Mirella Falcone

Good evening everyone and welcome to our webinar on hip and knee surgery. My name is Mirella and I’ll be your host for this evening. Our expert presenters are Consultant Orthopaedic  Surgeons, Mr William Dunnet and Mr Matthew Oliver. The presentation will be followed by Q&A session so if you'd like to ask a question during or after the presentation please do so by the Q&A icon which is on the bottom of your screen, this can be done with or without giving your name. If you would like to book your consultation, Emma Chandler and Chelsea Dann will be on hand to take phone calls after the webinar and we'll provide you with the telephone number at the end of the session. Please note the webinar is being recorded. I’ll hand over to Mr Oliver and you'll hear from me again shortly.

Mr Matthew Oliver

Good evening, ladies and gentlemen welcome to the hip and knee webinar. This evening I’m going to kick off talking about hip pain and hip replacements.. Next slide please. . With hip and knee surgery at our hospital, we're one of the leading if not the leading provider of hip and knee treatments in Kent and Sussex according to the Private Health Care Information Independent Network stats that were released in 2020. We offer treatment in an ultra-clean and calm environment in a state-of-the-art hospital that has recently been renovated, the team of surgeons here are very experienced and they're established in their field all working in the Kent and Sussex area, mainly for NHS trusts. We've all trained together and practiced together for many years, also our very important allied health professionals that help us achieve our goals and these are the physiotherapists here at Benenden and the expert care that the nurses and theatre nurses and scrub Nurses provide, not to mention the anaesthetic team. So on the whole we achieve very high satisfaction rates consistently and the hospital has embraced the rapid recovery program that many hospitals that perform joint replacements have up and running and I’ll talk to you more about that a bit later. Next slide please.

So my talk's going to have six main parts, I’m going to tell you about osteoarthritis at the hip the consultation process the treatment options that are available and then I will brush past the surgical journey, the salient points and talk a little bit about how one can optimize the outcome of a hip replacement some of that's down to you as the patient and some of that's down to us and then finally I’ll talk about some problems that can arise fortunately there they are few and far between. Next slide please.

So a little bit about myself, I’ve been a consultant Orthopaedic  surgeon now for 12 years, I have been started at East Kent hospitals in 2010, I started working here in 2012 and prior to becoming a consultant I was fortunate enough to go on an intensive adult reconstruction fellowship at the University of Calgary in Canada. I’ve worked for six different professors over there that looked after the tertiary referrals for the province of Alberta so they were serving a population of 5.5 million people. I’ve carried on using quite a few of the techniques that I learned over there in my everyday practice. Now in preparation for this talk I’ve looked at the national joint registry and my figures that are in there for all to see and I perform approximately double the national average of hip and knee replacements per year compared to my peers and when I looked at my last report I’m fortunate enough to say touch wood that I’ve only had four primary hips revised in 12 years I hope I haven't opened the floodgates now but here we go. Next slide please.

So osteoarthritis at the hip is essentially a wear and tear condition, the joint simply wears out it's usually of gradual offset but can indeed be rapid in some cases, there is no specific single cause, it's normally multifactorial but there are several risk factors that put you more at risk for developing this condition such as being overweight and obese because you're putting more force through the joint, having a previous injury to the hip, also being born with a congenital abnormality to the hip joint so it hasn't formed properly and continues to develop abnormally, this is known as dysplasia. There are a few paediatric or childhood hip disorders as well that can lead to secondary osteoarthritis at the hip joint and to date it still remains incurable but fortunately it's treatable. In recent years there's been great strides being made in joint preservation surgery for hip arthritis, helped by an explosion and interest in hip arthroscopy stem cells and cartilage regeneration, they haven't fixed the problem yet so it is inevitable that the hip will continue to degenerate unfortunately. The average age present for both men and women to receive a hip replacement in the United Kingdom is approximately 69. The condition for arthritis at the hip is due to a failure of the fluid film lubrication of the hip joint no artificial joint has been able to mimic this in a factory or a lab and essentially the pristine articular cartilage which lines the socket and the ball of the hip joint is provided the nutrition by the fluid that surrounds it, this is synovial fluid made by the lining of the joint, it produces almost a friction free environment. Unfortunately with age the fluid loses its zest and other environmental factors or injuries or being obese puts the cartilage under too much stress and as a consequence it starts to fray and degrade and by a bare bone is exposed the patient experiences initially a little bit of pain with exertion and a bit of stiffness but as the condition takes hold the pain they get in the groin which radiates into the thigh increases in intensity, the hip starts to get stiffer because it creates extra bone spurs or osteophytes as we call them and they have difficulty doing everyday things such as putting on their shoes and socks cutting their toenails getting it out of a car stride length also reduces and they develop an uncomfortable painful limp. Next slide please.

