Mr Alex Chipperfield

Hello, good evening. We'll just give it another moment or two for people to get settled in, and then we'll get started.

Right, half past. Let's get going. Hello, good evening, everyone, and welcome to this Benenden Hospital webinar. My name's Alex Chipperfield. I am an Orthopaedic Surgeon here at Benenden Hospital.

Today, the format of the session will be, I'll give a short presentation on knee pain, knee arthritis, and specifically Arthrosamid® treatment for knee arthritis, and then we'll have a chance for a Q&A session after that.

If you've got any questions at any point, please click on the Q&A icon on your screen, on the bottom of your screen, and you can type them in directly. Feel free to put them in at any time during the course of this evening.

If I see some questions that particularly leap out at me, then I'll answer them as we go along, but otherwise, we'll go through them, or as many as we possibly can, at the end of the session.

This session is being recorded, so if you want, you need to be aware of that. If you put your name in, then your name will be part of the recording.

If you want to book a consultation off the back of this, then we'll give you all the details on how to do that at the end of the presentation.

So, this is me, a little bit about me. I'm an orthopaedic surgeon, consultant orthopaedic surgeon, have been for knocking on 30 years now. I trained in the southeast of England, before going on fellowship to, Australia and then became a consultant in hip and knee surgery here in Kent.

Since 2010. I've been working here at Benenden since 2012, and for the last couple of years, as well as working here as a consultant, I've also I'm also the medical director here at Benenden.

I specialize in hip and knee surgery, and I spent almost exactly half my time doing hips, and half my time doing knees.

So the basic structure of this session will be that I'll talk about what happens, when you come along to see me or someone like me. Then we'll talk about knee arthritis, synovial pain, then we'll talk about Arthrosamid®, what it is, how it works, and the evidence behind it.

We'll talk briefly about the procedure, how the injection is performed, and go through the pros and cons of it, and then the Q&A at the end.

So, starting off, we everything here at Benenden will start with a consultation and an assessment.

So you make an appointment to come and see us here at Benenden, either self-refer or through, through your GP or another healthcare professional and the initial consultation is all about finding out what's going on, which part of the body it is, and what exactly the symptoms are. So we'll start with a full medical history, and we'll take note of the signs and symptoms that you have.

I then go on to examine your knee, looking at the range of movement, looking at the strength, looking at any provocative signs, and quite often, a thorough history and proper examination will give us an idea there and then as to exactly what the problem is and from that, we can talk about, possible treatments and solutions.

We'll discuss treatments, whether they be surgical or non-surgical, and we'll recommend the best way to proceed ahead.

It may well be that before we can have that full conversation, we need to get more investigations performed. We can get x-rays and scans, such as MRI or CT scans, looking at the affected body part.

Also, part of the consultation, kind of looking ahead, we'll be looking at your general health and fitness. If it comes to the need for surgery, then we'd obviously have to assess the suitability for you to have surgery in the environment that we're in.

So the first thing is the simple thing, really, what is knee arthritis? Well, it's basically when your knee wears out. It's, essentially, what happens is that you get the normally smooth cartilage that coats the ends of the bones and allows the joint to move freely and smoothly. Well, that cartilage starts to degrade and break down and when that happens, those lovely smooth surfaces become rough, and they can catch and grate and grind, and the products inside your knee break down, and everything wrapped around the knee can get angry and inflamed and stiff and weak, and painful.

Arthritis typically is a is a degenerative condition. It tends to be age-related, what people tend to call wear and tear, but there are certain diseases that can accelerate the wear in the joint, and also other problems such as repetitive trauma, or injury, or occupational, or other, other factors can lead to your joints wearing out sooner rather than later.

The kind of symptoms that people get, well, the main symptom is pain.

With that pain, you can get restriction in movement, you can get loss of function, reduced walking distance, disturbed sleep, difficulty performing your normal activities of daily living.

You can also get a lot of swelling, mechanical symptoms in the knees, such as instability and locking, and you can get joint deformity as well at, sort of, very late on down the, down the line.

So, arthritis of the knee is a very common condition.

Affecting many people, taking up a lot of time, 100,000 GP consultations, and, daily for musculoskeletal problems.

A lot of people have problems with their joints, a lot of people are worried.

That they will no longer be able to live the kind of life they want to, but they're also worried about the ultimate surgery for a worn-out joint, which is joint replacement.

