Vicky

Welcome to our webinar on Arthrosamid® injections to reduce knee pain. My name is Vicky, and I'm hosting this session. I'm joined by our presenters, Consultant Orthopaedic Surgeons, Mr Alex Chipperfield and Mr Mark Jones. This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so using the Q&A icon, which is at the bottom of your screen. This can be done with or without giving your name. Please note that this session is being recorded if you do provide your name. If you'd like to book your consultation, we'll provide some contact details at the end of the session. I'll now hand over to our consultants, and you'll hear from me again shortly. Thank you.

Mr Alex Chipperfield

Good evening, everyone. My name is Alex Chipperfield. I'm a Consultant Orthopaedic Surgeon here at Benenden Hospital. A little bit about me. I've been a doctor for 27 years and a Consultant Orthopaedic Surgeon for the last 15 of those. I work throughout East Kent and have been at Benenden since 2012. My specialist interest is in hip and knee replacements. I spend about half my time operating on people's hips and half my time operating on people's knees.

Mr Mark Jones

And hello everyone. I'm Mark Jones. I'm an Orthopaedic Consultant here at the Benenden as well. Working in East Kent hospitals as well. I've been a doctor for 15 years and a consultant for three years. And I specialise only in knee surgery, specialising in mainly sports knee injuries as well as arthroplasty surgery. So, we'll take you through the rest of the presentation.

Mr Alex Chipperfield

So tonight, we're going to talk to you about Arthrosamid®. We're going to frame that in a slightly different way. First of all, we'll talk about knee arthritis in very broad terms. Then we'll introduce the concept of synovial pain, which is where Arthrosamid® has been shown to benefit greatly. We'll then talk about Arthrosamid® itself and the treatment process and how it happens. We'll go through some results and the natural recovery process and then Q&A as previously mentioned.

Mr Mark Jones

So, what is knee arthritis? Well, we all know that knee arthritis is a chronic condition that affects you That's all joints, but we're talking today about knee joints. is when the lining of the bone and inside the joint, the cartilage, wears away, meaning that two bones on either side of the joint rub together. And then this leads to increasing joint stiffness. It causes swelling within the knee. And as a result, there's also pain because of the bone on bone. It does gradually worsen, and as a result, you get synovial pain within the joint itself, and then this leads to further disability. At the moment, the current treatments include non-operative treatments and surgical treatments. The non-operative treatments include weight loss therapy, exercise to strengthen the knee, as well as physiotherapy to maintain range of motion. Walking aids and other braces around the knee can also help correct the alignment of the knee, which can help offload the knee. We talk about pain relief with patients having a stepwise progression of starting on paracetamol, moving on to anti-inflammatories, ibuprofen, or naproxen, as well as introducing more opioid-based medications such as co-codamol. Injections are another non-operative management. Current injections include steroid injections or cortisone injections, as well as hyaluronic acid injections. But with both of these, there's little evidence to suggest they work for more than six months. And then lastly, there's a surgical option, which is joint replacement surgery. And this can either be in the form of partial knee replacements or total knee replacements.

Mr Alex Chipperfield

There's a few little facts and figures about knee arthritis and musculoskeletal problems in general. Essentially, what all these show is that it's a very common problem. Many people, especially later in life, will develop arthritis, and their main concern is limiting mobility and limiting life activities as you get older because of pain in the joints. Surgery is almost seen as inevitable for some people. And there's a lot of anxiety about the surgical process. And so, anything that can be done to avoid operations is thought to be a good thing.

Mr Mark Jones

So why do we get the synovial pain? Well, this is synovitis, which basically means inflammation of the synovium of the knee. And this is a common symptom that's explained by many patients with knee arthritis. The synovium is the lining or the capsule of the knee, and the cells within this synovial tissue become inflamed. And this is a strong link to the experience that patients get with knee arthritis.

