Philip Orrell

Good evening, everyone, and welcome to our webinar this evening from Benenden Hospital. We have a lot of people signing on to this tonight, so we'll just wait a few seconds for people to join.

Right, a very warm welcome this evening to our webinar. It's fantastic to see so many of you joining. We've got over 200 people registered for this session, which is tremendous, so it's great to have you all tuning in. My name is Phil, and I’ll be your host for this evening. I'm joined by our expert presenter and Trauma and Orthopaedic Surgeon, Mr. Matthew Oliver, who will be discussing treatment for knee osteoarthritis. For those who haven't attended one of these webinars before, the format is as follows: The presentation itself will last around 25 minutes and will be followed by a question-and-answer session. If you'd like to ask a question either during or after the presentation, you can do so by using the q&a icon at the bottom of your screen. You can do this anonymously, or you can give your name. At this point, we should let you know that if you do give your name, the session has been recorded for archiving. If you would like to book your consultation after this session, we'll provide contact details at the end.

Now, before we begin the main presentation, I'd just like to mention that if you're interested further in the topic of tonight's webinar, we are hosting an in-person event on the 5th of June. This will be at the Ashford International Hotel, and the event is titled The Robotic Revolution. Rosa and the future of joint replacement surgery, and it will feature Mr. Oliver and two of our other consultants, Mr. Alex Chipperfield and Mr. Raman Thakur, and they will be discussing the hospital's robotically assisted surgical system for knee replacement, more of which later, and with the rapidly evolving technology in the field of orthopaedics, there will be opportunities for questions, a buffet, and refreshments just to increase the appeal, and if you are a member of our new loyalty programme, Benenden Hospital Rewards, you will receive 500 bonus points for attending that in-person event. So that's the 5th of June, Ashford International, and doors open at 6:30 p.m. There's information on the screen there. If you're within reach of Ashford, we'd love to see you there, and you can book your place by visiting our website, where you'll see a large banner on the homepage. You can register via that link, and details on this event will be in your follow-up email after this webinar. That's quite enough from me, so without further ado, I will hand over to our expert presenter, Mr. Matthew Oliver.

Mr Matthew Oliver

Thank you very much. Phil Good evening, everyone, and welcome. I’m going to talk to you tonight about the management of osteoarthritis at the human knee joint. Included in this session is information about what osteoarthritis is and the treatment options. Both surgical and non-surgical information about the knee replacement itself and the patient journey that evolves when you have one, the risks of the surgery, and then quite a bit of time will be spent on the technology, especially talking about the robot orthopaedic surgical assistant or ROSA knee system. Benenden acquired this technology in December of last year, and it's up and running in the hospital now with increasing usage and success. We'll talk about recovery after knee replacements, and then we'll finish off with a question and answer session, so a little bit about myself. I was appointed a consultant orthopaedic surgeon in 2001. My NHS base is East Kent Hospital, so I work at William Harvey and the Kent and Canterbury hospitals, mainly because I’m a full-time consultant in the NHS. I started working at Benenden in 2012, and I solely specialised in hip and knee degenerative disorders in my elective practice. I've been on a reconstruction fellowship at the University of Calgary in Alberta, Canada, for a whole year, working for several renowned North American orthopaedic surgeons. I perform about double the national average of hip and knee replacements, according to the national joint registry, and I practice at all times as much as I can to enhance recovery protocols to make sure the patient journey is as smooth and comfortable as we can get it. I've got specific interests or special interests in patient-specific knee replacements. These are sort of the predecessors to the robots, and in recent months, robotic surgery has been gaining momentum as a specialist interest of mine. So what is osteoarthritis of the knee? essentially it's wear and tear of the knee joint unfortunately it's incurable and it creeps up with all of us there are some risk factors that make people more prone to osteoarthritis than others such as a previous in injury to the knee a nasty cartilage injury or ligament injury to in particular the anterior cruciate ligament even if this ligament is reconstructed the biomechanics of the knee is altered all forever and therefore it has a propensity to wear out faster obesity unfortunately puts too much load on the knee joint and is strictly and closely linked to osteoarthritis especially at the patellofemoral joint which is a very weight sensitive joint symptoms of osteoarthritis the early ones really are just a bit of discomfort when you exert yourself you find your knees a little bit stiff in the morning but within a few minutes you've walked it off and it's okay you can also have the sensation of a clicking or grinding feeling within the knee and that normally comes from the patellofemoral joint and it's caused by the cartilage frying on the under surface of the patella and on the top of the femur so it's no longer a friction free surface you may notice that your knee swells up a little bit as well but normally settles with breast and the occasional painkiller as the condition progresses the normal healthy shiny glistening articular cartilage starts to spray and fisher and break off especially in the weightbearing zones of the knee which are normally in the medial compartment that's where the brunt of weight bearing goes through the knee joint about 70% of the force goes through the medial side when that happens it acts as aids for further wear and the cartilage fragments and eventually bare bone develops at the same time and slightly before this occurs the meniscus or the shock absorber in the knee you've got one on each side of the knee joint that also phase and degenerates a bit like a washer on a tap so therefore the cushioning and the shock absorbing between the femur and the tibia is diminished and with every step you're literally tapping the femur on the tibia bruising the bone and damaging the cartilage this is when it hurts most of the time and you'll be taking more regular painkillers and noticing a reduction in your activity levels and an avoidance of some of the things you used to love doing when the bad the pain when it gets really bad the pain is there all of the time it's at rest especially at night the knee gets very stiff you find it uncomfortable to roll over in bed and you notice that your knee is changing shape it becomes a bit knobbly and sometimes you develop what's called a bowlegged or bandy leg deformity or not knee deformity and in some cases patients can get a knee on one side and a bowlegged on the other that's known as the wind swept deformity it looks like you've been blown from the side by the wind at that point the bad days usually outnumber the good and you come to see an orthopaedic surgeon These are nice schematic diagrams of the human knee joint, basically going through the various stages of arthritis that I’ve just explained, and essentially it's all down to losing the shock-absorbing ability that cushions the knee with every step, so the shock absorbers or the minis sky perish first, then the articular cartilage breaks off, and then eventually bare bone appears, and when bare bone and the cartilage have failed, bone touches bone, and that is osteoarthritis in a nutshell.