Joint replacement surgery is one of the huge successes of the 20th, 21st century, as far as medical advances go. But knee replacement, In particular, it is a it's a big operation to go through, it is painful, it's hard work in the early stages, and although the overwhelming majority of people are very happy with the results of their surgery at the end of it, it is a big chunk of your life, it is a big thing to go through, and a lot of people, quite rightly, are concerned about that.

If there is something that can be done to help their knee and help their symptoms without resorting to a destructive operation, then obviously, that's going to be a good thing that people are going to be interested in and that's certainly been the case with Arthrosamid®. Since we started offering it here, the popularity has gone through the roof.

So it is a it's a treatment that a lot of people have been crying out for for quite a significant period of time.

When it comes to Arthrosamid® and injections in the knee, They're working on a particular part, or a particular aspect of the symptoms that people develop with knee arthritis and those symptoms are what we call synovial pain, or synovitis.

Essentially, what we're talking about is not so much the skeleton itself, not so much the bones of the joint, but everything that's wrapped around it, the soft tissue envelope that encases the knee joint, the lining of the knee joint, which is called the synovium.

Gets irritated by the factors that are formed from the breakdown of the cartilage inside the knee, and you get this condition called synovitis, which is inflammation of the lining of the knee joint.

That synovitis causes a lot of pain, a lot of warmth, swelling, and, essentially inflammatory symptoms and all injections, but Arthrosamid® in particular, that is the cycle that they're trying to break, that is the area in which they act and it's important to remember that we'll talk about that a bit later on as well.

So like I said, with synovial pain, you get a pain cycle, it's almost like a vicious circle, where you get a buildup of, of debris inside the knee, which then damages and irritates the lining of the knee joint. That gets thicker, causing inflammation, causing pain, and also restricting movement of the knee joint.

But then inflammatory cells are produced by the body in response to that inflammatory change, and those cells can then further lead to degradation of the structures inside the knee joint, so you get a vicious cycle.

The idea with this kind of treatment is to stop that inflammation, break that inflammatory cycle, and allow everything inside the knee to calm down.

So what exactly is Arthrosamid®?

Well, there you go, that's the sales pitch there. It's a permanent injectable hydrogel that delivers long-lasting proven relief without surgery, redefining treatment for knee arthritis.

So in English what that means is that it's an injection. There are lots of other injections that you can put inside someone's knee. The difference between Arthrosamid® and the other injections are its mechanism of action and the duration of action as well.

A lot of a lot of traditional injections are quite quick-acting, but also quite short-acting as well. They don't they don't last they last for days, weeks, and months, rather than Arthrosamid®, which, the evidence is saying lasts months, if not many years.

Arthrosamid® is new to us, but it's not a new treatment, and it's been around for many decades. Thousands of patients have been treated with Arthrosamid®.

across Europe. So it is well proven and safe. It's not experimental.

So, like I said, it's a gel, it's a hydrogel, and it's non-biodegradable. The reason that's important is What that means is that when you inject it and it incorporates into the lining of the knee joint, it sticks, it stays there permanently. Other gels and other injections that you put inside someone's knee, they dissolve, they melt away, and that's when their efficacy stops working. But with Arthrosamid®, once it's in there, it's permanently in there, it permanently combines and binds with the lining of the joint, and that means that the action, the benefit that you get from Arthrosamid® is incredibly long-lasting as well.

So it permanently combines with the lining of the knee joint.

What we found that that does, when it binds with the lining of the knee joint, well, you get a couple of, you get a couple of benefits from that.

One is that it calms down the inflammation, and when you have less inflammation, you have less swelling, less pain, and less symptoms coming from your arthritic knee.

The other thing that it does, that's new evidence that's out there, is it alters the physical consistency of the lining of the joint.

The when the lining of the joint is very angry and inflamed, it's thick, and it's stiff, and it restricts the amount of movement and function that you can have in your knee joint.

What they know now is that with Arthrosamid®, Because it breaks that anti-inflammatory cycle and remains there permanently, it changes the consistency of the lining of the joint as well to bring back more movement and more flexibility into the joint itself.

The results it does take time to work. It can take up to 12 weeks before you get the full benefit from the injection, but if you do get benefit from it, then the latest studies are showing that you'll still be experiencing significant pain relief and benefit from the injection five years down the line.

Like I said, it's been around for decades.