Mr Alex Chipperfield

So, what we tend to end up with is there's a vicious cycle. Where the lining of the joint, the synovial tissue, becomes damaged and irritated because of the arthritic process. That tissue then thickens and gets inflamed, and that in itself causes pain. The pain response is that inflammatory cells are produced, attracted to the joint, and produced by the lining of the joint. And these are then released into the joint capsule in an attempt by the body to try and heal the damaged joint. A buildup of those inflammatory cells can result in a buildup of enzymes. And those enzymes are what are responsible for the breakdown of cartilage. And this means that the process then continues and is accelerated by the body's own healing mechanisms. So, the idea with Arthrosamid® is to break that inflammatory cycle and dampen down that response. And as a secondary result, to cause less pain.

Mr Mark Jones

So, we're talking today about Arthrosamid®. So, what is Arthrosamid®? Well, it's a permanent injectable hydrogel. that basically is injected into the joint and has long-lasting proven pain relief. And this is without surgery. And hopefully this is redefining the whole treatment of knee arthritis. And over many, many years, Arthrosamid® has been used all across Europe in over 100 clinics. a testimonial from a patient basically saying that he was unable to ski without his brace that needed hydraulic supports. But after two months after having given Arthrosamid®, he was back doing black runs again. So, it does change people's lives.

So, there's been lots of research in Europe regarding Arthrosamid®. It's about two decades worth coming out now, showing that it is a safe and effective treatment for patients with knee arthritis. And it does show that it can maintain benefit or clinical benefit for up to four years post-injection.

Mr Alex Chipperfield

So, I'll just give you a quick run-through of how the Arthrosamid® injection is administered. The first thing to say is it is done in the hospital environment, in the operating environment; it's done with you awake though. It is under local anesthesia. You come into the hospital in the morning. have the procedure, and you'll go home at lunchtime. A couple of hours before your injection, you will be given some antibiotics to take just orally, and then you'll come down to the operating room, where we will prepare everything. First of all, your knee will be cleaned, and then we do an injection of local anaesthetic around to numb the area, to numb the skin on the outside of the knee, and also to numb the lining of the knee joint. Next we will use an ultrasound machine, which they haven't pictured here. The ultrasound machine will guide the needle into the right part of the knee joint so that everything is going into the right place. Once we know that the needle is safely within the synovial cavity, we will then inject the Arthrosamid® gel into the knee. Now, for Arthrosamid®, the dose is six millilitres. But it's injected in six one-millimetre, one-millilitre syringes. Now, those syringes are attached to the needle that's already in the knee. So, we're not pulling the needle in and out of the knee six times. The needle is placed in the knee under ultrasound guidance. And then the syringes are attached to that needle six times to introduce the full dose of the Arthrosamid®. Once that's done, you go back up to the ward, have a cup of tea, and then you are up and about on your feet and go home later on that day.

Mr Mark Jones

So this is just a graph showing the clinical outcomes of offers amid. The three studies here show that the clinical benefit from Arthrosamid® comes along the highest at about weeks following the injection and can last anywhere up to four years on these current studies. And what it shows is there is a good benefit for most patients. The younger patients are the underpatients. Under-year-olds have a better outcome in terms of the benefits. So about % of patients who are under with knee arthritis will have a clinical benefit. In the overs, this goes down to %. But overall, for any patient receiving Arthrosamid®, about % of patients have a clinical benefit. from the injection.

So, frozen is the first and only approved injectable treatment that permanently combines with the knee synovial tissue, and it hopefully therefore decreases this vicious circle that we talked about earlier, so hopefully decreases the joint stiffness, diminishes pain within the joint, and hopefully allows for improved function of the knee. It’s a simple procedure that can be done in an outpatient setting. It doesn't have a long recovery period for time off work. And you can have a single pain reduction with just one treatment for up to four years.

So, what should you expect immediately after you have your treatment? Like I said, you leave the hospital the very same day. You may well feel that your knee is a bit tender and might sting a little bit on the inside. As the local anaesthetic wears off, it's common to have a little bit of discomfort in the early stages. Obviously, if that discomfort goes out of control, then you need to seek medical advice, but that would be incredibly rare. It's suggested that you carry on taking your regular medications and painkillers that you would normally take for your arthritic knee in the early stages. Like I said, you may well get some moderate pain and some swelling. Initially, your knee may feel a bit different as well. The Arthrosamid® is as thicker than the normal fluid that surrounds and bathes the inside of your knee joint. So, in the early stages, before it fully combines with the lining, your knee may feel a bit thicker and tighter than before.

