Philip Orrell

Okay, good evening, everyone, and a very warm welcome to our webinar tonight from Benenden Hospital.

This evening we’re covering the topic of hip and knee replacement surgery. I'm Phil, I'm your host for this evening and I'm joined by our expert presenter Mr Alex Chipperfield, who is our Consultant Orthopaedic Surgeon.

If you’ve never been in to our hospital and just to give you an overview of the format of the session, Alex Chipperfield’s presentation will last 30 to 40 minutes approximately and that'll be followed by a Q&A session and you could submit your questions for the Q&A session throughout Mr Chipperfield’s presentation or at the end of the presentation. You can do so using the Q&A icon at the bottom of your screen and you can submit your questions anonymously or you can give your name and we should remind you at this point that if you do give your name that this session is being recorded.

If you would like to book your consultation, we will be providing contact details at the end of this session.

That's enough from me for the time being and now I will hand over to Mr Chipperfield.

Mr Alex Chipperfield

Thanks, very much. Good evening, everyone. Thanks for thanks for dialling in tonight, my name is Alex Chipperfield, I am a Consultant Orthopaedic Surgeon here at Benenden and I'm going to talk to you today about hip and knee replacement.

So essentially, I'll talk a bit about myself first of all and then about where we are today at Benenden hospital and then I'll give you an overview of hip replacement surgery and knee replacement surgery, looking at both conditions, both treatments going through the causes, consultation, treatment options and likely outcome of surgery and then there'll be the Q&A session at the end.

So me I'm Alex Chipperfield, I qualified in London as a doctor in 1997. I trained in the South East of England and then before I became consultant I did a fellowship in hip and knee replacement surgery in Sydney, Australia. Being a consultant here in Kent since 2010 and surgeon here at Benenden for the last 11 years and the hip and knee lead at Benenden now and also a member of the hip society. I specialize in primary and revision hip and knee replacement surgery.

If you don't believe me you can look me up on the internet, these are a few websites and pages where you can look at me and read about what people have said about me and where we work as well.

I’m a high volume surgeon, so I do a lot of hip and knee replacements, it's how I spend most of my time. I did six of them today, so we do we do a lot here at Benenden and it works out that I do probably about three times the national average of hip and knee replacements compared to other surgeons around the country. So I do them regularly and we know what we're doing at Benenden Hospital. Here we're the leading provider of hip and knee treatments in Kent and Sussex according to the PHIN last year and I think, I don't know if any of you have been to Benenden but you'll find that it's an it's a clean and calm environment it's a nice place to be, it's a nice place to come and visit there's an experienced team of consultants and therapists and nurses and we get frequently we get high patient satisfaction rates, partly due to the quality of our surgery and the warmth of our welcome but also because of the rapid recovery program that we have in place here that allows people to get back on their feet quickly following this kind of operation.

It's not just me who works here, there are more of us here who perform hip and knee surgery. There should have been one of, I'm not going to name names, but one of these people one of this gallery was meant to be talking about knee replacements this evening, they got called away on an urgent skiing holiday, so I'm going to do both today.

If you look at how many operations are performed here at Benenden annually, you can see that we perform almost 2,000 hip and knee replacements per year which is head and shoulders above most of the institutions in Kent and Sussex.

So I'm going to start by talking about total hip replacement, I'm going to talk a little bit about arthritis of the hip and then I'll go through the consultation process, what treatment options we normally discuss at the surgical journey and then what particular risks and problems are associated with this kind of operation.

So osteoarthritis of the hip is basically what we call wear and tear, it's when the hip joint wears out, it tends to be of gradual onset, it kind of creeps up on you really. However, it can come on very acutely the typical decline that you see in most patients every now and again, you'll see someone who's absolutely fine until they're not so the the pattern of onset can be it can be gradual, can be sudden, can sometimes be related to a trauma, there tends to be no specific single cause for osteoarthritis, but family history is a is a huge one. As is occupation, sporting, activities, weight and previous injuries. There's no treatment for arthritis as in there's no cure, there's no pill that you can take that will make it go away and there are many ways that you can find to live with and deal with arthritic joints and joint replacement is very much the last resort. When all of those different treatment modalities have failed the the number one aim when you're dealing with arthritis of the hip is to try and preserve the joint surgery is very much a last resort, the average age for someone in England to have a joint replacement being hip or knee is 69 years old, this is average and we get people from teenagers to over 100 who end up needing joint replacement, hip replacements and what I've noticed over the last decade or so is that people are getting younger and people are getting to this the time where they need surgery at a younger age than they were when I when I started out.

