the final common cause of hip arthritis is something called femoroacetabular impingement, which has gained a lot of momentum in recent years.

This is when you develop a cam or a pincer-type lesion on the hip joint. A cam is a little bump that forms on the femoral head-neck junction.

And when you move your hip in certain positions, it bumps into the socket and damages that labarum. If it's detected early enough before arthritis takes hold, this CAM lesion can be shaved away arthroscopically.

The pincer lesion is when you grow a beak of bone from the top of the acetabulum, and again, when you move your hip, the pincer, or beak, digs into the femoral neck, causing pain. And again, through keyhole surgery, this can be trimmed off, and both of those procedures may slow down the development of osteoarthritis, but it's not guaranteed.

So here are a couple of pictures of what a healthy hip looks like and what an arthritic hip looks like.

What this doesn't really show is that you can also develop extra bone when the hip becomes arthritic. This extra bone, known as an osteophyte, develops to try and stiffen up the joint and fuse it, because that's the body's natural way of

Controlling pain, stopping it from moving.

It does show, though, that the cartilage is breaking down and fragmenting, and you can also see that the edge of the acetabulum is frayed and damaged, probably trying to portray the damage to the labrum that I described earlier.

So, the treatment options…

They start off with non-surgical and surgical, but before we really talk about these, I think we need to spend a bit of time talking about other causes of hip pain, because it's important to know that

You know, you may not have an arthritic hip, and the anxiety that you have is building up inside you before coming to the appointment, thinking you might need a hip replacement.

may not be necessary. So, the common things that present that aren't an arthritic hip are the conditions known as 'trochanteric bursitis' and 'gluteus medius tendinopathy'.

Together, they're known as Greater Trochanteric Pain Syndrome. They present very similarly to an arthritic hip. It usually causes pain along the side of the hip and a bit of an ache in the groin, but the actual hip joint still remains pristine.

It can be detected on an MRI scan, and it's absolutely the wrong thing to do to go ahead and give someone a hip replacement with this condition.

This is a difficult condition to manage, though. It takes a lot of perseverance and physiotherapy and activity modification to come to terms with it and to live with it.

Other conditions that mimic osteoarthritis of the hip are lumbar spine issues. If you have a lot of facet joint arthropathy, which is arthritis of the lower parts of the spine, this can cause buttock pain that radiates into the hip.

And again, the surgeon will be keeping an eye out for that when you have your assessment.

The rare causes of a degenerate hip have been talked about already. Avascular necrosis, when the blood supply to the femoral head is damaged. And also, there are some childhood conditions, such as Perthes' disease, which is a form of avascular necrosis where the child's femoral head never forms properly, and therefore it's a square peg in a round hole and causes problems in mid- to late adulthood.

So, let's say you do have an arthritic hip. What are the ways of managing it?

Well, first off is simple pain management with standard painkillers like paracetamol and non-steroidal anti-inflammatories, like ibuprofen and Nurofen.

You can get some stronger stuff from the GP, known as co-codamol, which is a codeine-paracetamol mix.

and also naproxen, which is a stronger NSAID that you can take twice a day. It's important to have omeprazole cover with this tablet if you get any acid reflux or any issues of indigestion.

Some patients aren't able to take stronger analgesics due to interactions with their other medications.

Lifestyle modifications. That simply means, you know, cutting back on the activities that cause you discomfort, which is sad in a way, because it means that your ability to socialise and participate in hobbies like dancing or playing racquet sports diminishes. Other modifications would be to try and lose weight.

Sensibly, with, like, load-bearing exercise and a good look at your diet.

I don't really place much emphasis on special footwear or insoles for my patients, but certainly having a walking aid, like a stick or a walking pole, can definitely help as an interim step, as it offloads the joint reaction force that would go through the pained hip through the wooden stick or pole. And you'll find that you'll be able to walk longer and more comfortably if you use the stick.

It's important to keep the hip flexible, so physiotherapy is a useful adjunct.

As are the other exercise modalities, like Pilates and yoga. And contrary to popular belief, it is important to stay active with your hips sore. Don't just sit in a chair; that's the worst thing you could do. You've got to take regular sensible exercise, because as the hip joint is used, it lubricates itself a little bit better, which will ease the discomfort and also ensure that the muscles around the hip joint are preserved, which is crucial for a good result after you've had your hip replaced.

So please keep active.

Steroid injections. I'm not a big fan of these as a treatment option. I sometimes use them if I'm not certain whether it's the back or the hip that's causing a problem. So, in my practice, I use them as a diagnostic tool, and any therapeutic benefits are a bonus.

I prefer not to use them. I like to leave the surgical field untouched. I don't want any foreign objects injected in there before having a hip replacement. There's a small risk of an infection from having a steroid injection, and one must wait about 4 to 6 months.

after having had that injection before proceeding to a hip replacement.

Moving on to the surgical management now, and I guess this is the time where we need to talk about the timing of having it done.

It's very important to consider this. Some people just leave their hips far too long. They're too stoical, too stubborn.

They put it off, they put it off; they think it's going to get better. It won't, and if you nip it in the bud when you're starting to realise it's curtailing your quality of life, your outcome following a hip replacement would be much greater, much more beneficial. You'll recover quicker, the muscles around the hip won't be so wasted and degenerate, and you'll have a much better functional outcome.

I sometimes use this in my practice. It's a 48-point score, asking 12 simple questions to the patient about how their hip affects them in everyday life.

And the optimum time to really think about having a hip replacement is when you score between 24 and 28 out of 48.

If you're still scoring in the 30s, then it's not right to proceed. If you're scoring 10 to 15, then really, you're in a really quite considerably bad way. And

So, talking about the surgical options now…

hip replacement, hip resurfacing, and hip fusion. So, hip fusion is a historical operation these days, very rarely done. I haven't performed one in my career. I converted a hip fusion into a hip replacement for someone many years ago. We don't really see many of those anymore.

Hip resurfacing was a pretty good operation and very successful up until about 2009 or 2010, when there was a big fallout in the hip world. It was due to metal-on-metal debris from the metal-on-metal articulation, shedding ions into the bloodstream and into the surgical field around the muscles.

And the metal debris, cobalt and chromium mainly caused a lot of damage to the muscles and pseudo tumours and so on.

So they considerably fell out of favour, especially using them in women, because the studies showed that the smaller implants were more at risk of developing the metal ion issue.

There's been a little bit of a resurgence in hip resurfacing in the last few years because they've moved away from metal-on-metal articulation to trying out ceramic-on-ceramic articulation.

And a few specialist centres in the UK are performing small numbers of ceramic-on-ceramic hip resurfacings, so we have to watch this space and see how this develops with time.

That's not to say that if you have had a hip resurfacing, you may have had an exceptional result. I saw a chap in the clinic today who'd had both of his hips resurfaced, one 27 years ago.

And the other one 13 years ago by the man that invented them, Derek McMinn, up in Birmingham. And he's forgotten he's had his hips resurfaced, so there are some outstanding results.

Possible with hip resurfacing, but you have to choose your patient wisely.

So, hip replacement.

This is the conventional gold standard, really, for osteoarthritis of the hip. It's been around since the 1950s, and in the previous millennium, it was voted the operation of the century, and it consistently ranks highly in the quality-adjusted years back to a patient. This is like a league table.

It's number three in this league table with…

cardiac surgery and cataract surgery, the only two procedures above it. The knee replacements come in number four.

So, it's a very reliable operation to give back a good quality of life to the patient, and you should be able to get back to most activities once you've recovered well from one.

So, this diagram here shows you what are the components of a hip replacement.

Several components. You have a shell which is press-fit into the acetabulum, or the socket of your pelvis.

You can see three screws here. They're not really used that often, but you can insert some screws through the shell into the bone of the pelvis to augment the fixation, but usually a good solid press-fit is achieved without using screws.

Your own bone then grows into the cup over a 3-month period, and you become one with it.

Inside the cup, a liner is fitted, and this can be made of plastic, or polyethylene, or ceramic. The one in the diagram here is a pink ceramic liner.

And then you have the femoral head.

Again, it can be made out of ceramic, like this one; it's nice and pink.

Or it can be made out of metal.

And then the head is fitted on a trunnion, or post, which is part of the femoral stem, and the femoral stem is press-fit into the top of the thighbone, or femur.

And… yeah, that's all I probably need to say about it here.

And the aim of the op is to relieve pain, get rid of the stiffness, and improve your quality of life to get you back to the hobbies that you enjoy.

So, a little bit about the choice of materials.

So you have ceramic on ceramic lining, which you can see circled here in the top left of the picture.

And that's not so commonly used these days.

