Louise

Once again, good evening, and a very warm welcome to our webinar on knee osteoarthritis treatment. My name is Louise, and I'll be your host for this evening. I'm delighted to be joined by our expert speaker, Mr Mark Jones, Consultant Orthopaedic Surgeon.

Tonight's session will begin with a presentation from Mr Jones, followed by a live Q&A.

If you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously, or to include your name.

Just a quick note that the session is being recorded, so any names will be shared or visible in the recording.

To help us get through as many as possible, please keep your questions brief.

If you're interested in booking a consultation, we'll share all the relevant contact details and an offer at the end of the session.

I'll now hand over to you, Mr Jones.

Mr Mark Jones

Thank you very much, and hello and good evening, everyone. Thank you for joining today. So, as I say, I'm Mark Jones, I'm an Orthopaedic Surgeon here at the Benenden Hospital, specialising in knee surgery.

I work in Canterbury, and Margate as my main NHS practice, specializing in mainly soft tissue knee injuries, as well as arthroplasty and arthritis within the knee and having learnt this, having done a fellowship in Brisbane in Australia.

So, today we're gonna cover knee surgery from start to finish. We're going to look at how you present to us in the clinic, and how we assess you, with all the, then, the investigations and the different types of treatments available to you, anywhere from non-operative management to the surgical management treatment.

So, usually what happens is you come and see us in clinic, and we have an assessment about your knee pain and your knee symptoms.

We take a full history, where we gauge through certain questions, trying to trying to pinpoint what the diagnosis is, mainly from the history that we take and the majority of diagnoses can be sought from the history, because of the kind of questioning that we ask.

We then back this up in the clinic with an examination, as you can see here in the picture of a knee examination, to try and basically point us further in the right direction of where we need to go

In terms of the diagnosis, what investigations we need, and we can then send you for either x-rays, which we can do usually on the day of the clinic appointment, or we can send you away for an MRI scan, which is then usually as an outpatient to be then seen back in clinic.

We assess you during the clinic appointment as well to see how fit you are for any future procedures in terms of the anaesthesia risks, looking at your past medical history, looking at medications, and seeing whether you're suitable to have an operation in terms of the risks and benefits.

During the consultation, if we've got a diagnosis, we'll be able to give you, then, an idea about the treatment options, and whether these range from surgical or non-surgical options, and then physiotherapy and exercise recommendations going forward.

So, first of all, let's start with what is knee arthritis. Well, knee arthritis is a degenerative wear and tear within the knee, and it basically usually presents with either stiffness or activity-related pain.

Patients will usually complain that they have a reduced walking distance, where they will get pain after walking a certain distance, and they have to stop that walk because of the pain.

Associated with the pain, they may have swelling, which can then inflame the knee and cause its own pain and then later on, you get pain at rest, as well as pain at night time and because of the arthritic change within the knee, you can then get deformity around this around the knee as well.

The causes of knee arthritis are mainly wear and tear, so you get breakdown of the cartilage within the knee joint itself, exposing the undersurface of the cartilage, which is the undersurface is bone, and then you get this bone-on-bone arthritis.

Usually, this is age-related but can also be due to trauma or injuries within the knee at a younger age, which have left you with maybe an unstable knee from ligament injuries or meniscal injuries in the past.

And as you can see here, it's a quick diagram of looking at healthy knee on your left-hand side, with all the ligaments intact, the cartilage intact, and the joint spaces maintained. So the arthritic knee on the right, with a lot of early wear with a lot of degeneration within that cartilage, within the knee joint itself.

So once we diagnose you with arthritis, and this is usually through x-rays, but maybe backed up with MRI scans, we can then give you treatment options. The non-surgical options are always there to be exhausted before we move on to the surgical treatment.

The non-surgical options include weight loss.

And this can be either through diet, can be through weight loss treatments, such as the Monjaro, or those these new injections, which can cause weight loss, or even through, gastric bypass or gastric sleeve procedures, to try and reduce the weight and the load going through the knee.

Activity modification is important because certain activities will flare the knee up and cause an increase in pain, an increase in swelling, and this will then have

Problems moving forward in terms of the range of motion of the knee, as the swelling and pain can lead to stiffness and weakness, which can worsen, then, the pain long-term.

