Phil Orrell

Okay, good evening, everyone, and welcome to our webinar this evening on knee osteoarthritis treatments from Benenden Hospital.

Thanks for tuning in. My name is Phil, and I'll be your host for this evening. I'm joined by our expert presenter this evening. Mr Kumar Reddy, our Associate Specialist Surgeon.

For the benefit of those who haven't joined one of these Webinars before the format is as follows, Mr Reddy will present on treatments for knee osteoarthritis for around half an hour.

This will be followed by a question and answer session. If you'd like to ask a question, pitch a question to Mr Ready during or after the presentation, you can do so by using the Q&A icon, which will be at the bottom of your screen, and you can do this anonymously, or you can give your name when you type your question, and if you do give your name, we should mention that this webinar is being recorded for future archiving.

If you'd like to book your consultation. We'll be providing contact details at the end of this session.

Now, without further delay, I shall hand over to our expert speaker, Mr Reddy.

Mr Kumar Reddy

Hello, good evening. Everyone.

Thank you so much, Phil, for the introduction and thank you so much, everyone, for joining this webinar.

It is your webinar, and you're most welcome to ask any questions and with regard to knee osteoarthritis and the treatments that we got available at Benenden Hospital.

Just a brief introduction with regard to disclosures which I have got. I'm a Trauma and Orthopedic Surgeon, and the Site Leader Hospital, Ashford, in Kent, and a member of Academy American Academy of Orthopedic Surgeons, and I'm also a member of BASK, which is a British Association of Surgeons of the Knee.

Also a member of Major Revision Centre at East Kent Hospitals, which we called the revision Hub, and I do have a lot of interest.

I've been doing for the last 25 years the total hip and total knee arthroplasties and uni-compartmental knee replacements, patellofemoral replacements, and meniscus repairs.

With regard to knee osteoarthritis I'll give you a brief introduction how the pathology will develop.

Osteoarthritis is a common disease affecting the joints in the body, most commonly the knee and the hip.

The joint services which are covered, as you can see on this model. A smooth articular surface.

At the end of the thigh bone, and also smooth articular surface in the upper end of the shin bone.

So these, over a period of time, they get thinned out and roughened, which produces pain.

Eventually there may be no cartilage left in some areas giving the sensation of crunching and grinding sensation in the knee.

There are other diseases that can also affect the joints like rheumatoid arthritis.

So the treatment options one can talk about is conservative methods of treatment which mainly include physiotherapy, appropriate splinting, taking some suitable painkillers to get rid of the pain and to improve quality of life.

You also have got other injections like local steroid injections, which, again, can give you some temporary relief of symptoms in majority of the cases probably about six weeks to three months, and you also have got this Arthrosamid® injections, which is a hydrogel polyacrylamide injections.

Eventually, if all these fail to improve your symptoms. Then you got the ultimate replacement surgery.

You’ve also have got robotic assisted surgery. Which I will talk to you briefly after I have spoken to you about replacement surgeries.

So with regard to early symptoms, as you can see, the knee joint itself is made up of the lower end of the thigh bone, which is called the femur and upper end of the shin bone, which is the tibia, and you've got a smooth articular surface, which is called the kneecap. It's called the patella.

The patella articulates along the smooth groove over the end of the thigh bone, which is called the Trochlea. This, how the knee joint is made of.

You can see the symptoms early symptoms of morning stiffness, pain in weight, bearing pain, on demanding activity. And you also get sensation of clicking, grinding, and crunching, and also experience swelling and also fluid collection in the knee.

As you can see, one can see on the radiographic appearance with regard to the knee joint you can see on the left hand side, which shows good preservation of joint space between the tibia and the femur upper end of the thigh, lower end of the thigh bone, and also upper end of the shin bone.

You've got a good preservation of joint space, whereas the deceased osteoarthritic joint looks like there's complete obliteration of the joint space.

You can see on the outer aspect of the knee, and also narrowing of the joint space on the inner side, which is the medial aspect of the knee.