The treatment for the condition can be categorised as non-surgical or surgical non-surgical management. It works quite well for the early to moderate arthritic knee, and that would be activity modification, avoiding the aggravating factor of weight loss to reduce stress through joint physiotherapy. Interestingly, people ask me why physio is good. If the knee hurts, it depends on the type of therapy. It should be light, low-bearing exercises and strengthening exercises that definitely help the arthritic knee move. Moving the knee joint improves the lubrication of the joint and diminishes the discomfort. It also means that the muscles around the knee are able to stabilise the knee, and that can help balance out the uncomfortable jerkiness or sudden discomforts that you can get if you step on an uneven surface. Simple painkillers are helpful, such as paracetamol, to start with, and then you go up the pain ladder with stronger analgesics from the GP; usually codeine-based nonsteroidal anti-inflammatory drugs work well in the beginning as well, as long as you're able to take them. They are sometimes contraindicated if you have asthma, take certain medications, or have some renal problems. Knee strapping and braces: there are loads on the market, and some of them are a bit clunky and cumbersome, but on the whole, in the early to moderate arthritic knee, they do have a role to play, especially offloading braces that can open up the knee joint, so the two bones don't necessarily tap together quite so vigorously. For injections, there's the tried-and-tested steroid injection. I'm not a great fan of these. I say to my patients, maybe up to two to three injections a year at the most, because the more injections you have, the more counterproductive and less effective they become, and they can also increase the risk of infection if you were to proceed to a joint replacement at a later date. Other injections include viscosity supplementation. This is a synthetic lubricant that's injected into the knee. It's not really a painkiller as such; it just reduces the friction between the two worn-out surfaces. It works quite well in the early to moderate stages of the arthritic knee, but once it's more advanced, it doesn't really work. These are the two injections that are available here at Benenden, and there are other ones that are available at other places, but again, the evidence is not robust enough to offer the mainstream surgical options. The first one is to correct the alignment of the leg with what's known as an osteotomy, which is quite crudely described as meaning breaking the leg and resetting it again. You need to have very concise indications to want to do this, and the patient also needs to be very resilient and have a full understanding of the experience because it's a lengthy recovery and usually reserved for the younger patient where arthritis is only minimal and there's a definite alignment issue. the idea is that the leg or the knee joint is realigned to offload the area that was getting worn it does make subsequent knee replacement surgery at a later date a bit more challenging because there's usually a metal plate to remove and the anatomy has been distorted arthroscopic techniques that we have to treat the arthritic knee with caution when it comes to keyhole surgery because we can make it worse so in my practice I think there's a lot to be gained from arthroscopic removal of a loose body that's a bit of bone usually that breaks off that can suddenly cause a an uncomfortable knee to lock up or give way or become a lot more uncomfortable when we whip the bit of bone out the patient goes back to baseline and is quite happy with the situation also unstable meniscal tears and an arthritic knee, there is a role to play in snipping these out, but just washing the knee out for arthritis is a sham procedure and should be avoided these days. Microfracture, another arthroscopic technique, is only really effective on small areas of complete cartilage loss, and you, as the patient, have to have full buying because you need to be touch-toe or non-weight bearing on your leg for about eight weeks. Rather, the fibrocartilage grows over the area that's been drilled with a little pick or a drill. Fibro cartilage isn't the same as articular cartilage; it's the next best thing, but it's not quite as robust, and again, the results are sketchy. Really, I would certainly only do it on very minimal indications. joint replacement   We'll talk about that in a minute. cartilage transplantation.  This is when you harvest cartilage from a non-weightbearing part of the knee and plug it into the worn-out gap, then put something like glue or a fibering clot over the cartilage, and then hope that it's taken by your own body and incorporated into the knee joint. It's been around for a while now, but it's only available in very specialist centres and also on a trial basis in the NHS. I don't think any private medical insurances cover this kind of transplantation, and it has quite a high cost, and it's not 100% approved by the National Institute for Clinical Excellence, so it's not available in the mainstream. So knee replacement is a good operation for full-blown end-stage osteoarthritis of the knee.