Mr Mark Jones

So again, this is just another patient testimonial saying that they're very happy with the outcome of the arrows with injection.

Mr Alex Chipperfield

Sorry, I didn't realise these were animated. Let's get them. All of the question, all of these things back up on here so we can. Here we go.

So, the commonly asked question is, When do I begin to feel less pain? From the graph that Mark showed earlier. You'll see that it does take a little bit of time for the Arthrosamid® to bind, to integrate with the lining of the joint, and therefore reach full efficacy. Most people do start to feel a little bit better in the early stages within a couple of weeks. But it can take up to 12 weeks for the full effect to be felt. Getting back to normal activities. Basically, you do what feels comfortable with your knee. We suggest that for the rest of the week, you take things a little bit easy, don't go mad on it, don't play six sets of tennis, or go ski on a black run. But slowly build up your activities. as your knee feels comfortable. One of the things that you'll get when you're in the hospital having this injection is that you'll get a booklet that will take you through a rehab protocol, giving your ideas of what kind of exercises and movements you can do in the early, medium, and long term time frames.

Mr Mark Jones

So, there are potential side effects to any injection that goes into the knee joint. But with the clinical trials that have been ongoing over the last two decades, there's been no serious side effects. The most common ones are kinds of joint swelling, which takes a few days to settle down, just like any injections with steroid or hyaluronic acid can have. And this can last from several days to up to several weeks. And the safety profile has been looked at, and it's been established over the last years in all this research to show that it is safe and safe to use in all areas of the body, multiple indications.

Mr Alex Chipperfield

Not everyone is suitable for this injection, though there are some what we call contraindications, which is where you absolutely must not perform that. Typically, that's if you have an active infection in your knee or if you've had any other kind of injectable implant in the past. If you've very recently undergone surgery. If you have an uncontrolled bleeding tendency or condition or are on medication that cannot be reversed as far as bleeding goes, those are the times when you must not perform this injection. There tend to be a few sort of looser indications. Which is, if you don't think that there's going to be a good response, then it might not be something worth considering. We've already touched on the fact that people over 70 don't respond quite as well as the undergroup. That's just one factor that we look at. Another big factor that we look at though is that not everyone will have the type of arthritis that has this large synovial element to it. So, people whose arthritis doesn't particularly affect the lining of the knee joint or produce a lot of extra fluid and swelling around the knee. In those cases, there isn't much for the Arthrosamid® to combat. So typically, if you're someone who is older with less of an inflammatory response, then the likelihood of making a significant lasting difference to your symptoms with this will be less. These are the kinds of things that you discuss. in your clinic appointment.

Mr Mark Jones

Okay, so I think we're going to answer some questions now.

So, the first question on our thing is if the injection is successful and gives pain relief for say two years. Is it possible to have a top-up?

So yes, the basic answer is if you've got unwell with the first injection of your Arthrosamid®. And after two years, if it's starting to wear off and your inflammation is coming back again, then yes, you can have another injection of the Arthrosamid®.

Mr Alex Chipperfield

There's a couple of questions from, well, a couple of statements here from Betty. Thanks for sharing. The first one says you turn down cortisone injections because you were too scared. Hopefully not scared of needles but scared about cortisone. One of the issues with cortisone or steroid injections is that they can have an effect on the rest of your body, not just your knee joint. And so, it can affect the density of your bones. It can affect the thickness of the skin, and it can have an impact on the way that hormones react in your body. So having multiple large doses of steroids can be a problem in the long term. You're absolutely right. You then go on to say that you had a hyaluronic acid injection, and that really helped. That's good to hear. The big difference between I'll Arthrosamid® and a hyaluronic acid injection is the longevity of effect. Most people will find that the evidence for hyaluronic acid is fairly weak after about six months. It's something that needs to be topped up. If it works, then it will be relatively short, acting short to medium term. Arthrosamid®, if that works, like we say, it gives many years of relief rather than months.

Mr Mark Jones

So the next question is talking about: would someone with symptomatic hypermobility syndrome with a history of dislocations be a suitable candidate for Arthrosamid®?