So when you're at that stage the consultation with an Orthopaedic surgeon is advisable and you can come to Benenden in three different ways, you can self-refer yourself you can come for a GP referral using your Benenden membership as well and you have 20 minutes with us to basically get to know us and for us to get to know you, it's a crucial time that I personally think because it develops the doctor-patient relationship which is absolutely essential to get a good result if we go down the surgical journey together. In that 20 minutes, a detailed history will be taken from the patient and quite a few of us use the oxford hip score which is a validated scoring system which tries to grade the severity of osteoarthritis it's out of 48 points and it's a simple 12 question questionnaire checking out the function or lack of function that you have with everyday tasks. Lots of research has been carried out upon it and the optimal time to have a hip replacement or the optimal score to have it replacement has been suggested to be around 26 to 30, that's the sort of range you also have a thorough physical examination to exclude other pathologies which I’ll talk about in a minute. If you haven't had an x-ray sent to Benenden advance of your appointment we may send you off for one on the day and when you return an individualized management plan will be created for you. Next slide please.

The consultation's primary aim is to work out where the pathology is, sometimes it is the hip sometimes it may be the spine or both sometimes it's the muscles and the tendons around the hip that hurt or the bursa, sometimes it's referred pain from elsewhere and we need to make sure that we ensure that the diagnosis is correct so the history and examination is key. Next slide please.

Special tests are sometimes required beyond the scope of a plane x-ray if we suspect it's a spinal problem then an MRI at the spine which you can see directly in front of you here there's a view of the spine and this reveals quite severe spinal stenosis to the trained eye this can mimic hip pain but there are some key differentials the history and the examination can help us work out an MRI at the hip is sometimes useful that can show whether you have inflammation of the bursa around the hip known as the trochanteric bursa or tendinopathy of the gluteus medius tendon or the hip abductor again both of these conditions can mimic osteoarthritis at the hip occasionally more specialized tests like an MRI hip arthrogram are required usually in a younger patient following a sports injury. Next slide please.

So if a differential if a spinal problem is detected then we are able to provide you if you wish with a cross referral to abandon hospital spinal surgeon where you'll be seen swiftly and treated appropriately but the other two conditions I mentioned previously bursitis and tendinopathy the mainstay of treatment is conservative with physiotherapy activity modification weight loss analgesics and sometimes a targeted injection into the painful area is arranged I prefer to use the interventional radiologist here at Benenden who will perform the injection under x-ray control. Next slide please.

Moving on now if the hip is the primary focus of the tension if you do have osteoarthritis at the hip there are some non-operative treatments available too because it may not be severe enough to need a hip replacement one thing to mention at this stage is that the hospital does have a threshold for surgery with regard to the body mass index and that's the number 40. So weight loss would be advised to try and reduce your body mass index several papers have suggested in the Orthopaedic literature that a high BMI is a counterproductive for hip replacements because it can lead to increased complications such as wound healing problems, infection, dislocation and also you're putting more stress through the joint so it may not last as long as you would wish. The non-operative management not only includes weight loss techniques but physiotherapy and light load-bearing exercise both of these have had studies showing that they're beneficial to the arthritic hip because an arthritic joint does not like to be kept still if you keep it moving you nourish the remaining cartilage of the synovial fluid and improve the lubrication which diminishes the discomfort painkillers can also be utilized such as non-steroidal anti-inflammatories and simple analgesics such as paracetamol and codeine or co-codamol some colleagues like to also provide an intra-articular injection into the hip of local anaesthetic and steroid this is useful in my practice from a diagnostic point of view if I’m uncertain whether it's the hip or the hip or the spine causing the problem or a bit of both this can be carried out in theatre under x-ray control or again an interventional radiologist can carry it out for us. Next slide please.

One thing to mention about the injection before I talk about the surgical journey it is best advised to probably hold off hip replacement surgery for approximately six months following this injection as evidence has shown there is an increased rate of infection following steroid injections to the hip if the operation is carried out too soon following it, so the surgical journey really starts with prehabilitation and that's down to the patient to try and optimize what they have ready for a major operation so good core stability exercising the hip to build up the muscle strength losing some weight eating healthily all helps with a swifter and a more rapid recovery if you have decided to have a hip replacement and we've been for the informed consent process in clinic. The next stage would be to be invited up for a pre-assessment appointment where you'll see a nurse and a consultant anaesthetist you'll have a thorough medical including blood tests and ECG and so on and they will look to see if there's anything that can be optimized prior to your operation, so if you have hypertension or high blood pressure this will need to be made better. If your diabetes is poorly controlled then this is essential to bring back into line again diabetes can complicate matters quite significantly with wound healing issues and increased infection rates so diabetic control has to be very stringent indeed anaemia may need to be corrected and we'll also advise you to look after the skin on your legs so there are no breaches in the skin barrier and also advise you to watch out for the routine infections such as a winter infection, coughs and colds we need to try and eradicate all of those prior to having your operation the rapid recovery protocol is quite well established now throughout the world and it's a multi-modal approach to help the patient through the surgical journey it starts with prehabilitation and pre-optimization I’ve already mentioned and then in the hospital setting it starts with making sure you're well hydrated well-nourished and that your analgesia is pre-loaded onto you before the operation starts we'll also use low dose spinal anaesthetic to numb you from the waist down and provide injections of antibiotics and drugs to not only reduce the rate of infection but also reduce the possibility of postal operative and intraoperative bleeding following the operation a nerve root block or a nerve block may also be given to you depending on the anaesthetist that performs the anaesthetic this provides prolonged pain relief on the ward to help you get a good start with the post-operative physiotherapy we try to avoid the use of opiate analgesia postoperatively as that slows down the process makes you feel groggy and causes other nasties like constipation. Next slide please.