And the late symptoms or pain on rest, and also disturb your sleep and also progressive deformity. If the inner side is worn out, you get genu varum deformity. If the outer side is wearing off, then it would progressively go into a valgus deformity.

Your ability to walk any distance will be significantly diminished because of the pain.

Throughout treatment options, as we say, I mean, known surgical being activity modifications impact activities, running, jogging. They're all good for your heart, but bad for the joints and weight loss programs which are available and physiotherapy treatment with a view to strengthen the muscles and to improve your quadriceps, function and extensor mechanism, and also simple ones like paracetamol, and also anti-inflammatories, which your doctor will be able to advise you on, as you would be the best person which are suitable to you.

Also sprints like simple, elasticated supports to the knee, and also offloading braces which are available on the market.

And you also have got injections that are available in the form of local steroids, duralene, which are hyaluronic acid injections, and Arthrosamid® injections which can also buy you long term benefit, as it would buy you some time before the eventual knee replacement surgery.

Right, with regard to the pain that one can develop in the healthy knee, and it's known to play an important role in osteoarthritis.

The synovium, strongly associated with the rapid increase in cartilage loss in osteoarthritis and in joints without osteoarthritis.

Majority of you are familiar with steroid injections. Now we talk a little bit more about Arthrosamid®, which is a hydrogel polyacrylamide injection. This is a non-biodegradable hydrogel, and 2.5% of polyacrylamide.

And majority of it is 97.5% is water, first and only approved injectable that permanently combines with synovial tissue, it decreases the joint stiffness reduces the pain, and it enhances the function and quality of life.

It can last even up to four years. It acts like a scaffold, and it is like an implant that can go on up to four years.

Surgery is not the answer for everybody and some of the patients might be quite young, and some of them may not be suitable for a major knee replacement surgery in those situations.

It's ideal to give this Arthrosamid® hydrogel with a view to improving their pain and also quality of life.

Unlike other options, Arthrosamid® has potential to provide multiple years of benefit, at least for a period of 3 to 4 years from a single injection.

In majority of the cases I'm not saying that it is 100% foolproof to give pain relief in each and every one that can be injected and Arthrosamid® is unlike any other injection. As I have said, it is a non-degrading, self-integrating, synovial implant.

Arthrosamid® injections are being administered as a day case, and it is done under strict aseptic precautions in theatre environment.

Usually oral antibiotics are given 1 hour prior to this procedure, and local anesthetic, which I normally use before administering the injection

and knee fusion is drained, and under ultrasound guidance. six 1ml of syringes is injected into the knee.

We normally advise patients to take rest and not to do too much activity for the next 48 to 72hours after it has been injected.

With regard to Arthrosamid® treatment, pain, and reduction over time, you can see on the graph how it has reduced the pain when compared to other studies as well.

So it has got a proven record that it can reduce significant levels of pain and also improve the quality of life.

With regard to the side effects that you need to know, it's got a 20 year safety profile of the technology, and no serious side effects have been reported.

People do get mild joint pain and swelling lasting up to few weeks after this injection, and there is a small risk of infection with any type of these injections.

The next one I'm going to talk about is durolane, which is a viscose supplementation injection. This is what we call the hyaluronic acid injection. This is done in the clinics as an outpatient procedure. Again, under strict aseptic precautions. This injection is administered, which is a 60 milligrams injection, with a view to increase the lubrication and reduce friction in the joint.

It also reduces pain, and the efficacy of this injection in majority of the cases lasts about six months.

It is administered in mild to moderate osteoarthritis, and this can be repeated as a booster after six months. It is not always effective, and may return for further injections later on.

This is a steroid injection along with the local anesthetic and 80 milligrams of either Kenalog or Dexamethasone, which is a steroid, can be again administered into the knee joint under strict aseptic precautions.

This again is for mild to moderate osteoarthritis of knees, and this can last up from six weeks up to three months, and most surgeons delay knee replacement for at least six months following injections because of the risk of infection.

The next surgical treatments, treatment options that are available. If all the conservative methods of treatment, including the injections, fail to improve the symptoms, or one is realignment surgery, which is an osteotomy that one can do.