Physiotherapy is important because physio can help

Guide you in terms of the exercises you can do to strengthen the knee, and strengthen the correct muscles, which can offload the knee and protect this worn-out knee from further damage.

Strapping and braces can also be used, particularly if you have a deformity within the knee, causing either a bowing of the leg or a knock-kneed appearance.

Certain braces can actually correct the alignment of your knee, so you can offload that damaged part of your knee, and put weight through the undamaged compartment, and therefore help with your pain symptoms.

Injections are an option, and injections include temporary injections, such as a steroid or a hyaluronic acid injection, or a more permanent implant injection, such as Arthrosamid, which is the new injection being offered here at Benenden.

Surgical options are there for those patients where the non-operative treatments have been exhausted, including pain relief, which I didn't mention.

But the surgical options really include either joint preservation surgery, and this is where we look at arthroscopic techniques to, try and rejuvenate cartilage or osteotomy procedures, where we try and correct the alignment so that we can put weight through the undamaged part of the knee.

These are knee preservation techniques that allow you to maintain your normal knee, your normal ligaments, and hopefully prevent having that knee replacement.

Knee sacrificing or joint sacrificing procedures include a partial knee replacement or a total knee replacement and this is where we remove the damaged bit of cartilage and replace it with a metal implant, such as a half knee replacement or a total knee replacement, to treat that arthritic pain.

So, a quick talk on Arthrosamid. If you've been to any previous webinars, you would have seen there's a lot being talked about at the moment about Arthrosamid.

It is a new medication on the market in the UK. It's been around in Denmark and Norway for about 15, 20 years, and has been used for the treatment of arthritis quite successfully.

It is a drug which is basically mostly water, but is a polyacrylamide component, which is about 2.5% surrounded in water and this is injected into the knee.

And it is defined as an implant, because it gets absorbed into the lining of the knee cells, the synovium, where it then acts and reduces the inflammation and reduces the pain within the knee. As a result, this reduces the joint stiffness and also allows you to

Increase your muscle bulk and muscle power around the knee to protect it further.

It's not like the usual injections such as steroid, which are temporary. This can last for a lot longer, but it takes a bit longer to work.

Usually, it takes around 4 to 12 weeks before you start seeing the benefits, but then once the benefits are there, the pain relief can be maintained for a significant amount of time.

I'm just gonna quickly jump to this slide before I go back. So this is what I mean by how it can last for a long time.

This is the these are the current studies looking at Arthrosamid, and what it shows is there are two studies which have which have been looked at, which show that benefits can last for up to 5 years, which is a significant benefit in patients where they may have had multiple steroid injections, which have only lasted months in the past.

This what this therefore means is you're delaying the need for the knee replacement long-term, which hopefully means that you can reduce your revision rates of total knee replacements down the line.

So how do we go about giving Arthrosamid? Well, it's we treat it like a surgical procedure, because it's an implant, and we're worried about potential risks, such as infection.

You're admitted as a day case procedure, and you come onto the ward and have a two antibiotics about one to two hours before you have the injection.

You then come down to theatre, where in the sterile environments of theatre, we, under local anaesthetic and under ultrasound guidance, we put a needle into the knee, we drain off whatever fluid there is within the knee, we inject a bit of local, and then 6 vials of this Arthrosamid injection into the knee.

Once this is done, you go back to the ward, and you go home the same day.

you rest for two to three days, and then once the pain starts improving, you can start doing the exercises, which are all on the Arthrosamid website, to kind of build up the strength and range of motion of this knee and then, hopefully, this will have long-term benefits for you.

There are other injections, which I mentioned earlier, and these are temporary injections. These are injections we can give in clinic, because there's a because they're temporary, the risk of infection is smaller.

The first one, which most people know, is a sterile ejection, or a cortisone injection, and this can be administered with some local anaesthetic.

It has a fairly quick, acting process, so within the first 48 hours, most patients will see some benefits.

The downside is it is temporary, and really, you're only looking at around 3 months of benefit from a steroid injection. But in that time, it is good to be able to then do your physio, do your rehab, so that you can offload this knee and try and regain some of that strength back, which the pain and swelling has reduced in your knee.