So in the surgical journey you're admitted on the day you have spinal anaesthetic and you can have sedation so you sleep through the whole thing and not know anything until it's all over or you can be fully awake and have a chat to the anaesthetist or listen to music it's patient preference. After the op you will go to the recovery suite and onto the ward where you'll have close monitoring post operatively by a dedicated recovery nurse and ward nurse, you'll have your own private room with ensuite facilities and you'll usually stay for two nights, sometimes a third is required but most people go home after two nights. It is expected that by the end of the first day you'll be fully weight bearing, once the spinal anaesthetic is worn off you'll be fully weight bearing using a zimmer frame and you should receive physiotherapy twice a day whilst you're an inpatient. Next slide please.  

Day one post-op you'll be reviewed by the resident medical officer on the ward and your consultant surgeon by the end of day one it is expected that you'll be mobile with two crutches you would have practiced the stairs and you'll be dressed in comfortable home clothes, you would have had your blood tests and an x-ray would have been taken for us to check that the components were appropriately seated and positioned. It is potentially possible to be discharged by physiotherapy on day one if you're flying which means you can potentially go home that day, if not then swiftly the following day. Next slide please.

So day two everybody recovers at different rates so more physiotherapy may be required. Most patients as I say go home with telephone support, when medically fit to do so they're discharged of a four-week course of all anti-coagulation. A follow-up appointment will be arranged in advance to see us again at six weeks. Outpatient physiotherapy will also be set up for you if you live in the vicinity of Benenden Hospital then you're welcome to come back to have it with the team here, if not we will help you arrange it in your locality and seeing a physiotherapist on a weekly basis in my opinion is absolutely essential to get a good result following hip or knee replacement surgery because they make sure that you meet this the milestones in the recovery passage and again hip precautions for the first six weeks. The physiotherapist will drum these into you whilst you're on the ward and you'll be discharged with an information booklet reminding you of these simply mean that you don't put your hip in risky positions while the musculature around the hip joint heals. Next slide please.

When you return at six weeks having had regular physiotherapy, it would be great to make sure that you're mobile with a crutch or a stick or perhaps nothing at all. We would check the wound and usually it would be safe to drive again and I’m quite relaxed at this point if everything is going to plan to discard hip precautions that means you don't have to sleep on your back you can sleep on your side and you can start to up the ante with your activities with the aim to get back to a good quality of life within three months of the operation. Next slide please.

So there are a few problems that can arise or complications that can arise from hip replacement surgery, fortunately they are rare so infection there are two types deep and superficial. It's the deep infection that's the very worrisome, one the range there's a range of percentages that are quoted in the literature depending on the surgical unit where you have your operation the national average it's about 1.5 percent but in private hospitals where it's a dedicated clean environment, the infection rate if all the pre-optimization has gone to plan and you're fit and healthy the infection rate should be closer to 0.3 percent. So it's very unlikely blood clots in the leg and the lung can happen, these are known as deep vein thrombosis and pulmonary embolism despite taking the blood thinning medication and again the rapid recovery protocol is essential here because the quicker you get up and about and move after your hip replacement the less likely it is that you'll get a blood clot in the leg. You can bruise quite heavily as this picture here shows this is reasonably common and is one of the unfortunate side effects of the anticoagulation medication, it doesn't necessarily mean that there is a problem and you will be warned in advance that your leg will go all colours of the rainbow and sometimes you can get bruising into the buttock and up the back and down to the little toe, it will gradually settle down. Nerve injury can be a risk depending mainly on surgical approach but you can get some foot drop and some numbness in the lower leg and then the foot, fortunately this resolves usually over a three to four month period. It is extremely uncommon this location that the ball comes out of the socket, it's down to us as surgeons to make sure that we carry out the operation competently and put the bits and pieces in you in the right place and it's down to you not to cut corners and discard the hip precautions too soon. If we stick to good teamwork it's extremely unlikely to happen. Leg length discrepancy, this is occasionally a headache but we aim to try and make sure your legs are the same length at least within a centimetre, there are various factors that make it more challenging such as if you have a curvature of the spine which is called scoliosis, it can tilt your pelvis altering the leg lengths. Also, if you've had a previous hip replacement on the other side it can sometimes make it more a little bit challenging to equalize leg lengths, just like the human hip implants wear out and they usually wear out quicker than the human hip. Unfortunately and the most important thing to say here the is that the longevity really is associated with the age of when you've had your hip replacement, so a patient in their 70s is unlikely to require hip revision everything being equal for it wearing out, whereas a patient in their 50s probably would need to have their hip revised in their lifetime. Next slide please.

This is a useful device, this decision support tool at the National Joint Registry devised a few years ago if you click on the link you can put in your demographics and they include your age your height and weight it will calculate your BMI and then you go through the Oxford hip score questionnaire and a chart is created for you giving you advice as to when it thinks you should consider having a hip replacement. It'll also give your percentage risk of revision in your lifetime at that moment in time and you can use it as many times as you like to track your progress, so you know if you feel your hip is just niggling a little bit then get your Oxford hip score and then check it again six months later if you wish. The national joint registry have also produced the surgeon's profile which quite a few patients seem to be aware of now, you can look us up on there and you'll find out how many hip and knee replacements we've performed in the various places that we work and it also tells you our 90-day mortality rates and again death from hip and knee replacement is extremely uncommon so I’m not sure if that's a particularly useful bit of statistics. Then the Private Healthcare Information Network also provides information for the patient in the public domain now about our length of stay and some hospitals are signed up to create feedback for the patient to enter into this website so you can review some of the patient reviews of the surgeons that have had their surgery and again there are other review sites such as iwantgreatcare.com or dot org I think it is and Doctify and I know Benenden Hospital uses Doctify quite a bit for gathering reviews, not only of the organization as a whole but also of individual surgeons and so on. Next slide please.