If it is an isolated medial compartment, or through osteoarthritis with a genu varum deformity, and one can do realignment surgeries with a view to correct the alignment that would improve the pain and quality of life.

The next one is arthroscopic techniques. Again, orthoscopic techniques, arthroscopic surgery in osteoarthritic knee is not a great indication unless people have mechanical symptoms in the form of locking and giving way with MRI proven large meniscal tears that get interfered with the joint.

There's a 15 to 20% chance of people getting their pain worsening following arthroscopic surgery in the presence of osteoarthritis, the next one is micro fracturing.

Again, this is useful. If the lesions are less than a centimeter where you can do micro fracturing with a view to relieving the marrow edema that would improve the pain levels and improve the function of the joint.

There's also cartilage transplantation which is which is not available at Benenden Hospital and knee replacement, surgery.

About knee replacement surgery. This is a common operation. It is approximately about 100,000 performed in United Kingdom every year.

Average age is between 68 to 70 years. 55% are female patients and 94% patients report health improvement. 80% of knee replacements can last up to a period of 25 years.

With regard to the aims of knee replacement for any joint replacement, surgery, either hip or knee, or partial knee replacement. It has to be for pain, relief, mainly to relieve the pain and to improve the quality of life, it will also increase your mobility.

It will also restore your function, and it will also realign the leg mechanical axis.

In younger patients high function demands, such as work and sports and greater expectations.

The knee replacement that we use in Benenden is Vanguard knee replacement, which is from Zimmer Biomet Company, and it has got a good operating of 15a, and the 10 year survivorship is 90

6%. It is a cemented replacement, with or without petal resurfacing without replacing the kneecap or with replacing the kneecap.

I can show you the picture that where we have got the replacement here all you do is resect the lower end of the thigh bone, and also the proximal end of the shin bone tibia, and then you put in a metal implant on the lower end of the thigh bone, and also the upper end of the shin bone which goes into the tibia.

With regard to uni compartmental knee replacement, this is a partial knee replacement.

Again, the option is, if it is isolated to the medial compartment or to the lateral compartment, one can do a uni compartmental knee replacement.

The prerequisites are, there should not be a fixed flexion, deformity, the fixed flexion, deformity up to 10 degrees one can accept, and majority of the cases, people should be able to extend the knee fully, and the range of knee movement should be at least more than 110 degrees.

And also the prerequisite is anterior cruciate ligament needs to be intact with regard to these type of surgeries, and there should not be any disease affecting the lateral.

Other compartments, including the lateral or petal femoral compartments, mainly the lateral facet of the Petula.

In this case I can show you the model here, where only the partial knee has been done on the inside of the knee, where the part of the bone is replaced with the lower end of the thigh bone being on the partial side, on the medial aspect, on the inner side of the knee, and again on the shin bone upper end of the shin bone you replace with the metal. Again, the plastic is in between the two.

The kinematics are maintained in partial knees. That is the main advantage, and the recovery is quicker, and the pain scores are much less when compared to total knee replacements.

You can see on the radiographic appearance on this side, where you got complete obliteration of the joint surface on the inside of the knee, and you also have got a prominent tibial spines with the outer side. You have got a good joint surface.

I'll show you the picture post operatively. This is a partial knee replacement. This is how it looks on the radiographs.

With regard to recovery from a knee replacement, surgery, and your hospital. Stay. You'll be staying about two days in your own private room with en-suite. There'll be a protective dressing, and a bulky dressing applied onto your knee.

Pain will be controlled with medications and ice therapy, and you've got an excellent team of nurses on the wards who will be taking care of you, and also the physiotherapist

to you to give you the exercise program. Once you're able to mobilize, they'll help you do the stairs up and down stairs. If you have got stairs at home, just to make sure that you're confident of doing stairs before you're discharged home.

We'll only let you leave the hospital once you're happy, and that it is, it's safe for you to do so. You can use either a frame or crutches.

The physiotherapist will make a rapid assessment and provide you the necessary walking aids that you need with you to mobilize after knee replacement.