The other injection is hyaluronic acid as a general, kind of, spectrum of injections, but here at the Benenden, we have Durolane.

Which is a long-chain polymer of hyaluronic acid. It can be injected into the clinic, and it acts as a lubrication and support within the knee to reduce friction and therefore reduce inflammation that the arthritis can cause and this has a slightly longer process of acting within the knee, around 6 months, compared to the steroid of around 3 months.

Both the steroid and the Durolane can be injected probably twice a year.

Moving on to the surgery of joint sacrificing surgery, so this is knee replacement surgery, we're looking at half knee replacement and total knee replacement.

Many knee replacements are performed across the UK, over 100,000 performed in the UK in 2000 in 2023, and this is from the National Joint Registry, where we look a couple of years back in the data.

The average age of a knee replacement in this country is around 68 to 70 and majority of these patients having a joint replacement are female.

The aim of the joint replacement is to get pain relief back in the knee, which should then therefore restore function, restore mobility within the knee, and hopefully regain quality of life.

For those patients that also have a slight malalignment because of the arthritis, it should realign some of that normal, leg mechanical axis.

The current total knee replacement that we use here at the Benenden is called Vanguard Total Knee Replacement from a company called Zimmer Biomet.

It has been around a long time and has good historical data, and on the NJR and on the ODEP rating, it's scored as a 15A, which basically means that it's got a good survivorship up to 15 years with good data to back this up.

The 10-year survivorship on the NJR is 96.4%.

It's a cemented implant, which basically means that the cement acts as a grout around the implant to secure it into the bone and then you can have a patella resurfacing or not.

It depends on how worn out that patella is and depends on the surgeons. There's usually three, types of surgeon. The one who will replace the patella every time, the one who will replace it if it's worn out, and the surgeon who will never replace it and the guidelines are pushing more towards replacing it if it's worn out, but there's no real research or good data to show that one is better than the other.

And this is a video of how it is done.

So you can see the arthritis on the what we would call the outside of the knee here and that is what, then, a knee replacement would look like.

So we access the knee by opening up with a skin incision, we find the arthritis, and these blue lines are our saw blades going through, removing the arthritic area. We prepare the bone surfaces so we can put the implants in, and then we put the knee back in and close all the soft tissues, leaving this total knee replacement in situ.

We then move on to half knee replacements. Now, half knee replacements are, again, a very good treatment of knee arthritis, but in terms of having a half knee replacement, you need to have the appropriate arthritis.

You need arthritis only in one of the three parts of your knee joint. You have the medial joint, you have the lateral joint, and you have the patellofemoral joint and you need arthritis in only one area, so that you can do the half knee.

If you have arthritis in more than one, then you're looking at having a total knee replacement.

You can the most common one is a medial half-knee replacement, and this is because this is where majority of people develop arthritis.

You can have a lateral compartment, unicompartmental knee replacement, as well as a patellofemoral joint isolated knee replacement and in some senses, you can have a medial and a patellofemoral joint, or a medial and a lateral, but this is not what we do here at the Benenden.

The benefits of a half knee, if it's suited for you, is that it has an easier recovery, it's less surgical dissection, the outcomes are more favourable.

Because the knee biomechanics are more suited to your normal knee and actually, most patients recover a lot quicker, and by 6 weeks, most patients are back to feeling like their knee is back to normal.

The downside of a half knee replacement is that it obviously, you can still develop arthritis elsewhere in the knee, so you so you may need a revision knee surgery because of that and also, because it's a half knee, it does wear out quicker than a total knee replacement, so the revision rates of a half knee are higher.

But, if it's done properly, it should still be lasting a long period of time, and hopefully not be revised in the future with good outcomes.

When we talk about knee replacements, we talk about two types of knee replacement, and the way and that's how we do the knee replacement.

The first one is a standard technique, where we use instrumentation to guide us about how to cut your both your tibia and your femur and this is through our own experience, as well as through average guidelines about patients' anatomy.

This has good outcomes and has been used routinely by many surgeons over many years.