It does have the best wearing couple; it takes the longest to wear out, but there are a few caveats with it. There's a slightly increased risk of a fracture of the ceramic because it's a brittle material and it's a hard material. It is only a very slight risk of…

fracture, but it exists. And also, on some occasions, you can have a squeaky hip.

Where the femoral head and the socket, or the liner, aren't quite lined up properly, and you get a bit of edge loading, and it plays a musical note every time you move or sit down or something like that, which can be very disconcerting.

So the most common wearing or bearing couple now is ceramic on plastic.

So, yeah, a ceramic femoral head on plastic, and that has a very good wear rate, only slightly less than ceramic on ceramic, but you don't have the worry of a hard-on-hard bearing. And the data coming out of the National Joint Registry is very compelling for this to be

the best compromise.

The other wear couple, or bearing surface, is a metal head on a plastic liner.

Again, it wears slightly quicker than the other two that I've mentioned, but only very marginally quicker.

And really, it's a health economy issue, whether you get a ceramic femoral head or a metal head. The ceramic heads are about 3 times more expensive than the metal head, so the metal head is usually reserved for very elderly patients.

Talking about the femoral stem, you can have an uncemented stem, which is press-fit into the femoral canal.

And that's useful, especially if you have really good granite-like bone. If you have any osteoporosis or soft bones, which most ladies do after the age of 65, it's best to have a cemented femoral stem, and that… you can see that one on the right-hand side.

That's either a highly polished stem or a

Yeah, usually a highly polished stem, and it uses a cement stem centraliser you can see at the bottom of the picture, and a cement plug is also fitted in the canal of the bone.

Bone cement has antibiotics in it, and it acts as a grout and secures the stem with an instant fix once it's set.

So, the ideal hip replacement would be a hybrid hip in my practice, where you have a cemented femoral stem and an uncemented socket with a ceramic-on-plastic bearing surface.

I reserve the uncemented hips for the younger generation that have the right.

Femoral morphology and femoral bone stock for that to be a success.

So what are the risks of joint replacement surgery? They can be split into three sections, really. So, during the op, there's a risk of injury to the bone or fracture. There's a small risk of nerve injury, including a foot drop. You can bleed and may need a blood transfusion, but they're very, very uncommon.

Especially with the latest, sort of, enhanced recovery anaesthetic techniques.

Which encompasses a spinal anaesthetic with sedation, so you're numb from the waist down. That lowers your blood pressure so you don't bleed so much. It also reduces the risk of having a blood clot in the leg or lung afterwards, so that would be the way to go.

During the recovery period, you can have wound healing issues. There are two types, really. You can have a superficial wound infection or a deep infection. A superficial one usually can be eradicated with a course of oral antibiotics and careful wound surveillance.

The deep infection is a bit more of a problem, and there's about a 1% or less chance of that happening. It's important that we keep an eye out for that, and that normally presents with a wound that doesn't quite heal. It will keep draining serious fluid, or even pus.

and a sinus might develop. The area of concern around the wound may be slightly erythematous or reddened and feel warm to the touch.

Then the patient themselves may feel under the weather with a fever. It is absolutely essential that you get in touch if you have any of these issues, because we need to tackle this early. If we can get to it early, within 3 to 4 weeks, we can sometimes, or most of the time, salvage the hip replacement with a good debridement and washout of the surgical site and an exchange of any of the components that can be removed and replaced.

You'd also need to go on antibiotics for a considerable length of time.

And there's about a 70% chance of salvaging the situation. If the infection were to unfortunately return.

Then, it would mean that you'd have to have a two-stage hip revision, which is a big deal.

So we go and do everything we can to try and avoid that, and that's down to us and down to you as a patient because you have to prehabilitate yourself.

You need to make sure that your skin on your legs is in good condition, you haven't got any infected toenails, your dentition is in good shape, you have no waterworks infections, and you have no chest infections.

You'll need to cut down on smoking, eat a healthy diet, and do some exercise beforehand to really get in the best shape you can before you have your operation.

Blood clots I've talked about already, but you will be placed on blood thinners for a month to reduce that risk, so…

You're very unlucky if you get one.

limp; you will have a limp post-operatively, and how long you have the limp post-operatively would depend on a few factors. Firstly, how bad the osteoarthritis was before the hip replacement. If you've been limping for 3 years, and the hips have crumbled away, and you've had a shortened leg, then it will be difficult to completely eradicate that limp. You'd have to retrain the gait psychologically as well as physiologically with intensive physio and perseverance, but it can be done.

Stiffness and swelling are not usually a problem. Stiffness is a ball-and-socket joint, and most people get an excellent range of motion back, and that's one of the big bonuses of having a hip replacement.

Swelling, yep. The leg will go all black and blue and bruised, and sometimes the bruising can go all the way up.

the back, you know, past your buttock into the lower part of your back and down to your little toe, and it's made worse by the blood thinners, making the bruising go all the colours of the rainbow.

Late complications. Well, eventually, the implant will fail.

But modern technology means that we can reliably say, everything being equal, a hip replacement will last at least 15 to 20 years.

There are a few things that bring it to an early end, such as having a fall, breaking the bone around the implant, getting an infection, or having a heavy fall where the ball dislocates out of the socket.

If that happens, we try to salvage it by popping the joint back together, usually requiring at least sedation, or sometimes an anaesthetic.

If it keeps dislocating, then the remedial surgery will be required.

So your hospital stay, Benenden, is ideally suited for hip and knee replacements.

You have your own private room with an ensuite, Wi-Fi, and a good selection of TV channels. You have your own dedicated nurse.

And you're usually in hospital for 1-2 nights.

You'll have physiotherapy every day that you're with us, and you'll go through a whole series of exercises to get you safe on your feet, progressing from a frame to crutches, and even being able to use the stairs.

We try our best to get you motivated to mobilise the day of the operation once the spinal anaesthetic has worn off.

But if you're last on the list at the end of the day, you might not get your first walk until the following morning.

The nurses, however, are skilled enough and trained enough to get you out of bed in the night to try to mobilise with a frame if you want to use the loo.

You'll have discomfort initially; that's to be expected, but with modern anaesthetic techniques and analgesic protocols.

Your pain will be well managed.

Back to normality within 6 weeks is a bit of a tall order, but certainly, you'll be way well on the way to recovery by 6 weeks.

So, the recovery is broken down into phases. For the first couple of weeks, you'll be relying on your painkillers, and you'll see the bruising I mentioned earlier. It will gradually recede.

It's important that you have and you stick to your physiotherapy exercises, and if possible, try and engage face-to-face with a physio from 10 to 14 days post-op, because they'll put the icing on the cake and make sure that you accelerate with your recovery.

You have to sleep on your back for 6 weeks and refrain from driving until that time frame has passed, but at 6 weeks, you'll be able to drive again, and you'll have a follow-up appointment with us to make sure that you're hitting your milestones. If we have any concerns, we will say so and hopefully put you back on track.

By about 3 to 6 months, you will certainly start to feel the benefits of the surgery and become much more active. If you're a golfer, you should be back at the driving range by about 8 to 10 weeks and back round the course by about 3 months, building up your holes gradually.

The same for racquet sports, doubles, tennis, and badminton. Should be able to return to that within about 3 months.

Other more athletic pursuits, like skiing, you can do, but at your own risk. You certainly would be able to enjoy cycling and going for walks, and some people would even get back to jogging and running.

So here are my colleagues and I; all five of us have been working here for several years now. We've all been colleagues at some point in the NHS.

And we're a good team.

So, patient support tools – there are three main ones. There's a fourth called Top Doctors, which is not mentioned on here, but Benenden have a very good relationship with Doctify, which is a review site, an online platform that enables patients to leave comments and ratings on the hospital itself and individual people that work here.

They're validated, anonymous, and

And I've certainly been uploading my Doctify data into my annual appraisal for my NHS bosses.

And for the medical and hospital directors in the private hospitals I work at.

So you can look me up on Doctify; there's my profile on the left-hand side of the screen, a snapshot of it.

The other one is the National Joint Registry. This one's been going for many years, and the data keeps growing.

The surgeon's profile and the hospital's profile are in the public domain. Doesn't give you that much info; it'll just tell you how many operations I do a year. It's usually about 18 months out of date, and it's a bit disappointing it's not more regularly updated.

But it will give you a breakdown of my practice at 12 months and 36 months of activity. It will also show you the mortality rate, which fortunately is zero.

The hospital profile is also on there, and you can look up how busy Benenden is, with the number of hip and knee replacements it performs.

And the top one is the Private Healthcare Information Network, or PHIN. This has been around, I think, about 5 or 6 years now, and again, the data is growing, and it's sort of metamorphosing into quite a useful bit of kit.