Millions of syringes of, of Arthrosamid® have been injected into lots of different patients, and it's used in the veterinary world, and the urogynecological world, as well as the orthopedic world. So, it's tried and tested across lots of different conditions, across many millions.

Patients and administrations and that slide essentially says the same thing.

So, how does it work, or sorry, how's it given? It's a one-step procedure. It's done under local anaesthetic, so you're awake, and we do it here at the hospital as a day case procedure, so you come in and out the same day.

We do it in our operating theatres in order for it to be a clean, sterile environment to have this performed.

Typically, you would come in to the hospital a couple of hours before the injection, either in the morning or in lunchtime or early afternoon and one of the reasons for that is that prior to the injection, we give you a dose of antibiotics, tablets of antibiotics that need to be in your system for about an hour or so before we can get you down for the injection. So you come to the hospital, we get you settled on the ward.

You have your antibiotics, and then an hour or so later, we get you down to the operating theater.

Once you're down there I've gone ahead of myself. Once you're down there, I use the ultrasound machine, which you can see there. The reason for using an ultrasound machine is so that we can clearly visualize the joint cavity to make sure that all of the Arthrosamid® is delivered to the correct area inside the knee. You can inject knees blind, but if you're putting in a permanent implant, you need to be sure that everything is going to be in your favor, everything's in the right place. So an ultrasound machine is, a quick, simple, but effective way of doing that.

So we image your knee with the ultrasound machine.

Then, I'm afraid it's needle time, we get the needle out, and the first thing that's injected in and around the knee is some local anaesthetic, which will numb the lining of the knee joint and the skin around it.

Once that anaesthetic is in, we then We'll attach the Arthrosamid® syringes to the needle that's in the knee joint, and inject the Arthrosamid® in. Now, Arthrosamid®, the dose of Arthrosamid® is 6 milliliters, which doesn't seem very much, but it might feel it if you're having it injected into you.

The way that the dose is broken down is it is in six 1ml syringes. So the needle stays inside the knee, and I attach a 1ml syringe and inject the Arthrosamid®, then I detach that, attach another syringe, inject, detach.

Do that six times, and that's the entire dose of the Arthrosamid® within your knee.

There we go, then you get a little sticky plaster, back up to the ward, cup of tea and a biscuit, and then you're free to go home.

The thing about Arthrosamid® compared with other innovations, treatments, is the thing that impressed me the most was the rigor of the scientific research behind it.

You will be a part of that if you come along for your injection. One of the things that's given to you in your discharge pack is a QR code and a link to join the National Registry for patients who've had Arthrosamid® injections and so your data you'll be completely anonymized, but your data will be we look at your symptoms, we monitor your symptoms over weeks and months, and look at your response, and so we can we can gather more scientific data to help with future treatment.

The data that's available on Arthrosamid® treatment, the studies that have been performed, we've got there are four studies on this graph here. Two of them are for five years and beyond. The other two are, well, coming up to about 18 months now and these are very well constructed, scientific studies that are Looking at the efficacy of the of the treatment and the drugs.

If you look at this graph, you can see top left, everyone starts at zero, which is with a painful knee, and then their symptoms decrease, pretty quickly. Looking at some of the studies there, you know, most people start to notice a difference within four weeks, but it can, like I said, take up to 12 to 13 weeks before you get the full benefit, the full drop in the inflammatory symptoms.

But the interesting thing here is that instead of a traditional injection where your symptoms would start to creak back almost immediately from that low point. With Arthrosamid®, once you get that decrease in symptoms, it is maintained and if you look at the lines going out to 5 years now, good maintenance of symptomatic relief for an extended period of time.

So, what are the benefits of Arthrosamid? The last 10 minutes extolling the virtues and benefits. Essentially, it's an injection that is incredibly long-lasting, that is safe, and it can be incredibly effective about alleviating the pain and symptoms coming from your arthritic knee.

It's simple, it's done as an outpatient, it's done with you awake, it's not you don't have a big, long recovery period, and like I said, the thing that attracted me to it, it is backed up by decades of research into it as well, so it's got scientific evidence behind it.

What would you expect in the early days? Well, you can go home, almost straight away.

The local anaesthetic that we inject into the knee, that lasts for a few hours. Once that anaesthetic wears off, your knee may feel a little bit uncomfortable. It may feel a bit stinging, or burning, or just sort of mild inflammatory symptoms around the knee.