After about a week. Most people can walk independently with sticks.

Recovery from a replacement after leaving hospital. It's two weeks of painkillers. There'll be visible bruising, and you can also do exercises at home given by the physiotherapist.

At six weeks we normally allow people to get back to driving, and also to do a bit of cycling and swimming three to six months feels you should feel majority of the patients feel the benefits of surgery returning to normal activities.

With regard to the complications that one can come across with knee replacement, surgery during surgery, during recovery and late complications during surgery you can come across bleeding risk where there can be large bleeding, which may require transfusions which is very unlikely, and there can be injury to the bone in the form of a fracture.

Intraoperative fracture. There can be damage to the nerve or the vessel. Again, it's all a very rare entity, and there can be damage to the ligament or the tendons during surgery.

With regard to during recovery phase, you can develop hematomas and wound problems, and it can be acute infection where the skin can become red and cause infections, and you can develop clots in the veins of your leg, and sometimes that can migrate into the lung.

With a view to prevent this, all the knee replacements that we do.

You do take anticoagulants for at least a period of 14 days. Some of my colleagues give enoxaparin which are subcutaneous injections, and I normally give in the form of tablet form, either Rivaroxaban or Apixaban, if they're already on Apixaban or Rivaroxaban.

And stiffness and swelling, that's why it's so important for you to follow the exercise program given by the physiotherapist, and it's very important to take painkillers which would allow you to exercise the knee after surgery.

And with regard to later complications, you can come across infections, and also you can have a loosening of the implant.

And these artificial joints are subjected to wear and tear. And if you're doing a lot of impact activities, and these are prone to wear, especially the plastic can wear off. It can delaminate and can produce poly wear, thereby subjecting your implant for loosening.

And for these you can have revision surgeries, and it's not a straightforward surgery, revision surgeries or complex surgeries. And this one has to bear in mind when it comes to impact sports following your replacement.

And there can be a periprostatic fracture. And you can also come across dislocation again.

These are all very rare entities, but you need to be aware of these complications. Your benefits should always outweigh the risk.

The next one is, I'm going to briefly talk to you about robotic replacement.

We got ROSA from biometric Zimmer for your replacement surgery. The ROSA knee system is precision. Robotic arm helps increasing the success of your knee replacement when compared to traditional or conventional knee replacements.

This would assist your surgeon in the placement of a needle placement in precise manner, to give you better alignment.

And this would enhance improve the survivorship of the implants, and this is also has proven that the pain levels are much less when compared to the knee replacements done by conventional methods.

Also it improves the patient outcomes in the long term, but we still do not have sufficient data with regard to this, that this is extremely superior when compared to the conventional methods or computer navigation.

The ROSA system is supported. Knee replacement offers several benefits over a standard non-robotic assisted total knee replacement.

This includes reduced likelihood of injury to the soft tissues surrounding your knee joint during surgery.

Robotic surgery is associated with reduced pain, so you may not need as much pain medication after your operation.

Potentially the shortest stay in hospital and a quicker recovery. So you can get back to your normal routine and daily activities.

Better knee function after your surgery.

I'll just briefly talk to you about the interoperative technique of this robotic surgery. Usually the sensors are attached to your thigh bone, which is the femur and also to the leg bone and the tibia.

If your knee moves, ROSA can make automated minute adjustments to ensure the plan designed by your surgeon is followed to exact detail, using the data to make more informed decisions.

Your surgeon can plan for and carry out your surgery based on your individual needs.

This would allow the surgeon to make an excellent, to give the patient an excellent alignment of the knee, and also to give the rotationally aligned knee, which it is extremely difficult in a deformed knee to get this by conventional methods.

It's important to note that the ROSA cannot move its own on its own. ROSA is guided by the surgeon who will still carry out the procedure of the knee replacement.

ROSA's job is to assist the surgeon in replacing your knee joint more accurately, and it is the precision that you come across with robotic surgery.

Every individual's knee is totally different, and their rotations are different. Their alignment is different, their flexion extension gaps are different.