With technology developing, we have now introduced here at the Benenden the robot, and the robot is there to assist us with the surgery by making it a more personalized knee replacement for you as the patient.

With a couple of sensors within the leg that we put in during surgery, we can have a look at the soft tissue balance of your knee pre-knee replacement.

And the machine and the computer, along with our knowledge of changing certain parameters, will help us cut the femur and the tibia in a more accurate way that is more personalized to you, to hopefully give you a better outcome in terms of your knee replacement.

The early research looking at two-year PROMS data, which is basically patient-reported outcome measures, is showing that robotic surgery is having a better outcome at that two-year stage than the standard knee replacement.

But obviously, we don't have long-term data coming through yet, because we haven't been using the robot for very long.

But hopefully, long-term, what the robot-assisted knee replacements will show is a higher percentage of happier patients with a lower revision rate down the line.

I think this is a quick video to explain.

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.

The 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 adjusts accordingly.

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

Mr Mark Jones

So, when we talk about joint replacement, we always have to discuss with you the risks of an operation.

We can break down the risks of an operation into three different ways. We can either do the risks during the operation that occur intraoperatively, we can do the early complications which occur early within the recovery process, and the late complications, which come at many months or years down the line.

In terms of during the surgery, there are injuries to ligaments, tendons that can occur, fracture, damage to nerves and blood vessels can all occur, and hopefully we can mitigate this about knowing where all the anatomy is and preventing it, but unfortunately, it does sometimes happen.

There's also the anaesthetic risk during the operation of potentially having an adverse reaction to the anaesthetic.

In terms of during the early recovery, we look at problems with the wound healing, and problems with the wound healing can mean opening up of the wound, infection within the wound, you can get blood clots within the leg, which can go to the lung, and the worst-case scenario, that can lead to death in this early scenario.

After a knee replacement, patients do go home on blood thinning medication to reduce this chance.

In the early stage, it's a painful operation, so patients will walk with a limp. The knee can be a bit stiff as well, while the soft tissues just react to the knee replacement and become a little bit more elastic and this can also lead to the limp and ongoing pain and swelling.

Long-term, we look at how, over time, the implant can actually wear out and loosen, and as it loosens, that might need further surgery, particularly revision surgery.

And also, because of the wearing out of the knee, and also because these knees knee replacements are in for a long period of time in potentially osteoporotic bone, there is a risk of fracture around the implant long-term, as well as potentially a dislocation of the whole knee, or just the patellofemoral joints.

I overall tell patients when I go through a knee replacement risk that there are 80% of patients who are very happy with their knee replacement long-term.

There are a group of patients, 15%, who are unhappy, but they're not worse off. Usually, there are high expectations from having a knee replacement, and not every knee replacement can match those high expectations.

But most of these patients are not worse off. Their pain is better, their function is better, it's just certain parts of it which they might not be happy with and then there's a group of patients who are 5% of patients who are worse off.

Sometimes there's an obvious complication which leads to long-term adverse effects, but sometimes there is just persistent pain within a knee replacement, which no one can get to the bottom of, and can't be sorted out.

During the joint after the operation, you will stay in hospital for 1-2 nights in the Benenden single rooms, and if the operation is earlier enough in the day that you've recovered from your anaesthetic, you will be able to walk around on the same day of the operation, get to the toilet, walk around the ward if you feel able.

We encourage your movement of the knee as soon as you regain function back in the knee, so that you can try and prevent any long-term stiffness, and the physiotherapy will see you on the ward to give you strengthening and range of motion advice.

And usually what we see with knee replacements is you're back to most normality within 6 weeks, but by this between 6 and 12 weeks, this does certainly improve quite significantly, so that you're, hopefully by 3 months, back to full function.

As I said, the first couple of weeks after any knee replacement is extremely painful, and I always tell my patients, you will hate me for a first couple of weeks after a knee replacement, because of that pain and it's important we get the pain under control, but even with painkillers, ice machines, the pain is still there, and it's not an easy time for recovery.

But during that time, it's important to get the knee moving. We manage, as I said, through painkillers.

Through physiotherapy does help aid the pain, as well as cryo cuffs and ice packs can help.