You may feel that your knee feels a little bit strange, because the consistency of the gel that's being injected into your knee is slightly thicker than the normal lubricating fluid inside the knee joint, so it may feel a bit restricted from that point of view.

Typically, people will get a bit of, pain and swelling in the initial couple of weeks afterwards.

But then you would expect to find that your symptoms would decrease, and then, like I said, over the days, over the weeks, over the first couple of months, your inflammatory symptoms will settle, and your knee will feel a lot more like it used to.

Like I've said, it's not a quick fix, they say up to 3 months.

What we tend to see, though, or what I've seen certainly here, is that, there are there's definitely a group of people where it does take that long before they feel the benefit, but there are others, just as many, who start to feel better within a couple of weeks. So, there's definitely Definitely people do respond more quickly, but it's by no means guaranteed.

What we say in the early stages is that you should take things easy to start with. We give you a rehab guide that will take you through a stepwise progress as far as rehabilitation and movement of your knee goes, and that, again, the color guide that you'll get following the injection.

Side effects? Well, the main side effects that we've already spoken about, is that you can get some pain and swelling afterwards.

The overwhelming majority of people, when they have pain and swelling, is mild, is self-limiting, and is alleviated by a few paracetamol, that kind of thing.

Since we've been doing Arthrosamid® here, we've done about 350 injections and there have been a couple of people who've had more a harder reaction than others. The mild swelling has been a bit more severe, has taken longer to settle down, and, you know, so there are some people whose bodies don't don't react well, and you can get more of an inflammatory response following this injection. So, it's by no although it is only an injection. It's by no means a benign procedure, and there are still risks associated with it. Like I said.

The main ones are mild, but there have been a few cases of people whose pain and swelling can be worse and can last longer as a result of the injection.

As far as the actual substance itself goes, well, it's inert, it's safe, and it's proven over decades of use.

The biggest side effect, or the biggest issue that you could have with an Arthrosamid® injection, is that it may not work. It doesn't work for everyone, and I'm sure there'll be some questions on that later, and I'll talk through that a bit later on, but it just popped into my head there.

Restrictions, we can't use it for everyone.

The main restriction I use it for is I do my best to try and figure out whether or not it will be of benefit to you in the first place. So, every not everyone who comes in and asks for Arthrosamid® gets it. In my book, it has to be an appropriate treatment, there has to be something for the Arthrosamid® to act on and quite often, that's not the case. I don't like to disappoint people, but I would only offer a treatment like this if I felt there would be some significant clinical benefit for you to do it.

There are other clinical indications why we should when you can't have arthrosumid. If you've had recent surgery.

That tends to be a no-no. If you've had a joint replacement, if you've had either a partial or a full knee replacement, then it's not advised to perform an arthrosumid injection in that.

If you have an infection, either in your knee or in the soft tissues surrounding your knee, then that's not a good thing. If you are If you're prone to bleeding, if you are a haemophiliac, or if you have uncontrolled anticoagulant treatment, then then it's not advisable.

A lot of people who have injections like this are on long-term anticoagulant therapy for one reason or another. As long as that anticoagulant is controlled and safe and stable, then by all means, we can still proceed with it. But if you've got uncontrollable bleeding, then again, that's not That's not appropriate treatment.

There we go. There's the Rogues Gallery. There are 7 of us, surgeons here at Benenden who offer this treatment and that's all of us, so you can come along and say hello to whichever one takes your fancy.

Prices so you have to There are a couple of things that you have to cover. One would be a consultation, and then and any investigations that come off the back of that and then the other one would be the Arthrosamid® injection itself.

So, the prices are up there. If you look around, I think you'll find that Benenden prices compare incredibly favourably to, to other competitors in the area.

I work down here at Benenden in Kent. I also have a clinic up in London, under the Benenden umbrella as well, and we can do consultations in either London, if it's closer to you, or down here in Kent and of course, being a Benenden member, you will get a discount for the Arthrosamid® injection, but Arthrosamid® is not covered by Benenden membership. The full cost isn't, but a discount is and as always, with these webinars, you, you know, because you've endured me talking to you, you get a benefit from it, and you can get 50% off your consultation using a code, KNEE50.

You can book online, or you can ring us up. There are people here until 8.30 tonight, we're happy to take your call, and arrange a consultation.

I'll leave, which one will I leave up? I'll leave that one up and So, let's start having a look at some of the questions, and I'll see if I can do See what I can do to help.