So that's why the ROSA plays an important role in assisting your surgeon and your surgeon will discuss whether this is the right option for you at your initial consultation.

I'll just give you a brief demonstration of how the ROSA Knee system works.

ROSA Knee is a robotic surgical assistant for total knee replacement.

Your surgeon is specially trained to use the robot.

ROSA Knee does not operate on its own. Your surgeon is in the operating room the entire time and making decisions throughout your surgery.

Your surgeon creates a plan for your surgery based on your unique anatomy.

Robot helps to ensure the plan is executed as intended.

ROSA knee uses a camera and optical trackers to know where your leg is in space.

If your leg moves, the robot can tell and adjust accordingly.

ROSA knee provides your surgeon with data about your knee. This helps to personalize your surgery based on your unique anatomy.

I just would like to enlighten with regard to the National Joint Registry. This national joint registry is a tool which can monitor the implants that we are using, and it also gives the long term survivorship.

And also it monitors if the implants are not behaving, then it would highlight and highlight to the patients.

And it is also a surgical tool as well for the surgeons where the surgeons can be monitored, and their complications are all being recorded in the NJR.

If any surgeon is an outlier, it would highlight, and it would inform the respective hospitals about the increased complications. If a surgeon is coming across too many complications.

It is entirely voluntary, and your data is kept confidential all times and you got you can review the surgeon's profile on the NJR registry and also the hospital profile.

You also have got other tools like private healthcare, information network or fin, and also the Doctify which reports the surgeons their patient reported outcomes and also their ratings by the patients.

Thank you so much for listening to this webinar, and please feel free to ask any questions that you would like to, and Phil is going to give us and talk with regard to the prices.

Phil Orrell

Thank you, Mr Reddy lots of information to digest there on the various treatment options available here.

One thing I should point out on this slide before we take some questions in the purple circle there you can see that we offer an orthopaedic price promise to match better prices locally, terms and conditions do apply to that. So visit our website. Please to view those T&Cs.

So as you can appreciate, we've got a lot of people attending this session. So we have quite a few questions to get through. We will plow on.

The first patient asks. I'm interested in details of Arthrosamid® injections. My question is, does having an Arthrosamid® injection slow down the deterioration of arthritis in the patella chamber?

Mr Kumar Reddy

Answer to question is untreated osteoarthritis of the knees the synovial fluid loses its viscoelastic properties, and the membrane contains an accumulation of inflammatory cells, and they are the precursor of joint swelling.

This can cause pain and swelling of the joint and synovial membrane is a connective tissue, and you got two layers, which you know is the intimal layer, and also subintimal layer, and the synovial membrane produces synovial, fluid, Arthrosamid® injection into the joint cavity, distributes within the joint fluid, and it begins to adhere to the synovial lining.

Macrophages, like enter the hydrogel, and are unable to phagocytose. A new layer of intimal layer forms on the top of the integrated synovial membrane.

This new layer consists of scattered non-inflammatory type cells and this act like a scaffold within the sub intimal layer.

This is the whole process. It would take approximately four to six weeks. The thickening of the synovial, fluid, intimate layer, it would cause distancing of the inflammatory cells and breaks the inflammatory cycle.

And with regard to your question, does it really stop the progression of arthritis? It wouldn't stop, I mean, it would at least contain, and your pain levels would be much better because it acts like a scaffold, and as an implant.

And thereby reducing the inflammatory response. And this is a long term. This is not a short term. It would last for at least up to four years, as you would have seen on the graph in my presentation.

Phil Orrell

Okay, thank you. This next attendee, David asks, is Glucosamine and or Chondroitin helpful in promoting good health for knees, and particularly in maintaining or even enhancing cartilage in these?

Mr Kumar Reddy

Yes, certainly it would help, but it is certainly proven in dogs.

The glucosamine and Chondroitin has significantly helped in arthritic joints. If it is bone on bone arthritis, I'm not sure, but if it is mild to moderate. Certainly, it would help.

