Hip and knee surgery webinar transcript
Good evening, everyone. I hope you're well and welcome to our webinar on orthopaedic surgery. My name is Louise and I’ll be your host this evening. Our expert presenters you can see in the panel are Consultant Orthopaedic Surgeons Mr Raman Thakur and Mr Richard Goddard and I’ll now hand over to Mr Thakur. Thank you very much and you'll hear from me again shortly for the questions.
Mr Raman Thakur
Thank you, I’m Raman Thakur, Consulting Orthopaedic Surgeon at Benenden Hospital, and welcome everyone. Just a few words about myself, I trained in orthopaedics back home in Hyderabad, India and completed a Registrar Rotation from South-East of England. I then further developed my hip and knee reconstruction skills with a fellowship in Learn Excel and Hospital for Special Surgery in New York and I have been practising as a Consultant Orthopaedic Surgeon in East Kent. I've been working at Benenden since 2012 so my remit of talk is on hip arthritis and hip replacement so let's start with the first obvious questions.
I've sort of titled my slides on the most common questions that are asked by patients during the consultation, so I'll try and answer those.
So normally hip is a ball and socket a joint which has smooth cartilage lining the bone ends and has got good, that allows good movements on the bone socket without any problems but with arthritis the lining the cartilage lining of the joint wears away and the underlying burden gets exposed this leads to the nerves becoming exposed and irritation of the nerves in bone with the movement of the hip and inflammation from the wear debris products causing pain and limitation of function.
So do I need a hip replacement is our next question. It depends on the individual patient and the answer really is you will know yourself and what do we mean by that so most of the symptoms in hip replacements can be divided into one pain and the pain can be felt in most people in the groin but also variably in the thigh down the thigh in the buttock and over the lateral aspect of the hip. Sometimes the pain can radiate as far down as the knee and very occasionally patients may just present with a painful knee and have no problems with the knee and severe arthritis in the hip.
The stiffness related to arthritis can manifest itself as the inability to do day-to-day stuff; bending over cutting toenails putting on shoes and socks and the pain can also manifest itself as instability and giving way from the hip. This combination can then manifest as interference in functions such as walking distances can get reduced it may affect sleep it may affect the ability to do other stuff climbing stairs gardening getting in and out of the car and driving so in effect all this pain and limitation of function affects the quality of life and when the quality of life is affected and things cannot be helped with conservative management such as painkillers and physiotherapy and occasionally a steroid injection in the hip if the arthritis is not too bad then I think and if conservative measures have failed then the possibility of looking at a hip replacement.
The next question commonly asked is what is the hip replacement made up of? So, in essence, an artificial hip joint has four components the acetabular component which is a combination of the shell and the liner and the femoral component which is a combination of the stem or the pin which goes into the femur and the bearing, which is the ball so the liner and the ball make the bearing surfaces and the liner most often is a highly linked cross highly cross-linked polyethene which is a hard bearing substance along with either a ceramic or a metal bowl and that moves freely with and with very low wear allowing long-term lifespan. Whereas the fixation of the prosthesis to the bone depends on the stem and on the shell which can be either. In this case, they are uncemented and they stick to bone and subsequently bone bones into them, or sometimes if the quality of the bone is poor or in certain situations and certain surgeons would like to use a cemented hip replacement where they use burn cement as a grout for fixing the prosthesis and the idea of doing this sort of procedure and using quality materials are to give a modern hip replacement which would hopefully last for decades.
How long will I be in hospital and what is the patient journey? So generally, patients come to see us when referred either by the general practitioner or an advanced practitioner because of pain in the hip. Sometimes the diagnosis may not be certain, sometimes the diagnosis has been made. Conservative treatment measures have happened and then a simple investigation such as an x-ray or very occasionally an MRI scan may be required to confirm the diagnosis and once the decision is made to proceed with the hip replacement surgery which is made as an informed decision with the patient and carers then certainly the pathway starts which involves then coming back and having assessments for pre-assessment with the anaesthetist and the team to physiotherapists as well as nurses to ensure um that it is safe for us to proceed with your operation at Benenden and give you more information on the pathway. Patients are admitted to the hospital on the day of the surgery and come down to the theatre to have their operation, most patients are up and about on the day of surgery particularly if it is done in the morning and they are recovered from the aesthetic. Sometimes, if it is late in the afternoon, it may be the day following surgery then they progress on with physiotherapy having blood tests and x-rays and if everything is looking fine they are discharged when they are safe typically within two to three days. The criteria usually are that you are safe on your feet and independently mobile most patients have done stairs and the wound healing is satisfactory and the dressings are dry.