From a patient's perspective, once an orthopaedic surgeon has hit 30 reviews or more, the feedback is then shared in the public domain and with the surgeon, so it will give you an idea of how busy your surgeon is and the volume of work that he or she gets through, and it will show you where they work and give you an idea, also, of the financial side of things, such as the surgical fees, etc.

So the National Joint Registry data is up here, and it just shows how, how, you know, what a big impact hip and knee replacements are having on the UK. In 2024, for example, nearly 117,000 hip replacements were performed throughout the hospitals in the UK.

And the overarching diagnosis is osteoarthritis at the hip 92% of the time.

Four percent is due to hip fractures.

And the average age is broken down there. It's around the late 60s, and women are more likely to have a hip replacement than men. The average BMI is stated there.

And then, the same on the right hand or the left-hand side is the data for the knees.

A few more knees are performed each year than hips, and again, women are more affected than men, and you can see the average BMI has crept up a little bit compared to hips. There's no doubt that the BMI is definitely linked to knee arthritis a lot more strongly than hip arthritis.

So, I think we've come to the end of everything I'd like to say, and we'll move on to the question and answer session.

Damien

Yeah, great, thank you, Mr Oliver, that was fantastic. Yeah, so if you've got any questions, please feel free to pop those into the Q&A box,

I think we've got just the one for the time being.

So we've got, actually, Sarah, Sarah's question here, and actually this related back to when you mentioned some issues that might

be misdiagnosed by the patients as having hip arthritis, and she was asking whether, I guess, a way of diagnosing those, whether those, can be detected on an x-ray or does it have to be an MRI?

Mr Matthew Oliver

Not, you know, the x-ray only really will show osteoarthritis at the hip. It will show hip dysplasia where the bone is misshapen, and it will also show advanced stages of avascular necrosis. It won't show what's going on with the muscles and the tendons and the bursae.

Or the bursae. So, things like greater trochanteric pain syndrome are only really diagnosed via an MRI scan, or…

Damien

Yeah, fantastic. So we've got John asking; you mentioned running after a hip replacement, and he wanted to ask what proportion of patients are actually able to do this.

Mr Matthew Oliver

Difficult to give you a percentage, but certainly people do get back to jogging, and

You know, we don't follow up with our patients long-term. However, when they potentially come back for round two of the other hip, they mentioned that they've been able to get back to running or jogging.

Certainly they've got back to racquet sports, playing tennis, and certainly there's a reasonable number that even take a risk on the ski slopes. Yeah, fantastic. John also asked whether his type 2 diabetes would have an impact on his surgery and his recovery. That's a useful question, because your type 2 diabetes is well controlled.

Certainly they've got back to racquet sports, playing tennis, and certainly there's a reasonable number that even take a risk on the ski slopes. Yeah, fantastic. John also asked whether his type two diabetes would have an impact on his surgery and his recovery. That's a useful question, because if your type two diabetes is well controlled.

Then it should have no impact on your surgery or your recovery. But if it's poorly controlled.

with the HbA1c, which is the blood test which informs one of how well you manage your diabetes over a long period, about 3 months. If that is raised.

Then it would mean that you would be at increased risk of getting an infection and wound healing problems. So, as part of the preoperative workup.

If a type two diabetic comes here, I would be asking for the HbA1c to be checked, and if it's above the threshold for safe surgery, then

Diabetic control would need to be optimised. But if you look after your diabetes and run good blood sugars and have a healthy diet, then it shouldn't really have any impact.

Damien

Great, thank you. Tim Jones has asked, 'Could you recommend any pre-operative exercises?'
Mr Matthew Oliver

Yeah, this is very trendy at the minute, and rightly so. It's known as prehabilitation.

And there's been lots of work out there in this field to really optimise the patient before the big day of having the operation. And, of course, it depends on what state the patient is in pre-operatively.

And we do see some patients that are wheelchair-bound and really just transfer from bed to chair to toilet, etc. And you can't really expect them to do too many exercises, but all of them should try to do at least some straight leg raises on the bed and some hip and knee flexion and extension exercises to try and improve the strength of the quadriceps and the hip flexors and the hamstrings.

If you're still ambulant and can walk reasonably well, then using an exercise bike and going swimming and doing core stability exercises through things like yoga and Pilates will definitely hold you in good stead prior to having a hip replacement.

Damien

Grand, grand. So we've got John again, and

Oh, excuse me. He's asking, are there any movements which the new hip will restrict? I know this might be quite difficult, such as lying on his side or any other position.
Mr Matthew Oliver

So you have to ideally lie on your back for the first 6 weeks, but once that has passed, you can lie on your side.

You can lie on your tummy; you can lie, you know, anywhere you like.

There are a few movements that you'll have to be cautious about, and those are deep hip flexion, so if you're sitting on a very low-slung sofa with your knees up by your chest.

That's not really ideal. And you know, high flexion manoeuvres at the hip, especially with internal rotation, are a little bit risky, certainly for the first 3 months.

But after that period, you should be able to, within reason, be able to move your hips anywhere you like. That is possible. Fantastic.

Damien

So, Sarah's actually on blood thinners, and this is a bit of a concern of hers: whether she could still have this done at a private hospital like ours.
Mr Matthew Oliver

That shouldn't be a problem, as long as the chronic medical condition that you have that requires you to be on blood thinners is well controlled.

All you would simply have to do is come off the blood thinners. If it's one of the DOACs or the modern tablets, like Apixaban or Rivaroxaban, you'd need to stop that for 48 hours before the op.

And then, commence it again. If you have a metallic heart valve, then you would have to have bridging anticoagulation so you'd come off the therapeutic anticoagulation that you would need so the surgery is safe.

Damien

Okay, yeah, nice one. So we've got another anonymous question here, and I think this is if you are an at-risk patient, perhaps, for surgery, can this be lowered by a spinal block?

Mr Matthew Oliver

Certainly, that's the preferred anaesthetic technique to numb you from the waist down, because you look after your own heart and lungs then.

However, there are a few medical conditions that will preclude you from having the surgery here. If you have severe sleep apnoea, or you have significant lung disease, like COPD, and you're on high-dose inhalers and steroids.

Then if a spinal anaesthetic is not possible, it would be very risky to go ahead in a unit like Benenden to give you a general anaesthetic, because we would have some issues trying to extubate you, or take the breathing tube out afterwards.

So, it would probably be best to have that operation done in the NHS hospital for all the backup. But spinal anaesthesia definitely is the way to go; it's the safest way.

Damien

Okay, great, so Tim's got two here. So it's actually asking, firstly, whether it's likely that the other hip is going to be needed to be done in the future and maybe even the knee.

And he's also asking whether his fungal nail infection could be a problem.

Mr Matthew Oliver

So, it's not an absolute dead cert that the other hip may need to be replaced. It may be that the hip that needed to be replaced was injured at some point in your life, you know, as an adolescent or a young man or woman.

And that was the nidus for the osteoarthritis to develop. It may mean that the uninjured hip is functioning very well. There will be clues on the X-ray whether the second hip will need to be done, and the biggest clue of all is the dysplasia I mentioned, where it's slightly misshapen and the femoral head is not covered completely by the socket, which we find on a quite regular basis in athletic males.

It shouldn't be a problem, but an untreated fungal nail infection would be a contraindication to proceeding, because a fungal hip infection is a nightmare. It's one of the hardest infections to eradicate.
Damien

Oh, wow, okay. So, Elizabeth is asking, does having polymyalgia rheumatica affect having a replacement. I'll let you pronounce that properly now.
Mr Matthew Oliver

Not really, no. If you're on a high dose of steroids for it, which usually happens when you're first diagnosed, it's best to wait until the prednisolone dose is tapered off.

affect having a replacement. I'll let you pronounce that properly now. Not really, no. If you're on a high dose of steroids for it, which usually happens when you're first diagnosed, it's best to wait until the prednisolone dose is tapered off.

If you're on 5, maybe up to 10 milligrams a day of prednisolone, then hip replacement surgery can probably proceed.

And so you wait until you taper it.

Damien

Okay, grand. We've got another one here. Do you use… well, so we know that we… yeah, so spinal anaesthetic, so we're talking about that spinal, block. If there is an existing spinal damage and sclerosis. What would you use a general anaesthetic in those?

Mr Matthew Oliver

That's down to the anaesthetist to decide. Some anaesthetists are more skilled than others with spinal anaesthesia, but the vast majority that work here at Bendon that I've been fortunate to work with.

Have been wizards, and have been able to provide a spinal anaesthetic with quite a lot of degeneration in the spine and with a scoliosis.