So, right at the top, right at the top, a question from Julie, Julie White. Julie asks, will this help with meniscal tears, which I have in both knees?

The short answer is no but the longer answer is possibly.

So, an injection will not cure a tear in the cartilage, so a meniscal tear is a torn cartilage in the knee.

Now, you can get torn cartilage for a couple of reasons. One is if you have an injury, like a football injury, or you fall down a flight of stairs, you can tear your cartilage that way. The other way, though, the other way that you can develop a torn cartilage in your knee is by something called a degenerative tear in the cartilage and what that means is that as part of the arthritic process that's happening inside your knee, as part of your knee beginning to wear out, the meniscus, the cartilage that sits inside the knee also starts to disintegrate, and it can split and crack and tear almost spontaneously.

Or with very minor trauma.

Now Arthrosamid® or any injection can't deal with a degenerative meniscal tear, but it can deal with the fallout from it. Like I said, the way that the lining of the knee joint gets angry and inflamed is because of all the structures inside the knee that are breaking down and releasing these enzymes that then irritate and upset the lining of the knee joint. So, Julie, your degenerate meniscal tear may be irritating your knee and causing that inflammation and swelling and pain, which an Arthrosamid® injection may well help with.

What can I expect after an injection in terms of mobility, swelling, pain? Hopefully, I've covered that. If I haven't rewind, because I'm pretty sure I said most of it in the talk there.

Bernard asks, what criteria determine whether steroid, hyaluronic acid, or Arthrosamid® are indicated in my case?

As I said earlier, There are all sorts of different things that you can inject into people's knees.

The top three, the main, the main ones that, that, traditionally we use here at Benenden.

Cortisone, or steroid, hyaluronic acid, which is the lubricant gel, and Arthrosamid®.

All of these, have slightly different indications, but they're all, as a very general rule, they are anti-inflammatory injections.

What we tend to find is that people who respond well to one kind of injection will respond well to Other kinds of injections as well.

There's a big difference in price between them all. Arthrosamid® is the most expensive of the three.

Typically, what we tend to a steroid injection tends to be used as a short, sharp shock. If something is very angry and inflamed, you want something that's very quick-acting in order to dampen down the inflammatory symptoms inside the knee, and that's what steroids are good for. Steroids are not good for multiple or repeated injections, because steroids can be fairly toxic to the body if you take them for long periods of time.

So, steroid is a quick fix, a one-off shot.

Hyaluronic acid tends to be in people who've had too many steroid injections, you want to try something else, again, that's quick and short-acting. The Arthrosamid® is the longest-lasting but also longest-acting injection.

So, yeah, that tends to be what we tend to do. Of the three, the best injection that you can have for your knee that we currently offer is Arthrosamid®.

On a scale of one to 10, how effective is Arthrosamid® injection, compared with oral glucosamine tablets?

The answer to that is massively. I don't know what that is in 10.

So, oral glucosamine tablets, glucosamine and chondroitin joint supplementation.

These are tablets that you can take that are, that are meant to be.

Protective, or have a dampening down effect on symptoms coming from knee arthritis and a reasonable proportion of patients get some kind of relief from taking oral supplementation. Now, that Number tends to be somewhere between 5 and 7 out of 10 patients.

But what is difficult to quantify is the, the amount of benefit people get, and the longevity of that. Essentially, if you're taking glucosamine, the benefits are there when you're taking it, but when you stop it, the benefits wear off.

So, as far as glucosamine goes, you might find a bit of relief whilst you're taking it, in about five or six out of 10 people.

Arthrosamid, if it is if it works, it will it's a one-off dose that lasts for years, not just the duration of your digestive tract.

The relief that I would expect you to get from that would be about 80%. So more relief for a longer-lasting period of time on a one-off dose.

Can I have Tina asks, can I have these injections with metal in my leg and knee after breaking my femur twice?

It depends on the metal in your knee, but in theory, yes, if you've got a femoral nail or some kind of plate, they tend to be extra articular implants, and so it shouldn't be a problem. If the metal in your knee is a knee replacement, then, like I said earlier, that's it's not currently licensed for that.

But if you have some metalwork in the vicinity of your knee, I would say that that probably won't be a problem, but I would suggest come along, have a chat.

We'll look at an x-ray, and we could go from there.

If you want to continue lifting weights, exercise, etc, are injections masking causing injury, so do you need to stop normal life?