There are hip precautions which will be explained to the patients and are usually in place for about six weeks after surgery. Postoperatively patients ask about various activities and when they can start and save walking as we said on the day of surgery driving riding a bike and travel. Probably travel, driving and riding a bike would usually be ok at six weeks post-surgery. Travel here is in the context of air travel and again if it is a long-haul flight certainly not before six weeks, the concern is problems with blood clots post-surgery and obviously, the air travel increases the risk of blood clots so hence the delay for travel.
Other questions: having sex, and getting back to work again, which may be anywhere between four to six weeks. Again, it must be gentle, certain positions should be avoided with sex and getting back to work, most people depend on the type of work if it is light work, or a desk-based job, after four to six weeks. Once you start driving if you need to get to work for six weeks. However, if it is heavy duty and intensive then there may be a phased return to work usually two to three months down the line. Playing golf and tennis again, you can start sort of driving and putting anywhere between four to six weeks but further swinging and playing golf on the course and swinging would be certainly anywhere up to three months. Skiing is usually advised to skip during the year of hip replacement and follow the following year.
What things could go wrong? Hip replacements are a very successful operation, over 100,000 hip replacements are done per year in England alone and over 90 per cent of people are happy with the outcome of surgery but there are some risks, and these are real. They are rare and the most common is probably blood clots and blood loss. If patients are on blood thinners and if any person loses a significant amount of blood, they may need a blood transfusion to restore their haemoglobin levels. Infection is extremely uncommon at Benenden, less than one per cent. However, infection is one of the most serious complications that can happen and the concern is if the pros infection goes to the prosthesis it may mean that the prosthesis may have to come out to clear the infection and if it is not cleared by antibiotics dislocation and likelihood discrepancy that's what we meant about taking precautions in that first six weeks because the hip replacement is held in by sutures alone and having put the hip into a position where the sutures are tested and can cause a ball to pop out of the socket.
Very rarely damage of tissue, surrounding all the clockwork is very close by to our operation and there is a risk of damage to tissues in the longer-term hip replacements can come loose or the components can wear and they might require revision surgery. Sorry apologies for showing these pictures of scars, just to give a little brief on how hip replacement scars. These are none of my patients but just a collection showing from counter clockwise from the bottom right; early within one week of surgery, three to four weeks and then a bit more ventures car three to one or three months down the line, bruising is something and swelling that can be quite common. Usually, it is not as marked and as alarming as in this patient, but the important thing to remember is for reducing the blood clots we put patients on blood thinners and therefore any bleeding can actually accentuate and where if somebody is sitting for a long time after the hip replacement, which happens in most patients, then that bruising can track down with gravity to the knee and sometimes down to the ankle and sometimes may be associated with swelling and muscle cramps in the lower limb.
There are various support tools to enable patients to make a decision and one of the support tools is on the national joint register patient page if you go and click on the patient decision support tool it will open up the thing and give you a page where you can put in functional answers to some questions which include the demographics and the functional limitations of yourself and then it produces a personalized chart showing the benefits and the revision rates and risks more accurate to the individual, and help guide decision making for surgery
Mr Richard Goddard
Thank you, Raman, for your talk, it was most enjoyable so good evening, everyone, my name is Richard Goddard, and I'm one of the orthopaedic consultants here at Benenden specializing in knee surgery. So, I'm going to talk about knee replacements and do a whistle-stop tour about the various types of knee replacements and why you should have one or consider one. So, knee replacement is a common operation mainly for wear and tear osteoarthritis but patients with inflammatory arthritis such as rheumatoid or damage due to gout also may need a knee replacement and patients who've had previous injuries perhaps sporting injuries damaging the ligaments and cartilage this also leads to secondary arthritic changes and people who've had accidents trauma fractures also may need a knee replacement in the future. The aim of a knee replacement is like a hip replacement it's aimed to restore function to help someone's pain, realign the deformity of the leg and increase patients' mobility and improve their quality of life. I'm seeing time and time again patients becoming younger for knee replacements and have greater expectations so it's important to know what you want out of a knee replacement and discuss that with the surgeon. Knee replacement similarly to hip replacement is a very common operation, approximately 100,000 performed in the UK every year. The average age is 65 to 68, but this is an average for people who make the average a lot older, and many patients now are younger. Slightly more females than males have knee replacements and approximately 94 to 95 per cent of patients report a good health improvement following a knee replacement similar to hips they're lasting many, many years and approximately 80 per cent of knee replacements can last around 20 and even 25 years.