We can also use it to treat inflammatory arthritis, such as rheumatoid arthritis, but we don't see many of these cases these days because they're so well managed with medical drugs. The disease-modifying drugs can be used to treat a post-traumatic knee where a nasty fracture has damaged the joint, or if there's been a severe ligament injury, a more constrained hinge-type knee can be used. The aim of a knee replacement is overarchingly to provide pain relief for the patient with some improvement in function and mobility, and it can also be used to realign the leg to a more neutral alignment to hopefully give a more sturdy gate pattern and a stable platform to stand on. People are coming to us at a younger stage, now in their late 40s and 50s, with quite arthritic knees, usually as a result of sports injuries that have caught up with them or previous surgery to the knee. They're still in the workplace and still wish to be active and play sports, so these patients need careful counselling about expectations following knee replacement surgery. It's a common operation that about 100,000 people perform every year in the U.S. The average age in the national joint registry for a knee replacement is about 69 for men and women. Most of the patients, just over 56% of them, are female, and, most importantly, it's pleasing to see that about 95% of patients report health improvement after receiving this operation. 80% of knee replacements do seem to be lasting for 20 years or more now, which is also quite pleasing.

So here are the options available with regard to replacements: You have the partial knee replacement or compartmental replacement where you go ahead and replace the worn-out parts as they wear out, so you do the medial side, and the medial uni compartmental knee replacements are offered here at Benenden, either the Oxford knee or the Zouk knee. Again, I would recommend seeing a high-volume surgeon if you're going to have this procedure; it's a niche procedure and it needs to be done with the right indications in mind just in case there's progression of arthritis elsewhere in the knee because that would lead to its early failure. Lateral unicompartmental knee replacement is very rarely done; it's a difficult operation to get right, and again, choose your surgeon wisely—a high-volume surgeon for one of those patellofemoral replacements is very rarely done these days. About 1% of all the joint replacements and all the knee replacements in the UK are patellofemoral replacements. Again, it has to be absolutely isolated. Patell femoral arthritis, if not, may need to be revised at a later date, so the partial knee replacement does work really well for a lot of patients. It's a less invasive procedure with a quicker recovery, but it does carry a higher revision rate. The total knee replacement can be performed with standard instrumentation or using computer navigation. Computer navigation has really now been superseded by robotic technology, as has the signature or patient-specific knee replacement, which doesn't use a computer in theatre. The signature or patient-specific knee replacement uses pre-operative scanning of the knee, hip, and ankle to produce a plan and then moulds that are fitted to the bone, but really they've been superseded. Now, by robots, the constrained knee replacement is only really carried out when there's been severe deformity to the knee in a revision procedure or if the ligaments have failed, so the workhorse knee replacement at Bon Hospital is the Vanguard knee made by Zimmer Biomet. It's been around for a long time now, and it is the successor to the very successful AGC knee replacement made by Biomet. That knee replacement was removed from the market about 5 years ago, and a lot of the design features of the Vanguard are big improvements from this knee replacement. It's performing well; it has an ODEP, or orthopaedic data evaluation, of 13a, which means that 95% of them are still going strong at 13 years in validated survivorship charts and in the national joint registry. I looked up the figures for this talk, and the 10-year revision rate for it, whether it's patella resurfaced or without resurfacing, averages about 2.8%, and the same 15-year revision rate is 3.8%, which is very comparable to other well-known knee replacements on the market. It's usually cemented in place, so the consultation Thank you for your appointment, and have 20 minutes with us to develop the doctor-patient relationship, which is absolutely crucial for knee replacement surgery because it's all about managing your expectations and making you aware of all the issues that are involved. Because this is a painful procedure for the length of your recovery time, you'll have a detailed history taken, a physical examination, x-rays, and other tests that may be required. It would be great to be able to give you an individualised management plan on the same day, but sometimes you may have to return for a follow-up if specialist images are required If it's been decided that you are going to have a knee replacement, then it's all about getting you optimised for the big day. It's important to really get as fit as you can while trying to lose some weight and controlling your pre-existing medical conditions. Diabetes, in particular, is an independent risk factor for infection, and it has to be stringently managed. Prehab has been a big buzzword in the last few years, especially with enhanced recovery protocols. It basically means getting yourself physically fit—not just the leg but the whole of you—ready to go for a big operation and recover from it, and it usually means taking gentle exercise physiotherapy. When you visit a gym, you'll have a preassessment appointment as well, where you'll have a full talk with the nurse, and sometimes you need to see the anaesthetist to discuss your health issues in more detail. The journey really begins with prehabilitation, and while you're waiting to come in for surgery, you're going to try and optimise yourself as best you can. All being well, you'll pass all of the tests set by the pre-admission team and come in for surgery.