I’d like to finish off with this video here of one of the success stories of hip replacement surgery here at Benenden. Please press play, thank you.

Patient testimonial

“How I was feeling before was very very very very very nervous I’ve never experienced anything like this before. I don't know what I was worried about at all I felt no pain there was no discomfort at all so I don't know what I was worried about as far as I would suggest to anyone that could have been offered that sort of treatment, go ahead 100%. I was in the hospital for only the day, and I was up walking two and a half hours after the operation, I felt as if I could run a marathon in all fairness.

I’m hoping to be out there Sunday playing golf, I’m going back to work tomorrow so okay don't put it off and as far as where you go to you cannot beat Benenden Hospital.

Mr Matthew Oliver

I'd like to hand over now to my colleague Mr Dunnet who's going to talk about knees, thanks.

Mr William Dunnet

Okay, well good evening everyone it's an absolute joy to have you here with us this evening. I can safely say that presentation we've just heard from Matt was the slickest most informative presentation I’ve ever heard on hip replacement ever, it took 24 minutes and in that I would say there is all the information I would ever want to teach a medical student or a junior surgeon to prepare their patients for hip replacement and you'd be well advised to go through the tape that we're going to give you after this presentation and listen to it again because it is absolutely priceless and I would really emphasize what Matt had to say in that establishing the doctor-patient relationship that he will do in 20 minutes it’s something that's fundamental to all our surgeons that work here at Benenden, we are a team and we all understand the importance of establishing rapport and trust between us. The surgeons, the nurses, the physiotherapists, the ancillary workers and you the patient and that trust and that respect is being developed from today onwards and that's why all you people who are here listening to us this evening you are already winners because you want to know about your surgery you want to know whether now is the right time for you to have a knee replacement or a hip replacement or perhaps do you need to wait and perhaps go ahead and have a more conservative treatment to start with.

Anyway, what about me? I’ve been a consultant in Kent for 23 years, I trained at Cambridge and Guy’s, I spent a lot of my time out in Australia where I learned about knee reconstruction related to sports injuries because that was my first love but as time has gone by I’ve also realized that I love doing knee replacements and hip replacements so I do all three in fact.

So first slide, knee replacement what is the most important aspect of knee replacement? Well, we want to give you pain relief that's all that matters if you have pain and it's coming from the knee then the chances are you're going to need some form of Orthopaedic intervention, if however you have a wonky looking knee this is called a k-shaped knee you can see that's a nice straight knee and the left knee of this gentleman is wonky because the articular cartilage is worn out on the outside so it has given you a deformed knee if that's pain free it's unlikely we're going to recommend replacement surgery. With this lady here she's got what's called a varus knee where she's lost articular cartilage on the inside, if that is pain-free then we wouldn't dream of any major Orthopaedic intervention but if however we've got pain in the knee then we've got to start looking at ways of addressing that pain. So how about knee replacement, what's the commonest indication for it? Osteoarthritis, now if you remember Matt in his slides he went through the causes of osteoarthritis he said it's multifactorial, it most certainly is, it can be related to fractures where the joint surface becomes misaligned, it can be related to ligament injuries, actually the biggest cause is we don't know it is usually related to your genes, so as many good attributes that your parents or your grandparents have given you I’m afraid to say they're probably also giving you arthritis, so it is a strongly genetic predisposition. Less common nowadays is doing knee replacements for inflammatory arthritis, this is usually rheumatoid type arthritis or gout related arthritis and that's where the main problem is in the capsule of the joint the capsule becomes thickened and inflamed and that's what causes the pain and actually while I remember, if we go back to osteoarthritis, that is primarily a problem with the bearing surface joint whereas inflammatory arthritis with rheumatoid is a problem with the capsule of the joint and were on to a very interesting little problem that we can't satisfactorily answer and that's why some patients are going to suffer severe pain with relatively little arthritis and why do some get relatively mild pain for what amounts to a lot of arthritis and the answer to that is we actually don't know. In a lot of cases where the pain generator is in arthritis because when you lose the bearing surface in osteoarthritis, that bearing surface has no pain fibres in it so often the patient is not aware of the arthritic change, it's only when they start getting crumbling of the bone where you have pain fibres they then often become aware of the arthritic symptoms. The final thing I want to mention in this slide before we move on is we're now finding that knee replacement is so successful and the results are so long lasting that we're beginning to operate on younger patients, now these are a special group in that we know they are going to outlive their knee replacement so we're trying to do special methods to avoid knee replacement or if we have to do it then we're trying to do half or partial knee replacements which are going to lead to easier revisions in the future, but I’ll cover this a little bit later.

