Louise King

Good evening, everyone. Welcome to our webinar on knee osteoarthritis. My name is Louise, and I’m your host this evening. Our expert presenter is Mr Richard Goddard, a Consultant Orthopaedic Surgeon. This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so by using the Q&A icon, which is on the bottom of the screen, this can be done with or without giving your name. Please note that the session is being recorded if you do provide your name. If you'd like to book your consultation, we'll provide contact details at the end of this session., I’ll now hand it over to Mr Goddard, and you'll hear from me again shortly.

Mr Richard Goddard

Good evening, everyone, and welcome to the Benenden webinar on knee osteoarthritis. My name is Richard Goddard, and I’m a Consultant Orthopaedic Surgeon working here at Benenden. I also work in the NHS at the Conquest Hospital, and I only deal with knee problems and knee surgery, so in this session we'll go through a number of topics. We'll talk about what osteoarthritis is, we'll talk about the stages you may experience, there's various options of treatment, we'll go through the non-surgical options and the operations that could help, we'll talk about knee replacement surgery and the various options that we have for knee replacements, and we'll talk about what a typical patient would experience with their journey having a knee replacement, and we'll also talk about the new exciting development, which is the ROSA robotic knee replacement system, which we've recently introduced here at Benenden, and there'll be plenty of time for questions at the end of the session.

So, bit about my background I trained at the University of Leeds and graduated in 1997, which seems like a very long time ago. I then did some research at the University of London, obtaining a Master of Surgery degree, which was actually a knee ligament reconstruction and an MS thesis. I then joined the Southeast 10's surgical rotation, and I now work as a consultant in the southeast.

So, what is osteoarthritis? The diagram at the bottom left of the picture shows a normal knee joint, and if you open a normal knee joint and look inside you, the bone is lined with cartilage. A good visual description is that if you think of a snooker ball, the white billiard ball, that's what the articular cartilage should look like. It's lovely and smooth; there are no imperfections, and it seems almost quite shiny. That's normal articular cartilage, so if you look inside someone's knee who's 18 and the cartilage looks like a brand new snook ball, osteoarthritis is basically wear and tear of that perfect bearing surface, and it starts with minor damage, scratches, and scuffs to the articular cartilage, and then the articular cartilage starts crumbling away a bit like an old road, and you get potholes in the crumbly areas, and then eventually the cartilage wears away to the bare bone, and then eventually you may get bone on bone arthritis, which the x-rays at the bottom are showing, and that's when people have severe pain and arthritic symptoms and usually would need a knee replacement. You may be able to do normal daily activities without a lot of pain, but after something more excessive, such as a long walk or perhaps playing golf or other sports, you may feel some discomfort. You may feel the knees well after activity, and you may get a sensation of clicking, crunching, grating, and grinding. These are all early signs and symptoms of osteoarthritis. When the arthritis progresses and gets very bad, people have constant pain. just sitting in a chair pain at night lying in bed and often patients describe they're woken up at night due to severe pain relatives and friends may notice that they're walking with a limp and their knee and leg becomes bowed and def formed and patients then are not able to walk the distance as they used to like to walk and become more housebound chair bound osteoarthritis goes through a number of stages and these are seen on x-rays and MRI scans mainly it starts where there's early cartilage thinning and on an x-ray it may look particularly normal but an MRI scan may show some early cartilage loss then you get mild arthritis where an x-ray you see narrowing of the joint and this then progresses the joint space gets narrower and narrower until all the cartilage is worn away and then one ends up with bone on bone arthritis and often this is accompanied with severe pain and limitation of activities and it's quite obvious usually on an x-ray without any need for any further imaging like an MRI scan

How do you treat arthritis? Well, to diagnose arthritis, you'd visit a GP, a physiotherapist, or someone like myself. We'd take a history, examine your knee, and do various tests like x-rays and MRI scans. The non-surgical treatment is really to try and treat anything that's correctable, so if you just get pain after running 10 miles, then perhaps try cycling instead of running; that might help your pain. If someone is overweight, the facts and figures of being overweight are that around seven times your body weight goes through your knee joint going up and down a hill or up the stairs at home, and if you just lose one kilogram in weight, this is multiplied by seven going through the knee, so a loss of say one stone in weight equates to a loss of seven stone of force going through the knee joint on normal activity, which really helps someone's pain. You may see a physiotherapist to do muscle strengthening and ligament strengthening. Keep the joint mobile and supple. You may take simple analgesia over the counter, paracetamol, ibuprofen, or stronger painkillers from your GP, then try knee brace strapping often with activity, playing sports, etc. We can do various injections for pain and inflammation; you can have a steroid injection; and there's also something we can think of as a biological oil change for the knee. It's a vile or biologically active gel or oil that's placed into the knee joint and then works its way all around and provides a coating. It's like an oil change in a car engine, lubricating the joint, and it's also biologically active, trying to nourish the cartilage. It's important to try all of these measures first before rushing straight into a knee replacement. You don't have to try every single one, but you have to try a number of them to try and improve before an operation. We then come to what operations are available for the arthritis. If there's just an area of arthritis with good cartilage everywhere else, then something called a micro fracture can be very useful. With keyhole surgery, trying to make little holes in the bone and trying to generate some scar tissue to fill in the pothole in the knee can help in the right circumstances. In younger people with severe deformities, we may try to avoid a knee replacement and try to correct the alignment by realigning the bone, and that's called an osteotomy. As one gets older, it's usually not advisable because a knee replacement is the gold standard operation for curing arthritis. I’ve put their cartilage transplantation. This is very experimental again; it's not for generalized arthritis; it's for specific patterns of arthritis commonly in younger people, commonly in an isolated part of the knee joint. But this is an up-and-coming and exciting technology that may be the future of knee surgery. At the moment, we rely on joint replacements to cure severe arthritis.