The knee replacement every surgeon uses at Benenden is the vanguard knee replacement made by Zimmer Biomet, this has the highest rating of the knee replacement can have, it has a very good 10-year survivorship, with more than 96 per cent lasting 10 years and it has a long heritage of a predecessor knee replacement, the AGC which approximately 70% were lasting 30 years. The ones used at ben and are cemented to the bone and you can do the knee replacement with or without replacing the kneecap for the patella and there's a progression of knee replacements which can be more stabilized to deal with severe deformities.
So, what are the symptoms of osteoarthritis of the knee? Early you may just get pain on demanding activities; long walks, sporting activities, running, walking around the golf course, and playing tennis. Some patients have stiffness and swelling in the morning and a sensation of the knee clicking crunching grinding symptoms, later, which are very similar to what we've heard with the hip patients, they have more severe pain limiting their mobility, limiting their walking distance, pain at rest and just sitting in a chair is very common and patients as well describe pain at night. They may wake during the night and find it difficult to get back to sleep also the knee is commonly wearing out on one side or the other and patients then get a deformity which can either make the knee go as a bow-legged deformity or knock-kneed and the x-ray just there on the page shows that the patient is getting knock-kneed compared to the normal x-ray.
So, arthritis goes through several stages and it damages the cartilage inside the knee joint so the normal cartilage is lovely and smooth and looks similar to a piece of China or a billiard ball. In early arthritis, the cartilage is slightly soft and becomes damaged and in stage two arthritis you see the cartilage becoming fibrillated meaning it looks like blades of grass or seaweed underwater. This then progresses, the cartilage becomes very thin and starts crumbling away and a good analogy is to think of the surface of a road and a surface of a dirt track - it looks more like a dirt track or the surface of the moon and then as arthritis becomes very severe with grade four, you get full-thickness cartilage lost the bones are exposed and on weight-bearing, you may get bone on bone which is evident on x-rays that will be taken.
So, the treatment of arthritis of the knee isn't just isn't always surgical, there are non-surgical treatments which must be tried first, weight loss is always a good starting point if one considers themselves overweight, and exercise and physiotherapy modify activities enough to expectations of what your activity level should be. Simple analgesia over-the-counter medication, paracetamol, and anti-inflammatories if tolerated and then visit your GP to be prescribed stronger painkilling tablets. Some patients have good benefits from various knee straps and supports which can help with walking and playing sports and there are various injections that you can try such as steroid injections and lubricating injections. The one shown in the picture is Duralane, which we commonly use at Benenden. There are several surgical treatments if you catch arthritis early, sometimes keyhole surgery can be helpful in some instances, especially for younger patients you may try and correct the alignment of the limb but commonly end-stage arthritis would need a knee replacement.
So, before surgery, it's important to optimize one's health, weight loss and pre-existing medical conditions such as diabetes and high blood pressure, that type of thing should be well controlled to make the anaesthetic surgery and subsequent recovery quicker. Rehabilitation is trying where possible try and strengthen the muscles around the knee to improve muscle memory and muscle strength, this not only helps recovery but also in some patients can improve their sort of length of stay in hospital and that type of thing before knee replacement you'll have pre-assessment by the nurse and see the anaesthetist who will discuss the suitability of an anaesthetic with the individual patient and the various options for anaesthetic but commonly a spinal anaesthetic is used for knee replacements.
So, after a knee replacement, there's close monitoring on the ward, pain management, sickness control from the anaesthetic drugs, early mobilization so similar to a hip replacement we try and get you out of bed walking around the same day, sat in a chair doing your exercises and improving the range of movement. You'll have routine blood tests and x-rays to check the operations all gone well and most people would stay in the hospital for two nights.