So what happens when you first come through the doors, well there's an initial consultation, you will have been referred here either through your GP or self-referral through contacting the hospital directly and the the purpose of that consultation is to get to know each other really, to figure out exactly what the problem is what your limitations are what your expectations are and whether or not there's anything that can be done to help. We take I take a detailed history of your problems and the pattern of symptoms that you have and we also look at your previous medical history as well, we take a thorough physical examination and we take some imaging as well. Generally that would involve x-rays, x-rays are instant and available on site, we also have different imaging modalities like MRI scans and CT scans, they tend not to be instantaneous, often we have to book them generally the plain x-ray will be at the initial in investigation, if any further imaging is required then we will arrange that here, once all the imaging is in place, once we've got the history, once we've got the examination, once we know what's going on and what can be done, then we can talk about how best to manage your problems.

Treatment options with arthritis of the hip, generally the the first thing is if if you are overweight and by overweight we mean seriously overweight, this is we're talking about a body mass index of over 40 which is classified as being obese, if you if you do have a BMI over 40, the number one thing that you can help to do is is lose weight, this takes pressure off the joint, makes things feel better but it also puts you at a lower risk of developing problems during and after the operation. Most private hospitals will have a cut-off point as to a body mass index that they are happy for patients to come along for planned surgery and that tends to be around forty as well. The non-operative treatment options are things like physiotherapy, activity modification, exercise and painkillers in the form of anti-inflammatory medications, either tablets or gels that you rub on and also painkillers, whether they be pills or patches to try and alleviate the symptoms. Alternative therapies such as acupuncture, reflexology, all this kind of stuff again very useful and very helpful to help someone live with a painful arthritic joint. Sometimes you may be suitable for an injection into the joint, this tends to be more common with arthritic knees rather than hips, arthritic hips you there's a very special set of circumstances required but we do perform steroid injections into the hip joint, this tends to be done in an operating theatre under a heavy sedation or a general anaesthetic if those non-operative treatments either fail or they stop working and if your quality of life becomes unacceptable then you'd be looking at surgical intervention and around the hip the the main surgery.

So, the surgical journey starts with that consultation, with what we call prehabilitation so making sure that you're fit and healthy enough for the operation, starting to exercise, starting to move before the the surgery takes place. The the stronger you are, the more mobile, the more supple your joints are, the stronger your muscles are that are surrounding your joint before the operation, then the the quicker you will recover afterwards. So that's a very important thing to get moving as much as possible, you'll have a what's called a pre-assessment appointment where you meet the nurses the physiotherapists and quite often the anaesthetists as well and that will be basically an MOT to make sure that it's safe for you to have your surgery performed in a private hospital such as this. That pre-assessment will involve a pre-optimization looking at control of chronic diseases such as blood pressure or diabetes to make sure that everything is safe to proceed with surgery, the pre-operative phase is also where the education and planning of our rapid recovery protocol.

The surgical journey itself, you'll come into hospital on the day of the surgery. We tend to, although we operate all day, our operating lists are split into morning and afternoon sessions, so you will either be admitted early in the morning at 7am or around lunchtime, depending if you're having your surgery in the morning or the afternoon. Typically, the kind of anaesthetic you will have for a hit or a knee replacement is what's called a spinal anaesthetic, that's where you have an injection into the lower part of your back, which puts your legs to sleep. Now a lot of people are concerned about a spinal anaesthetic, they're worried that they will be awake during the operation, they're worried that they will hear all sorts of banging and crashing and unpleasant noises and sensations and just generally not be comfortable in in the operating theatre. This generally isn't true, on top of the spinal anaesthetic you will also have some heavy sedation as well, so at a minimum feel a pleasant floating sensation, but most of the time people are pretty much asleep during it and remember absolutely nothing following it. Immediately after the operation you'll then go into the the recovery ward where you'll be closely monitored to make sure that you're that your observations are stable following the surgery and then you'll go back up to your room on the ward, you'll be in hospital for either one or two nights following your operation, we tend to see that more and more people are going home the following day, which is which is pretty impressive actually. You'll be allowed to fully weight bear immediately after the operation as soon as your legs wake up from the anaesthetic, we will get you up and about and give you that confidence even on day zero that you're standing that your hip replacement is strong enough to hold your weight and that will help with your early recovery and discharge and whilst you're an inpatient you will receive lots of intensive physiotherapy as well to get you back on your feet and get you comfortable and confident to get back out into the world once you're discharged from hospital.