So it's becoming an increasingly common operation, knee replacements. Back in the 60s when hip replacements are very much to the fore, they were successful and they were giving great results, however in the 1960s knee replacements were not so good because we had a misunderstanding as to how the knee replacement should work, we thought it should be a nice rigid robust hinge which would then give patients a durable pain-free result. Unfortunately that was not the case because if you put a rigid hinge into someone's knee it will loosen very rapidly, so we've then developed this system that has now been around for 30 years which is the AGC or the vanguard system and what I’d like you to do is if you look at this replacement here you can realize what we're really doing is not replacing the knee we are resurfacing it. This metal here is nine millimetres thick and it will resurface the bearing surface but we leave the majority of the bone of the knee intact, so that's resurfacing the femur we resurface the tibia and we just place this polyethylene insert in between and you can see there's no hinge here. What we're relying on is a nicely conformed surface that allows for rotation and glide and pivoting but it is being stabilized by the ligaments of the knee, so it is a resurfacing it's not a replacement and it's the skill of the surgeon by balancing the ligaments that you will get a lovely result that we hope will last for anything up to 25 years. The average age, similar to hip replacements, is quite low at 65 to 68 in the country, as a whole in fact in East Kent in this area our demographic is such that our average age of hip of hip and knee replacement is actually a little bit older than this and I would always tell my patients that I operate on them when they need their joints and if they're in their late 80s or early 90s I’m still more than happy to give them a knee replacement because the most important thing is to give people quality of life and if you can relieve pain and relieve unnecessary pain I don't mind. If people are at age 90 as long as they are fit and strong they'll still get a lovely result, so this is just covering this the system we use it's made by zimmer Biomet the ODEP rating is 10. What does ODEP stand for? That's the Orthopaedic Data Evaluation Panel rating and that means the 10-year survivorship is recorded as being 96% and again we go back to what matt was saying about the NJR, The National Joint Registry that has all this data now of every single joint replacement surgeon in the country has to have 100% of all his data recorded in this registry, so it's an extremely valuable tool and my wife, who obviously had to overview this presentation before I gave it to you, she's a GP she said I have to emphasize it's not survivorship of the patient so in other words you're not all gonna die after you've had the knee replaced for 10 years, it's the survivorship of the component so I do reassure you that you've got a chance of having a revision and even a revision of the revision if you live to a grand old age, so I’m going to cover a little bit more about the kind of knee replacements we can offer for you because some of them will be more stabilized than this vanguard primary knee.

So first of all let's go into the symptoms of arthritis and this is where we come to that important 20 minute time we have to get to know you when you're seeing the surgeon for the first time. We have to determine whether we believe your symptoms are related to primarily arthritis of the knee or whether they're related to something else, so what about the early symptoms morning stiffness well I’m afraid to say as you get well into middle age morning stiffness is very commonplace, you just have a little bit of swelling, perhaps you have been using the joint for a few hours so it's very common for people to wake up with slight stiffness, but as long as it settles within 10 minutes of use then that's just a normal wear and tear process, we don't worry about it. If you start getting pain on demanding activity that you didn't have a few years earlier such as going up and down multiple flights of stairs or perhaps walking the dog for more than an hour on uneven terrain, then that might be a sign that the joint is beginning to wear. Clicking and grinding, I never worry about that on its own, lots of people have clicky joints and there are many reasons for that, it could be you perhaps have a tendency to have a little air in the joint, maybe your ligaments tend to abrade a little but it's not a problem, however if the clicking is becoming more frequent or you're associating pain with the grinding in the joint then that's a sign you might be getting early arthritis and of course swelling of a joint is a sign all is not well, there's some irritation there so that can be a sign of early arthritis but all these symptoms would not normally justify going ahead with a knee replacement. The later symptoms are rest pain, particularly at night time if it wakes you up and if the knee starts looking wonky that's a sign things are getting pretty bad and if your symptoms are stopping you enjoying life, stopping you walking the dog then that's is a symptom that should be regarded as being relatively high impact and we've got to start considering doing something for you. A GP will always send you from the x-ray and say well if your x-ray is normal you can't have arthritis that's not quite true, remember a normal knee x-ray just shows the thickness of the bearing surface there and there is relatively normal but it still doesn't mean you haven't got craters in the bearing surface like where things are beginning to break down, it just means the majority of the bearing surface is still intact so an apparently normal knee joint like that still might have symptomatic arthritis. So it's critically important that you see a doctor or a surgeon who can examine you and take a history and just as matt was saying it's that face-to-face examination that is very important, don't just rely on x-rays this is a very badly arthritic joint by comparison but don't be fooled that could also be an arthritic joint so this is just an x-ray grading and we're now 12 minutes into my presentation so I’m not going to spend too much time on this apart from just telling you it shows how arthritis does gradually progress by showing diminution of the articular cartilage height.

So what's the treatment? Very similar to what matt was saying about hip replacements, activity modification if stairs aggravate you a lot don't use stairs so frequently if you've been putting on a bit of weight through not exercising very much, go on to a weight reduction regime and you may well find a lot of your pains will improve. Physiotherapy can help arthritic pains, the reason being the source of pain and arthritic knee is not always coming from a joint it might be coming from overload or imbalance of the muscles and if you can restore balancing muscles, restore tracking of the kneecap with physiotherapy, that can relieve you of a lot of pain. Simple remedies, your paracetamols at night-time to help you sleep are always going to be your first line treatments, they're unlikely to lead to any long-term harm they won't lead to any addiction they're very few side effects from paracetamol for instance and I’d always favour those rather than considering any form of surgical intervention. Bracing can help in the early stages, every patient is different as to how well they respond to braces but the rule is avoid surgery if you possibly can and injections there is a role for injections for short-term relief but not long-term management of arthritis.