By 6 weeks, most patients will be back driving and will see you in the follow-up at clinic and then by 3 to 6 months, the real benefits of the surgery come through, and you return to these normal activities, as I mentioned.

And sometimes patients come back at that point for their other needs to be done because they are happy.

These are all the hip and knee surgeons throughout Benenden. Obviously, there's just me and Mr Goddard, who just specialise in knee replace or knee on its own and then you've got Mr Chipperfield, Mr Oliver, Mr Reddy, Mr Thakur, and Mr Dunnett, all who specialize in both hip and knee conditions, who can advise you about your hip and knee pain.

You have to decide on who you want to see, obviously, and there are different ways you can do this. Doctify is an important website which you can actually go and research your surgeon's patient feedback. It's all anonymized, so patients will leave anonymized feedback on there and rate the surgeons with this starring rating.

And it's important to see what kind of procedures they're doing, the ratings they're getting for that, and you can then make your decision from this, as well as things like the NJR, which you can see your surgeon's profile, seeing the number of operations they've done, where they operate and, early and some, patient outcome data.

And then there's the Private Healthcare Information Network, which again feeds into all the private hospitals looking at the procedures that each Consultant performs, and the number of that they perform.

The joint registry data, again, is there for everyone to see. If I focus on the knees today, the data we have at the moment from 2023 shows that there, as I said earlier, over 100,000 knee replacements done in the UK in 2023, with the majority of patients being female.

And what we can see is that there's a split between there's about 14% of patients having a half-knee replacement.

I think over the next few years, that number will increase, and we're being guided by our own knee society that we should be doing it's in terms of a knee surgeon, my practice should be about a third of patients getting a joint replacement should be I should be doing a third of these as a half-knee replacement.

So, I think I'm handing over to Louise now, who will just talk you through some of these, and we'll go through the question-and-answer session.

But thank you very much for listening, and I'll be happy to answer any of your questions.

Louise

Thank you, Mr Jones. That was really interesting, and yes, we'll go on to the Q&A session now.

The first question we have is, can a partial knee replacement be changed for a full knee replacement in the future?

Mr Mark Jones

Yeah, absolutely. So, the benefit of having a partial knee is that you maintain all the ligaments within the knee and the other two compartments, which means that your knee feels more normal.

The downside, as I said, is that you can develop arthritis in the outside of your knee and on the patellofemoral joint as well and if that happens, or the implant becomes loose, then you can have a revision surgery, which is where you remove the half knee replacement, and you put in a normal total knee replacement.

Depending on how much bone has been taken in the first place, and how much what the bone quality is like, and the reason you're doing the knee replacement, it depends on the type of constraint you need within that full knee replacement. But yes, the idea is that you can change the partial knee to a fairly standard knee replacement in the future.

Louise

Patrick asks, can you have a steroid injection at the same time as having Arthrosamid as an injection?

Mr Mark Jones

No, I personally wouldn't, I don't know if anyone is doing that elsewhere. It's not recommended.

One of the reasons being we're a little bit concerned about Arthrosamid not having an increased risk of infection, but obviously, because it's an implant, we do worry about infection and obviously, if we give a steroid as well, that can lead to a bit of an increased risk of infection because of more injections.

And so, I personally wouldn't do it and I'd also I don't think it's needed, because the Arthrosamid, if it works, will work for a lot longer than a steroid would.

Louise

Yeah, that makes sense.

With the ROSA, operation, with the robots, are people more able to do, activities more, in the future, or will it be the same?

Mr Mark Jones

The PROMS data, which is all in the research, looks at the outcomes between standard knee replacements and robotic knee replacements.

The two-year PROMS data does suggest that the patient-reported outcome measures are slightly better, which basically means that maybe function is slightly improved, but I do think, actually.

I would be very hesitant to say yes to that, because I don't think the long-term data is there to prove that and actually, I think if you can find as many papers to show that that function is improved as you can that it's not improved and the data is very diverse at the moment, and I think we really need to

Work on getting the data better for patients and surgeons, so we can make that clinical decision.

But do I think long-term, will it have a success? I think I think it will give you a knee replacement which is more accurate, and I think that will help, and we have such a high group of patients who are unhappy with knee replacements, that 20% group, that if we can even improve that 20% to 10%, we are helping a high number of patients.