So day one post-operatively, you'll have an x-ray, you'll be reviewed by the ward doctors and also by your surgeons will get you up and about, we'll we'll be going up and down the stairs, we'll do blood tests, we'll do X-rays and quite often like I said more often these days you'll end up going home that day. If you're in for day two, you'll have more physiotherapy and again once once you're safe and comfortable to go home you'll get to go home. When you do go home you'll go home on medication, that medication will include painkillers, it will also include a course of blood thinners or anticoagulants. These are prescribed routinely following hip and knee replacement surgery to minimize the risk of blood clots in the post-operative period. You'll be seen as an outpatient by this physiotherapist and you'll also be seen by your surgeon again normally at about six weeks post-operatively, there's mention of hip precautions at the bottom here for the first six weeks, generally there's a list of of things that are advisable that you don't do in the early stages following a hip replacement. The trouble with hip replacement surgery is that it is so good at rapidly getting rid of people's chronic pain that they equate the loss of that pain with recovery from the operation and trying to run before they can walk, this operation does take time to get over and the muscles and tendons around your hip need time to strengthen and to rebuild and to heal following the surgery so it's important you don't do too much too soon.

At the six-week post-op appointment, most people following hip replacements at six weeks actually they walk unaided at that stage, most people seem to get rid of their crutches or sticks at about three or four weeks after the operation, driving it depends on a which hip you've had done and you know what kind of car you've got whether or not it's safe to drive, essentially you need to be able to control the vehicle with your right leg you need to be able to stamp on the brakes to perform an emergency stop without hesitation, generally is around about the six week period but everyone is different, everyone recovers in it at a different rate, some people it's a couple of weeks some people it's a couple of months really what feels best for you.

There are complications associated with the surgery, it is a big operation to go through and although it is big, it is routine, we do them day in day out but complications problems do occur. The thing that we worry the most about is infection, infection is a potentially catastrophic problem following any kind of joint replacement surgery and can result in multiple subsequent operations including having to remove an infected joint, so it's a it's a big bad thing to happen to someone is something that we take very seriously. The infection rate here at Benenden is the one of the lowest in the country but it's not zero and people do get infections and if you do get an infection then we have to deal with it. Blood clots I've already mentioned there are really two types of blood clot, one is called a DVT which is a blood clot that you can get in the lower leg that can give you pain and swelling in the in the calf muscle but not much more than an inconvenience, the problem blood clots are the ones that form in the lungs so I called it PE or pulmonary embolus and they can be potentially catastrophic. So everything about how we prepare people for surgery and how we treat them during and after the operation is designed to minimize the risk of blood clots, but it doesn't completely eliminate it the other complications that can occur, you can have damage to the nerves that supply the skin or the muscles around the leg. A hip replacement in its early stages can dislocate, can pop out of joint, that tends to be why we tell people to to take things easy to start with while everything heals and so you can minimize the risk of dislocation. It is possible to change the length of your legs during surgery, we tend to plan to restore the the length of the leg back to how it used to be before you developed arthritis, but sometimes people can feel a bit longer or a bit shorter after this operation. Another complication wear and loosening that's not really a complication that's simply a fact, artificial joints even modern artificial joints with incredibly long lasting and hard-wearing bearings they still do wear out eventually so the younger people are and the more active people are following joint replacement surgery it is more likely that the hip joint may wear out, modern implants the last decades but not forever.

Whistle stop tour of hips, now we're on to knees. There's there's quite a lot of crossover between the two so I'll skip through those things.

Again, it's a common operation again around 100,000 are performed in the UK and about a thousand of those happen here at Benenden, again the average age is mid to late 60s, there's a slight slight majority of ladies having both hip and knee replacements compared to men, again they're very good operations and the overwhelming majority of people feel better for having had them done and again they last an incredibly long time.

Reasons for knee replacement, again the commonest reason that we see is arthritis and that kind of arthritis that we deal with most is the osteoarthritis, the the wear and fair kind. There are other forms of arthritis, inflammatory arthritis, these are more of a disease that affects your body and can affect your joints and wear them away. The commonest of those inflammatory arthropathies is rheumatoid arthritis, there's been a dramatic change in the treatment of rheumatoid arthritis since I became a doctor in the last 25 years, the treatment or the treatments available with biological agencies really revolutionized the treatment of rheumatoid arthritis and at one stage when I started about one third of all joint replacements with a rheumatoid arthritis now it's about one percent, so there's been a huge huge advances in the treatment of rheumatoid, leading to less people with burnt out worn out joints from rheumatoid. There are other inflammatory conditions such as gout and pseudo and gout that can also lead joints and knee joints post-traumatic is another another reason for developing arthritis needing surgery either broken bones or severe ligament injuries can cause instability of the knee joint leading to premature wear.