So, knee replacement is a very common operation. Now, I personally do around 3 to 400 knee replacements a year, mainly for wear-and-tear osteoarthritis that can also be used for a variety of inflammatory arthritis, such as rheumatoid patients with gout and patients with previous cartilage and ligament injuries, perhaps due to injury or sport. not here at Benenden commonly, but in the NHS for people who have severe fractures, falls, and trauma, we do primary knee replacements to treat severe fractures. The aim of a knee replacement is to cure the arthritis, which then helps the patient's pain and increases mobility. get people walking back a number of miles as opposed to only a few 100 yards or meters, restore the function of the limb and the function of the patient, and try and correct the alignment of the knee. We're seeing many, many younger patients now present for knee replacements, and this poses an extra challenge because younger patients rightly have greater expectations. higher functional demand such as they're still working and want to do various sports and generally everyone has higher expectations of a knee replacement and it's important to realize that a knee replacement isn't the normal knee you were born with or had when you were 1820 it's an artificial joint it's metal and plastic it's far better and less painful than a severely arthritic knee joint but it's not as good as the one you were born with so in the UK there's around 100,000 knee placements performed a year we enter all the data on a national joint register which as surgeons we can see our own data and our colleagues and we can compare how knee replacements are doing for various problems in various patients men women various problems The average age of a knee replacement in the country is usually around 66, 67, or thereabouts. Slightly more women have knee replacements compared to men. Knee replacements are more common in younger men and sort of ladies as they get older; approximately 95%, or 94 and a half% of patients, so 95 out of 100, that's around six months, report that their knee after a knee replacement is a lot better, and many studies show that there's a good health improvement after a knee replacement. New replacements don't last forever; they're metal and plastic, and the weak link here is the plastic bearing, which is the new cartilage. They're tested in the lab on various robots and simulators, and the plastic bearing, just like the rubber of a car tire, will wear away over time. 80% of knee replacements nowadays last up to 25 years, which is really good.

So, what are the options for a knee replacement? The most common operation and the most common type of arthritis demands a total knee replacement, where you replace or resurface the knee joint, replace the kneecap, replace the end of the thigh bone, and replace the end of the shin bone, the tibia. That's the diagram in the middle that's a total knee replacement, and the x-ray on the right-hand side shows that, in certain circumstances, if there's just arthritis in one part of the knee, you can do a partial knee replacement. Commonly, the inside of the knee gets worn, and you can do a medial knee replacement. The one we use here is the Oxford knee replacement, and occasionally, but more rarely, you can replace the kneecap joint in isolation or the outside of the knee with a knee replacement. There are many ways of doing it so commonly, and the vast majority of surgeons use standard instruments, which means we use x-rays and various instruments during the operation to take measurements and get the alignment of the specific patient. There are techniques one can use for computer navigation, and that's moved on now to the ROSA robotic system, which we'll talk about in a short while. Also, there's a signature knee replacement we do here at Ben, which is pre-planning with MRI scans, and all of these have their relative advantages over each other. Certain patients present late with very severe deformities and ligament injuries, and then we need more complex knee replacements, building the bone, restoring the alignment, and compensating for damaged ligaments. The takeaway message from this is that if you have arthritis of the knee, it's better not to ignore it. It's better to get it checked out by an expert. Get x-rays and take advice, because if you ignore it and leave it, it can get to the stage where a simple knee replacement is not going to help you. It can be cured with a more complex knee replacement, but the results of those are not quite as pleasing to the patient; it's more of a salvage type of operation.