So, like hip replacements, knee replacement is a big operation and there are several risks during the surgery. There's a risk of bleeding, one could need a blood transfusion, and a lot of knee replacements are done under a tourniquet to stop blood from going to the knee and this often limits the need for blood transfusion. Damage to the bone with fracture and perforation of the bone is fortunately very rare. Injury to the arteries and nerves again is fortunately very rare, approximately one in ten thousand during recovery. There could be wound problems, wound leaks, wound infection requiring antibiotics, again blood clots in the leg, deep vein thrombosis and these can travel to the lungs as an embolus we prescribe blood-thinning medication for two weeks to try and help prevent this. The knee is painfully stiff and sore and patients walk with crutches or a frame and there'll be an obvious limp for the first few weeks. Later on, knee replacements similar to hips they're made of artificial materials metal and plastic and this can wear, subsequently loosen and fail and need revision surgery, with a knee replacement, if one is to have an accidental fall from a ladder etc, it's theoretically possible to fracture the bone around the knee replacement.
Next slide. So, knee replacements, there are several options you can have a total knee replacement, replacing the end of the thigh bone and the end of the shin bone and sometimes the kneecap. This is the most common type of knee replacement, in specific situations, you can replace just part of the knee, replace the inside the - so-called oxford or medial compartment knee replacement and you can replace isolated kneecap joints. Although, these operations are quite uncommon because that pattern of arthritis is relatively rare. As one progresses through knee replacements, you can then need more constraints to larger knee replacement surgery to cope with various deformities and loss of ligaments.
So here we see a common deformity, this patient has bilateral arthritis of both knees and he's got the bow leg deformity we can see the x-ray after the operation shows that the deformity is nicely corrected and the picture in the middle shows the knee is nice and straight and this is a common pattern of arthritis that we all see.
Some patients, unfortunately, leave their knee to go into severe arthritis and this poor patient had a very subluxed knee, severe deformity requiring (as we see on the x-ray on the right) a more constrained type of knee replacement and we'd urge patients to have their knee checked out before it gets so bad. All is not lost, there are even more complicated knee replacements where the top part and the bottom part are physically linked together with a hinge this is an unusual operation but commonly for severe bone loss, severe deformity and patients having revision surgery.
So, what are the requirements of a knee replacement? We need a knee replacement to restore the mechanical access of the patient. It's known that if the knee replacement is put a few degrees out of alignment then the forces going through the knee replacement are altered and it makes the knee replacement more prone to failure. So each surgeon will use various techniques to restore each patient's mechanical access and we need the implants to have good longevity and improve flexibility so the surgeon can decide what the best knee replacement is as the progress of the operation.
Patients are becoming younger, and all patients' demands are getting more and more with respect to work, sports, hobbies, patients wanting to ski, do long walks, climb mountains etc, and so patients' expectations are changing. There are several advances in knee replacements, and we use in special circumstances a signature knee replacement, this is not better than the standard knee replacement but it has several indications. Commonly patients who've got abnormal anatomy either due to how their bones have been formed at birth or following various fractures which make standard instrumentation during the knee replacement more difficult and in very young patients those in their 40s and 50s you may want to use the signature to try and get the alignment as accurate as possible.
So, with a standard knee replacement, commonly we take our measurements from weight-bearing x-rays. With signature knee replacements, we take MRI scans or CT scans at the hip, the knee and the ankle and then a special computer program works out with the surgeon the patients' mechanical alignment and then a plan is formed which the surgeon has to agree or disagree with once it's approved, then the final plan is put into place.
So special guides are made, these are disposable but instead of using normal standard instruments, these guides fit the individual patient and they're so specific that if you leave them made for three months/nine months, the knee joint may have changed subtly so they don't fit as accurate as they should.
So the end outcome is the same as a standard knee replacement, you still end up with the same vanguard replacement but you're using the signature to try and get the components as seated as accurately as possible and in the best alignment as possible, which theoretically can improve recovery and range of movement but it's worth stressing that not everyone is suitable for a signature knee replacement, it's down to the individual surgeon to discuss that with you.
So that's my whistle-stop tour of knee replacements and we're both happy to take any questions that you may have.
Thank you both, that was very interesting. Okay, we do have some questions the last and the first is a little long so I'll say them slowly. This person has had osteoarthritis in their knee for several years and it's become very painful recently they manage this with the use of pain relief medication adjusting the dosage as and when necessary they keep as mobile as possible and do physio physiotherapy exercises although not as frequently as maybe they should they would like to know if they can continue to be managed long term or possibly improved with exercise or is it inevitable that they will indefinitely and need some surgery at some point.