Again the aims of any kind of treatment including knee replacement are to get rid of the pain to allow you to mobilize more and get back to living your life really, the other thing that we can do especially with knee replacements there's a couple of examples at the bottom of the screen there of what we call a varus knee and a valgus knee so your legs can either bow outwards or you can develop quite a severe not need deformity with with arthritis and knee replacement surgery will restore the normal mechanical alignment of the knee. Again I mentioned with hips we're seeing a lot of younger patients so people the average age is is dropping and younger people want to do more so people have a higher function higher demands greater expectations so all of these with advances in technology and hardware and implants along with rapid recovery we're trying to meet those with technology to try and improve outcomes and the longevity of implants.

The symptoms of knee arthritis, pretty similar to hip really the main thing is pain along with pain is stiffness generally it it starts off with with pain with activity but then develops into pain at rest and night pain and particularly is a there's a bad sign with stiffness then leads on to deformity reduced function you can also get creaking and grinding and clicking and swelling of the joint with particular patterns of arthritis you can also get quite severe feelings of instability in the knee as well and once you lose faith or trust in your knee, it's very difficult to to continue living with it and the way it is treatment options again you break into either surgical or non-surgical the non-surgical options again activity modification, exercise, movement, weight loss, physiotherapy mapping and bracing people can find useful as well and again painkillers and anti-inflammatory medications. Injections, there are there are more injection options when it comes to knees as opposed to hips, injections again you can do anti-inflammatory steroid injections there are also lubricants that you can inject into people's knees to try and allow them to move a bit more freely there are also newer newer injections that are being developed things like PRP and stem cell therapy at the moment these are experimental but this is where the the future of injectable therapy goes they're suitable for a very small number of people at the moment and not common practice and not generally funded by insurance companies they have to be self-funded. As far as surgical options go you can realign the knee joint to take the pressure off worn areas that is quite a rare thing to do here at Bennington it is it's rare that we see someone who is suitable for that kind of surgery keyhole surgery can be useful in the early stages of arthritis not to deal with the arthritis itself but to deal with some of the consequences of arthritis such as degenerate tears in the cartilage or loose bodies floating around or smoothing off rough surfaces to try and improve movement and function in the knee but the Mainstay of surgical treatment of arthritis is joint replacement.

Now knee replacement there are there are lots of different types of knee replacement, whether you replace part or or all of the knee and ultimately that depends on the particular pattern of disease in your particular case. If you are suitable for a partial knee replacement such as an Oxford medial unicompatmental knee replacement, then generally my advice would be to to have a partial knee replacement if suitable, these are slightly less of an operation but more importantly they they tend to feel a bit more natural than than an artificial a total knee replacement can. When it comes to total knee replacements they there are different brands and different types and different ways of performing this kind of surgery, there are many different innovations looking at trying to make knee replacement surgery more accurate and I'll talk about them a little bit later on, the bottom part talking about constrained knee replacement these are the extreme operations when you're either talking about redo surgery or in people who've got severe deformity or multiple ligament failures again they're they're fairly highly complex specialist operations that it's rare that we do them on site here.

The the commonest form of knee replacement surgery that we do here is a Vanguard knee replacement, that's the brand name and there's two pictures of them there it's manufactured by a company called Zimmer Biomet, it has the OD rating which is a safety rating to see how how well these things work and the Vanguard has the highest OD rating that is possible, looking at the figures, looking at the activity and survivorship of this kind of knee replacement, these again say last decade were 97% 10-year survival for this kind of implant so they're incredibly reliable, long-lasting, things they are cemented we use what's called cement to fix them in it's not actually cement it's actually an epoxy resin that acts as a grout an interface between the bone and the the metal that under surface of the metal implants to to hold everything in place with or without patellar resurfacing so you can replace the the under surface of the of the kneecap as well I tend to do that about 75% of the time every now and again someone's knee someone's knee is worn everywhere apart from the kneecap in which case we can leave that kneecap alone and just replace the the rest of the knee itself.