Now onto the surgery, remember I was talking about the special case for the person who's under the age of 65 who's young and fit, we can sometimes realign the knee which means we ensure that your weight-bearing axis goes through the preserved part of the knee joint and offloads the arthritic area, this can lead to good symptomatic relief for quite a few years without needing a knee replacement but we don't tend to consider it for people aged 65 and over because we have better more permanent solutions. Arthroscopic techniques and keyhole techniques can help if you have problems of loose bodies and things catching in the knee but again rely on the doctor-patient examination relationship to determine if that's good. You might hear something called micro fracture that's where we create injury in the knee in very small areas by cracking the bone and you have increased blood supply to that fracture and then the body heals the fracture with a form of scar tissue that is similar to cartilage that can give you a little bit more life before you have a joint replacement so you can see everything is aimed at delaying joint replacement, still absolutely necessary. You may have heard of cartilage transplantation, we tend to use that for patients who have a small area of cartilage loss with a periphery of normal bearing surface so it's not used for traditional arthritis is used for someone who has had trauma to the knee which is a very special case so on we go prior to the knee replacement health optimization, as Matt was saying we make sure you don't have blood pressure that isn't well controlled, ensure your diabetes is well controlled and weight loss is always fundamental now. This thing called prehabilitation, gentle physio exercises to improve muscle strength that is important for two reasons, one physio can help alleviate the pain of early arthritis improve the balance knee and delay surgery but two if you do require surgery to establish a rapport with a physiotherapist to learn how physiotherapy can help you will actually improve the rate at which you recover after the surgery, so it's very much a matter of taking away the fear of the unknown by knowing what to expect after surgery by seeing what kind of physio you're going to get involved with and as Matt said on a weekly basis it's nice to touch base with a physiotherapist usually over the phone mind you often nowadays we don't do it as a face to face but a little chat over the phone can help improve your morale enormously and here in Benenden we have a very thorough pre-assessment clinic and most importantly you'll have a discussion with a anaesthetist as well so you can have a chat about whether or not a spinal or a general anaesthetic would be more suitable for you.

So after the knee replacement as Matt was saying that was very beautifully presented by that patient who was ready for home on day one and said he was ready to play golf almost within a day or two and we do get you going as soon as possible after the operation but we keep a very close eye on you, we make sure the pain management is good. Everyone's frightened of being sick after surgery, yes it can happen but we have very good ways of controlling it and it's very, very short-lived and as Matt was saying you can have problems of the wound healing and certainly in the general hospital you'd expect a 1.5% risk of infection but here in Benenden our risk of wound problems infection is much lower than that, but we do keep an eye on things. Range of motion is very important to the knee replacement as is with the hip replacement we want to get you up and moving on your crutches as soon as possible, with a knee replacement we want to get that knee bending as soon as possible because to remember to get out of a chair comfortably you have to bend the knee to 105 degrees, so we will be tyrants and we will nag you and get you to bend that knee straight away and as Matt was saying it usually is a two-night stay, one day in hospital is pretty amazing. We do have patients to do that but count on two nights and again we're back to the rapid recovery protocol which is very well established here in Benenden and we've had some wonderful results from it.

Potential risks I’m not going to cover these because Matt's already covered them already in great detail but you might think oh my goodness couldn't you tell a few white lies and not tell me about the risks and patients do sometimes tell me that. Actually I honestly believe it helps you with your recovery to know all the risks beforehand and you've got to be honest and you'll recognize that here at Benenden we have a very open approach, we are people that speak our mind and we don't shirk our responsibility to tell the truth at all times and you'll find you realize you trust us enormously because we're not trying to hide the facts, we're telling you everything and so we're empowering you to really help make your own decision because everyone's different when they're ready for joint replacements and if we can give you all the knowledge and tell you truthfully with our eyes wide open. This is what you can expect then you find patients are reassured, they're empowered and they will then know how to make up their own mind when is the right time for them to have a joint replacement so all of this can happen but it is all rare. So I have now come up to almost 20 minutes so I’m just going to say in these last two slides really.