The implant we use here at Benenden is the Vanguard Knee Replacement. This is one of the top three most commonly used knee replacements in the country. It has a very good track record. It has the highest ODEP rating, which is the panel of Orthopaedic experts that monitors the data, and it has a 10a rating, which is the best that it can have. The 10-year survivorship rate is over 96%, which means that six out of 100 vanguard knee replacements are lasting 10 years. Probably the predecessor was the AGC, which's now not used anymore, but the vanguard is the newer version of that, and at 35 years, which had 70% survivorship, the vanguard's not been out for 35 years yet, but we're hoping the data carries on being good and it lives up to the same benchmarks as the old AGC replacement. We use surgical cement to secure the knee replacement to the bone, and studies show a slight improvement over uncemented knee replacements. There are fewer early failures, and you can replace the knee joint with or without the kneecap, the patella. That depends on the amount of arthritis seen on the kneecap and the individual surgeon's preference. The good thing about the vanguard knee replacement is that it's very modular, and for more severe deformities, which you may know beforehand or may find out during the operation, you can swap and change and make it more stabilized if necessary.

So how does it all begin? You would come see one of us here at Benenden. We would probably spend the initial consultation probably 20 minutes having a chat about your symptoms, finding out how sore you nears are and how it's affecting you. Have you had any injuries? We would like to know about your past medical history. Do you have any other medical problems? Do you want any medications? Do you have any allergies? It's very important to tell us, especially if you think you may be allergic to metal or nickel, because all NE replacements contain metal or NLE, and if you have an allergy, we can use a special Vanguard replacement that doesn't contain nickel, but this usually has to be pre-planned and specially ordered. We'd want to take x-rays of the affected knee to see the damage that's there, and other imaging like CT scans or MRI scans may be required if we're not 100% sure of the problem and what's going on following this consultation. After the examination and the x-rays, we tailor an individualized plan for how we should treat your arthritic knee, which could start with advice. pencil injections all the way to surgical intervention Many patients I see by the time they've got to my clinic have tried and exhausted all the conservative measures, and we just take those boxes and accept that the next stage is a knee replacement.

So, what should a patient do prior to a knee replacement? Well, you need to optimize your health. It's a good idea to try to get healthy and lose weight if you can. This would certainly help your recovery. help the anaesthetic and certainly make the knee replacement function better and last longer in the long term if one has pre-existing medical problems. heart problems high blood pressure and diabetes; these should be optimized with medication and advice from your GP prior to having an anaesthetic and surgery. It's a good idea to do exercise before a knee replacement, which we call prehabilitation. You can do exercises off the internet or see a physiotherapy physiotherapist, but this is basically getting the muscle strong and getting the knee moving the best it can, and so after the operation, the muscles have memory and know the exercises that they're meant to be doing, which makes the recovery swifter and easier for the individual patient.

Once we've decided you're healthy to have a knee replacement and you've optimized medical problems, it's time for preassessment with nurse screening, who will do various blood tests. possibly a tracing of your heart, and if there's any worry that there may be medical problems, then you're referred to one of our anaesthetic colleagues, who will carefully assess you from an anaesthetic point of view and discuss the suitability of various anaesthetic options. Most patients who have a knee replacement commonly have a spinal anaesthetic rather than a general anaesthetic, which works well for pain relief during and also after the operation in the early hours of recovery, which is very important. So, in the surgical journey, we've talked about the exercises before optimizing one's health. I can't stress enough that if someone has diabetes, it's really important to have good diabetic control, and we'll be very strict with various blood tests. If the blood sugar levels over a period are too high, we want them to be lower because there's an increased risk of complications and wound healing problems. skin breakdown, which we don't want, and we'll also be advising patients over the rapid recovery protocol, which is really saying modern thinking after a knee replacement is to get going quickly, don't stay in hospital very long, get back home, get back using the knee, do everything you can yourself, make your cup of tea, make your sandwich, and go up and down the stairs to the hospital. This is all rapid recovery and a good way of recovering from a knee replacement and getting maximum function out of it. Patients are now commonly admitted in the morning or afternoon of surgery. You'll see myself, and you'll see the anaesthetist, who will discuss the relative anaesthetic techniques with you during

after the operation you'll have close monitoring commonly patients stay in hospital two nights very occasionally you have someone who goes home the next day but two nights is normal clearly if you have problems some patients feel nauseous after an operation or a little bit light-headed and dizzy you're not sort of discharged the next day or the day after if you're in well you stay in as long as necessary but the average length of stay is around two nights the day of surgery will fully weight bear you so if your operations in the morning hopefully after lunch will get you sat out in a chair bending the knee and you might walk with help from a physio or a nurse with crutches or a frame from the chair to the loo and back and that would be a really good first day of rehabilitation and whilst an impatient you'll be doing exercises and have intensive physiotherapy around twice a day for your two-day stay after a knee replacement a knee replacement is very painful you must take painkillers it remains quite painful for a good two to six weeks to be over the worst of it and it takes another few months to settle down but pain is normal where surgically cutting the bone and this is sore we give you lots of pain relief and everyone's different in the strength of painkillers they need and you'll be discharged home with the appropriate pain relief that help you some patients feel a little nauseous and we give you medication to help sickliness we try and avoid changing the dressings but we keep the wound covered with a sterile dressing and this is usually changed in the community when you have the stitches or staples out at around 10 days to two weeks after the operation you'll have blood tests and an x-ray afterwards to make sure everything's okay and you' be really encouraged get out of bed and do your exercises and really get going and this is the rapid recovery