I mentioned about new technology, different ways of people trying to increase their the accuracy of this kind of operation customized knee replacements have been around for a couple of decades now actually and I think the fact that they've been around for so long but still are a fairly niche procedure tells you really everything you need to know about them the amount of customization and personalization that you can achieve with standard knee replacement implants means that it is very unlikely that you need to have one specifically built for you. The times when customized implants really come into their own are in cases of extreme deformity or in revision surgery, navigation and robotic surgery are essentially the same thing these are this is a picture on the screen there this is a Rosa who is a she is the one of the companies knee robots robotic surgery or navigation surgery is all designed to try and make the cuts in the bone as accurate as possible to try and allow you to implant the knee as accurately as possible. The the jury's still out on whether or not robotic surgery is or benefit it is a procedure that is being driven quite aggressively at the moment by the companies by the implant companies that manufacture their robots and the implants and there's uptake of it in several centres around here at Benenden it's something that we are looking at I think it's important not to jump on a bandwagon and we are looking at ways of implementing it if it will be of benefit to patients without causing it to be prohibitively expensive.

What happens after the knee replacement, well the same as same as the the hips really you are monitored down in the recovery area and then back up onto the ward knee replacements pain management's very important and that will be with painkillers also with ice packs to try and help alleviate swelling and tightness around the knee mobilization physiotherapy working on getting your knee moving and bending again the normal checks of blood tests and x-rays more likely to stay in hospital for two nights than a hip replacement would but again A reduced Hospital stay due to the rapid recovery program getting you up and about afterwards and again going home with the normal anticoagulant medications and follow up with the physiotherapists and with your surgeons. As with a hip replacement again the risks of knee replacement similar to those of hip replacement the the one the one complication that is more specific to knees than hips is stiffness or swelling or stiffness in particular knee replacements in the early days are quite painful and the success of a knee replacement depends on getting a good range of movement in the early days so in the first month or two it's important to get your knee moving as quickly as possible the trouble is that it's painful and people can get stuck in those early stages and people will end up with stiffness as scar tissue forms around the knee before the range of movement has been achieved in that case sometimes you need further further help surgery to break down that scar tissue to try and get the knee moving again so stiffness of the knee is a is a a complication that you can see again infection again wear and tear and revision surgery again needed towards the end of the knee replacement's life which many decades down the line.

There are lots of different ways that you can find out about whether or not it's right for you to be thinking about joint replacement there are you can you can look at your surgeon through the national joint registry every surgeon has a has a profile on the NJR and that will tell you what level of how many operations they do what their case mix is like you can also look at satisfaction levels and patient reviews and scores either on review sites or through the Private Health Information Network. There are lots of patient support groups out there a lot of my patients find that there are Facebook groups that are useful and lots of they tend to be more American based but again can give you lots of tips and tricks about before and after this surgery the website at the bottom there is a is a is a way for you to be able to visualize how much better off you will be following a joint replacement you you type in your particular details and your particular symptoms and the it's part of the national joint registry uses the data from hundreds and thousands of previous people's operations and satisfaction levels to to predict exactly what your response will be and exactly what your tailored risks are for any particular operation it's a very useful thing to do and worth looking at if you're if you want an idea of how things will be particular.

That is about it for me, I'm sorry that was a quite a whistle stop tour of of hip and knee replacement surgery. Please feel free to ask some questions and I'll do my best to answer them.

Philip Orrell

Okay, thank you for those insights into the patient journey, some some excellent detail on treatment options there and we've got quite a few questions coming in to get through, we'll do our best to get through these.

So, this person asks what symptoms am I likely to experience as a hip replacement starts to become necessary?

Mr Alex Chipperfield

As a hip replacement, so the the symptoms that you will get the symptoms of arthritis of the hip it tends it initially most people dismiss it as a groin strain or something like that, so you tend to get pain right in the groin right at the front of your thigh and that that pain initially will come on it may well come on when you when you sit down or when you're standing for long periods of time or taking part in in prolonged activity what then tends to happen over time is that that pain will will spread. It can radiate around the back into the buttock and also down the front of the thigh towards the knee the severity of the pain will increase and the duration of your symptoms will increase until you get to a stage where the pain can be there at rest disturb your sleep and be be there pretty constantly along with the pain. You'll get stiffness and that tends to manifest itself again with a hip replacement with potential for a hip replacement looking at things like finding it a struggle to put on your shoes and socks getting down to cut your toenails can often quite difficult getting in and out of cars that kind of thing you may find that your walking distance decreases that you particularly struggle on uneven ground and hills so that would be how it starts and progresses .