So, yeah, the anaesthetist will always recommend a spinal anaesthetic first, and try their best to provide that, and if they haven't been successful and you're anaesthetically fit enough, then the procedure can go ahead with a general anaesthetic.
Damien

Okay, great, thank you. So actually, this is quite an important one, actually, and thanks, Brian, for this. This is so he's actually booked in for a hip replacement on the 6th of July. But he has had a PRP injection, only just a few months ago. Will this be a problem?

Mr Matthew Oliver

That's an interesting question. Probably it will be okay by July, because that would have been probably four months since the injection and PRP doesn't really have any steroids in it. It's his, platelets that are used. It's his own blood, usually, that is centrifuged and spun and then injected back into the hip. Should be okay, yeah.

Damien

Nice.

So yeah, so Paul is actually asking, so again, back on the spinal block, can you actually request a general anaesthetic over a spinal block?

Mr Matthew Oliver

You can do, but I would recommend that you seriously consider the pros and cons of both, and

I would recommend that a spinal anaesthetic be the ideal way to go, because of a general anaesthetic.

Once you wake up, you feel the pain. You know, it's there straight away. Whereas with a spinal block.

The pain comes on very gradually, and it gives you a chance to get some proper painkillers on board to manage it and get the ice packs on the thigh.

You're talking about 4 to 6 hours of reasonable post-operative pain management, with it gradually coming on in that period, whereas with a general anaesthetic, as soon as you wake up, it will hurt.

Damien

Yeah, okay, yeah, understood. And Sheila's asking that; I guess she's been told that. She's told that she's stable but in a lot of pain and to just do physio. When do you know when you need to investigate further?

Mr Matthew Oliver

So, I would recommend potentially doing the Oxford Hip Score, recommend getting an up-to-date x-ray and coming to see one of us to have a clinical assessment, and then we'll be able to advise her accordingly.
Damien

Damien

Yeah, absolutely.

Tony asks, after the operation, will one need to use a raised toilet, and if so, for how long?

Mr Matthew Oliver

Usually for the first 6 weeks, the raised toilet seat, which will be provided for you as part of the kit, along with usually a grasper, so if you drop something on the floor, you don't have to…

To crouch over and pick it up with your hand, you can use the grasper.

Damien

Okay, great. Dominic, following a scan showing an displaced articular fracture on the right side, I have a scan showing periarticular sclerosis and subchondral cysts.

With chondral breakdown. The NHS has said that they would like to administer a steroid injection once the fracture has healed. I've struggled with mobility in the hip and my overall gain for a few years and done physio, osteopathy, Pilates, etc., etc., but with no success. And I'm keen to have a hip replacement, if possible.

Mr Matthew Oliver

Okay, so, yeah, we definitely have to wait for the acetabular fracture to heal.

And if it doesn't heal, that will make placing a standard acetabular component into the hip socket a little bit risky. It just depends on where the fracture is and its configuration or shape.

I certainly wouldn't recommend having a steroid injection into the hip until the fracture is healed, because that will probably slow fracture healing.

With regard to what you're doing, with physio, osteopathy, and Pilates, that's admirable, and I would carry on doing that; despite the fact you're not getting any better, it's at least keeping the muscles, ligaments and tendons strong and supple.

And with regard to having a hip replacement, as I say, we need to make sure the acetabular fracture is healed. So, in your case, it would be advisable to probably get a CT scan rather than an MRI scan, because that shows the bone.

better than an MRI scan. And again, come along and see one of us, and we can assess if hip replacement is possible here at Benenden.

Damien

Absolutely. I think this one might be the last one, so we've got Tony asking, and I'd probably need similar help with this one, Tony. Have you got any tips on how to ensure that you stay on your back at night?

Mr Matthew Oliver

Yeah, it is tricky, and if you wake up on your side, don't panic; just right yourself and go back onto your back.

Some people put pillows down either side of them or try and sleep in a maternity sort of V-shaped pillow that sort of holds them in place.

As long as you have a pillow between your knees when you go to bed, which you will carry over to your left or right side with you as you sleep, it shouldn't be too bad, but what we want to avoid is, one, you lying on a healing wound.

And two, that the legs don't cross over too much in the early stages to ensure that there isn't too much strain on the repair while you heal up, because there's a very small chance of dislocation, but it's only very small.

Damien

Okay, grand. Yeah, well, thank you, Mr Oliver.

Well, thanks again for all your questions and being part of this evening's session. We didn't get to answer all your questions, but if you have left your email and contact details, we can get back in touch. I perhaps recommend re-listening back to the webinar when that's sent back, because there are quite a few repeat questions that you might notice.

Right, so as a thank you for attending,

Cool, let me move that on to the next one, sorry.

And you've provided your name and email. We'll follow up with you as a thank you for attending, and you'll be able to take advantage of 50% off the value of your first consultation. A call back from your dedicated private patient advisor.

An email with a recording of the session, treatment information and loyalty reward points, and updates on future events and health news.

So we would really appreciate if you could take a moment to complete the short survey at the end of the session. It helps us to improve and tailor future events and webinars to your needs.

So if you'd like to speak to someone to book your consultation, our private patient team are available until 8.30 this evening and from eight till six, Monday to Friday. You'll find the contact number on your screen now.

We also have upcoming webinars on a range of topics, including knee pain, tummy tuck surgery, diabetes, and urology, so you can sign up to those on our website. So finally, thank you again from us here at Benenden Hospital and from Mr Oliver. Thank you.

Vicky

OK, good evening, everyone. Thanks for joining us. We'll just give it a couple of moments to allow everyone to join and get settled.

So once again, good evening and a very warm welcome to our webinar on shoulder pain treatment and surgery. My name is Vicky and I'm hosting tonight's session. I'm delighted to be joined by our expert speakers, Consultant Orthopaedic Surgeons Mr Nik Bakti and Mr Daniel Neen.

Tonight's session will begin with a presentation from Mr Neen, followed by a live Q&A session. If you have questions to ask at any point, please feel free to submit them using the Q&A icon on your screen. You're welcome to ask anonymously or include your name, but just a quick note that as the session is being recorded, any names that you share may be visible in the recording. And to help us get through as many questions as possible, we'd ask to please keep your questions brief.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session. I'll now hand over to Mr Neen. Thank you.

Mr Daniel Neen

Right. Good evening, everybody. Thank you very much for joining us. Hopefully, over the next half an hour or so, my colleague, Mr Bakti, and I will be able to answer any questions that you have and maybe clear some of the subject matter around this area of concern up.

A little bit about myself first. So, I graduated from medical school. I took a fairly routine route to becoming a consultant. I graduated in 1999 from UCL and gradually worked my way through training posts as a registrar. I was in the southeast of England, mostly, Kent, Surrey, Sussex, worked for a lot of the older consultants in the area, some of which are still around.

And then as we normally do, towards the end of our training, we go on a fellowship, and we can go either somewhere in the UK or abroad. And so, I hedged my bets and did both and trained in Exeter and then in New Zealand as well. And then finally ended up as a consultant being offered a job in Dartford and Sidcup, where I practise most of my NHS work now. The following year, I was invited to join Benenden Hospital and have been here ever since.

During my journey, I have been part of the management team, particularly for the NHS side of things, and I have the proud ownership of bringing a reverse shoulder to the area in Dartford, when it was first started. And now I'm just above average with the number of operations for shoulder replacements that I do in the country. And between myself and Mr Bakti, we're quite a high-volume centre at this point in time. So now I hand you over to Mr Bakti to introduce himself.

Mr Nik Bakti

Evening everyone. My name is Nik Bakti and I'm Mr Neen's colleague, both in the NHS and here in Benenden. I graduated from Guy's St. Thomas's and King's Medical School in London in 2008. I travelled most of the South.
I mean, during my training, so I started off my core surgical training in Oxford and then did my orthopaedic specialist training in Kent.

During that time, I completed my Master's in orthopaedics in the University of Sussex and finishing my registrar training, I went to do my fellowship in Perth in Western Australia, concentrating on shoulder replacement surgery. I got my consultant post in the NHS at Durham Valley Hospital where I joined
the ranks of Mr Neen, and we've been busying ourselves with shoulder replacements ever since. I picked up the post of the trauma lead for the Trust at Dove and Grisham in 2022, and I've been holding on to it since. And I've also been appointed a visiting senior lecturer at Canterbury Christchurch.
leading the year three medical students there, hoping to foster the new generation of orthopaedic surgeons in the future.

Now, in this session, over the next 30 minutes or so, we are hoping to introduce a few bits about the shoulder, the anatomy, and what can go wrong with it, and why you may be in pain, and what different treatments we can offer, not just surgery, but also physiotherapy and injections.
And hopefully at the end of it, we'll be able to answer most of the questions, both directly and indirectly.