No. In fact, the opposite is true, as far as that goes. One of the things that we find with these injections is that they inhibit the inflammatory response inside the knee, and also increase the flexibility and movement in the knee joint, and this allows people to get back to their normal daily activities. It allows people to get back to their exercise, to start building up the strength and confidence in their knees again.

So, yeah the worst thing that you can do with a worn-out knee is stop moving. You need everything around that knee to be as strong, supportive, and helpful as possible.

Often people struggle with that because they can't get through that pain cycle in order to exercise, to help them build up the strength and lose weight around their knee. So having something that breaks that inflammatory pain cycle, that allows people to start to do more with their knee it's a good thing, not a bad thing.

Once the effects of Arthrosamid® have worn off, can the treatment be repeated. That's Richard's question.

Yes is the answer. Yes, but, If you don't get any benefit at all, then I wouldn't repeat it. If you have months or years looking at 5 years relief, but then your symptoms start to creep back, or you start to get worse again, then absolutely, it can be repeated. What I would suggest is that you if you've had 5 years relief and then things are coming back again, the first thing to do would be to take stock of your knee at that point, so it may well be that you have further investigations or a repeat scan, because it could be that the arthritis has progressed to a level where an injection would no longer be the appropriate treatment, but if appropriate, absolutely it can be repeated.

Do you drain off any fluid that is on the knee before the injection?

Sometimes, yes. If there's a lot of extra fluid around the knee, if the knee is very tense, very tight, very swollen, then you can drain off that fluid when the needle is in there, before you inject the Arthrosamid® in. I like to leave a little bit of fluid inside the knee. I think that helps with the getting the injection in the right place, and to allow the injection to circulate throughout the knee joint itself. But obviously, a very big, tense, swollen knee, yes, you would drain that effusion, before injecting.

Catherine asks, is it effective for the over 70s and for very severe arthritis?

The answer to that is it can be, but obviously, I said, remember this point when I was talking earlier about the synovitic pain, about the inflammation in the lining of the knee joint, which is the main area where Arthrosamid® or other injections works on.

The other things that wear out inside the knee, the bones themselves, like I said, you can once that smooth coating on the ends of the bone wears away, you have bone grating on bone, and the bones can wear away, and you can get progressive deformity and stiffness that comes from a skeletal problem.

Now, any injection, it doesn't matter how amazing or expensive it is. Injections are limited into what they can and can't do. They can deal with the inflammatory problem wrapped around the joint, but if the joint is completely destroyed, if you've got bone-on-bone arthritis throughout that knee.

If you've got bits scraping against each other, if you've got worn-away bone and deformity, then of course an injection's not going to be able to alleviate that. It may help with some of the swelling around the worn-out joint.

But you've got to be realistic about what you're dealing with here. You're talking about an injection.

It's not going to miraculously grow you a new knee, it's not going to deal with the mechanical symptoms that come from skeletal problems inside your knee joint. It will deal with the inflammatory problems that come from the soft tissue wrapped around the knee.

But not everything and like I said earlier, I spend a lot of time Trying to determine whether or not people will be suitable for this injection, as in whether or not it will help them.

If you have very little in the way of inflammatory symptoms, but a lot in the way of structural or skeletal problems, then you're not going to get relief Unless you have something that deals with that skeletal problem, and I'm afraid that means knee replacement.

The other part of that was with the 70s. Age is not a factor when it comes to me considering you for Arthrosamid® injection.

If you look at the scientific data, the younger patients do better with Arthrosamid®.

The reason for that is that younger people tend to have less severe arthritis, which means that they have more in the way of inflammatory symptoms and less in the way of those skeletal symptoms.

But if you're 95, with a very swollen, inflamed knee, then, yeah, why not?

If surgery is needed further down the line, does the surgeon have to be experienced in the use of Arthrosamid®?

Daisy's question there. The answer is No. I have personally operated on two people who've previously had Arthrosamid® injections and if I hadn't have known they'd had Arthrosamid® injections, I wouldn't have known from doing the surgery.

The there there's no a risk associated no different risk associated with a knee that's had Arthrosamid® treatment in the past than having a knee replacement, compared to a knee that's not had Arthrosamid® treatment in the past that then goes on to have a knee replacement.