Phil Orrell

Okay, thank you. This next attendee asks, can the patient have more than one course of Arthrosamid®?

Mr Kumar Reddy

The answer to that is. Yes, I mean, after a period of time you can certainly have when it wears off, and if you're having pain, but usually it is recommended as one dose, but people are giving injections when it wears off, after at least after a period of two to four years, and if it wears off after two years you can have another injection.

Phil Orrell

Okay, thank you.

I think you may have already answered this next question within your presentation, Mr Reddy, but this attendee asks, is the Arthrosamid® injection performed in theatre hygiene conditions?

Mr Kumar Reddy

Yes, certainly it is performed in theatres under strict aseptic precautions. And under Laminar flow and yes, I mean, because of the risk of infections we don't carry out as an outpatient procedure.

Phil Orrell

Okay, thank you.

This next attendee asks, can you explain severe lateral, patellofemoral, chondromalacia, can medial meniscal tears heal?

Mr Kumar Reddy

Medial meniscal tests in adults and elderly. They do not heal once there is a tear it's always going to be tear. Whether it causes mechanical symptoms or not. It is a different ball game altogether.

If it's a degenerative tear, it will be annoying. That's why, if any person who do not have any mechanical symptoms, if you do have arthritis, it is not a good idea for you to undergo arthroscopic surgery, as there is a 15 to 20% chance of your symptoms getting worse after orthoscopic surgery.

Phil Orrell

Okay, thank you. This next person asks which scan is best for assessing the extent of damage. I've had an X-ray, but would like to know the condition of the soft tissue?

Mr Kumar Reddy

With regard to bony damage and bony extent a plain X-ray, which is a weight-bearing X-ray is sufficient to assess the joint surfaces. However, if you want to see the with regard to your cartilages, and whether there's marrow edema where there's a thinning of the articular cartilage, the best scan would be an MRI scan to assess your knee.

Phil Orrell

Okay, thank you.

This next person asks, I'm a 76 year old male. I have grade three degeneration in the left knee. What is the success rate with the Arthrosamid® injection for my age?

Mr Kumar Reddy

There's a good indication to do an Arthrosamid® injection, because you do have moderate arthritis in the knee, and it is still not advanced, which is a great for advanced arthritis. There's a good chance you may benefit from Arthrosamid® injection.

Phil Orrell

I feel that this question is somewhat of a follow-up question, is there a stage such as such as advanced arthritis that would make arthritis with injections not viable?

Mr Kumar Reddy

We do inject for patients with arthritis even advanced in some of the cases, and they do want the injections because they don't want the knee replacement surgery, or they may not be fit to have this knee replacement surgery.

So it is reasonable for you to have a consultation with your orthopedic surgeon to determine whether you would benefit from this injection or not.

Phil Orrell

Okay, thank you. This gentleman asks, will Arthrosamid® get between and separate bone on bone contact?

It's a hydrogel injection where you got polyacrylamide, and also majority of it is water, and it acts like a scaffold.

As I told you, it reduces the inflammatory response from the inflammatory cells, and thereby acting as a scaffold, and also separates and distances the inflammatory cells

With regard to bone on bone contact, it would help in relieving the pain, but it is not that it would create articular cartilage for you, so that you will not have a bone on bone.

Phil Orrell

Great, thank you.

Huge amount of questions coming in here on Arthrosamid® the next person asks how many times would you inject with each injection option you've mentioned before considering replacement surgery?

Mr Kumar Reddy

With regard to I hope it's for Arthrosamid® injection. The question was if it was for Arthrosamid®. Usually we recommend you have one injection which should last at least for a considerable period of time, and during majority of the individuals, the hyaluronic injection should last about six months.

And after that six month period. They do recommend a booster for a six month period, which can last for the period of 12 to 18 months, or even up to 2 years, whereas Arthrosamid®, we've got majority of the injections lasting for up to four years. But if you do develop pain after a period of time, and if you wish to have another Arthrosamid® injection. By all means, you could have this injection.

Phil Orrell

Okay, thank you.