Again, it comes down to what the symptoms are. If the symptoms are pain and the pain is associated with a bit of arthritic change, particularly to the patellofemoral joint from the previous dislocations, and that's causing an inflammatory response within the knee and a synovitis. And absolutely, Arthrosamid® would be a good option to try. So yes, I think it would be. But again, it would be for a discussion with you and your consultant when you see them in clinic to find out exactly where your symptoms are coming from and why you're getting them.

Mr Alex Chipperfield

Then we've got one saying, if you've already had a steroid injection. Is it still okay to have Arthrosamid®?

And the answer to that is yes, you had your steroid injection over months ago. That would be absolutely fine to have an Arthrosamid® injection if you were suitable.

Vicky

I think they also asked that she's recently had kidney cancer.

Mr Alex Chipperfield

Yeah, there was another paragraph that came up to the bottom there. I've also recently had kidney cancer and have had to reduce or more or less stop pain medications. Is there any reason why I can't have the Arthrosamid® cancer now gone but under review? Well, I'm glad it's gone and you're being followed up, which is the sensible thing. No, there shouldn't be any reason from what you've said; there'll be no reason why that would have any effect on your suitability for Arthrosamid® treatment.

Mr Mark Jones

So someone's getting knee swelling that appears after they play golf the next day; could Arthrosamid® be suitable for me?

Yes. I mean, again, we'll have to investigate with x-rays and look for some arthritic change, but if you're getting a few or swelling within the knee due to a synovitis type problem, then yes, again, the Arthrosamid® should work for that because it would dampen down that synovitis within the knee and stop that vicious cycle. getting back to playing golf after the injection. Well, as we said, it's kind of taking it easy for a couple of days, letting everything settle down, the fullness of the need to settle down. But it's getting back to things gradually and listening to your knee read about when you think you can go around, maybe not starting with the full 18 holes straight away but building up gradually to the 18 holes and seeing how you go over those first three months.

Mr Alex Chipperfield

Next one is another double question. After four years, can you have another injection, or is it just a one-off treatment?

We touched on that before. Yes, as long as you are still suitable, then it is possible to have a top-up dose later down the line. And then the next part of that is, can you potentially go back to impact sports? The answer to that, again, would be yes. I mean, this isn't what you have to remember, though, is that none of these treatments are a cure for arthritis. You will still have arthritis in your knee after you have an Arthrosamid® injection. So there will be some limitations that that knee arthritis gives you now. Arthrosamid® will help with the pain and the swelling, but the mechanical symptoms—you may still have stiffness and feelings of instability as well—are these kinds of things. that you know that are because the joint is worn away and the Arthrosamid® injection won't have an impact on that. So I would suggest that you absolutely can get back to exercise. You may not be able to get back to all exercise to the same degree that you had before you had arthritis.

Mr Mark Jones

So a good question here has come in about I assume Arthrosamid® is not relevant to those who've already had, as in my case, replacement and half knee replacement?

So at the moment, that's correct. Anyone who's got any implants within the knee has a contraindication to having the injection. I reckon studies will be coming out fairly soon looking at the injections in patients with maybe a painful total knee replacement or painful half knee replacement. Because again, it's that sign of arthritis within the knee that the Arthrosamid® focuses on, and sometimes pain from a total knee replacement can cause synovitis. And I think our resume probably does have a role to play in those painful total knee replacements. So not yet, but potentially in the future.

Mr Alex Chipperfield

I'd agree with that. Watch this space. Has it been used for people with a high BMI?

Absolutely, it has. It's one of the things that it can be used for as an alternative to surgery for people who are not suitable for surgery for whatever medical or health grounds. One of the limiting factors, unfortunately, for joint replacement surgery is having a BMI that is too high for the institution where you want to have surgery yet. So a non-operative treatment such as Arthrosamid® can be useful in patients who would otherwise not be suitable for surgical intervention.

Mr Mark Jones

What is the best time to have the injection?

Well, again, it's looking at the reasons why our frozen midweek works. It works in those patients with synovitis and inflammation within the knee. So if you've got an inflammation within the knee that's causing this swelling, then taking the Arthrosamid® at that point to dampen down that inflammatory response is probably the best time. particularly at the time if we know that there is an effusion or swelling within the knee, we take fluid out of the knee at the same time as then injecting the Arthrosamid®. So I think that's probably the best time. I mean, it's just really what's best time for you, which is why I'm fitting it into your life about coming in for an operation or a day-case procedure, but in terms of the symptoms, I think it's when you're symptomatic enough to want something done, and the indications are needed for that.