Doing keyhole surgery on patients who've had arthrosumid injections, at some point in the past. Again, there's no increased risk or, particular issues that you come across. It's important that your surgeon knows what treatment you've had in the past in order to determine what treatment to have in the future, but having this injection does not Jeopardise any future treatment you may well have on your knee.

Jane asked, is Arthrosamid® suitable for the posterior aspect of the patella, and what about hand MCP joints?

Second bit first, as far as treatment in the UK, licensed treatment in the UK. It is currently only licensed for knee joints. I'm asked quite a lot of the time, like I said, I spend half my time doing hips. A lot of people ask me whether or not Arthrosamid® is an option for hip joints.

At the moment, that is not the case, and that goes with the other joints around the body. The smaller joints, like the MCP joints in the hand, would come under that.

Now, having been to the factory where they make ArthrosMid, which is in Copenhagen, and having discussed this with European colleagues, there are there are physicians and clinicians on in mainland Europe who do use this for injections into other joints, with varying degrees of success.

But at the moment, in the UK, it is not currently licensed for hand joints.

I can't remember what the first part is oh, patella. Yes, if you have again, though, like I stressed earlier, If your only problem is a mechanical problem with your kneecap.

If it's if you're talking about bone grating on bone on the undersurface of the kneecap, then no injection changes that.

What we can what the injection can do is deal with the inflammatory, symptoms that you get in conjunction with that, but it won't it won't regain the surfaces that you have lost due to the degenerative process.

So it is just as Likely to help as any other injection for kneecap joint arthritis.

Anonymous asks, do you have to wait 6 months after a steroid injection before having treatment with Arthrosamid®?

You do have to wait. The reason Is because there's a slightly increased risk of an infection if you have an intervention within a certain period of time following a steroid injection and that's the same whether you have an Arthrosamid® injection after steroid injection, or if you have a joint replacement after a steroid injection. So, you do have to wait before that.

What Carol asks, what is the percentage of failures?

I guess what that depends on is what you mean by failure. There are people Who don't feel any benefit from it.

You would like to hope that you would be able to eliminate most of them, before they ever get to an injection by making sure, or to the best of your ability, seeing whether or not they have a problem that Arthrosamid® can help with.

So, you'd like to think that a lot of those kind of failures, as in the non-responders, would be weeded out before you actually get to the point of having to pay for an injection and go through it.

But it is true that, it doesn't work in everyone.

To be honest I'm quite surprised about the number of people it does work on. I my looking at my data and our data from Benenden, we the figures we quote are around 85-90% of people who have an injection like this do feel benefit.

Now, the amount of benefit you feel can vary. The amount of time that benefit lasts for can vary as well.

I would consider failure to be either not responding at all or to be made worse by the injection and that figure is significantly less than 1%. It's not zero, but it is an incredibly low number.

Bernard asked, what if the diagnosis doesn't support injections? Well, then we have to look at other forms of treatment.

One of which would be, well, which would be, if you're coming to talk to me, a surgeon, then we're going to talk about surgery.

Stay tuned. I'm doing another webinar in February, where I'll be talking about the surgical treatment of knee arthritis. So, Bernard, sign up for that, and you can hear me talk about all the various different options that would be available if an injection is not suitable.

My knees are unstable and give way without warning. Can Arthrosamid® help? It depends on the etiology of your instability. If your knee is unstable because you've got a non-functioning cruciate ligament.

Or because you've got a musculoskeletal problem, or if you've got a neurological problem, or your muscles are in some way compromised, then no, because injections are limited in what they can do.

If your knee is unstable because There's a lot of pain and swelling, Then, yes.

We are running out of time. I'll take another 2 or 3 questions.

Here we go. I've had an osteotomy some 14 years ago. Would that preclude me from this procedure?

So, for those of you who don't know, an osteotomy is an operation where you break the bone to realign it, and the reason that you would do that is if one part of the knee joint is more worn out than the other part, if, say, the inside part is more worn than the outside part.

But you don't want to go for a full replacement at that stage. You can break the bones to realign it so that more pressure is put through the less damaged part of the knee joint.

It's quite a big, brutal operation to go through, but what it can do in younger, more active patients is it can postpone or delay the need for joint replacement surgery until a time where it would be more suitable operation for them. So that's what an osteotomy is.

Can you have Arthrosamid® if you've had an osteotomy in the past?

Well, yes, you can but again, I would only advise that you have Arthrosamid® if you have a problem that Arthrosamid® can deal with.