Philip Orrell

Okay, thank you. Next question, you mentioned outpatient physiotherapy, how frequent this is and is it arranged before leaving hospital?

Mr Alex Chipperfield

It is and it is it obviously it depends on where you are, Benenden is lovely as in it's in lovely in the countryside, but we get patients who come a long way to have surgery here and it doesn't make sense for those patients to have their physiotherapy here afterwards because the journeys are too long. So if you do come from away away then your physiotherapy can be arranged local to you, this would be through the Benenden head office in York, most people will find that there are approved physiotherapists local to you. I would advise that you arrange that before you come in to surgery because quite often arranging local therapy can take a couple of weeks to set up and you don't want to be waiting for that to start after you've had your operation generally if you if you are local to here or it's convenient for you to come here then like I said the physiotherapy actually starts in the pre-assessment clinic and then you'll be seen on the ward and you'll have to satisfy the physiotherapist that you're safe to go home and able to cope most physios afterwards they tend to see you they will tend to see you about either two or three times in that first six week period really depending on how you are the Physiotherapy is not just something that you do when you're with the physio though it's something that you have to keep doing yourself every day the physio is mainly to to monitor your progress and to guide you but it has to come from you.

Philip Orrell

Okay, this next attendee asks I'm 61 and I still work full time, I've been recommended to have a knee replacement, I do quite a lot of repetitive heavy lifting at work, would I still be able to do this for a few years after I've fully recovered?

Mr Alex Chipperfield

I said people people having joint replacements younger and younger and they tend to be more demanding and you know either demanding professions or demanding activities afterwards and it is difficult ideally you know. It always used to be that joint replacement surgery was for after you retire, that's not really the case anymore most people do get back to work and I tell people normally to take about two or three months off work, but you will get back to it. Most people who are at the stage where they have a knee replacement, they can no longer do that kind of heavy manual stuff at work anyway, that's one of the reasons that they they come to have their operation. If your level of function is still high enough that you can do a very demanding job, then it may be that it's not quite the time to have a knee replacement just yet. If you find that you're struggling at work because of your knee and you can't do what you need to do to fulfil your job then after a knee replacement you should get back your movement, you should get your strength but it will take time and it will take effort and it's not 100% guaranteed you'll get back to the level you that you want.

Philip Orrell

The next question is does bakers cyst impede a knee replacement, can you get rid of the cyst in any other way?

Mr Alex Chipperfield

Bakers assist is a collection of fluid that comes from the joint and bulges out the back of the knee so quite a lot of people with arthritis in their knee they'll feel a lump in the in the back of the fold of their knee and that's a big assist that fluid is formed inside the knee it's your body's response to a worn out joint. Your body's trying to produce more fluid to lubricate the joints and allow it to move more freely again and that excess fluid gets forced out the back and bulges out the back of the knee it doesn't impede a knee replacement at all it's it's a sign that you might need one because it's a sign of there being a problem inside your knee joint knee replacement surgery does not cure a baker's cyst once that Baker's cyst has developed once that potential space out the back of the knee has formed and the fluid has been forced out through that then fluid can always get forced out again the difference after your knee replacement though is that the the knee will produce much less fluid than it was beforehand because your knee will be calmer and in less trouble and less inflamed and angry so people who have baked assists may still feel some fullness in the back of their knee following knee replacement surgery but it's never quite as extreme or as painful or or problematic as as beforehand.

Philip Orrell

Okay, this person asks if you have a Vanguard knee replacement, does that mean you would have to have another one in 10 years?

Mr Alex Chipperfield

No.

As that simple as that, I mean any artificial joint one of two things will happen, either it will wear out or you will die, eventually one of those things will happen. If you die before your joint wears out then lastly for the rest of your life, if a joint replacement wears out or needs revising before you know at any point, then yes, you'll need another one but it's not it's not 10 years, the the days of these things only lasting 10 years a long one. These modern implants last much longer than that, there are some reasons why people need early revision surgery they tend to be the the problems such as infection or broken bones or ligament damage that kind of thing the the sort of post-traumatic almost reasons for revision they can come on at any time particularly the early ones knee replacements or hip replacements wearing out does happen but after many many years.

Philip Orrell

This attendee asks who determines how long I am an inpatient? Do complications become apparent immediately and what happens if complications arise after discharge?