Mr Alex Chipperfield

Sandra says, I take rivaroxaban. Is there a way I can proceed?

Absolutely. I said that there was a contraindication for people who have uncontrolled bleeding tendencies. Rivaroxaban is a blood thinner that you would take for probably an irregular heartbeat or something like that. And what we would suggest that you do is that you would omit your rivaroxaban for 48 to 72 hours prior to coming for the injection, and then you could start it again the evening after you've had your injection. So yeah, it's entirely possible to go that way.

Mr Mark Jones

And I think the next question is fairly similar: is someone on a low dose of a fixed plan prevented?

No. So same response.

So can you have a joint replacement after the injection?

Absolutely. Obviously, there's a small risk of any injection causing an infection, and putting a joint replacement in the knee, we'd worry about a high risk of infection. But as long as we leave at least three months after the injection, potentially up to six months after the Arthrosamid® injection, then a total knee replacement is not contraindicated.

Mr Alex Chipperfield

I mean, the idea is that this would minimise your symptoms, so the need for joint replacement surgery would be much less. Typically, you would hope that you would get years of relief before you start thinking about joint replacement following this.

Do you need to have an x-ray before having the injection?

It does help. It helps us grade the level of arthritis that you have. And also confirm the diagnosis. Again, when I was talking about suitability for this injection. If you have severe bone-on-bone arthritis in all three compartments of your knee joint. Then it may well be that injection therapy is less likely to work with you. So an x-ray is useful diagnostically but also prognostically, giving us an idea of how you may respond to the injection.

Mr Mark Jones

So someone's asking if it would be suitable for chondromalacia or is it only suitable for arthritis? Well, technically, chondromalacia is a low-grade arthritis. It's not the bone-on-bone arthritis, but you can still get the arthritic-type pain with the synovitis and the effusions within the knee from the chondromalacia. So again, it's discussing those symptoms with your consultant in clinic and coming up with a plan. But potentially, yes, it would.

Mr Alex Chipperfield

We've got one that says, Is it possible to have both knees done in a single treatment?

Of course it is. Not a problem at all.

There was another one I just wanted to address above, which is a specialist. The MSK doctor has told me that Arthrosamid® may have an adverse impact on future replacement surgery if that becomes necessary. Is that correct?

No, that's not. I mean, we discussed it earlier. Having any form of major operation after an injection very soon after an injection does come with a slightly increased risk. But once that window has passed, there's no evidence that an Arthrosamid®-injection in your past has any impact on the success rate or longevity of your joint replacement.

Mr Mark Jones

We're getting sort of flicking around. Prior to the procedure, do you need a knee scan? My last scan was nine months ago.

Again, nine months is not that long ago. And if there's still the arthritis and the pain you're getting. And we know from the MRI scan or the x-ray that you've had that there is a diagnosis that we can work with, and potentially you wouldn't need any more scans. It depends on the consultant in the clinic.

Mr Alex Chipperfield

We've got two questions here: two people, two ladies who have previously had hyaluronic acid injections. One says I previously had an injection, and it didn't help. Could I still try Arthrosamid®? The other one says exactly the same; hyaluronic acid didn't work for me. Is it therefore less likely that Arthrosamid® will work?

The confusion lies in the hyaluronic acid; people often talk of it as a lubricant or a gel that's ejected into the knee. The mode of, forgotten the word now. The way it works is a completely different way from the way that Arthrosamid® works. Just because hyaluronic acid wasn't successful doesn't necessarily mean that Arthrosamid® won't be successful. The more important factors, like we mentioned earlier, are about the severity of the arthritis in your case. the amount of inflammatory symptoms that you're getting, and also age becomes a factor as well. But just because you've had a failed hyaluronic acid injection doesn't mean that Arthrosamid® wouldn't be suitable. I think the best thing to do would be to come along and be assessed in the clinic and have a conversation at that stage.