This next person asks, do you encourage and advise weight loss before considering replacement surgery? As a physiotherapist, this significantly impacts on recovery and success. Is there a weight guideline that the prosthesis can tolerate?

Mr Kumar Reddy

And with regard to the second question, there is no great guideline that the process can tolerate.

It would be in your best interest to lose weight before surgery. I know it is extremely difficult because you're in a catch. 22 situation. If you exercise, you tend to get more pain, and walking or running makes symptoms worse. You're in a very difficult situation.

and best thing is to see the weight loss programs and see what best you can do before surgery. And with regard to cutoff. We got a cut off of 40 BMI at Benenden Hospital.

Phil Orrell

Okay, thank you.

The next person asks can you just have the kneecap replaced. As my husband has been told, his knee joint is good, and his kneecap has arthritis?

Mr Kumar Reddy

If the knee joint is normal, and if you had had an MRI scan, showing that there is no marrow edema in the other parts of your knee. If it's only the kneecap one can do a partial replacement, which is called a patellofemoral replacement. That means replacing the kneecap.

And where we replace the just, the kneecap here, and also this articulates with the groove on the end of the thigh bone called Trochlea. So this is called a patellofemoral replacement, and the recovery is quicker with regard to isolated unicompartmental patellofemoral replacement. So one can do this, and I'm 1 of the surgeons who does them.

The patellofemoral replacements.

Of course you can have a patellofemoral replacement rather than having your total knee replacement if it is isolated and restricted to only your patellofemoral joint.

Phil Orrell

Okay, thank you, Mr Ruddy.

This is quite a broad question. Could you talk a bit more about success rates and research findings on the arthritis sections you mentioned in the presentation?

Mr Kumar Reddy

It's a very broad question for me to answer about with regard to the arthritis and also replacement surgeries, as I've mentioned in my presentation that we are yet to see robust data because people have just started doing robotic surgeries. And the outcomes are also really showing improvements than the conventional methods or computer navigated replacements.

That's all I can say, and with regard to the revision rates, outcomes there's not sufficient data to say that robotic outcomes outweigh the conventional methods. But I'm pretty positive in the years to come.

You got pretty good data available that with the superior outcomes with robotic surgeries.

Phil Orrell

Okay, thank you. A two part question from this next person with the gel injection. What is the eligibility, please? And can you drive yourself home afterwards?

Mr Kumar Reddy

With regard to Arthrosamid® injection, we always advise for you to come with a chauffeur or your family member to bring you here. It shouldn't take long, so hopefully you should be driven home, because sometimes you can have more pain from this injections, because it's a thick gel that's being administered into the joint.

I would recommend you get somebody to drive you home back. Though it is done in the local anaesthetic.

Phil Orrell

Okay, this next attendee asks or at least says you said that surgery is only advisable for six months following an injection.

Not 100% sure which injection they're referring to what infection is likely to occur. I've been told that 3 months is acceptable.

Mr Kumar Reddy

I mean to be safer, I mean, we say, about six months, but I would say about three to six months it is advisable to have surgery if you were to have an injection in the interim, because it is proven that the infection rates are slightly higher.

If one were to do the surgery immediately after the injection.

Phil Orrell

Okay, thank you.

Moving on to the next question. Once this injection has been done and all has settled, is one able to kneel down as before. And are you able to have replacement at a later date? As you said, the injection could last several years?

Mr Kumar Reddy

Yes, the data shows, the Arthrosamid® injections can last up to a period of four years, and with regard to kneeling, I would advise all my patients, even after knee replacements, that they can kneel after a period of six months.

So there's no restriction with regard to kneeling with the injections. I mean, usually for up to a period of four to six weeks, I would advise them to refrain from kneeling and crouching, and after that one can kneel or crouch.

Phil Orrell

Okay, the next person asks. I'm a 77 year old male who walks 12 to 15,000 step daily walk. But I've started to have pain in both knees, especially when walking up hills and stairs to my apartment.

I have edema in both lower legs. Will arthritis be beneficial for me in reducing pain and is the edema a cause of the knee pain?