So how common is shoulder pain? It's actually very common. It is thought to be about 14% of the complaints that patients may have at any one time. And it may sound like a small number, but up to 2% of patients who present to the GP annually comes presenting with shoulder pain.

And of this number, about 70% of them come from around the rotator cuff and in the subacromial region. And we'll explain to everyone what the subacromial region is in a second. Next slide, please.

So there are various reasons why shoulder pain may develop. It can be due to age, so it can be due to degeneration. It can be due to repetitive movement, and this can be due to occupation like a window cleaner or
builder, or due to sports, like overhead movement, throwing movement, such as for cricketers. But it can also be secondary to injuries. So, mountain biking injuries are quite common. Cricket injuries, as I mentioned, is quite common.

And there can be various possible diagnosis. There could be 10, 20 different diagnoses, but the most common that we encounter would be frozen shoulder, calcific tendonitis, fractures from falls, rotator cuff damage both from falls and degeneration and arthritis, and we'll try to cover some of this thing.

To those who are not aware, this is just a simplification of the shoulder joint itself. There are three main joints in there. The biggest of them would be where the ball and socket meet, and this is called the glenohumeral joint. The next most common joint is the acromioclavicular joint, and that's where the collarbone meets the shoulder blade itself. The next is not quite a joint, it's often referred to as space, and that's the space between the ball and the roof of the shoulder, and that's known as the subacromial space. And this area can be a source of pain in about 70% of cases because there can be quite a lot of inflammation here, both from the tendons and also a tissue called a bursa. Next slide, please.

So, the glenohumeral joint itself, or the main joint in the shoulder, is quite inherently unstable. The reason for this is because it needs to accommodate for quite a huge range of motion. So, it can't be restricted. The downside of this is that it is at risk of dislocations. As you can see from this diagram here, it's akin to a golf ball and a tee, which makes it very flexible, but like I say, very likely to dislocate if it is injured in a specific way. Next slide, please.

This slide just shows the various ligaments and tendons around the shoulder joint. The one that goes around the shoulder bone itself into joint, it's called the long hair of biceps tendon. And not only it's important in shoulder stability,
but if it's inflamed, it can cause quite a lot of pain. This slide here just shows the other ligaments around the shoulder that is very important in maintaining shoulder stability but also allowing it to move.

And I feel that the next slide would be the muscles around the shoulder, which again, not only moves the shoulder, but also maintains its stability. There are four main rotator cuff muscles and tendons around the shoulder. And the most important of which would be the supraspinatus tendon, which is at the top of the shoulder and its main function is to initiate shoulder abduction or lifting the elbow away from your body.

The other tendons, the subscapularis infraspinatus and teres minor, are also at risk of injury, but less common. Subscapularis tendon is at the front of the shoulder. Its function is to help you get your hand to your back - internal rotation. And the infraspinatus and teres minors are less commonly injured and less commonly repaired. So, the two most commonly injured tendons in the rotator cuff are the supraspinatus and the subscapularis tendon.
Next slide, please.

This is again a diagram to show all the muscles and tendons around the shoulder and how it helps move the shoulder but also stabilise the shoulder at the same time. So, it's important that when we do exercises, and we'll discuss this later, that both the front muscles and the back muscles are equally exercised and stretched and strengthened, to provide or produce a stabilised and well-balanced shoulder. I'll pass you on to Mr Neen for this bit.

Mr Daniel Neen

So just thinking about this, you've been diagnosed with this shoulder pain, what sort of treatment modalities can we use in order to help you? And you'll be pleased to know that it's not straight to surgery. We do have a few other things up our sleeves that we can try and utilise.

And the other good news is that, by and large, 90% of these conditions will be helped without surgery and they will just get better on their own. So, in general, physiotherapy is a core treatment that we use. As Mr Bakti was talking about, the shoulder is a very highly balanced joint, very easy to come out of a joint or, if something is stronger on one side, it can damage that area more quickly if it's not balanced up with the strength from the counter opposite side of it.

And so, the physiotherapist's job is basically to help range of movement. So, they will help stretch out the joint that's becoming contracted. They will balance that joint front and back particularly. They will help with posture - and posture is a very important thing we see more and more of these days, particularly with a lot of desk-based work where your shoulders are rounded all day - because that's the space that we alluded to earlier on above the tendons becomes compressed by the bony ledge at the top there, the acromion. And that causes pinching effect and irritation. And so, by helping improve the posture, sometimes you open up that space and help allow it to settle down. And then the strengthening exercises, again, just to help drive those muscles into balance and range of movement on their own.

So, physiotherapy, your GP would normally refer you for physiotherapy after seeing you and diagnosing you or having an idea as to what's going on. But more and more we see people going to seek help from physiotherapists themselves. We've discussed the exercises that they can help
manage and there are far more of them available online these days, obviously, with people actively seeking them out on YouTube.

But you just have to be a little bit careful as to where you gain this information and which exercises they're actually telling you to do. Far better to see a professional face-to-face who can guide you to the appropriate website if you were thinking of that potentially.

Ultimately, if the physiotherapists haven't been able to help you, or in fact, if they think that there is something else going on that they're not comfortable treating, they will refer you on, sometimes via your GP, to a surgeon. And that's where Mr Bakti and I potentially step in and try and help.

So other forms of treatment for shoulder pain come in various forms. And obviously a lot of people will already be taking drugs, medication, painkillers to try and help with the pain. One form of the painkillers is something called a non-steroidal anti-inflammatory or NSAID. And examples of that are like, for example, ibuprofen or Nurofen. And whereas we wouldn't necessarily prescribe that to you, because you can get that readily in a chemist, we potentially would give you a steroid injection. And that sometimes puts
the fear into some people is they think that they're going to start growing muscles in all different places, but it's a different type of steroid that we actually use.

So whereas those medications are the non-steroidal anti-inflammatories, we're using the steroidal anti-inflammatories, which are a next level up in terms of anti-inflammatory effect. And we can direct those in various places around the shoulder quite precisely, just to try and dampen down the inflammation that's going on causing the pain while we get to the underlying cause.

If all of this fails, we sometimes do suggest surgery and there are various operations that we perform around the shoulder, a lot of which now are keyhole surgery rather than open procedures. The name arthroscopic basically means the keyhole aspect of it.

Arthroscopic subacromial decompression is a bit of a mouthful but is the most common operation that we do. And it involves burring away a little bit of the bone on the under surface of the acromion, that ledge of bone at the top of your shoulder, just to create a bit more space. We can also take away the end of the collarbone, the acromioclavicular joint, and that opens up that joint, taking away any arthritis, any inflammation in that area. We can repair tendons if we need to. We can release a joint, making it more freely available to move. We can stabilise it if it's been dislocated and torn some of those stabilising ligaments and we can even replace the joints.

So just taking some of these more common conditions to the next level, shoulder impingement, as we said, is a very common diagnosis and accounts for 70% of these shoulder pains that present to the GP. In essence, whenever you take your arm away from the side of your body, you're using that
top tendon, the supraspinatus, to help do that, to keep the ball centred in the middle of the joint and the glenoid.

And there can be a wide variety of reasons why that tendon might be hurting and causing you pain as you do that movement. But the shape of the acromion does come into play quite a bit, hence the subacromial decompression operation.

This is a common form of imaging that we use. This is an X-ray, and you can see that it's been labelled for us, but in essence, the ball is the head of the humerus, the humerus being the arm bone. The socket is quite a flat surface, it's quite small as well, and we call that the glenoid. And then you can see the ledge of bone where the arrow is pointing on that side there, highlighted in dark blue. And that's where the top tendon, that supraspinatus tendon, comes and attaches.

So, as you take your arm out to the sides, as it rotates around the centre of the socket there. If you have a spur of bone jutting down, it's more likely to pinch that tendon just as it gets to the top. A little animation here showing how that works. So, you can see that tendon being squeezed between the top ledge, which isn't moving, and the ledge of bone where the tendon attaches. That sack, that light blue area just above the tendon is a cushion, and it's called a bursa.

We have bursae all over the shop in our bodies, and this one in particular can aggravate and add to the problem if it becomes inflamed as well, becomes swollen. And that can also be addressed at the same time we do that keyhole surgery.

This is a picture, again, that we use. It's an MRI scan picture, and we normally have a variety of different views that we use with the MRI because it does do it in 3D, but it's in essence a slice through the joint, through that X-ray picture that we just saw. And what we can see on this is just where that green arrow at the top is pointing down, there's a white space, and white on this particular image is water.