Protocol: Any operation carries benefits and risks. Fortunately, the risks of knee replacements are uncommon, but during the operation, it's possible to injure nerves, arteries, and veins. This is, fortunately, very rare—less than one in a thousand. Occasionally, there's excessive bleeding, and one would need a blood transfusion after the operation. This is becoming less and less common nowadays. There can be damage to the perforation of the bones during an operation, very rarely a fracture, which I can't remember the last time I saw but is obviously a theoretical risk during recovery. It's important to keep the wound nice and dry. We worry about infection, and we give you antibiotics during and after the operation to prevent infection, but it's important to keep the knee wound covered and dry. Avoid getting it soaked in the bath, and avoid pets, etc., sniffing and, in the best of intentions, licking near the wound because that can cause infections. Blood clops and thrombosis are risks, and you're more at risk of this if you're sitting and not moving around. It's important to get up and about, and we give you blood-thinning tablets commonly for two weeks to help prevent deep venous thrombosis. Obviously, it will be sore. You'll be walking with walking aids, often with a LMP, for a few weeks, and the knee will undoubtedly be stiff and swollen, and this settles over time. Years and years after the operation, knee replacements can wear out due to the plastic bearing failing, and we call this aseptic loosening. Occasionally, patients fall over or have an accident, and you can fracture around a hip or get a new replacement. Infection can manifest late, and this can be due to a bloodborne infection from a serious illness like pneumonia or an infection from other sources like a urinary tract infection.

so this poor patient here has a very severe deformity you can see both knees are very severely bowed we call this a varus malalignment and this is very common and this patient's deformities were not correctable so we had to do a more stabilized knee replacement which you see here on the x-ray but importantly on the middle picture the middle x-ray you see that afterwards the knee is lovely and straight so even very severe deformities we can correct with our vanguard knee replacement if you leave it too long this is an example of a patient I saw about 10 years ago this poor chap had neglected his knee arthritis left it far too long and presented with a very severe deformity his knee was and it eroded the bone and we had to do a very complex and constrained knee replacement and this is a situation we need to try and avoid because the results of this type of knee replacement are not quite as good as having the more simple total knee replacement knee replacements do become more complicated and we can go on to rotating hinges we very rarely use these here at Benenden but one would use it for severe bone loss or if someone's had severe deformity or ligament damage causing the knee joint to be very unstable

So, what are the surgical requirements for a good knee replacement? Obviously, we want to cure the patient's pain. We want to make the knee straight, which means restoring that person's individual mechanical axis. Not everyone's leg is straight when they're born; some people have bowlegs; some people have knocked knees, but we're trying to get the knee replacement aligned to your hip and your ankle and try and restore your leg alignment to what it was prior to the arthritic process. We want to take as little bone as possible, preserving the bone in case there's a need for future surgery, and we want to get the implants as accurately placed as possible in good alignment, which then helps prevent early wear and loosening and subsequent failure.

Recently introduced here at Benenden is the ROSA robot IC knee replacement. This has been used in various countries and more recently in the UK, and we did the first ROSA robotic knee replacement at Benenden this week on Monday. My colleague Alex Chipperfield did the first ROSA robotic knee replacement, which all went very well, and we were very pleased with it. Why change well? All operations and all medical interventions get better with time. There's a new improvement in how knee replacements are done. Patients are becoming more demanding. You often get younger patients, but anyone can have ROSA. It's not just due to those who are very young and in high demand; anyone can have it to try and improve the outcome of a knee replacement. the idea of the ROSA robot is to give real time feedback during the operation so the surgeon knows they're taking the right amount of bone at the right angles and at the trial stage when you put in a knee replacement before the definitive one you get information on how the knee's moving or the ligaments balanced and if all these are correct then you get the green light from the robot that all is okay and with a standard knee replacement you don't get this information it's all based on surgical experience so the ROSA is giving us real time feedback that things are going well during the operation clearly if things are not quite as good as they could be then we can go back a step and make it make improvements to make the knee replacement as perfect as possible so the indications anyone can have a ROSA but especially we'd be wanting younger patients to consider it Patients with high demands are the ones to get back to sports, perhaps skiing, where you're putting more demands on the knee replacement, and having a little bit of malalignment may lead to early wear and failure, so getting it as perfectly aligned as possible would be very important. This patient had a road traffic accident, and as you can see on the x-rays, they fractured both their femur and their tibia, so getting the alignment in a standard fashion during the operation would be very difficult, and this would be an ideal candidate to have the ROSA robotic knee replacement. With the technology, there's a robot in theatre, which you'll see in a video shortly. The surgeon uses the robotic arm, which has various cutting blocks. The robot isn't doing any of the surgery with a normal knee replacement. I put the cutting blocks on the bone using various instruments to get the alignment with the ROSA robot we tell the robot where the patient's hip knee and ankle is in space and time it's a bit like using satellite navigation satellites knowing where your mobile phone or your car is so the robot then knows via the satellite navigation technology where your knee is in space and time and then it tells us the deformity how tight the ligaments are and then we can on the screen you see here that's the screen I see and I can then input to the computer what cuts I want to do before deciding it's the correct surgical plan and then once we tell the robot we've got the green light to do the operation all the robot k is doing is placing the cutting block on the bone in the correct place if the surgeon or the assistant accidentally moves the leg the robot knows this and the robot will accommodate and move with the patient so you can't trick the robot and the idea of this is to make the operation more accurate and also get the feedback during the operation so this video produced by them