You come in on the day you have a spinal anaesthetic, and you're usually sedated, which means you're numbed from the waist down. You're closely monitored throughout by the anaesthetist and his ODP, and postoperatively, you'll be looked after by your own dedicated nurse. You have your own on-site room, and you usually stay two nights. It is possible to leave after the first night the following morning or afternoon if you tick all the boxes, the physios are happy with you, and you're medically fit. If you're medically fit, there's really no benefit whatsoever to staying an extra night in the hospital; you'll be better off in your own home with your own creature comforts. It's important that you have confidence in your new knee and weigh it fully on the day of surgery. Once your legs have woken up from the anaesthesia, the physiotherapist will see you twice.

Today's rapid recovery protocol It's all about making sure that your sickness and pain are well managed, getting you out of bed quickly, and immobilising you quickly so you have confidence in your new knee. The anaesthetic techniques used these days don't just include spinal anaesthetics; several anaesthetics use pain-relieving nerve blocks around the knee, which can make your knee feel very comfortable indeed for at least 72 hours—well, at least 36 hours after the operation, sometimes into the day too. You'll have x-rays and blood tests to make sure all is well, and after discharge care, there's a telephone service that you can ring into if you have any queries. The experienced nursing staff is usually able to answer those queries, and if they can't, they take a message and get in touch with your consultant about the risks of gery. It's a big operation, so there will be risks involved, but they're usually quite rare. You can bleed, but it's incredibly uncommon to need a blood transfusion after a knee replacement. The bone can break either during the surgery or afterwards. If you have a foot injury, you can get two types of nerve injuries. It's quite common to get a patch of numbness over the knee that usually shrinks to the size of a 50p coin on the lateral side of the knee over the month that passes, and you don't really have a problem with it. The other kind of nerve injury is very rare, and that's known as a foot drop. When the common personal nerve is stretched, it usually recovers, but you'd need to wear a splint in your shoe while it recovers. A tendon injury is an incredibly rare complication, but it is a headache. If it happens without the patella being attached to the tibia, you can't straighten your leg, so it has to be repaired, and when it's repaired, it means you keep your knee replacement out straight for 6 weeks, which unfortunately means the knee gets stiff, so you're going to have to work much harder on your