If the reason that you're symptomatic now is because the other side of your knee has now worn out as well, and you've got bone scraping on bone in both sides of your knee joint, then I'm not sure an injection is the right thing for you. You may be looking at getting towards that Inevitable knee replacement that would have that the osteotomy would have given you 14 years of avoiding.

When can I start running, cycling, gym work again after an injection?

We, give you, we give you a rehab program as part of your discharge package when you have your Arthrosamid® injection, and you can look at it on the Arthrosamid® website and link to it from the Benenden Hospital website as well.

Essentially what we tend to say is that 48, 72 hours after the injection, just take it easy, essential journeys only.

The first week or 10 days is just, normal daily living, and then after about the 2-week period, you can start to, build up your normal exercise regime, starting gently, listening to your body, building up from low to high impact to weights after that.

Can it be used in other joints? I've spoken about that already.

I have type 2 diabetes and high blood pressure, will this still be okay? As long as your other medical conditions are well controlled and stable, then yes.

If you have uncontrolled diabetes, then you've got an increased risk of infection, and so that's not a great thing to be, to be heading to an intervention, a surgical procedure with. If you're, again, if your blood pressure is completely out of control, then you should get that dealt with before you have any kind of elective procedure. But if you have stable diabetes and stable high blood pressure then yes absolutely appropriate.

Bernard, I feel that we're having a our own, Private consultation here, or public consultation.

Bernard, consultation would require an MRI, possibly. It depends on the signs and symptoms that you're demonstrating, it depends on what previous imaging you've had, but essentially, what you need is a history, examination, and from that, if any further tests are appropriate, then we would discuss that at the time.

The last question I'm going to answer, because we're just coming to it, is, Neil, are you suggesting we would have to wait up to 12 weeks to return to activities like running, cycling, or will that depend on individual reaction to rehabilitation?

It will depend on individual reaction to rehabilitation. The 12 weeks is the time it can take for you to feel the full benefit from the Arthrosamid® injection.

If you are unable to run and cycle because of the inflammatory problems inside your knee, then you won't be able to do that again until those inflammatory problems settle.

If you are running and cycling despite those inflammatory problems, but your knee reacts After some exercise, then you can get back to things more quickly. Like I said, it's a gradual process. The first 2 to 3 weeks, you would be avoiding that kind of thing, but then I would bring things back into it gently over time.

Let's just scroll down. I'm just going to go down, because the we've got lots and lots. I'm going to go wow.

We've got a lot of questions here. I'm going to one last one, I'm just going to go down here we go. Margaret It's your lucky day, you're the last question to be answered. Margaret, you ask, is there a BMI weight limit?

So, for those who don't know, BMI stands for Body Mass Index, and Body Mass Index is how heavy you are compared to how tall you are.

you take those two numbers, and it gives you a figure and that is a figure that is used in healthcare to determine whether or not certain treatments can be offered.

Typically, you'll see it in private hospitals. So, in hospitals such as Benenden, there is a BMI limit for joint replacement.

The BMI limit for joint replacement at Benenden Hospital is 40.

If you have a BMI over 40, then you will not be offered a joint replacement at Benenden or indeed, any other private hospital in this region.

All of them tend to have a cut-off point of 40.

To give you an idea, the technical term for someone who has a BMI of 40 is morbidly obese. It is a it's a yeah. There is no such limit BMI limit when it comes to Arthrosamid® injections.

Again, that's one of the advantages of Arthrosamid® injections over, say, a knee replacement. One of the indications for Arthrosamid® is that you can use it in people who are not suitable for surgery due to medical comorbidities, lack of fitness, and included in that would be high BMI. So, I personally have injected people who have a BMI Considerably over 40. Because it's a treatment that you can offer in that case.

So there we go, There are many, many other questions, which is fantastic. Thank you all for coming along. I'm sorry I can't sit here all night and answer them as much as I would like to. What I would suggest is that they all of your questions will be logged, they will be answered.

Hopefully a lot of the questions will have been answered during the talk that I've given anyway. If you have any particular questions, please email in, or please come along and have a consultation, and we can, like Bernard, we can have a chat and, you know, come along and see one of myself or the other six people here who will be able to give you personalized advice, about your knee and the treatment options that are available.

So, yeah, once again, thank you all for tuning in today. Hopefully you found it useful. I look forward to seeing some of you in the future in the clinic but that's it for me for now. Thank you.