Mr Richard Goddard
I would probably say it's not set in stone that you'll need a knee replacement, but I'd probably urge you to have a consultation, have x-rays and then the surgeon can see the severity of arthritis. If it's a pattern of arthritis that's not too severe and the surgeon's happy there's no bone loss and no severe deformity and the ligaments are stable, then you can carry on with gentle exercise, physiotherapy strengthening the muscles and painkillers as long as that's working for you. If you remember, one of my slides that showed a patient with a very severe deformity they'd ignored their symptoms and so I'd urge you to at least have a consultation, get an x-ray and take advice but by having a consultation it doesn't necessarily mean you will need a knee replacement.
Yeah true, thank you. Okay, this person is thinking of having steroid injections into the hip before resorting to surgery what would this involve and is it something that we recommend trying before surgery at Benenden?
Mr Raman Thakur
So there is an escalation of treatment pathway and if people are finding that the pain is not controlled by simple analgesics and physiotherapy and more often than not if there is a need for a short term improvement in symptoms, so if there's an occasion coming up say attending a wedding or a holiday and you want to have a few weeks of good control of pain then certainly having a steroid injection can allow you to have that temporary benefit. In terms of relief of pain and possibly improvement of function, now there are if it is early arthritis where patients sometimes you do get patients who have had not a lot of change on x-ray but their level of symptoms are much significant then in that spatial scenario certainly the steroid injection relief can last several months and could possibly be repeated to allow them to continue to function so I think as Richard has said earlier I think the first and foremost thing is a consultation to see if that is the right thing to do and secondly to understand how further down the line in arthritis the hip has gone and how long the benefit of having a steroid injection will be for a in your particular case and to also understand that steroid injections are not a course it is not something that we will recommend having multiple injections because it doesn't actually cure the problem it is still a injection to help with relief of pain and reducing inflammation in the joint so the underlying process will still continue so if people are taking steroid injections and carrying on the likelihood is that they are going to wear out their joint more and more so it is it is I think in an individualized situation certainly worth review by a specialist and having that discussion as whether appropriate in your case or not.
Thank you, okay I have a question for you Mr Goddard. Does needing a knee replacement on the same leg affect recovery from a hip operation?
Mr Richard Goddard
Assuming it's the same leg as the hip, yes. If you've already had a hip replacement many years ago then it's usually safe to have a knee replacement, if you've had a recent hip replacement then I’d probably wait for the hip replacement to fully settle down before you need a knee replacement 9n most circumstances. If you can still mobilize, it's probably worth leaving the hip replacement six months a year to sort of settle down because during a knee replacement under the anaesthetic you are moving the leg around and we don't want to sort of disrupt the healing of the hip or cause a dislocation or anything like that. If a patient is very severely affected with hip and knee arthritis and they're essentially wheelchair-bound and unable to mobilize due to both joints and in those extreme situations, you may do a hip replacement first and then two or three months later then do a knee replacement so they can gain mobility. But generally speaking, it's quite common for patients to have a successful hip replacement and then several years later have a knee replacement and vice versa. Patients who've had a successful knee replacement can have a successful hip replacement.
Okay, thank you. Okay, Mr Thakur, could you advise on the criteria for them to have a hip replacement if you're a very large person?
Mr Ramen Thakur
So, BMI is the word used to quantify the cut off for surgery at Benenden and what it means is the relationship between height and weight of the individual, at the moment the cut off at Benenden is 40. So, if you are over 40 then certainly having measures to help reduce the weight will certainly be important for us to make the operation safe and there is certainly advice from your doctor and there are also some weight management specialists at Benenden who can advise on that, yeah.
Thank you. Okay, this person is a 68-year-old, they walk long distances most days. However, they've recently developed inside right knee pain, which is a sharp shooting pain. They also experience pain just above the right buttock, the right knee is swollen and has some sort of fluid on the outside. What would you recommend they do?
Mr Richard Goddard
I mean so certainly this patient needs further investigation, so attending, I mean you can pop to your GP and discuss that with them or if you want an answer quicker then you can have a consultation see one of us and with those symptoms. The most common place to have early arthritis in the knee is on the inside so-called medial compartment arthritis so at your initial assessment we'd get some weight-bearing x-rays of the knee and from those x-rays would be able to tell if there's any significant arthritis or not. If there is significant arthritis then that's the diagnosis made at 68 if the knee joint looks perfect then we'd probably do an MRI scan to see if there's any cartilage damage which can occur at any age but commonly we'd be operating on cartilage damage in younger people. If someone complained of buttock pain at the consultation, we'd want to assess the movement of the hip joint and if we were worried that they could have arthritis of the hip and this as well if there's stiffness reduce movement of the hip this could be contributing to the knee pain so we'd get x-rays of the hip and the pelvis and also we'd ask questions to see if any of the pain could be radiating from the lower back which is also common.