Mr Mark Jones

The next question is, do I have a job for us in the same leg as the bad knee while you're streaming on my knees still work? Yes, there's no reason why if there's no reason why someone with a drop foot's not going to have the knee arthritis, which has the inflammation, and the Arthrosamid® would work as well.

And then that was a quick one. So will the initial consultation identify suitability for the Arthrosamid® injection?

We'll see you in the clinic. We'll assess your knee, take a history, get some imaging and some x-rays on the day if we need to, and we can then come up with a plan with you and see whether you're suitable for that injection.

Mr Alex Chipperfield

There seem to be lots of questions coming through about people who've had hyaluronic acid injections that haven't worked. or one that has worked but now worn off again. The answer is yes; as long as you're appropriate, you're suitable, and then of course you could have an Arthrosamid® injection.

One from David says, I have a meniscus tear too. Will this help?

The Arthrosamid® won't help with the meniscus tear. Typically, the kind of meniscus tear that you'd be talking about would be what's called a degenerative meniscal tear. Which is when the meniscus in the knee starts to degenerate and fragment and split and tear as a result of the arthritic process. Now, quite often, the reason for the way that meniscus tears are symptomatic is twofold. Firstly, they can irritate and upset the inside of the knee joint and cause a lot of inflammation. And the Arthrosamid® would certainly help with that. The other way that meniscus tears can cause trouble is that they can cause what we call mechanical symptoms. So clicking, clunking, locking—feelings of instability in the knee. Arthrosamid® is less likely to be able to deal with those symptoms. So the answer to that question would be yes and no.

Mr Mark Jones

Can I have a knee replacement?

So we discussed that once the effect is finished, yes.

So severe arthritis, which can only be managed by pain relief and ultimately rectified by replacement surgery, but I do not get any real swelling in my knees.

Again, it depends. As surgeons, we'll assess your knee and see whether there is any swelling within your knee; whether there's minor swelling, even the small swelling, you may not notice on yourself, but we can assess that in the clinic. But actually, if you're not getting the swelling within the knee and getting that synovitis and the swelling associated with that, then Arthrosamid® might not be suitable for you.

Mr Alex Chipperfield

I think with all of these things. We have a discussion looking at the risks and benefits. I mean, this is a treatment that will cost you money. And in my book, you have to be confident that there's a more than chance that it will make a significant difference to your symptoms for a significant period of time because you're spending your own money.

So, you know, we spoke about the over 70s and the under 70s. If you look at the data, overs, there's still, you know, two thirds of people over are getting good relief. They're just not the they're not; you know, it's not 80% of people like in the under 70s. So it's all about weighing up the risks and benefits and your particular personality, the personality of your knee, and the personality of the symptoms that you're getting. Ultimately, we're looking at a low-risk procedure that is minimally invasive and has a low morbidity. So those are all on the plus side. On the minor side, like we said, it doesn't work for everyone, or the chances of it being successful may be slightly less. But ultimately, that is a conversation that we would have in the clinic and a decision that we'd come to in a shared way.

Mr Mark Jones

This next question is, I've been told that maybe I'm too young to have major knee surgery and can't have any more steroids or arthroscopies too young. I'm having pain management with a high BMI. Would this have a negative effect?

Well, no. So if you've got arthritis and you've been told by a surgeon that you're fairly young and trying to postpone major knee surgery such as knee replacement is in your best interests, then actually having an Arthrosamid® injection if you've got this inflammation within the knee would help, and particularly the younger you are. We know this has a better outcome, with 80% of patients under the age of 50 having a clinical benefit from Arthrosamid®. So actually, it'd be worth coming along to have a discussion and seeing whether you would be suited because it is different from a steroid injection. And it's not major surgery, so it may tick all your boxes.

Mr Alex Chipperfield

Another one: can you have this if you are diabetic?

Yes, you can; as long as your diabetes is under control, then that's absolutely fine.

Mr Mark Jones

How do you assess if it has worked besides feeling better? Do you look at MRIs or scans?