So I think long-term robotic surgery is the way we will be going, because I do think it will improve outcome and with both types of replacement, can you do sports like cycling afterwards?

Yeah, so I would I would always encourage patients to get back to any activities they want after their knee replacement. I know there are certain surgeons who are a bit hesitant to say yes to go back to running, or jumping out of an airplane, or anything like that, because actually there is a higher risk of having injury if you've had a knee replacement. If you do more on that knee replacement, it will wear out.

But actually, the point of doing the joint replacement for you is to give you back a quality of life that you haven't had because of the arthritis and if that quality of life is to get back out on a bike or go for a run, then do that. As long as you know the risks that it could potentially increase the wear and tear throughout that knee replacement long term.

And might need a revision down the line. But certainly, you can get back to any activity you want.

Louise

Yeah. Another attendee's asked a very similar question around cricket and other kind of sports, like, and how many years it will last, but it will depend on the person?

Mr Mark Jones

It depends on the person, how much you're using it. Obviously, if you're gonna run ultramarathons every day of your life then it will wear out.

Also, if the heavier you are, the more likely our joint replacements are to wear out. So, it's all about doing things in moderation, but getting a quality of life back, and that's the most important thing about doing this joint replacement.

To see patients, you know, enjoy their quality of life that they weren't having because they were in pain.

Louise

Yeah, thank you.

This person has been diagnosed with arthritis in their left knee, and they're not they have a feeling that the right knee might also have it. If they had their left knee replaced, how can they prevent that other one progressing, especially if they rely on it for recovery?

Mr Mark Jones

I mean, it's not, we do tend to find that patients are fairly symmetrical, and so if you have one knee that's arthritic, the likelihood is that there is probably some wear and tear in the other knee as well, and then one knee becomes painful and you start overloading the other knee, then that again causes more wear and tear. There's no way, really, in that early

post-operative recovery to protect the other knee, apart from just using your crutches, taking things a bit slower, until you can use both legs equally at the same time, so that you're offloading both legs. But there's nothing really in that early recovery that you can do, it's just about maintaining strength and mobility in both knees.

Louise

Thank you.

Sue had plasma injections privately in both knees in September last year, and she was told to, due to the condition, to expect a 60 to 40 success rate. She's been told that she needs knee replacements, and she's trying to lose weight. Is it worth still exploring Arthrosamid injections?

Mr Mark Jones

Yeah, so you've not said whether you had any success from the injections, all injections work by usually taking away the inflammation that the arthritis causes.

There are two modes, really two modes of pain that arthritis that you get because of arthritis. You even get bone pain because of the bone on bone and the overload. Or you get an inflammatory pain with swelling within the knee, which then causes pain.

I found, through kind of experience and kind of through other injections, that the bone-on-bone pain doesn't tend to get better, because the inflammation from the injection doesn't get better within the bone. But if your arthritis is causing a bit of swelling within the knee and inflammatory pain then the pain will get better and I think if you've had benefit from an injection of any kind then Arthrosamid tends to work in the same way, but it's just more permanent. So yes, I think it's always worth exploring non-operative treatments.

Does it work in severe arthritis? Not as well as it does in mild to moderate arthritis. But actually, I am seeing patients who have bone-on-bone arthritis, and their pain is better.

So we're there are ways that this Arthrosamid drug is working, that we're waiting for research to show us a bit more about how it's working, but it may have other modes of action as well.

Louise

Sue says she did have a little relief for about 6 months, so it does sound like it's a good option.

Mr Mark Jones

We're speaking to one of the clinicians in clinic to actually discuss the options, have a look at your x-rays, and have a kind of informed decision about whether you go down that Arthrosamid route or a knee replacement route.

But certainly, if you're not keen on a joint replacement, then the Arthrosamid is certainly a good option.

Louise

Okay, Nick says his right knee is falling inward slightly, but there is no pain. It becomes more exaggerated the longer he walks. Can he correct this with exercises?