So, this is the bursa, which is inflamed, and we can see that sitting just on top of the tendon. The red arrow is pointing to another white patch, and that white patch shouldn't be there. In essence, just next door to it, you can make out a tendon ending, and that ending tendon shouldn't be ending up there, it should be attached down onto the bony ledge. And so, this is a torn rotator cuff, torn tendon, and this is something that we can help, and we think that it's probably due as a spectrum condition where it starts out with inflammation and if the inflammation goes on for too long it can end up wearing away that tendon altogether so it comes off.

So, we have a little, another little animation here. So, this is the keyhole surgery. There's a camera that goes in at the back. There's a burr, that's a fast-spinning blade, and it goes in and just basically cuts away the undersurface of the bone.

As we said here, it's a day surgery normally for this. So, you come in, you go home the same day, you still have a general anaesthetic, you're still asleep for the operation, but there's no need to stay in hospital anymore these days.

We remove the tendon; we can assess the rotator cuff because it's all visible right in front of us. And then thereafter, you're in a sling, not even for 10 to 14 days sometimes, just for a couple of days for comfort sometimes if it's just a decompression. There are a couple of little stitches sometimes that need to come out after a couple of weeks and you're back to work usually within three to six weeks depending on what your work involves.

I'll hand over Mr Bakti to discuss what a frozen shoulder is.

Mr Nik Bakti

So, frozen shoulder, again, something that's quite common, sometimes left to be treated in the community for quite some time, because diagnosis can be quite difficult. For example, today in clinic, I must have seen at least five patients, or my 15 patients, with frozen shoulder. But it's something that is quite painful. It's quite debilitating. It can affect you quite a bit because it affects your range of motion quite significantly.

Unfortunately, despite lots of research that's been put into it, we still don't know why it happens. So, the common name given to this condition is idiopathic frozen shoulder. So, we don't really know why it happens, but it's risk factors or it's very much related to patients with diabetes, with hormone issues, often around the perimenopause at times, patients with endocrine issues, so issues with thyroid, can be more susceptible or at risk of developing frozen shoulder.

And sometimes it can happen spontaneously. You wake up one day and your shoulder becomes painful and progressively more stiff, or it can be due to an innocuous injury. So, you knock your shoulder on the frame of the door and very rarely it can happen after a shoulder operation. So, it's one of the complications from a shoulder operation. Next slide, please.

So, what happens in frozen shoulder is that the capsule around the shoulder joint itself, which is normally quite spacious, and it allows good range of motion, becomes very constricted, very scarred and very tight. The mainstay of treatment for frozen shoulder is physiotherapy, stretching. But this can be difficult because of the pain. So sometimes if, despite physiotherapy, the pain is still an ongoing issue, we recommend a steroid injection targeted into the shoulder joint itself within the capsule, both with local anaesthetic and steroids to help with the pain.

Often, we pair this with a procedure called hydrodistension. This is when a lot of high volume of fluid - so sometimes 50 mls, 100 mls - is put into the capsule itself at the same time - under either x-ray guidance or ultrasound guidance - to make that space bigger again, big again, capacious again, so that your range of motion is better.

Following this injection, often pain is much better. This will allow you to do your physiotherapy. And again, 75, 85% of my patients with frozen shoulder, this is all the treatment that they need, injections and physiotherapy. It can take up to 12, 18 months for things to settle. But most of the time, they don't move on to the next stage, which is an operation.

Often, operation is discussed or considered if patients continue to have stiffness and difficulty carrying out their day-to-day activities because of the reduced range of motion to the affected shoulder. And if this happens and we've tried everything else, then we recommend a keyhole operation, very similar to the decompression procedure. So, it's a day case under general anaesthetic, and you have several keyhole scars around your shoulder, where we would then use a device called a probe to release the scar capsule around your shoulder.

And at the end of this procedure, while the patient is still under general anaesthetic, we would then make sure that the normal range of motion can be achieved in your shoulder.

Again, physiotherapy is key. If you then keep your shoulder in a sling for too long after the operation, there's a risk that it may scar back up. So, we recommend only a short period in a sling up to seven days and intensive early physiotherapy after that. Again, depending on the occupation,
you can return to work as soon as or as quickly as three weeks after the operation. Next slide, please.

Now, rotator cuff injury is probably the most common operation that I do after decompression surgery. And the reason for operating on rotator cuff tears can be either due to an injury or after a fall or due to repetitive or chronic impingement, as Mr Neen discussed earlier. The most common symptom of this is not just pain but also reduce or weakness in range of motion.

And these two pictures at the bottom just shows the tear of the rotator cuff. These are two different imaging techniques that we use to diagnose rotator cuff tears. The one on your left is an ultrasound scan, which can be done out in the community in GP practices, and we do also offer it here at Benenden Hospital. The one on the right, similar to one that was shown by Mr Neen earlier, is an MRI scan of a rotator cuff tear. As you can see, just to the right of the ball of the shoulder, you can see a ledge. There shouldn't be that white speck there. And that white speck there represents the rotator cuff tear.

Ideally, patients should all have MRI scans because it gives us an idea of how big the tear is and it helps us plan and predict how successful a repair can be after an attempted repair. So, it's very important to mention that not all rotator cuff tears require an operation. This is particularly important for partial thickness tears. So, these are tears that do not go all the way through and is often due to chronic impingement or degeneration of the tendon.

This is best treated with physiotherapy and injections. It is only when all this conservative treatment of physiotherapy and injection has not helped after about 12 to 18 months, then surgery is considered. Surgery is also considered as the first stage for rotator cuff tears, the secondary to a fall. So, this is when you have a normal shoulder function, you've had a fall, and your shoulder is not functioning normally anymore, and you have an imaging, either an ultrasound scan or an MRI scan to confirm a tear.

These cases are considered a traumatic cuff tear, and we recommend surgery sooner rather than later. A rotator cuff repair is again done under general anaesthetic as a day case and all done by keyhole, arthroscopically. There is a slide after this, I think a few pictures to show what is done during a rotator cuff repair. Let's have a look. Next slide, please.

So, this is a view that we would normally get during surgery. So, the gold rod there is a device that we use to introduce our sutures into the top of the shoulder, very close to the ball and socket joint. Next slide.

We then introduce 4 stitches into the bone, which we'll then use to repair the tendon. So, the next slide will show the final arrangement of and how it would look like following a cuff repair. So, as you can see, there's no longer a rent or a tear on the rotator cuff. And in this particular image, it's the supraspinatus tendon at the top of the shoulder that's been repaired. And this is probably the most common rotator cuff to be repaired in surgery.

Following a rotator cuff repair, we recommend six weeks in a sling. You can still use your wrist and your elbow and we actually recommend or encourage the use of your wrist and your elbow to prevent those joints from being stiff. The only thing that we would like to avoid in these first six weeks is lifting your elbow away from your body as doing this in the first six weeks risk that repair failing.

As you can imagine, if you have not been using your shoulder for six weeks, it will then be stiff. So, the next phase of physiotherapy after that six weeks will be stretching exercises to overcome the stiffness. And this can take up to four or six weeks further.

And once you've managed to overcome the stiffness, then you move on to phase three of physiotherapy, which is then aiming to regain strength in your shoulder. Most patients can return to driving at 6 to 8 weeks, depending on ability. And work-wise, again, if it was a sedentary desk-based job, you can return to work at 6 to 8 weeks, but it's slightly longer for more manual occupations, such as builders or carpenters.

I'll pass you on back to Mr Neen to discuss shoulder arthritis.

Mr Daniel Neen

Right, yes, so for the final topic, arthritis. Arthritis, it happens all over the body. It's not just in the hip and the knee, although they are the most commonly replaced joints.

Arthritis can be either a degenerative change so, as we get older, the surface of the joint, the cartilage, wears away. And that process initially can be pain-free. So, cartilage itself has very little sensation at all. But unfortunately, once that cartilage has been damaged or gone altogether, the underlying bone becomes involved and it's that that starts giving you that ache and acute pain with the good and bad days.

The other aspect of it is traumatic. So, where you have a fracture, particularly if the fracture is through a joint, we know that the cartilage must be damaged and the underlying bone.

And now the sequelae of that is that you then develop this traumatic arthritis as a result further down the line. It can take many years for this to progress.
Pain is the main issue that we're sort of focused on as orthopaedic surgeons, but obviously function will be a secondary effect of that.

So, the pain will stop you doing certain activities. But equally, as the shape of the bone starts to change, the actual shape of the ball and socket can stop you doing things as well.

Some people describe a clicking sensation. Some people say it's just very stiff, particularly first thing in the morning. The severity can change day-to-day. It can become more prevalent after doing a certain amount of an activity a day or two afterwards.