This is an example of a half knee replacement, this is something I’m very interested in it's one of my areas of expertise. I consider all patients for half knee replacement if they satisfy special criteria but if they do then I can say hand on heart, my half knee that I will give you will last just as long as a total knee and the satisfaction you will get from it will be even higher than the total knee, it will feel more natural it will be more supple and you'll recover from it a little bit quicker as well, but that's open to debate. So we will assess whether or not you're going to be a half knee or a total knee and sometimes we use special forms of navigation rather than standard instrumentation to do the knee replacement but again that will depend on you the patient and we're now back to that all important 20-minute relationship that we establish right at the beginning of your journey here in Benenden. So I’m not going to cover this because this is something I was going to fill in if we ran out of time, this is more just about the engineering aspects of knee replacements I find it great fun but I think most patients find it deadly dull so I will leave that be. So what are the requirements of total knee replacement? Accurate restoration of the individual's mechanical axis, we want to get your knee working in an optimum way and that happens if we restore the individual's mechanical axis by balancing the ligaments and that is the skill of the surgeon and nothing can replace the surgeon's skill in doing that and so we have to have accurate bone resections and you have to do a trial reduction and make sure intraoperatively you get the right degree of flexibility and if you have optimum placement and you have good flexibility and you plan your operation properly that will lead to the great longevity of your implants. So that's the end of my presentation here is our team and what I would emphasize all of us are friends we are not competitors, we rely on each other's opinion when we have difficult cases we meet in multi-disciplinary meetings we get together and we work out solutions. When I have a difficult case I’ll actually refer you to one of my colleagues for a second opinion and sometimes I have colleagues in London I’ll refer you to as well but we are all working together to look after you as a group and that's what you'll notice here at Benenden, whether it's the nurses on the ward or the physiotherapist or the resident medical officers, you'll feel as though you've actually joined a big family and you'll think it's the most beautiful place to actually have your surgery and in fact you'll probably think my goodness I want to stay here a few more days it's so good, but I’m telling you tough you can’t, you have your two days and then you're ready for home and that's me finished. Thank you very much.

Mirella Falcone

Thank you very much that was a really interesting presentation, we'll now take a couple of questions.

So first question is what is the difference between a total knee replacement and a partial knee replacement in terms of recovery?

Mr William Dunnet

Well most people will say the recovery from a partial knee replacement is quicker, there's a study from Scandinavia and several studies from Oxford and they have done a day case surgery now and they have found that 90 of their patients in Oxford who were selected for day case surgery have been discharged home within 23 hours, so they satisfy the criteria of the day case surgery but I must emphasize the reason that they have been discharged within the 23 hours is usually because of the special anaesthetic techniques. They have to ensure they have beautiful blocks they don't have any pain but they have good restoration and muscle function it's all about patient expectation and the total knee replacement is still a wonderful option but if you want to know the truth of it and you wants to know the literature, the recovery both with regards to discharge from hospital and from restoration of normal function is a little better in that you would expect someone after a half knee replacement to be feeling pretty good at eight weeks whereas a total knee replacement they'll be feeling pretty good and ready to get back to normal life at about 12 weeks, so there is a difference of eight weeks in the recovery.

Mirella Falcone

Thank you, next question. I’m 62 and suffer from arthritis in both knees would you operate on both at the same time? If so how would this affect my recovery?

Mr William Dunnet

Now that's a fascinating question if you talk to an anaesthetist there'll be a sort of drawing in their breath sucking between their teeth and so I wouldn't do both knees at the same time, not a good idea and that's a bias that has been in the Orthopaedic  community for many years because if you have both done at the same time the operation will take longer. It's more of a strain on the heart the potential for losing blood is slightly higher and the general insult to the body is slightly higher, but if you actually look at the literature the risk of doing two separate knee replacements compared with the risk of doing simultaneously replacements is slightly higher. If you do them with an interval apart, as long as the patient is fit and well so that's what the literature shows that nonetheless, most anaesthetists will not be keen on doing bilateral knee replacements. My own personal view is that I will do two knee replacements at the same time for two distinct groups of patients, the first one is an a fit patient who has no morbidities at all, in other words they don't even have blood pressure, they're not overweight, they're a perfect physical specimen and if they are completely healthy, I will then do bilateral knee replacements but I will ask them why do you want to have both done at the same time because it's going to be quite a challenge. You're literally going to feel you don't have a good leg to stand on and if they say well actually I’m the bread earner for the family, I’ve got to have as little time off work as possible so please get it done then I will go ahead and do it and in fact at Benenden I do bilateral knee replacements and a few years ago they produced a little video presentation and be doing a bilateral knee replacement for the patient and he sustained a beautiful recovery, so it can be done but you will be discouraged. Now that's the first group of patients, in other words someone who's very fit and well and they need to be getting back to work the second group is someone who has extremely severe deformities in their knees so if you straighten one knee you'll find the other one is so bent and deformed that actually you can't walk properly because you're just walking completely asymmetrically and this stiffness and the bent shape of your knee will stop you straightening out the good knee you've had replaced so you have to do both at the same time, I would say that's fairly rare and I probably have to do that once every three years.

Mirella Falcone

Thank you, if you could just move on to the next slide please just so we can have the, thank you very much. Next question is I’m 75 years old and struggle with hip pain, is there an age limit to having a hip replacement and would I need it done again?

Mr Matthew Oliver

There's no age limit it's all down to personal fitness and when the time is right for the individual you can have it done as early as in your teens or as old as nearly 100 or 100 or more, if you're fit enough so there's no age limit if you have a hip replacement at 75 and you're otherwise fitting well then it is unlikely, I cannot say impossible but unlikely that you're required to have a hip revision in your lifetime because most hip replacements go for at least 25 years the things that creep up along the way such as you could fracture the hip if you have a heavy fall later but if you're safe on your legs and you stay well then it should serve you well for the rest of your life.

Mirella Falcone

Thank you. Next question is I’m overweight which I feel is contributing to my severe hip pain but I’m also struggling to lose weight through exercise because of the pain, would you consider surgery if I’m still slightly over 40 BMI so I can be active again?