Mr Mark Jones

Yeah, usually the knee falls in most of the time because of weakness around the knee, so it's not just weakness within the knee, and lots of knee rehab is traditionally focused on building up quadriceps muscles to try and protect the knee and actually, what we do know is you need to focus on everything from the core down, so looking at your stomach muscles, your pelvic girdle, your hip muscles, and as well as your calf, your thigh muscles, to try and protect this knee.

When you put your foot to the floor, every muscle in from your core down needs to protect that knee from rotating. If there's a weakness, particularly, say, in your hip, your hip might internally rotate, which will then cause your knee to twist in.

If your ankles are weak, your ankle might twist in, causing your knee to twist again. So, working on your entire core, working on your strength and conditioning, will try and offload this knee, will stop it twisting, and will maintain a linear movement of that knee as you put weight through it, which will only benefit your outcome long-term.

Louise

Yeah, thank you.

Slightly connected to that, Joseph says he's been told he's been told that as he's not suffering from pain, he might be less happy with a knee replacement.

Mr Mark Jones

Yeah, I agree.

Louise

That makes sense.

Mr Mark Jones

Knee replacements are traditionally for a painful arthritic knee. There are many x-rays that I see of an arthritic knee which could be treated with a knee replacement, but the patient doesn't have pain.

Or the pain isn't bad enough to warrant a knee replacement and when I say not bad enough, I mean they're not taking painkillers, or they don't get night or rest pain, it's not affecting their everyday activities, that kind of thing and I think for those patients, we really need to focus more on the non-operative management of the knee arthritis to try and delay that knee replacement as long as possible.

It's when it affects quality of life, and most of the time, quality of life is affected by the pain that restricts you from doing stuff. It can sometimes be stiffness, but that stiffness is a bit harder to treat. It will get better with a knee replacement, but it's not guaranteed, whereas the pain, hopefully, will get better with a knee replacement. So, I would always say only have a knee replacement.

For the majority, 99% of cases, for knee pain that is not manageable with non-operative options.

Louise

Great, thank you. Are operations under general or local anaesthetic?

Mr Mark Jones

So it is very much a personalized thing to the both the patient and the anaesthetist, but the majority of knee replacements will have some kind of what we call regional block. Now, that may be an injection within the spine, which numbs the leg we're operating on.

Or an injection around the knee, which blocks the nerves supplying the sensation. Or a combination of both and the reason being that these are long-lasting, so when you

Finish the operation, you still have that prolonged pain relief on the ward, which will help your early recovery.

Some patients will then also have a general anaesthetic, so they're completely asleep with a tube down their mouth that the anaesthetists are helping them breathe with. Some patients will be sedated, where they actually are maintaining their own breathing, but they're in a deep sleep.

Or some patients like to hear all the saws and hammers and will stay wide awake for it and it's completely up to you and the anaesthetist about the decisions you make in terms of the anaesthetic side of things.

Louise

Yeah. Can you explain what jiffy knee replacements are?

Mr Mark Jones

No, sorry.

Louise

No. I've not actually heard of that term either.

Mr Mark Jones

Jiffy, I can try and find out for you and let the team know to reply to you, but no, I can't.

Louise

No, that's fine.

Can, if you've had two, hip replacements already. Can you still go ahead with a knee replacement? And this person also asks, is Arthrosamid as an injection painful?

Mr Mark Jones

Yeah, so if you've had two new hip replacements, you can have two knee replacements. It always depends on the complexity of your hip replacement, on how the knee replacement might have to be done.

If you've had multiple revision hip surgeries, which have left you with long stems down the femur then it may be that you're more suited to a robotic knee replacement. If you've had fairly straightforward knee hip replacements, then you can have a fairly straightforward knee replacement too.

And what was the other one? Are Arthrosamid injections painful?

Louise

Yeah.

Mr Mark Jones

Not initially. So, obviously, it's an injection into the knee. That can be a little bit of bit of uncomfortable pushing and prodding, but most of the time, patients don't really complain of too much pain.

After the operation, or after the injection, it can swell the knee up, it can flare the knee up, so in the first few weeks, you can actually get a bit of a reaction within the knee, which makes your pain slightly worse.

That does usually settle down long-term, and by 3 months, well, hopefully, you'll be recovering, and you'll be seeing, then, the benefits of the injection.