Thank you. Okay, we have another knee question. My right knee will occasionally lock when I've been sitting and it is painful, is there something wrong with my knee joint?
Mr Richard Goddard
So-called mechanical symptoms; locking and giving way are common and often but do not always mean there is a potential problem. So common causes of locking would be osteoarthritis, could be loose bodies like little bits of like pea-sized bits of bone and cartilage which can form like kidney stones you could say and they can occur in the knee and cause locking and also cartilage problems such as meniscal cartilage tears and loose and torn cartilage could cause the knee to lock. So if you have locking of the knee and it's painful then I’d certainly say it's abnormal and then you want to seek advice where we can get x-rays and possibly an MRI scan to look into it further.
Okay, thank you. Mr Thakur, this person used to be a keen runner and would train for long distances, they were about to do, would they bear to do half marathons again after having hip replacement surgery?
Mr Raman Thakur
So generally, the advice is to avoid impact activities following any joint replacement, whether it's a hip or a knee and marathon or long-distance running would certainly fall into that category. However and therefore it is something that one would generally advise against, however, I have known people who have done it and who have been successful at it in terms of completing it but it is not something that one would officially condone and say yes everybody can do it. The bearings that were developed to allow people to be able to do a lot more impact stuff were like the metal on metal hip replacements but obviously, there's been a lot of press and awareness that such bearings have caused people more problems and they have caused an early revision in a lot more number of patients than was expected. So we are still I think the bearing combinations which we have with the ceramic and the plastic are very good and with normal usage have decades of service. If somebody does a lot of impact activity then the failure and the wear of the plastic and the joint longevity will be significantly reduced so it may not cause problems in the short term but in the long term, it's going to cause problems.
Okay, thank you. Mr Goddard, this lady is considering bariatric surgery, how long after this surgery is considered the right amount of time to get knee replacement surgery?
Mr Richard Goddard
Thank you, I mean it's very difficult to answer accurately but I would probably say have the bariatric surgery and then obviously you'll be monitoring the weight loss. I've had patients before I’ve referred for bariatric surgery and a number of those have come back after losing significant weight saying their knee arthritic pain is a lot better and they've delayed their knee replacement for several years. As Mr Thakur was saying it's really what your BMI is so if you're even after bariatric surgery ideally we'd like your BMI to be below 40 and that then makes the operation a lot safer. So there's no definite target for how much you must weigh it's really whether when your BMI is in the safe range and if after losing the weight your symptoms are still severe.
Okay, thank you. Mr Thakur, would you do a hip replacement on an eight-year-old?
Mr Ramen Thakur
I think age is certainly not a criterion to deny anybody a joint replacement, I think more importantly is the fitness and the medical condition of the individual and we have certainly operated on people in their 90s and given them hip replacement surgery and sometimes if people have gone to the age of 90/80 they have proved that they are physically and physiologically much better than somebody in their 70s with other medical uh conditions. So I think what is most important is the level of symptoms, the physical fitness of the individual and their medical conditions so if those criteria are met and certainly the hip needs operation and I would certainly offer one.
Okay, thank you. How long after a knee replacement can you fly or drive?
Mr Richard Goddard
A very common question, so in a nutshell, I’d probably say a knee replacement is a very painful operation, it's more painful than a hip replacement. So usually for the first six weeks, it's getting the knee moving gently pottering around at home taking analgesia. You must get a good range of movement of the knee early, most patients we wouldn't recommend driving until six weeks after the knee replacement. However, if you're a little bit slower to get going, still on crutches or sticks then you may be eight weeks or slightly longer. Occasionally people with automatic cars have their left knee replaced and they're off their sticks by four or five weeks, then it may be safe at that stage to drive short distances but generally speaking, driving is six weeks. Flying I usually say to people most people wouldn't think about or enjoy going on a holiday for probably three months. So I’d certainly give it a good three months before flying, physically you could probably fly at six to eight weeks but with a knee replacement, you certainly wouldn't enjoy a holiday, most people for about three months afterwards.
Okay, thank you. Right, we do have quite a lot more questions, but I think we'll pause them for now and we'll answer them after the event if you two are okay with that. We'll just, we'll email you all with the answers. I hope that's okay. So, if you would like to book a consultation please do contact us.