The options that we have to treat arthritis are very much in a stepwise progression but does depend to a degree on how severe it looks on an x-ray. Mild to moderate arthritis, we would tend to suggest protecting the joint, modifying what you do if you can. Physiotherapy again to help maintain suppleness and strength of the joint if possible. Injections to try and help with that inflammatory process.

When it gets beyond that, though, and it becomes more moderate to severe arthritis, that's where we can start to consider shoulder replacements. The pictures we got here are x-rays, again, showing arthritis in progress. And I think you can maybe make out on this one, the ball and socket joint looks slightly different to the one we had before earlier on, with what appears to be the bone now touching the bone on either side.

So, the ball, the head of the humerus, is now touching the glenoid bone because the intervening cartilage has been worn away completely. That bone becomes inflamed and you have changes within it and that causes the pain that you get along with the stiffness.

Sometimes you get these large growths of bone coming out and they can be an early indicator, in fact, of damage to cartilage before the pain really kicks in. Just at the bottom of this ball, the head of the humerus, you can see a large bulbous bit sticking out. We call these osteophytes. And in essence, again, it's just an indication of the process that the bone is trying to spread the weight out of this damaged joint.

And this is a terminal event here with this arthritis in particular. You can see that the ball is heading out of the socket altogether and is heading up and has formed its own new joint underneath that ledge of bone, the acromion, which has become thinner and thinner. And this particular type of arthritis we call the rotator cuff arthropathy.
And it occurs because that rotator cuff tore off at some point in the past, years and years ago. And without that ceiling holding that ball down into place, it allows the ball to head upwards and start articulating up underneath the bone in a place that it shouldn't do. The bones have tried to adapt as best they can, but you end up with a very painful joint potentially.

So, the big question is when would you consider replacement and when would we offer it? And it very much depends on, as I said before, pain primarily. So, in general, this ladder that we use to sort of gradually go towards the shoulder surgery starts off with general painkillers and activity modifications. So when those painkillers stop working and the pain has stopped you doing what you enjoy doing, including work, potentially, if it starts interfering with sleep in particular - that's a big red flag for us, because everybody needs a good night's sleep - and we've tried all these other conservative efforts that we've talked about, physiotherapy injections, then we can start saying, okay, well, I think a shoulder replacement would be best for you at this stage.

There are various things that have come on with time with shoulder replacements, and it's still surprising to me that a lot of people haven't heard of shoulder replacements, let alone reverse shoulder replacements, which we will briefly mention.

In essence, in a couple of decades, over the last couple of decades, really, things have really moved on with shoulder replacements. It used to be that they just used to replace one side of the joint, but obviously the other side is worn out and still caused pain. Then there was also the problem with that top tendon being absent. So, then you would get the metal ball starting to head upwards and metal against bone was never a good thing, potentially.

And so they started shifting away from just replacing one side to trying to replace both sides of the joint, both the ball and the socket. But it was recognised that the problem without the tendon at the top was still a big issue because the ball wouldn't sit in the centre of the joint and would still migrate up, causing more issues.

And so, there was a chap in the 90s called Grammont who came up with an idea of reversing the shoulder biometry so that your socket became a ball and the ball became a socket. And that way it didn't rely on any of these tendons. You could still use the muscle that was firmly attached, and it did that by stretching it, so it made it work a lot harder, but also didn't allow the arm bone to head upwards underneath the acromion. So, we could ignore that top tendon tear altogether.

And the results have been astonishingly good and have come on and on over the last decade in particular. Mr Bakti and I, in particular, use this particular type, this brand of shoulder replacement. There are a variety on the market, and they are all monitored with something called the National Joint Registry, which Mr Bakti will talk about shortly.

So, the advantage of this particular brand is that this is a platform system. It basically means that the stem is the same if you use it for the reverse or the anatomic. And if you have to swap one to the other, the stem can stay put. We don't need to necessarily change anything. It has good stability these days and the longevity data, how long these things last, year on year, is coming back with better and better results. So, it's far more encouraging. And I'd say probably about 90% of my shoulder replacements these days are reverse shoulders, interestingly.

So, what would you expect if you were coming in? Obviously, nervousness, adrenaline, which is all entirely normal. You come in on the day of surgery. We don't normally admit people the day before anymore. You're seen and checked in by nursing staff, the anaesthetist and the surgeon. You are offered a general anaesthetic. In general, you are asleep for it, but they also say that they can numb up your arm so that you have no pain after the operation. You just have a numb arm. And that can be a little off-putting for some people, but I think the advantages far outweigh the risks.

Normally after a shoulder replacement, people tend to stay one night. It's nice to know that when the nerve block wears off, that you're not in absolute agony and that it's all controlled in hospital. However, more and more these days, we know how good this is, how good these nerve blocks are, and people tend to start to want to go home the same day.

You're in a sling, usually while the arm wakes up, so it's not flailing all over the place. But thereafter, we encourage you to take the arm out of the sling just to keep that wrist and elbow moving so it doesn't stiffen up.

And the physiotherapy will then ensue and you're talking usually two to three months of physiotherapy, and we check in on you once or twice during the first six months in general.

Movement-wise, people always wonder how bad it's going to be afterwards. And in general, it's a lot better than they expect. We aim for about 50% of the pre-operative movements by week three. This is passive movement. And passive movement means that you are having the arm moved
for you, either using your other arm or somebody else moving it for you.

And so, we want at least preoperative level by week 6. And then with active movements, i.e. movements that you're doing yourself, we want the preoperative level by week 12. It means that you can be driving from week 6, depending on if you feel you're able to, and that can be a confidence thing.

We suggest golf from week 12 and freestyle swimming from week 12, although breaststroke can be a little bit earlier because it's a little bit of a limited range of movement.

Lifting weights, we have to be a little bit careful with false joints, as you'd expect. And so, 3 weeks would be fine for lighter weights, but heavy weights, I'd suggest waiting for a few months as the scar tissue builds up in strength, just to reinforce it. Mr Bakti, the National Joint Registry.

Mr Nik Bakti

So, as Mr Neen alluded to earlier, there is a national effort to monitor every replacement joint in the country. And in this country, in the UK, it's called the National Joint Registry. And it started off first with hips and knees but, more recently, all other joints, including shoulders, ankles and elbows are being monitored as well. The main reason for this is for patient safety.

And as you can see, the most common joints to be replaced are, as we know, the hips and knees in the hundreds of thousands a year. The only time that the numbers have gone down would be during the COVID times, 2020 and 2021.

And for shoulder replacements, we are looking at 9,000 shoulder replacements a year when it was last collected, which was in the year 2024. But, compared to the hips and knees, it's a fraction, when we look at shoulder replacements.

However, if we look at when we first started collecting this data back in 2012, so next slide, please, the numbers has increased significantly.

Back in 2012, it was only two and a half thousand cases of shoulder replacements and 27% of them were reverse shoulder replacements. And the latest one, it's 9,800 replacements and 70% of it being reverse shoulder replacements. And the most common reason, according to the registry, for shoulder replacement would be arthritis.

And the next most common reason for replacement would be arthritis that's developed secondary to a rotator cuff tear, a chronic rotator cuff tear.

And in 15% of the cases, these shoulders were replaced for trauma. So not only that shoulder replacements are used for chronic problems like arthritis or cuff tear, but they can also be used to treat fractures. But this is only in about 15% of cases. Next slide, please.

With the system that Mr Neen and I use, it allows us to enhance a patient's potential recovery and function with technology. With this particular implant that we use, it allows us to navigate our shoulder replacement. What that means is that we can plan your operation. We arrange for you to have a CT scan of your shoulder. It gives us a 3D model of your shoulder, both the ball and the socket. And it's often that the socket is the more difficult of the two joints to replace. So, this allows us to plan the operation before the operation.

During surgery itself, we have this monitor on our site. So that's the picture on our right, which tells us exactly where we've planned our implant. And the theoretical benefit of this is that it places the joint exactly where we want.
and the result should be a better range of motion following the replacement. So, this is just a video to show what we can see during the planning process for a replacement, shoulder replacement surgery. We decide that
we want to put the implant exactly there and we can reproduce this during the operation with the technology from our shoulder implant that we use.

Vicky

Lovely. Thank you both very much for that. I think we might be having some technical issues with the Q&A. So, we'll go on to the chat instead. So please feel free to ask your questions in the chat.

So, the first question is, if you cannot be operated on for rotator cuff repair but are offered an injection, is it a one-off injection or can you have further injections?