So basically, we assess you via your clinical symptoms. We will assess you to see whether you're suitable for it. And this is looking at either your x-ray, looking at the MRI scan, and also on your clinical examination to see if you've got this swelling within the knee. But then clinically afterwards, we assess your symptoms and see whether your pain is getting better and whether your quality of life is improving because of it; your stiffness is going from the knee. And actually, you think, I'm happy I've had this injection and I've gone through with it because that's really what we want. And that's the studies I showed you earlier looking at the results; that's all looking at what we call their problems. Basically, they're questionnaires looking at patient outcomes and assessing knee pain scores, and those clinical benefits are all improvements in that score to show that the pain is better. So we don't rescan or anything to find out what your effect is. We talk to you in clinic and follow you up at about three months to find out what your outcome is.

Mr Alex Chipperfield

Yeah, ultimately, it's your symptoms that the only reason for doing this is to help with your symptoms. So that's how it's monitored. Now, the way we do that is a little bit more prescribed than just asking you how you are. One of the things that you're doing while you're waiting for your antibiotics to take effect, waiting for the injection to happen, is you'll be given a brochure to sign up to an international registry where all patients who undergo this treatment or any kind of joint-preserving treatment are monitored and followed up for an extended period of time. That's how we get all the evidence as to whether or not a treatment is effective and how long it is effective for. It's anonymous and voluntary, but it is a very helpful thing to do. You'll be given questionnaires looking at your symptom level and your function level of your knee pre-injection and then at periods of time following that injection as well. So that's how we monitor you essentially.

Mr Mark Jones

I'm 72 with osteoarthritis; knee mobility is becoming less, and I also have lymphoedema.

Again, the whole thing. You're, so you've got a slightly lower chance of it working, but it's still two-thirds of patients over the age of do have a good benefit. The lymphoedema doesn't give a contraindication. So it's just seeing whether you're the suitable patient in the clinic.

Mr Alex Chipperfield

We've got another question about having it after you've had a knee replacement. This is potential for the future, but it is not part of the treatment profile for Arthrosamid® at the moment. So it would be an off-license treatment, I wouldn't, and we wouldn't go down that path at this stage.

Mr Mark Jones

So I'm currently seeing the physiotherapist that then is in, and my kneecap is fused. I've had four arthroscopy procedures and am still having joint pain.

But again, this sounds like an arthritic knee joint around the patellofemoral joint. And again, if you're the suitable candidate with information in the knee and we feel it appropriate and you don't want to go down the surgical route, then getting Arthrosamid® would still be a benefit potentially.

Mr Alex Chipperfield

One says, I've lost weight, but I'm still overweight. Is it better to be lighter before having this injection?

For your knees in general, it's better to be lighter. The less pressure you're putting through a damaged joint, then the less pain you feel. So yes, the answer is yes. Technically, it doesn't make any difference to the person performing the injection; the ultrasound will guide us into the knee no matter how padded it is. But the response that you get If you are lighter, if you're putting your knee through less stress, then your knee will in general feel better.

Mr Mark Jones

If you have your Arthrosamid® injection, can you have any treatment on your knee?

We've covered this. So again, it's about waiting a certain amount of time after the injection to then have particular treatments such as knee replacements or other management of this knee.

And again, almost a similar question. So you have to wait months after steroid injections to have Arthrosamid® injections.

No, not 15 months. I would probably say, you know, Arthrosamid® injection hasn't worked. I'd probably leave it six months to see if you get any clinical benefit. And then, if you really still don't want surgery and want to try something else, a steroid injection at six months.

Mr Alex Chipperfield

Probably is okay Yeah, I would say I would go for six months. What are the typical signs my arthritis is synovium-based rather than another type of knee arthritis?

It's a great question. Essentially, so the synovium is the lining of the knee joint. And it extends up beyond the kneecap towards the lower end of the thigh and around the front and the back. Typically, the synovial picture would be one where everything around the knee is very swollen, tight, and inflamed. You may well experience some swelling at the back of the knee called a baker's cyst. This is often a sign of an excess amount of fluid and inflammation around your knee. The normal bony type of arthritis would be very much more; there's a single point of tenderness either located to the medial front or lateral side of the knee joint. So the synovial picture that we're looking at is much more than he is angry and inflamed. generalised egg and pain extending above the kneecap. further up to up the thigh.

Vicky

We'll just take a couple more questions.