This is a ROSA Knee is a robotic surgical assistant for total knee replacement. Your surgeon is specially trained to use the robot, which does not operate on its own. Your surgeon is in the operating room the entire time, 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 [music] 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.

Video Audio

So that's the ROSA robot, which is a new and exciting technology that we're starting to use here at Benam, so the outcome of the ROSA robot is that the new replacement will be more accurate. Studies have shown in America that there's fewer surgical outliers, so there's virtually 100% of cases within 3 degrees of the intended surgical plan with standard knee replacements. There's less accuracy, but I must say that studies have shown that surgeons who do many hundreds of knee replacements tend to get it right more often than surgeons who just perhaps do five, six, or 10 a year, so it's important with any operation to choose a surgeon who's doing many, many knee replacements a year, so the result should be any knee replacement we want. Accurate component sizing: knee replacements come in various shapes and sizes, a bit like buying a pair of shoes; they come in sizes and half sizes, so with ROSA or standard knee replacements, we take measurements during the operation to get the exact size for your knee. I’ve never known a patient have to wear a normal off-the-shelf knee replacement that doesn't fit perfectly and doesn't work. We want an excellent range of movement on the table. It must be stressed. I think it's important to realize that the range of movement a patient has before the operation is one of the determining factors of the range of movement, so if your knee has been very stiff and you struggle to get it straight and struggle to bend it beyond the right angle, it's not realistic to expect a knee replacement to give you the range of movement you had as a child. It will hopefully be better than what you started with, but it may not be the perfect range of movement that you had before the athletic process took place.

Mr Richard Goddard

Hold on, and this is all of my colleagues who do knee replacement surgery, and any one of us would be happy to see and assess you in the clinic. Well, thank you for your attention, and I hope the presentation was enjoyable. We can now open the floor for any questions.

Louise King

Thank you, Mr Goddard. Okay, we have quite a few questions that have come through already, and if you're considering asking a question, please use the Q&A icon at the bottom of the screen.

Our first question is: How soon after the consultation could surgery commence?

Mr Richard Goddard

That depends on a number of factors. obviously hospitals have operation lists that are planned so commonly if you don't need any extra medical tests or don't need to see us for extra sort of medical checkup we would be hopeful that your knee replacement could be scheduled within 6 to8 weeks after the consultation occasionally earlier if there's a space but often the theatre lists are well booked up six weeks in advance so I usually advise patients it's better to come early if you've got holidays or important life events planned it's better to have the consultation early and it's easier to plan an operation if I see you tomorrow it's a lot easier to say you want your operation in July rather than say you want it next week but generally we can sort of try and accommodate within six to8 weeks

Louise King

Thank you. Maria says if I already have an arthroscopic operation, I suffer from osteoarthritis. I am 60, so I wonder whether I would benefit from any further operations. I was a swimmer left knee and pain every day

Mr Richard Goddard

well it sounds it sounds from the you know from the basic information I’ve got that you have quite significant arthritis if there's a lot of pain and swelling if you've already had an arthroscopic surgery then repeating the arthroscopy is usually not beneficial we would want to see you in clinic get an ex-ray possibly an MRI scan to look into it further if these show there's full thickness c loss then a knee replacement is probably the next step if the scan showed there's moderate arthritis but not severe would want to be delaying a knee replacement operation trying the injections and that type of thing first this is dependent on patients age for example if you're younger than 60 we' want to try and preserve the joint for as long as possible but that said if you have severe arthritis we would do a knee replace m if someone comes who's 85 with sort of moderate arthritis then we'd say well let's just go ahead and do a knee replacement because we appreciate it's going to get worse and the knee replacement is going to last a good 20 25 years but I’d probably say to answer your individual question we need more information with x-rays and MRI scans to get a grip of how severe the arthritic process is

Louise King

Thank you. That actually relates to Allison's question. She says, Why would my consultant be saying that she's too young for a partial knee replacement? She was diagnosed in 2020, and it's getting worse and worse. She's now 58, and her lifestyle is massively reduced by the pain and instability that she experiences.