Mr Daniel Neen

To start off with, it's a one-off injection just to see if this helps matters for you. Number one, if it doesn't really do anything for you, we wouldn't normally repeat it. Sometimes it can be guided injections that we use. Sometimes it doesn't have to be. In general, I know that at Benenden (Hospital), if you're a Benenden Society member, they will support one injection, i.e. pay for that one injection. And if you require more than it's usually a case of self-funding or coming via an NHS route for further treatment.

You can certainly have more than one injection. I tend to suggest not having more than one, more than two, sorry, depending on what it is that we're treating and how effective the first injection is.

I don't know if you have anything else to add, Mr Bakti, to that.

Mr Nik Bakti

I completely agree. The first injection often sets the tone for the treatment. And especially if it doesn't work, then I'll be very hesitant to offer a second one. And the flip side of the argument is if the first and second one does work, then I'll be quite keen to keep injecting it and we'll probably be opening up a discussion about further treatment in the form of surgery.

Vicky

OK, lovely. I hope that was helpful. Next question, what's the one thing most patients with a frozen with frozen shoulder wish they'd known at the start?

Mr Daniel Neen

So, this is actually a relatively easy one to answer because it's something, I mean, I get a very skewed view with frozen shoulders. So, I see people coming with a severe, stiff, painful shoulder, having failed all sorts of modes of treatment and the decision making is relatively straightforward at that stage.

I think the problem with frozen shoulder is that it's a great mimicker right at the start. So, you get this inflamed joint, you have full movements and you may have no trigger at all as to why it's come about. And so by and large, everybody would say painful shoulder, the most likely thing is a subacromial impingement, the impingement. Go and see a physiotherapist.

The problem is with frozen shoulders that there are three stages. There's a freezing stage, a frozen stage and a thawing stage. Each of those lasts a variable amount of time, but the whole process can go on for a couple of years. So, it's a long-haul thing.

And the initial stage, the freezing stage, we know that the physiotherapy can actually make it worse. And it's a very difficult balancing act. And this is where experience of the physiotherapists do come in, because they sometimes recognise the fact that they're making things worse and that the potential is that this is a frozen shoulder and will then refer it back.

Vicky

OK, lovely. Thank you. Is there a BMI limit for shoulder surgery at Benenden Hospital?

Mr Nik Bakti

Sorry, I didn't I didn't get that question.

Vicky

Is there a is there a BMI limit for shoulder surgery?

Mr Nik Bakti
I believe there is, I think, and I need to cheque this. And the last time I was told that the BMI limit is 40. Mr Neen, have you heard differently?

Mr Daniel Neen

No, I think that's correct. I think that's correct from an anaesthetic point of view rather than a surgical one.

Vicky

Thank you. Next question. If I've had an injection already, how long do I have to wait until I can have surgery?

Mr Daniel Neen

So, in general, we would say I'd wait as long as possible, and we tend to say a minimum of three months. And the point of that is because of the risk of infection. By the steroid dampening down the immune system in that area, as well as the anti-inflammatory effect, you potentially open yourself up to an increased risk of infection taking hold, particularly if we are implanting something, a foreign body within your body.

So, things where we're repairing the tendon, for example, or specifically if we're doing a replacement, we're going to be implanting this foreign material into the body where it doesn't have a blood supply and you've had a dampened immune system and therefore the risks of that infection after the operation increase. So roughly 3 months.

Vicky

Lovely, thank you. Next question, I have a burning pain on the back of my right shoulder blade, especially after use and the lady here is a lawn bowler. Is this arthritis? And she says the pain is very different from the pain of her knee arthritis.

Mr Nik Bakti

So, burning pain is often related to nerve problems. It can still be a symptom of inflammation in the joint, but often when I do take a history and if patients complain of a burning pain, then I often look for a nerve course for this. Now, in the shoulder clinic, it's been said that 20% of patients who come to a shoulder clinic complaining of a shoulder problem actually have a neck problem. And that's due to referred pain.

So, you can certainly have a nerve problem from your neck that causes sensation of increased pain or burning around the shoulder. And it's often a more a different issue. It's more of a degenerative spine problem in the neck.

Mr Daniel Neen

There's another there's another diagnosis as well that potentially comes to fruition is something called notalgia paresthetica. So, it's basically where these sensory nerves come through the muscle at the back, multifidus muscle of your back, and they are affected and it can cause a burning and itching pain for some people. And it again is a nerve type issue, and it can be quite
difficult thing to treat.

It's certainly not a surgical treatment, unfortunately, but getting the diagnosis is key, I think. So, nerve type, the burning type symptom that you have, I definitely think is a nerve symptom. But quite what is causing that is another matter.

Vicky

Okay, thank you very much. Hope that was helpful. Next question, with a full rotator cuff tear that's not been treated other than with physio for two years, is it possible to repair or can you then go on to a full shoulder replacement or is that no longer possible due to the muscle shrinkage?

Mr Nik Bakti

So, for this, I think it is quite important to have a full assessment to see what your symptoms are but also be assisted by imaging like an MRI scan. Because the key thing here is how much retraction or how far the tendon end is from the ledge of the bone where it belongs.

And secondarily, the MRI scan will tell us how much muscle has wasted away. Often, if it's a chronic cough tear, something that's been going on for years and years, if we often say that if there's more than 50% of the muscle that's wasted away, the outcome following operation to repair this will not be as good compared to patients with less than 50% of muscle wastage.

And the third point that I would like to make is even despite seeing patients, and having a look at the MRI scan, often the decision whether the tendon can be repaired or not is an intraoperative decision. So, a decision is made during the operation, because although the MRI scan suggests that it may be repairable, sometimes the tendon quality doesn't allow it to be repaired during the operation, and therefore it cannot be repaired.

Mr Neen, anything to add to that?

Mr Daniel Neen

Just to answer the second part, it depends again a little bit about age and function as to whether we could go on to do a full shoulder replacement. If it's the top tendon that we're talking about having torn off, then a reverse shoulder is the type of replacement that you'd be looking at, probably. And so absolutely you can go straight to that sort of thing if there is an ongoing issue and pain is a particular issue for that.

Vicky

Lovely, thank you. I think we've got time for one more question. I have pins and needles in the morning. Is this related to the rotator cuff problem?

Mr Daniel Neen

So, pins and needles, again, is a very nerve related issue. It's not necessarily to do with the shoulder itself directly. So, the pins and needles, what we do when we have pins and needles is we look at the distribution of those pins and needles as to which area or if it's in the hand, which fingers are affected. And that can give us a very precise diagnosis as to what is happening to you.

As an example of trying to join the two together, you do get a lot of shoulder pain and swelling, and that can put pressure on nerves, which then can lead on to pins and needles. But it's unusual. Usually, it's a completely separate issue altogether.

Vicky

OK, lovely. Thank you. And might be able to get this last one in. How can I prevent a frozen shoulder?

Mr Nik Bakti

Oh, that is the million-dollar question, I think. As I mentioned earlier, I don't think based on research, we know why they happen. And because of that, it's quite difficult to prevent frozen shoulder. But if you look as to which patients are more likely to develop frozen shoulder, so patients with diabetes, with endocrine issues such as thyroid problems, they're more likely to develop frozen shoulders.

So, I think the only thing that you could do to reduce your risk of developing frozen shoulders if you have other medical issues such as diabetes is to make sure that you have good sugar control, use your shoulder as much as you can, stretch it regularly. And I don't think, apart from that, there's anything you can do to prevent frozen shoulder.

Mr Daniel Neen

No, there's a lot of interesting studies and work being done now regarding hormones because it typically affects ladies of a certain age as frozen shoulder business. And so, they think there is a correlation between the perimenopausal aspect of things that Mr Bakti mentioned during his talk. And so, there's more work going on about hormones and their relation to frozen shoulder, but again, it's early days for that.

Vicky

Okay, lovely. Thank you both very much for answering those questions. If we haven't answered your question and you provided your name, we'll follow up with you via email.

So just to round off the session this evening, we're pleased to offer 50% off the value of your initial consultation, a call back from your dedicated Private Patient advisor, an email with a recording of this session, treatment information and loyalty reward points, and updates on future events and health news.

We’d really appreciate it if you could take a moment to complete this short survey at the end of this session as it helps us to improve and tailor future webinars to your needs.

If you'd like to speak to somebody to book your consultation, our Private Patient team is available until 8.30pm this evening or from 8am to 6pm Monday to Friday or Saturday 8am to 4pm and you'll find the contact number for them on your screen.

We've got some webinars coming up on a range of topics, including eyelid surgery, glaucoma treatment, hip and knee surgery, Arthrosamid injections and gallbladder treatment. And you can sign up for these on our website.

Finally, a thank you from all of us here at Benenden Hospital, from Mr Neen and from Mr Bakti, and thank you again for joining us, and we hope to hear from you soon.

Goodbye. Thank you.