Exercises and other risks wound problems: you can get superficial wound infections that are normally managed with antibiotics and good wound care by primary care, but sometimes we need to get involved, and I always would like to know if there's an infection. Rather than finding out at the six-week follow-up appointment, it's important that you engage with your surgeon if you have any concerns. You can get a deep infection. The national rate of infection in the knee is about 1% at Benenden Hospital. I’m sure it's much lower than that. This is a super clean hospital, but if you were to get a deep infection, we would need to treat it rapidly and effectively. You would need to have the remedial surgery carried out in an NHS hospital with a multidisciplinary approach from a microbiologist, physiotherapist, orthopaedic surgeon, and infectious diseases specialist. Essentially, we have to wash the knee out, change any of the components that we can, exchange bits, and give you really strong antibiotics for about 6 weeks. About 70% of the time, that solves the problem, but in the other 30%, unfortunately, the infection comes back and more surgery is required with the removal of the implants. The other risks include blood clots in the leg and lung stiffness and swelling, so there's no pain or gain from the exercises; otherwise, it will become a big peg leg full of scar tissue. I can't emphasise enough the importance of doing the range of motion exercises; it seems a game changer is lots of ice. You can use a pillowcase for a device, or you can even use a Crier Cup device that you can have or buy from Amazon, eBay, or places like that, but that really does make a difference with pain management. The later complications are infections. Again, you can get an infection from another part of the body, such as your water, which travels through the blood and lodges in the knee, or from pneumonia in your lungs. But it's very uncommon and very bad luck. Eventually, the implants will wear out and fail. Unfortunately, people do fall over and break the bones around the plants, making them loose. Here are a few examples of some quite severe deformities. This is a varus knee or a bowlegged knee; both of them are actually bowlegged for this chap, and you can see the corrective surgery on the x-rays here, giving him a much straighter alignment: sometimes standard knee replacements aren't enough, and this guy here has a very, very deformed knee. The left knee is swung right out into the varus, and when he walks, he'll have what's called the varus, and as you can see from the x-ray on my left hand side, there's been bone loss, and the ligaments have been considerably contracted on the inside and stretched on the outside, which means that a standard knee replacement won't suffice and you'd need to have a hinge, which is what you can see here on the radio. Raps are more complex operations not carried out on the NHS portfolio here at Benenden here's a picture of the rotating hinged knee it's highly constrained it's usually used for severe deformities ligament injuries and in cancer surgery so the requirements for knee replacement include accurately restoring the individual's mechanical axis an accurate bone resection and if those things are achieved it should hopefully give good functional outcome and a theoretical bonus of making the implants last for as long as possible and that's when the ROSA or the robotic knee replacement comes into its element really basically as I mentioned earlier the patient demographic is changing patients of younger more demanding want to carry on working in manual jobs also play sports and hobbies and we have to manage their expectations we're operating on a wider range of ages these days from about 40 to 90 plus years of age and the ROSA robot is a significant advance in knee replacement surgery and it is here to stay we can see it in other walks of life if you look at YouTube and download what the warehouses look like you see 30,000 little robots going around on this amazing tracker system collecting people's groceries or you watch a video of a car manufacturing plant robots building cars and even more recently for myself when in December of last year when I went to cologne to the rose head office or the main training course the hotel that I was put up in there are robots delivering orange juice at breakfast and collecting plates it just blew my mind so they're here to stay so the indications for ROSA it's basically out there for anyone really who has an arthritic knee but I think it really comes into its own when you have abnormal anatomy or significant deformity or previous fractures to the tibia and the femur where the alignment of the leg is altered it makes a standard knee replacement extremely challenging whereas with a ROSA we don't have to worry about standard instrumentation so how does it all work well essentially you the robot is in theatre with us it's our assistant it doesn't do the op we do the op it just helps us optimize the variables that end up making the knee replacement and how to get there is that we have to put trackers into the femur in the tibia and then once these trackers are in they communicate with the robot and through real time movement we collect lots of data about anatomical landmarks such as the centre of the femoral head the centre of the knee the centre of the ankle and also the bony anatomy of the knee joint all that information is sent into ROSA's computer and it designs a real time model of the patient's knee we can then put the knee for a range of motion and see the level of deformity or whether it's correctable and we strain the ligaments on each side the medial and collateral ligament to see where is where it's stiff where it's contracted all that information is fed back into the computer and then a provisional plan is formulated and you can see on the screen here it's already fitted a knee replacement into this person's knee and we haven't even made any bony cuts yet this plan isn't set in stone it can be adjusted and tweaked to the surgeon's preferences and sometimes a little bit more bone is needed to be taken from the femur or the tibia or the rotation of the implants has to be slightly adjusted to improve the ligament balancing of the knee once we're happy we confirm the plan and then ROSA really comes into its own the surgical cutting guide is accurately placed onto the patient's knee and on the femur and on the tibia if we move it out of place just a little bit it will stop working and let us know it has to be precisely position like the plan said so once it is we fix it in place with a couple of pins and then cut the bone in the conventional way we would do a normal knee replacement once the bone has been cut all the cuts are validated against the computer plan and they're all extremely accurate indeed they're all within a millimetre or half a degree from what we decided on the plan sometimes they're absolutely spot on to the plan a millimetre here and half a degree there won't make much difference it does make a difference if you're three or four millimetres out and therefore you have the opportunity intraoperatively to adjust the cut if you were to be out of alignment, I think this might be a video. Is this the video? Guys, I’m not sure if this is the video or not. Yes, this shows us what happens in knee replacement. We're using ROSA knee, hoping it's going to work. It's a minute, and it just shows. 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, and 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 adjust accordingly. ROSA knee provides your surgeon with data about your knee; this helps to personalise your surgery based on your unique anatomy.

So, there you go. In a nutshell, the whole idea is to give you an individualised, personalised knee replacement that is well balanced, with the implants optimally positioned to hopefully give you the best functional outcome and the swiftest recovery possible. The early to medium-term data from the ROSA knee, where it's been used in institutions around the world, is indeed looking very promising, and that's why Benenden Hospital has adopted this technology, as have several other hospitals throughout the UK. Apologies for that. Just move it on to the next slide, hopefully.