Mr Richard Goddard

yeah it's a common a common question actually when I all those years ago when I was a surgical trainee my supervising consultant wouldn't be doing knee replacements on patients under 60 so it would be my job in clinic to see these poor people and say you know we can't do any replacement painkillers come back when you're 60 that type of things times have changed and we try to avoid a knee replacement if one is too young but 58 certainly is a good age to consider a partial knee replacement generally speaking if you're under 50 we really try and avoid a knee replacement the youngest need replacement I’ve done is someone who was 39 so it's not saying we won't do it we do it in anyone who needs it but knee replacements don't last forever so if you have a partial replacement they commonly don't last as long as a total knee replacement in studies so you may be looking at 10 to 15 years and so if you're 50 that may wear out when you're 60 or 65 and then you'd need to have that change to a total knee replacement and there are only so many knee replacement you knee replacements you can have before running out of options at 58 if your x-ray showed severe arthritis I think I’ be you know happy to do a partial knee replacement for you even a total knee replacement if patients have got severe arthritis needing it

Louise King

Thank you. How long does Durolane injection lane last, and how effective is the option?

Mr Richard Goddard

This is a very difficult question to answer. I see it either works or it doesn't, so a steroid injection you probably have, and most people who have a steroid injection would say it's helped a little bit, so it might help for a few days, a few weeks, or a few months. Durolane seems to be the exact opposite it's not a painkiller it's not an anaesthetic it's not an anti-inflammatory so we usually inject a bit of local anaesthetic into the knee then you have the Durolane it's gel most patients find the knee a bit sore and irritable for a day or two and then it settles down commonly it takes a good few weeks to notice if it's had a good effect or not some patients after a few weeks don't notice a benefit and I’ probably then declare that the injection hasn't worked for you but on the flip side of the coin a lot of patients have a good long-lasting benefit and it can last three months six months nine months up to a year everyone's different but virtually all the clinics I do here at Benenden and elsewhere I have patients who come every three months every six months every year for a repeat Durolane injection and if it works for you then patients tend to have a good number of years benefit from them great

Louise King

Thank you. You have mentioned curing arthritis with a knee replacement, but is it possible that arthritis can return after a knee has been replaced?

Mr Richard Goddard

so osteoarthritis as we saw on one of the earlier slides is the damage and wear and tear and crumbling of the articular surface so think of it like a car tire the car tire is worn and when the new tire goes on that ball tire has been fully cured so when I do a knee replacement if it's a full knee replacement a total replacement I cut away all of the arthritic surface and if I replace your kneecap as well which commonly I do in virtually everyone then there's no place left in the joint for arthritis to come back if someone has in inflammatory arthritis then the damage to the joint is replaced but the inflammation of the arthritic process such as rheumatoid is still there and patients can still have swollen and achy joints from the soft tissue inflammation but the most common arthritis that patients have is osteoarthritis and that's fully cured with a full knee replacement

Louise King

Thank you. Christine asks, Are you awake throughout the operation?

Mr Richard Goddard

That's a very good question. commonly you would have a spinal anaesthetic so if I was to have a spinal anaesthetic now I would be awake as I am but I wouldn't be able to feel my body from the waist down so you would appreciate the leg is moving you' appreciate that someone's moving your body but you wouldn't feel any pain any touch or anything like that most patients don't like the idea of being awake hearing the operation feeling things happen so the anaesthetist often gives them some sedation which is not an anaesthetic but it's a sedative you fall asleep and then after the operation they switch off the sedation and then you wake up the beauty of the spinal anaesthetic is that in the hours after the knee replacement you've got good pain relief you can sit in the chair you can start to move the knee you will slowly feel the sensation come back and instead of having severe pain you'll feel an ache at first you can then tell the nurse that your spinal is wearing off and then they'll start giving you the pain pills if you have a general anaesthetic you're asleep for the operation under full anaesthetic but as soon as the operation's over the anaesthetics turned off and you will then feel quite severe pain and then patients have a poor start so that's why we really like as surgeons to for the anaesthetist to do the spinal anaesthetic vast majority of people would have the spinal in sedation so they're not truly awake and truly hearing the operation and feeling it a few patients want to be awake bring music to listen to and a few patients actually keep awake and try and chat to myself or the other surgeons

Louise King

Wow, that's brave, so Jane says, Are there any existing health conditions that would exclude surgery? She has AF, and she takes medication.