Mr Alex Chipperfield

So the the discharge process it's a multi-disciplinary one, really there is everyone has certain targets criteria that they are happy with people going home and they are different from what I'm happy with to what the nurses are happy with, to what the physios are happy with, to what you're happy with as well. So essentially the the team will come to a decision if everyone feels that you've reached the right level of function to be able to go home, including yourself, then you get to go home that typically like I say is around the two nights in hospital. Sometimes it can be three or four sometimes it can be one or none depending on on whether or not you meet all the right criteria. Complications, it depends they can be apparent if the complications can come on early medium term or late so obviously a complication can become apparent whilst you're in hospital and if it does then it can be dealt with there and then if you develop a complete education once you have been discharged from hospital then yes the first port of call if you have any concerns or worries the first thing is to get in touch with the institution wherever it may be the institution where you had your surgery generally that that would either be to ring the ward if you if you you just got home and noticed a problem either ringing the The Ward and one of the one of the senior nurses on the ward will be able to answer any questions or worries you might have or bringing up the the secretaries here the orthopaedic secretaries who can then pass on a message to your surgeon to arrange either you're coming up to the ward to be seen or to be seen more urgently in the outpatient clinic there are some complications that we can't deal with on site and if those happened because we don't have an emergency department here we don't have an intensive care here if people develop serious complications that require a level of input that cannot be provided on site here at Benenden then you will either be advised to attend your local hospital or if you are here then you may be transferred to a local hospital that has enhanced enhanced facilities fortunately the level of transferring patients out of hospital is is very very very low but it's again if if needed it is we had an agreement with local hospitals it's it's a seamless transfer.

Philip Orrell

Okay, onto the next question. Following surgery will full mobility be returned?

Mr Alex Chipperfield

The the best prediction of what kind of movement and mobility you will have after the operation is what you have before the operation, so if you have not straightened fully straightened your knee for decades it would be unrealistic to think that you will immediately have a full range of movement in your knee. All the joint replacement surgery does is it replaces the worn out joint surfaces that are rubbing and grinding against each other, what you need to also what determines your your function and your level of movement is the the state of repair of the the muscles and ligaments and tendons that support and move your joints, that's why it's so important before an operation to try and be as mobile and flexible as possible because the recovery depends on you moving it. You're using it and building up the strength the confidence and the stamina in the muscles again having said that generally most people's level of function following joint replacement in you know in a normal situation gets back to pretty much normal, but it does take time it takes work on your part as well as mine.

Philip Orrell

Okay, next question is can a hip replacement be done via keyhole surgery?

Mr Alex Chipperfield

No, I mean keyhole surgery the technical definition of keyhole surgery is incisions that are about four or five millimetres across and the size of the implant means that you can't get those can't get things in through that size hole. You can perform what's called a minimally invasive hip replacement which is where you I mean you you try and make the incisions as small as possible a minimally invasive hip replacement is defined as a hip replacement that has an incision of less than 12 centimetres typically generally that really depends on your personal shape and size if you have a very large leg then the minimally invasive surgery becomes more and more difficult essentially a hip replacement is performed through I'll add an impressive it's performed through the size of the incision that is required to put it in properly and safely and not one millimetre more.

Philip Orrell

Okay, this gentleman seems to be suggesting that he may need two knee replacements and he's asking what the time span would be between each of those procedures?

Mr Alex Chipperfield

So bilateral knee replacements they we do in very in exceptional circumstances, we can perform them at the same time on the same day a bilateral joint replacements I do hundreds of joint replacements every year and about once a year I would do a bilateral knee replacement. The reason being that you need that unique mix of someone's who is as equally as debilitated with both knees but who is also young and healthy enough to undergo essentially a double operation which is a major procedure more common is a sequential or a staged procedure where you have one knee replacement and then the other one done at a later date, generally I advise people to wait about six months between between sides if you can that gives you enough time to fully recover from the first side and also to to build up the strength and reserves that you'll need to go through it all over again so six months.

Philip Orrell

Okay, this attendee asks last time I saw a consultant about knee replacement he told me to wait until I was in agony, would you agree?

Mr Alex Chipperfield

Depends on your definition of agony, but my advice tends to be that you live with your knee as long as you can, but when you get to the point where you can't live with it anymore and you can't find any other way of dealing with it, then it's time to have your replacement. Like I mentioned in earlier answers you know getting to the point where you're housebound or completely immobile generally isn't a good thing, it means that you will be weaker, your recovery will be tougher, your surgery will be more complicated, so you know don't wait until you can't leave the house. It is very much though, it's the last thing you do so you need that balance between being able to live your life or do what you want to do and not suffering unnecessarily.