Now this basically goes back to what I was saying earlier about the accuracy of the cuts: it provides highly resections or bony cuts and improvement in the patient's limb alignment, and it reduces the outliers. Basically, a standard knee replacement with conventional instrumentation, if' done well with a high volume surgeon, there's nothing wrong with that; you will still get a very good result, but this just improves matters a little bit more and makes things a little bit more accurate, so accurate component sizing and good positioning provide real-time information on ligament balance and range of motion on the table, and everything is validated every step of the way to ensure that the pre-operative plan is followed inter-operatively. If we don't like the plan, we can adjust. If it's going pair shape, we can abandon and go back to conventional instruments, but it very rarely has a problem.

These are my colleagues that perform knee replacement surgery here at Benenden Hospital, and we all work together in the NHS. We're all colleagues and friends. It's a good team.

So, we're going to move on to the question-and-answer session now. Please feel free to ask me anything you like, and let's go for that.

Philip Orrell

Thank you for all that insight and information. There's quite a lot to digest there, so we'll take some questions from the audience. The first question we have is from Allison, who asks, Do you offer nuanced knee surgery for patients with patellofemoral arthritis, and what are the pros and cons of this?

Mr Matthew Oliver

Patella replacements do exist, but as I was mentioning in the talk, they only account for a very small number of knee replacements done in the UK because the indications for them are very narrow. Indeed, you have to have truly isolated patellofemoral arthritis.

Philip Orrell

The next question is from Susan, who asks, Is it true that after a total knee replacement, no one can continue to knee, squat to garden and wash floors, or sit back on your heels and sit cross-legged?

Mr Matthew Oliver

It's not an absolute contra indication, but it is uncomfortable to kneel on the knee replacement, and therefore most people, before they've had their knee replaced, are struggling to kneel anyway, so they don't mind continuing with that compromise, but if you had to kneel and you padded the floor out, I don't see that that really being a problem. Squatting is all down to the range of motion that you get in your knee afterwards. You'd need to get at least 120 degrees, I think, to be able to squat and to have the strength in your legs to hold the squatting position for any length of time. So that's down to rehabilitation for the patient, who is really cross-legged. If you can, then there's no reason why you shouldn't.

Philip Orrell

Okay, thanks. The next question is: will the use of a collagen supplement help before any knee surgery?

Mr Matthew Oliver

This is an interesting question; anecdotally, I think there is some benefit from collagen supplementation. It doesn't just help your skin, your hair, and your nails. It does seem, anecdotally, to be helping some patients a bit, like turmeric and glucosamine. That being said, I did read a scientific article recently that said that collagen comes in two forms: whole and hydrolyzed, and both of them don't really penetrate the joints, so it may just be a placebo effect, but in my own practice, I’ve seen people say that it helps them.

Philip Orrell

Our next attendee asks, I’m probably in stage three moderate osteoarthritis, and I’ve been seeing a physiotherapist for several months. I'm interested in duralene as I’ve heard it described as an oil change for the knee, but I’m not sure how to go about this.

Mr Matthew Oliver

If you're a member of Benenden, you're able to have one of these injections for your membership, and it's performed in the outpatient room under aseptic technique. Your knee is cleaned, and it's simply injected into the joint. It's a lubricant; it's synthetic hyaluronic acid, and it's supposed to reduce the friction and hopefully reduce pain in about 60 to 70% of patients with mild to moderate arthritis. I have noticed a difference when the knee is badly worn; it doesn't really have much effect. If you're one of the lucky ones where it's effective, then the injection can be repeated a few times a year if necessary, and yeah, it's available for your membership, so please make an appointment.

Philip Orrell

The next question is from Robin, who says I’m 76 and damaged my knee during prolonged skiing in early 2023. An x-ray identified mild osteoarthritis but no bone injury or abnormality. I've managed the knee pain through physiotherapy, and I can now play golf again. I'm uncertain about surgical intervention. Any thoughts?

Mr Matthew Oliver

If you're managing your knee and you're having an active lifestyle, then there's no real need to go to the next step, but if you keep having setbacks, peaks, and troughs and you remain in the trough, the bad days are outnumbering the good. If the arthritis is just isolated to the inside of your knee, the medial compartment, then you may indeed benefit from a medial unicompartmental knee replacement. Which is less invasive and has a quicker recovery time? It's certainly worth having your knee assessed by one of us to see if that's of benefit to you.

Philip Orrell

Okay, the next attendee asks if I need a patient-specific knee replacement as I have a rod the full length of my femur. I’m concerned that I need an experienced surgeon to do this. The rod has been in for 40 years, and I’m not keen to have it removed. Do you have any advice, please?