Mr Richard Goddard

So, most normal health conditions high blood pressure, diabetes, and atrial fibrillation Most heart conditions previous heart attack, previous stent, or anything like that, it's very common to have a knee replacement. If you've got a multitude of health problems, then we probably want the anaesthetist to check you over before the operation in the preassessment clinic to make sure that it's safe to have an anaesthetic. if you have atrial fibrillation we would stop your blood thinning tablets the waring before the operation and then restart it afterwards to prevent bleeding during the operation but it's very common you know once or twice a week I’ll be operating a knee replacement on someone who's got atrial fibrillation and it's not a contraindication the main contraindications are infective processes so if someone had say diabetic leg ulcers or an open wound on the s on the leg we were going to operate on this would definitely be a contraindication because of the high risk of infection and patients with severe vascular disease who've had operations on the arteries and veins behind their knee would have to think very carefully about doing a knee replacement because we could damage the arteries that have been either replaced or bypassed so there are a few specific contraindications but the vast majority of people we can do a knee replacement for

Louise King

Okay, is there an upper weight limit for you to consider before you operate?

Mr Richard Goddard

to answer the question the other way around here at Benenden we have a BMI so it's not your weight it's BMI is your weight over your height so it depends on how tall you are but they have a strict BMI limit of 40 so if one is overweight and the BMI is above 40 we'd advise you're here at Benenden to lose a bit of weight obviously diet exercise try and get the BMI below 40 which patients usually manage to do and then it makes the anaesthetic the surgery and the recovery a lot easier I have an odd few patients who can't get their BMI below 40 and the NHS hospital I work at doesn't have a BMI cut off and I often need replacements to anyone whose BMI is over 40 at the NHS hospital but here at Benenden and most private hospitals they do have a BMI cut off which is usually around 40

Louise King

Thank you. This person asks if you can reflect back on how tight the ligaments are.

Mr Richard Goddard

as the arthritic process develops the ligaments begin to contract so most patients born with a neutral straight leg if you look in a mirror the knee is straight there's obviously a normal anatomical variation people can have knees and bow legs but just say the average person has a straight leg with arthritis commonly it's the inside of the knee the medial side that's affected mostly and as that cartilage crumbles away the knee joint becomes bowed if I saw you within a year of that happening the ligament on the inside of the knee is probably correctable and that means in the examination of your knee on the examination couch I can make your bowed leg go straight and that means the soft tissues and the ligaments are correctable and that knee possibly would be a good knee to have a partial knee replacement on or a total knee replacement however if the deformity is not correctable that means the soft tissues and ligaments have contracted and got very tight and the deformity is not correctable and that means more surgery needs to be done to correct the deformity with various ligament releases and sometimes that needs a more constrained type of knee replacement which we often decide before the operation and occasionally during the operation we will change but what I meant by that slide was it's the deformity that's either correctable or not correctable so if you have medial arthritis and the deforms is not correctable it's not a good idea to do a partial knee replacement

Louise King

Okay, Tim asks: Does a previous successful ligament replacement impact the success of a knee replacement?

Mr Richard Goddard

With all total knee replacements, the cruciate ligament and the anterior cruciate ligament are sacrificed, and so if you have a native ACL, if you have injured your ACL and had it reconstructed, or if you've injured the AC and not had it reconstructed, it doesn't halt the success of a total knee replacement because the ACL is taken during the operation and the conformity and design of the knee replacement compensate for the ACL's stability. If you're thinking of a partial replacement, then an ACL injury is often a contraindication to having a partial knee replacement. Most patients who've injured the ACL end up having a total knee replacement. Even if you've had an ACL reconstruction, there are some surgeons who are doing ACL reconstructions and partial knee replacements. I probably say at the moment that this is more experimental and there's no long-term studies to suggest or is this a good idea in the long term or not, but as a general rule, if you've injured your ACL, you can still have a total knee replacement.

Louise King

How soon could someone travel after having surgery? For example, if they were to live in, say, the northwest of England and they wanted to have surgery in Kent, when they wanted to travel home, like two to three days afterwards, is that feasible?

Mr Richard Goddard

I mean, here at Benenden, we're fortunate enough to have patients travel all over the country, so I’ve had patients from Nottingham. I’ve had patients from North Wales travel from South Wales, so patients do manage to travel a good number of hours, but you have to remember that in the first few days after a knee replacement, it's painful; it's swollen. Ideally, you wouldn't want to be sitting in a car for hours on end, so you probably have to plan your journey very carefully. If it's a 5-hour drive, you probably want to be stopping every hour and a half every two hours to get out of the car and stretch your legs. That type of thing can be done, but certainly you need to think about it very carefully. Another option is to obviously stay low-local for, you know, a couple of weeks, but often that's difficult because it's not in your own home and that type of thing, but I’d probably say it can be done, but you have to be one stoical about it and two, plan your journey carefully such that you can. We don't want you sitting in a car for six hours, the knee getting stiff and sore, and you having trouble when you get home, but I'd probably say if you got out of the car every hour and a half and stretched your legs for 20 minutes, it's probably doable. How long after surgery could one walk fairly normally, e.g., for a mile or two?