Philip Orrell

Okay, this next question is does being overweight prevent you from all treatments by the surgical and other methods?

Mr Alex Chipperfield

No, I mean so if you another statistic which is on a different talk not that one the the majority of people who have knee replacements in the UK have a BMI over 30 and a BMI of over 30 technically puts you overweight and is knocking on the the extremely overweight category, so no being overweight doesn't preclude you from surgery and it doesn't preclude you from any other treatments. Being morbidly obese, having a BMI of over 40 will limit your choices as to where you can have your surgery and who would be happy to perform that surgery generally.

Generally the first the first line of treatment before you ever get to surgery will be to try and lose weight because that has you know huge benefits on your general health and fitness as well as the pain that you're currently in, the safety of the operation and the longevity of the implant afterwards, so people will if you are overweight people will keep advising you to lose weight it's not because that's the only way you get treatment is because it's the first line of treatment and it will make everything else so much easier I do appreciate though that you know you're dealing with a problem that that renders you a mobile telling someone who can't move their knees or who can't get out of the chair without help to go and do some exercise and lose weight is unrealistic if you are extremely overweight then the first treatment May well be weight loss surgery in order to help you lose weight if you can't mobilize before you end up having a joint replacement I know it's another topic but there are you know there are many several weight loss surgeons here and there if you look into another one of the webinars there's always one quite common one about weight loss surgery that performed here so you know if you're you know massively overweight then that would be the first thing to do but no it doesn't it wouldn't preclude you from any particular treatment.

Philip Orrell

Okay, this lady asks can a hip replacement solve soft tissue pain around a moderately arthritic hip, I had an arthroscopy up eight years ago and still had pain.

Mr Alex Chipperfield

Depends on the soft tissue pain around her hip, depends on the cause of that soft tissue pain, now if your soft tissues are painful because the the the muscles and ligaments around your hip are struggling to move that hip because it's very stiff and very worn then a hip replacement will allow everything to move more smoothly and and have a knock-on effect on that. I wouldn't recommend that you have a hip replacement as a primary procedure in order to deal with the soft tissue problems around that hip it seems like a bit of a sledgehammer to crack a nut genuine generally the the soft tissue pain and the deep hip pain tend to be linked together and so I can as a result you know having a hip replacement can help but I would try and exhaust all soft tissue measures first before going down that route.

Philip Orrell

Okay, this gentleman asks I have a knee operation next Wednesday with Mr Goddard, the pain I want to cure is pain from the knee down to the foot when standing and joint pain when walking, can I travel home alone by taxi?

Mr Alex Chipperfield

Depends where you are, yeah they don't specify like I mentioned earlier we have people from all over the place here and they you know they regularly I operated on a man from Wales this morning and so we get people all over the country who come and have their surgery here and they do have to get home again. Generally most people are safe to travel, it's always nicer to travel with family rather than in a taxi, it's cheaper as well but yes you you will be able to sit in a car for a for a period of time you may find then if your journey is more than a couple of hours then you you break up the journey you stop you stretch your legs, you get up and up and about halfway there that kind of thing but no it's perfectly safe to travel to and from by car. I would recommend you drive but having friends or family drive or indeed a taxi if necessary the fair might be a bit higher because you will you may need to break up the journey. Okay do you mentioned about the pain I'm sure so Richard is a very experienced surgeon he knows what he's doing if he if he has seen you and assessed you and he's confident that the knee replacement he's going to perform will help your symptoms then it would be the right thing to do.

Philip Orrell

Okay, we are nearing the end of the session now so I'm afraid we've run out of time for questions, but I'm sorry if we didn't answer your questions, if you've provided your name we will do so via email.

If you'd like to discuss or book your consultation, our Private Patients team will be available to take your phone calls this evening until 9pm or between 8am and 6pm, Monday to Friday.

We're offering a discount for all attendees of this session for seven days with the terms listed on the screen, so you can take advantage of that.

Following this you'll receive a short survey and we'd be grateful if you could take a few minutes to give us your feedback on this session.

Our next webinar will be on the 14th of March covering varicose vein treatments and you can visit our website to sign up for that.

All that remains for me to say is on behalf of our team here at Benenden Hospital, I'd like to say thank you very much for tuning in and we hope to hear from you very soon. Thank you and goodbye.