Louise

Yeah, thank you and can you have Arthrosamid more than once?

Mr Mark Jones

Yep, so because it's not being used for very long, but we are seeing, and the studies are showing that you can have either top-up of injections, and some patients are requiring a top-up of the injection around 6 to 12 months down the line, and that's because it is a dose-related thing.

We're giving 6 mils of this drug to everybody, but obviously some people will differ in terms of the drug dosing that they need, and they may find that they've had benefit, but not a huge amount, and so then have a top-up at 6 to 12 months and then show that they get this increased benefit.

And some patients will have good benefit for many years, and then when it wears off, will then have another one with just as good success. So yes, you can have more than one.

Louise

Yep. Brendan says, he has, pain and some inflammation on the right superior tibiofibular joint.

Which he suspects may be osteoarthritic. What's your thoughts on that?

Mr Mark Jones

That's a very different, knee arthritis. So, it is a very specific joint, and they can become arthritic and very painful. Sometimes they're caused by trauma in the past, injuries that have been knocked, and then this has caused injuries within that, superior tibia fibular joint.

Most of the time, because of the arthritis, they become quite stiff, and then actually they start to fuse, and the pain then gets better. There are treatments you can get where you can actually destroy the joint and fuse the joints, but you can't replace this joint.

So it's treated in a very different way. You can also have injections in it, but these injections tend to be more under ultrasound guidance by radiologists, because they're a tighter joint to get into. But certainly, there are you can get arthritis in this joint.

But it would be a diagnosis which you'd need to see your surgeon about, and it would be treated differently to a normal knee arthritis.

Louise

Interesting, I've not heard of that before, thank you. This person's recently had a High hyaluronate injection.

I don't know if I'm saying that correctly, which didn't improve the pain in their knee. So therefore, how likely would our Arthrosamid injection be successful?

Mr Mark Jones

It's hard to say. So, they obviously have different modes of action, and

All because one injection doesn't work doesn't mean another injection won't work.

I do find that with this steroid injection, if a steroid injection works, then the Arthrosamid does tend to work as well, and the reason being, I think they both get rid of that inflammation. Durolane is a more of a viscose supplementation injection, which aids with the lubrication of the joint, so it does act slightly differently.

That lubrication but does then reduce the inflammation within the knee joint, and so it does affect inflammation, but not in the same way as the steroid injection or the Arthrosamid injection does. So it would still be worth having a discussion.

I would if you were really adamant that you didn't want surgery in terms of knee replacement and or that there's no other treatment options available and you're struggling, it certainly wouldn't be ruled out, and it would be potentially a good management option for you, but might that could potentially work and we always I think with Arthrosamid, I always quote what the company has shown in their research is that 80% of patients under the age of 70 have a good clinical benefit of Arthrosamid.

The older you get, that clinical benefit does decrease, and so in the over-70s, that clinical benefit the benefits are about 60-65% of patients will have a clinical benefit.

It, again, depends on the bone-on-bone arthritis and the inflammation within the knee. So it's all a little bit specific on the patient and the investigations and examination. But it certainly would be worth talking about, because it may save you from having a knee replacement.

Louise

Great, thank you.

So, that's all the questions we have come through. So thank you everyone for sending in those questions and for being part of this evening's session.

If you move on to the next slide, please.

So, as a thank you for attending, we're pleased to offer 50% off the value of a consultation for a limited time, a callback from your dedicated Private Patient Advisor. An email with a recording of this session, treatment information, and loyalty reward points for joining the session and updates on future events and news.

We'd really appreciate it if you could take a minute at the end to complete a short survey on this session, as it helps us improve and tailor future webinars to your needs and if you'd like to speak to someone to book a consultation, our Private Patient team are available this evening until 8pm and they're normally available at 8am to 6pm, Monday to Friday. The contact number is on your screen.

We also have upcoming webinars on a range of topics, including hip replacement surgery, gynaecology, and plastic surgery. You can sign up for these on our website.

So on behalf of Mr Jones, and all of us at Benenden Hospital, I'd like to say thank you very much for joining us, and we hope to hear from you soon.

So, take care, and goodbye.

Mr Mark Jones

Alright, thank you.