Louise King

So, what's the normal recovery?

Mr Richard Goddard

So, the day after the operation, it's definitely walking with aids. You're walking on the ward up and down the corridor, and the physios will teach you to do a flight of stairs. Even on the day of the operation, if it's done early in the day, you'll walk from the chair to the loo. The first two weeks are really pottering around at home with or without crutches, with or without a stick. everyone's different You're doing your exercises as much as possible. I recommend five minutes of exercise every hour in the waking hours to get the knee moving. You're pottering from room to room. You're not expected to walk a long way in six weeks. Most people are back-driving with their knees still. Most people are able to walk for 20 minutes around the supermarket, and I have patients who walk a mile within the first six weeks, but I’d probably say a sensible aim is probably two to three months to be comfortably walking a mile or two. Most patients who want to play golf talk about doing a half round of golf at three months and a full round of golf, which is probably four or five miles, you know, at four or five months, but everyone's different. Some patients come at week saying I’ve walked a mile, but it's really the take-home message that you need to get the knee moving to prevent stiffness. Everyone will be able to walk, but just potter around at home for the first few weeks and build up slowly. What we don't want you doing in the first few weeks is doing a long walk, the knee becoming swollen, and then you're less able to do your exercises, and then you take a step backwards, unable to get the knee moving, but generally speaking, in six to three months, you will be able to walk a mile.

Louise King

That relates to quite a few questions we've had, like how soon can I get back to playing tennis, going running, or skiing?

Mr Richard Goddard

I guess the answer depends on the person, and yes, so I’d probably say to all of these questions, you can do all of these fantastic things. You have to remember that it's a metal and plastic knee replacement. Some things are sensible, and some things aren't so certainly low-impact sports. You know, tennis, badminton, and all the swimming. All the cycling, you know, a bit of gentle football, that kind of thing, all that's fine. Skiing is high-risk, but if you've skied all your life, that's fine. I’d probably give it a good six months to nine months a year before you go skiing. Sometimes wearing a knee support might just help prevent any ligament damage from skiing and running. I usually say running isn't sensible after a knee replacement. I have many patients who ignore what I say and run. You can run, but you have to remember it's a plastic or metal placement, and the more pressure and impact you exert, the quicker it's going to wear out. So, you can run, but in my opinion, it would be more sensible to do more swimming and cycling than some sort of long-distance running.

Louise King

Thank you. We've got many more questions. I’m afraid we won't be able to answer them all, but we will answer by email afterwards. I’m just going to put two last questions into one, which is: do you have an upper age limit for a new replacement, and if so, if someone is older, does it take them longer to recover, say, for example, an 83-year-old male?

Mr Richard Goddard

83 is a common age to have a knee replacement, so the average age in the UK is around 66–67, which means patients are younger and older. The age ranges I’ve operated on are 39, the oldest being 92, so there's no upper age limit. Clearly, the older you are, the bigger the operation and the harder it is to repair and recover. recover from the operation, recover your strength, get walking, and do your exercises. 83 is the perfect age to need a replacement, so it shouldn't be a problem. It's usually not age that's the cutoff; it's usually medical health in combination with age, so if patients have memory problems or dementia and are elderly, those patients tend not to do terribly well with a knee replacement, but if you're in your late 80s, you can still have a new replacement if you recover perfectly well in your 90s. It's possible, but you have to remember it's a big operation and a lot of stress for the body, and we try and avoid big operations that are not absolutely necessary on people who are very elderly in their 90s, but in your early and mid-80s, that's not a problem, and it's very routine. You know, every week I’d be operating on someone who's in their early to mid-80s, so that's not an issue. Well, thank you.

Louise King

Thank you very much for going through all these questions, and if you did ask a question and we didn't get time to answer it, if you provided your name, we will be able to answer yours via email. As I mentioned earlier, Mr Goddard, would you mind moving on to the last slide?

Mr Richard Goddard

Of course, no problem.

Louise King

Thank you. So as a thank you for joining this session, we are offering 50% off the value of your consultation. a call back from your dedicated Patient Advisor and an email tomorrow with a recording of this session and further information and updates on news and future events. We'd be grateful if you could complete a survey at the end of this session that helps us shape future events. If you'd like to discuss or book your consultation, our Private Patient Advisor, Chelsey can take your call until 8.30pm this evening or between 8am and 6pm Monday to Friday using the number on the screen. You can also book your consultation on our website with the discount code KNEE50. A link to the book will appear once you've submitted your survey response. Our next webinar is on European gynaecology, which you can sign up for via our website. On behalf of Mr Goddard and our expert team at Benenden Hospital, I’d like to say thank you for joining us today. We hope to hear from you very soon.