Mr Matthew Oliver

The hospital has a threshold cut-off of 40 so you have to get to 40 or below in my practice here at Benenden Hospital, it's not all about exercise it's multi-modal weight loss it's about looking carefully at your diet portion control eating the right foods cutting out processed foods and on top of that with light load bearing exercises swimming and aerobics, it should be possible to bring your body mass index down. Also, there are lots of groups out there now like Slimming World, Weight Watchers etc that will be able to motivate you to reach your target and it is a target that is worth reaching because it will mean that you'll recover much better when you when the operation.

Mirella Falcone

Thank you very much, next question is why is arthritis of hip and knees accompanied by significant weakness in the legs even though I’m still walking and taking a certain amount of exercise?

Mr Matthew Oliver

Well because the joints are painful and invariably stiff the hip and the knee aren't moving through the same range of motion as they once were so the muscles around the joints do wither a little bit but we also have to be aware that there are other conditions that could lead to weakness in your legs you may have spinal stenosis which is a wear and tear order of the lumbar spine that can make your legs feel quite wobbly and uncomfortable after just a short walk and then when you take rest the problem goes away again, so it might not necessarily just be hip and knee arthritis but on the whole I think it is mainly because the muscles aren't being used as they once were so they tire easier. I don't know if you'd agree with that Bill or not you have anything to add on that?

Mr William Dunnet

I wish I did because it's open to a lot of debate, there's been a lot of research done about this and they have found that if you do develop an arthritic joint you do get this reflex loss of muscle mass way more than just not exercising, I would suggest so if you have someone who has unilateral arthritis of their hip they are walking the same amount with both their legs but you do find the musculature in the arthritic limb wastes away more quickly than the musculature in the normal limb even though you're still walking and using it just as much, so there is a lot of debate as to why you lose so much muscle and so quickly and we can't answer the question properly.

Mirella Falcone

Thank you very much, one last question from Madeleine. What progress on knees stroke hips to exactly fit the patient rather than one from off the shelf?

Mr Matthew Oliver

Oh that's an interesting one, so 3d printing custom made joint replacements. There has been strides made in this, various guides are available you have patient specific instrumentation which uses off-the-shelf implants, they've been around for a while now and they make the implant more customized to the individual because they help with the position of the implant and optimize the size of the implant to fit that individual but you can go the next step, you can actually have the implants made for you and I think one of the brand names is called the conformist knee, I haven't had much experience with it yet as it's not available in the here or in my NHS practice and again it is important to add that you want a tried and tested implant which has a good survivorship Mr Dunnet alluded to the ODEP rating and these more novel techniques that you've asked about are just off the drawing board really and haven't really got the long term results for us to you know fundamentally say yes I can guarantee this will last 10 years 96.4 percent of the time. Would you like to add anything to that Bill?

Mr William Dunnet

There's one thing I would add, I’ve had a little experience with the conformist knee replacement and that is a knee replacement where the components are designed custom made for you the individual patient so it's not plastic it's not the 3d printing but they do design it and they produce something that's dedicated for you, the patient. There are two problems with that, the first is you don't really know what your knee looked like before it's arthritic because the bone has already eroded away, it's now become misaligned so there's a bit of guesswork, you may well say well can't you use the other knee well you can't because the other knee may well be arthritic but also there's often a degree of asymmetry between people's knees so it's got to be a best guess. Now the second thing about the conformist knee is that although you have your best guess to the design and shape of it, this still the fundamental thing about all knee replacement is balancing of the soft tissues as I said in my presentation, a knee replacement or a knee resurfacing is not a hinge it is resurfacing of the bearing joint and then balancing the ligaments and if you resurface it and you cannot balance it properly then it will be a very poor outcome and it will only last six to seven years before it wears out and with the conformist knee they found that once they had manufactured these components to match the patient's physiogrammy, if the computer design was poor then you had a very difficult situation to try to restore normality in the perioperative environment and they've created a lot of special jigs to try to overcome this problem but then you've turned what should be a relatively straightforward operation into something that is technically very difficult and I’m afraid to say the conformist knee run into problems with this and so the data we've got from it has not been terribly persuasive, so I come back to you need the skill of a surgeon who plans properly and pay pays a lot of attention to balancing of tough tissue, it's not about the component you put in it's the surgeon that puts it in that matters.

Mirella Falcone

Thank you very much. so our webinar has come to an end, I’m sorry if we didn't answer all your questions but if you've provided your name, we'll do so after the event. If you would like to book your consultation, please contact us on the number on your screen, it's after eight o'clock now but contact us between eight and six o'clock between Monday to Friday. We are offering attendees 50% off any initial appointment with the terms on the screen and you will receive a short survey and I would be grateful if you could spare a few minutes to let me have your feedback on today's webinar. Our next webinar is on the 25 August with Consultant Vascular Surgeon, Mr Aaron Sweeney who will be speaking about varicose vein treatments. So on behalf of our Orthopaedic Surgeons, Mr William Dunnet and Mr Matthew Oliver, myself and the team at Benenden Hospital, I'd like to say thank you very much for joining us this evening and we look forward to you joining us again for another webinar soon. I wish you a good evening, many thanks.