Mr Matthew Oliver

Yeah a patient specific knee replacement should be able to deal with this problem as long as the rod at the bottom part of the femur isn't too close to the bone surface on the front of the femur because if it is when we make the cuts for the knee replacement the implant and the saw may make contact with the bottom part of the rod or the nail if that's the case then the metal work ideally needs to be removed if it's if that isn't the case then the MRI patient specific knee replacement would be a bit challenging because the metal in the rod would affect the scanner and the quality of the images so you may have to have a CT patient specific knee replacement where a cat scan is done instead or alternatively the robotic ROSA knee replacement, you won't need to have any scans, and that would be able to all being well, leave the rod in place as long as I say the rod isn't too far down in the bone and too close to the edge of the top of the femur.

Philip Orrell

Okay, thanks. We have a second question from Allison, who asks, Can two compartments of the knee be replaced instead of a total knee replacement?

Mr Matthew Oliver

If the other compartment is normal, that is a possibility. It is practice in a few units around the UK, and I saw it on occasions when I was on my fellowship in Canada back in 2009, and you have each part of the knee replaced as it wears out, but you have to bear in mind that it's an operation each time, and with every operation there's the risk of introducing infection and also post-operative stiffness, so you just have to bear those factors in mind. It might be better to have one operation done well.

Philip Orrell

Okay, thank you. We have a question from Carol. Bear with me; it's quite detailed. I had a total knee replacement in June of last year. My knee is hyperextending and is now unstable, making walking difficult. I’ve been advised by two surgeons that revision surgery with a hinge joint should improve matters, but I’m reluctant to have more surgery. But no, things won't get better without the alternative of wearing a brace. But the new surgeon doesn't think a brace would be a good idea. Should I seek another opinion? And how do I find a specialist revision surgeon?

Mr Matthew Oliver

So if your knee is unstable and two different surgeons have advised that revision surgery is a sensible option then it sounds to me that a hinged or fully constrained knee replacement will remove that instability for you this is specialist surgery because it would mean the old knee replacement would have to be removed and it is a brave step for you to take but of course if you to leave things as they are it most likely get more unstable and you'll be at risk of falling to find a revision knee surgeon you need to go to your local NHS trust or you can have a look online but most large NHS trusts now have a revision hip and knee teams the one I work for in the east Kent certainly does where there's a multidisciplinary team and all the cases are discussed and the best plan is decided on an individual basis.

Philip Orrell

Okay, thanks. We have a question from Malcolm, who says I’ve moderated peripheral arterial disease in both legs. I’ve heard that this may be a complication in knee surgery where a tool is used to reduce blood flow.

Mr Matthew Oliver

Yeah, that's correct, so if you did require a knee replacement, it is a slightly higher risk, so it's best to do your knee replacement without one, and that's quite widely practiced now. A few of my colleagues at this hospital don't use tourniquets, so there's no risk of any trouble for your peripheral vascular system because the blood supply is left to flow throughout the case. It just means that the surgeon has to be extra vigilant with stopping the bleeding, which increases slightly the risk of needing a blood transfusion afterwards, but you can do a knee replacement without a tool.

Philip Orrell

Okay, thanks. Mike asks how much flexibility a knee replacement has compared to a normal knee.

Mr Matthew Oliver

Well, a normal knee without any arthritis should have a range of motion from zero to about 140 degrees of flexion, so that's when you bring your heel right back to the bottom of your buttock, so you're, you know, sitting on the floor of your knees, fully flexed, and when arthritis goes into the joint, it stiffens up. Sometimes the preoperative range of motion is a very good indicator of how much postoperative range of motion you'll get, so if you start off with a knee that only bends to 90 degrees and you can't extend it so it has a fixed flexion deformity, then your knee replacement will hopefully get your knee out straight, so the fixed flexion will be dealt with. However, the flexion we'll be lucky to get is more than about 105 to 110°, so it all depends on the preoperative range of motion and unt. In a few cases, people have an adverse reaction and develop lots of scar tissue, and the knee is actually stiffer than it was prior to the operation, but that's very few and far between.

Philip Orrell

Okay, Emma says there is a BMI that you need to be under in order to be considered appropriate for surgery at Benenden Hospital.

Mr Matthew Oliver

The BMI cutoff is about 40, I believe, and you need to be otherwise medically very fit as well. In the NHS, the BMI in certain hospitals is a bit more flexible, but I think a BMI of 40 or less is what you need to aim for. The next person asks, I have varicose veins. Is this an added complication? It shouldn't be again. The large varicose veins are very easy to see and will need to be tied off if they get cut during the surgery. They're quite superficial varus veins, so we can either skirt the incision around them or they'll move out of the way, but if they're directly in the way, then the surgeon will tie them off and carry on as normal, so it's not a contraindication or an added complication.

Philip Orrell

Okay, thanks. Diana asks if, after total knee replacement, a person can walk up and down stairs normally again.