Mr Alex Chipperfield

Yeah, we've got four minutes.

Mr Mark Jones

How does Arthrosamid® stay in the knee joint? Doesn't the body try and get rid of it as a foreign substance?

Well, so Arthrosamid® is a hydrogel that binds with the synovial cells and actually integrates with them. So this actually becomes part of it and is not recognised as a foreign body for the body to get rid of. So it does stay within the joint. And that's why we call it an implant. And that's why we take you to the theatre to give it to you in a clean environment and give antibiotics beforehand because, obviously, with an implant, we don't want it. We want to reduce the risk of infections as much as possible.

Mr Alex Chipperfield

I have no Mr Alex Chipperfield and previous medial ligament repair. Do you think that this treatment would be suitable? Knee swells during the autumn winter months, but I do my best to try and live my life to the full.

Good. Keep living your life to the full. That's the most important thing. Your knee has a couple of the main stabilisers that have been damaged in the past. So your crucial ligament, your medial ligament—they're some of the things that keep your knee stable. So if you've lost them or they've been damaged, the most important thing is to keep everything else that's wrapped around your knee as strong and as supportive as possible. So keeping those muscles good and keeping the remaining tendons as healthy as possible would be useful. Arthrosamid® won't have any effect on the stability side of your knee. But if you get inflammatory symptoms as well, which it sounds like you do, then the Arthrosamid® would certainly help with that. And that may well allow you to stay more active to keep everything else as supportive as possible.

Mr Mark Jones

So there's one question here about what can it be used in other joints?

So not at the moment in kind of normal clinical use. So at the moment, it's only licensed for use in the knee. But I think in studies, particularly Arthrosamid® is keen to perform more studies around the country and is trying in maybe hips and ankles. But again, they would be in a research project rather than for normal clinical use. So not at the moment.

Vicky 

Okay, I think we'll take one more question.

Mr Alex Chipperfield

One more. Okay, let's go for Jeremy. Jeremy, you're lucky you've got the last question of the evening. Does the degree of wear on the joint determine if this would be a better choice than surgery, i.e., grades one to four?

So what we're talking about there is the x-ray grading, the severity of the damage to the surfaces of the bone in arthritis. And when people talk about arthritis, you may hear terms like bone-on-bone arthritis. That is when the normal smooth coating on the ends of the bones has completely worn away and you have the bone scraping against the bone. That process is a gradual one, and you can grade it from grade zero, which is nothing wrong, to grade four, which is the bone on bone level. As I already mentioned. The severity of that bony element of the arthritis is another factor that we talk about when we're weighing up whether or not Arthrosamid® would be suitable for you. So typically, what we try to say is that people with mild to moderate degrees of joint space narrowing or grades of arthritis tend to perform better than people with more advanced. So, you would look at grades one, two, and three as being more suitable for someone who has a grade for degenerative change. So, if you had grade four bone on bone arthritis in all three compartments of your knee, along with little in the way of inflammatory symptoms. and you are over, then the likelihood of it being the right thing for you is significantly less. I don't want to end on a negative. But that was the name pulled out of the hat there.

So, here's a positive. You get a free knee pain consultation.

Vicky 

Yes, sorry. Sorry, we didn't answer all your questions. We're just inundated, so if you provide in your name, we'll answer yours via email. Obviously, you can make an appointment to see one of our consultants here. So as a thank you, as Mr Chipperfield said, for joining this webinar. We're going to be offering a free knee pain consultation for a limited period. call back from one of our private patient advisors. We'll also send you an email tomorrow with a recording, treatment information, and loyalty reward points. and update on news and future events as well at the hospital. And so, we'd be really grateful if you could complete the survey in this session. It really helps us to shape our future events. And if you'd like to discuss further or book your consultation, our private patient team is available to take your call until 8 pm. this evening. or between 8 a.m. and 6 p.m. Monday to Friday using the number on the screen. Our next webinar is on knee replacement surgery with robotic assistance, and you can sign up for this via our website.

So, on behalf of Mr Chipperfield and Mr Jones and the expert teams here at Benenden Hospital, I'd like to say thank you so much for joining us today, and we hope to hear from you very soon. Thank you very much.