Mr Kumar Reddy

I would sincerely advise you to come on board, or to go to your doctor to get an X-ray done. It's often that it is.

It's important for you to have a consultation with your orthopaedic surgeon, and who can assist you properly, and to determine that it is coming from the knees, not from the hips.

Often people get caught out, and some of the patients whom I see complain of a lot of knee pain, and when you do, the X-rays are normal, then you need to be assessing the hips, and when I send them for an X-ray.

They have advanced osteoarthritis of the hips, so it is just in your best interest to book an appointment to see one of the orthopedic surgeons with you to assess you properly in the clinic, and do necessary investigations, and then give you advice with regard to the treatment that you may. That is suitable for you in your best interest.

Phil Orrell

Okay, thank you.

Not a huge amount of detail in this next question. But this person asks, why is my knee pain much worse at night?

Mr Kumar Reddy

Basically, if you're having rest, pain then, and especially picks you up at night, then that means you got moderate amount of inflammation in the joint.

And daytime you'll be concentrating on other things which your mind will be diverted, and it is the pain that is causing you most at night means that means you're having rest pain, which indicates that you got moderate arthritis in the knee, and it is in your best interest to see an orthopedic surgeon for an assessment and also have a treatment that is available.

Phil Orrell

Okay, thank you. Moving on.

Is Arthrosamid® helpful in buying a patient time to get fit and lose weight or end state of total knee replacement?

Mr Kumar Reddy

Yes, it's certainly helpful to get fit because it reduces your pain levels, and also it improves the function and stiffness in the joints thereby you can do exercises, and as it is buying you time, in the meantime you can lose some weight before you go on to replacement.

Phil Orrell

Okay, Sue asks, is it necessary to have a scan before being offered Arthrosamid®?

Mr Kumar Reddy

Normally we do get an X-ray, and unless you got mechanical symptoms, if you got mechanical symptoms in the form of intermittent locking and giving away of the knee, it is advisable for you to have an MRI scan before the Arthrosamid® injection.

But normally, if you do not have these symptoms, a plain X-ray will be sufficient enough to see the degree of arthritis that you've got in the joint.

Phil Orrell

Okay, thank you.

This person asks, would you advise an ultrasound guided procedure for standard steroid injections in the knee not for steroid injections.

An experienced surgeon should be able to find where the joint space is. It's easily injectable into the knee joint. If you do have an ultrasound machine in the clinics, it is a hundred percent safe way of doing the injection into the joint.

Phil Orrell

Okay, thank you. The next person asks, is there a weight BMI limit for Arthrosamid® or durolane injection?

Mr Kumar Reddy

As far as I know, there's no weight or BMI limit for either hydrogel or Arthrosamid® or hyaluronic acid duralene injections.

Phil Orrell

Okay, I think we're going to have to wrap up with the questions. Now, as you can appreciate, we've had a huge amount, and we've made a dent on most of them.

I'm sorry if we didn't get around to answering all your questions, but if you've provided your name we can answer yours via email.

And just to remind you there that on the slide, on the screen all the prices for the different treatments that Mr Reddy discussed are listed there.

Could you please move to the final slide, Mr Reddy? Thank you.

So just to run through. Your exclusive offer for attending this webinar 50% off your initial knee pain treatment consultation, available for a limited period.

As it says, there you'll receive a call back from your dedicated private patient advisor, and you'll receive the recording of this session and some treatment information pricing and loyalty reward points by email, and you can sign up to receive updates on upcoming news offers and future events.

You'll also receive a survey at the end of this session to help shape future events. So we'd very much appreciate it if you spent five minutes filling in that survey, it helps us inform these webinars.

If you would like to discuss or book your consultation this evening, our private patients team can take your call until 8.30pm this evening, as it says, on the screen there on the number listed.

Or 8am. To 6pm. Monday to Friday. They are also available using that number on the screen.

We do have further webinars coming up this month on the topics of tummy tuck surgery and shoulder pain treatment. And you can sign up to those via our website.

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

Mr Kumar Reddy

Thank you very much, everybody.