Mr Matthew Oliver

Hopefully. It takes a bit of time, but yeah, you should be able to go up and down the stairs normally as long as the knee is stable and your pain is well managed. It does take a bit of time, though, to learn that again.

Philip Orrell

Okay, this next attendee asks: will the osteoarthritis always progress to a worst-case scenario, or can it halt and not get worse?

Mr Matthew Oliver

Unfortunately, it is incurable and will gradually get worse, but the timeline is really variable. Some people can soldier on with quite shockingly arthritic knees, and some people's pain management or pain threshold is lower and they can't tolerate it, but unfortunately, there is no cure at the moment for all these novel therapies. I mentioned earlier that you can temporise the affair—you know, slow it down or make it more manageable for the patient—but in the long run, no one can stop it from progressing.

Philip Orrell

Okay, thanks. The next person says I’m having steroid injections, which ease the pain and grinding as the knee is not deemed bad enough for surgery. How long should this continue, and how many should be given in my practice?

Mr Matthew Oliver

I don't recommend any more than two to three per year, and eventually the injection will become less effective. Once it becomes less effective, it's best to get reassessed for a fresh x-ray and examination, and then perhaps think about the next stage.

Philip Orrell

Okay, thanks. This next person asks, I’ve had an operation for my cruet ligament when I was in my 40s after doing it when I was 11 and damaging it. I'm having severe problems now—very swollen and problems with the back of the knee. Would a knee replacement help?

Mr Matthew Oliver

I think it's definitely worth touching base with an orthopaedic surgeon to have a thorough history, examination, x-rays, and maybe an MRI scan, and then we'd be better positioned to see whether we can help you with a knee replacement. I certainly wouldn't recommend the knee replacement. If the articular cartilage was still reasonable and you didn't really have too much bone on bone, if you do the knee replacement too soon, then the results are usually quite disappointing. That being said, if the knee is grossly unstable, then perhaps knee replacement—a more constrained knee replacement—is an option that really needs to be seen by one of us first.

Philip Orrell

Okay, Helen asks I’m bone-on-bone on the medial surface. I’ve been fitted with an offloading brace; this is of little effect, and I need crotches to walk any distance. I have a locking sensation throughout the day, and at night, am I at the point of needing a total knee replacement?

Mr Matthew Oliver

Again, it's worthwhile to make an appointment to come and see us so we can examine your knee and x-ray it. If it's just isolated to the medial side and the correction is the bow leggedness or the varus correction is possible and your cruciate ligament is intact and the arthritis elsewhere in the knee is minimal, then half a knee replacement might suffice, but if there's wear and tear elsewhere and the deformity is fixed, then a total knee replacement is the thing to do if the bad days consistently outnumber the good.

Philip Orrell

Okay, the next question is from Emma. This is quite a common one that we get in these webinars. I need both knees replaced. What would be the time scale between operations?

Mr Matthew Oliver

If you're super fit, they can both be done at the same time, but very rarely these days, and I haven't done that for years. I personally think it's best to do it in stages, with a minimum of four months between each.

Philip Orrell

Okay, thanks. The next person asks, Why do you think a washout is not a good procedure?

Mr Matthew Oliver

In the new England journal of medicine, which has a very high impact on a factor medical journal, a large meta-analysis was done about the effectiveness of arthroscopy of the knee in the presence of osteoarthritis, and the overall, statistically significant conclusion was that it's a sham procedure. Just go in, wash out, and come back out again. It might give you a few weeks’ worth of relief, but the risks of the anaesthetic and the complications that could happen to the knee, such as a blood clot, infection, or bleeding, far outweigh the benefits, and from a health economics point of view, it is also tasteful.

Philip Orrell

Okay, thank you. I think we've unfortunately run out of time for any further questions, and I’m sorry if we didn't answer all your questions, as you can appreciate. We had quite high attendance for this, and we've made a small dent in the questions, but if you've provided your name, we can answer your question via email, or if you're able to attend our in-person event on the 5th of June, you can ask your question in person. We just moved on to this slide. So as a thank you for joining this session this evening, we are offering, as it's listed on the screen here. 50% off your initial consultation. Using the code listed there, you will have a call back from your dedicated private patient advisor, and you will receive an email tomorrow with a recording of this session and updates on news and future events. If you'd like to discuss or book your consultation, our private patient team will be here until 8pm to take your call this evening, or between 8am and 6pm Monday to Friday, using the number listed on the screen on your right-hand side, you'll receive a survey when this session closes, and we'll be grateful if you could fill that in. Your feedback obviously helps us improve future events. Our next webinar is on breast surgery, and you can visit our website to sign up for that. All that remains for me to say is on behalf of the team here at Benenden Hospital. I'd like to say thank you for tuning in today, and we hope to hear from you very soon.

Mr Matthew Oliver

Thank you, and goodbye.