Philip Orrell

Good evening, everybody, and welcome to our webinar from Benenden Hospital. Just allow a few seconds for you to join. It's excellent to see so many of you signing up tonight.

Okay, a very warm welcome to our webinar this evening from Benenden Hospital. Tonight, we are covering knee replacement surgery. My name is Phil. I'll be your host for the session, and I'm joined by our expert speaker, our Associate Specialist Surgeon, Mr Kumar Reddy. For those of you who haven't attended one of these webinars before. The format is as follows: Mr Ready will conduct a presentation, which will last around 25 minutes approximately, and this will be followed by a question-and-answer session. If you wish to submit a question to Mr Ready, you can do so during his presentation or following his presentation, and you can do so by clicking the Q&A icon, which you can find at the bottom of your screen now. I should mention that you can do this anonymously or you can give your name, but please bear in mind that we are recording this session if you do provide your name if you wish to book your consultation. Following this session, we'll be giving details at the end of the webinar. That's quite enough from me for the time being. I will hand it over to our expert speaker, Mr Kumar Reddy.

Mr Kumar Reddy

Hi, good evening, everyone. Thank you so much for taking your valuable time to join this webinar. I hope this webinar will be useful. I'm going to talk to you about knee replacement surgery and its indications, as well as the post-knee replacement effects of knee replacement. I hope you'll enjoy this session, and Phil, thank you so much for the introduction. I'm one of the lower limbs orthopaedic surgeons who has been doing hip and knee replacements for the last 25 years. My large NHS practice is at Kenton Canterbury and William Harvey Hospital, where I do most of the joint replacements, including revision total hips and total knee replacements. We have quite a big team of orthopaedic consultants working at Benenden Hospital who perform loyal Lim surgery. I'll be going through it with you all with regard to the definition of arthritis, its treatment, and the surgeries. what is going to be required, the types of knee replacements, the surgical process, the brief recovery process risk, and also talk about the patient tools. I've been an orthopaedic surgeon, and I'm currently the site lead at William Harvey Hospital and a member of the Academy of Orthopaedic Surgeons. My clinical and surgical interests are mainly total hip replacements. total knee replacements, partial knee replacements, revision hip and knee replacements, arthroscopy, ACL reconstruction, meniscectomy, and meniscal repairs

You'll all be pleased to know that Benenden Hospital is a leading provider of private hip and knee orthopaedic surgeries. With regard to patient satisfaction rates, we have a very high satisfaction rate when compared to other hospitals and trusts, and we are also heavily involved in the rapid recovery programme. Here are our orthopaedic consultants, who are experts in orthopaedic surgery: Alex Chipperfield, William Dunnet, Matthew Oliver, Raman Thakur, and Omar Yanni Raj Shrivastava, who just retired Richard Goddard and Mark Jones, who recently joined our team with regard to private knee replacement unit volumes, can see from the slide that the Horder Centre, which stands at 305 Bon Hospital, is 225 from last year, but this year we'll be heading towards 450 a year. Next is Kims, which was last year (175). There is also an increase in volume with regard to the replacement surgeries in field temps, and as food one, what is osteoarthrosis with regard to arthritis? It's a common disease affecting the joints of the body, most commonly the knee and the hip. The Joint surfaces which are smooth over a period of time they would get damaged and gradually the AR cartilage becomes thin and roughened and there'll be loss of C cartilage as you can see in the slide on areas where the bare bone is exposed this would result in immense pain and this was also cause stiffness in the joint pain on weightbearing and you'll also find sensation of clicking and grinding sensation in the knee and there will be recurrent swellings and also effusions of the knee and the late symptoms you can see rest pain and also pain that wakes you up at night and you'll also be noticing some deformity like the bone getting bowed and also sometimes the bone can go to other direction where you can develop a valgus knee resulting in a knock knee and your walking ability also will be getting reduced because of the pain you can see from the slide the normal knee on the left which shows a good preservation of the joint surface all throughout and you can see on the right side there's complete obliteration of the joint space with ostop fides all around in the lateral compartment and also you can see the spines becoming quite prominent indicating that this is an arthritic joint with regard to treatment options of knee osteoarthrosis not that we all jump into doing an any replacement surgery in the beginning and everyone has to be sensible and go for the activity modification like if one is playing Impact Sports they need to reduce and be aware that mostly impact activities can cause more pain and also one is overly overweight then it would be reasonable for them to go for weight loss program and get the weight reduced so that one can offload the weight on the joint next is physiotherapy can be very beneficial with regard to strengthening the quadriceps and also improving the extensive mechanism of next is taking by simple painkillers and also taking some paracetamol neurophen or naproxen and co-codamol all these can help in relieving the pain there are some braces which are offloading braces you can have weight relieving braces for your knees and injections also in the early to moderate phase can significantly help in improving the symptoms One is steroid injections; the other is hyaluronic acid injections, which we give in Benenden; and there are also PRP injections that are available on the market. if all the conservative methods of treatment which have stated just now fail to improve your symptoms then if one has got significant symptoms that are evidence on the radiological appearance that he got significant arthritis then it would be reasonable to offer surgical treatment which can be osteotomies in the form of realignment surgery where we can correct the alignment of the knees by doing a high ostomies in genu varum knee that would help in relieving the symptoms as your offloading the medial compartment and transmitting the load evenly the other techniques are orthoscopic techniques where if there is an isolated conodal defects one can do a moving of the compartment to encourage the new cartilage to form and there are also in young patients where one can consider cartilage transplantation where we are not doing here at the moment it can be done in the tertial centres like in stanu or UCL and eventually one can consider a knee replacement surgery provided all these failed to give reasonable pain relief with regard to knee Replacements surgery It is now a common operation; approximately 100,000 are performed in a year. The average age of the patient is between 68 and 17, the majority of the patients are 56.5% female, and 95.94 percent of patients report improvement in symptoms. 80% of the knee replacements can be lost, and their survivorship is between 20 and 25 years. One needs to understand: do I need knee replacement surgery if the pain is the limiting factor and if it is significantly affecting your sleep and quality of life, provided there is radiological evidence of arthritis in the form of a significant narrowing of the joint space, and provided all the conservative methods of treatment like physiotherapy, steroid injections, and braces fail to improve the symptoms? It would be reasonable for one to be considered for a knee replacement, and the common conditions that one can come across are osteoarthrosis, rheumatoid arthritis, and posttraumatic arthritis, where one has fractures of the tibial plateau. If there are inner fractures in the long term, this may go on for osteoarthrosis, and there are other conditions like gout and psoriasis that can also contribute to arthritis with regard to Aims of knee replacement surgery Improved pain relief: there's a tremendous amount of pain reduction following knee replacement surgery. increase in mobility, restoration of function, and U-realignment of the mechanical axis in anger patients; it is a high function demand such as work and sports; some of the patients would have gone back to non-impact activities like cycling and swimming; and also higher impact Sports like getting back to football or tennis are not advisable as these are artificial joints, and these artificial joints are subjected to wear and tear. It would be best to avoid any impactful activities, but most of the patients can return to golf and other activities. What are the types of knee replacements that one can offer at Benenden? So, there's a partial knee replacement, which we call the medial uni compartmental or lateral uni compartment. With medial uni compartmental, you have Oxford uni compartmental knee replacements, which are again mobile bearings, whereas unicompartmental knee replacements are fixed bearings, and both are doing extremely well in the National Joint Registry. The second one is lateral unicompartmental knee replacements, which I do when individuals have isolated lateral compartment osteoarthrosis. These are mainly done as fixed bearings, as mobile bearings will have an increased risk of dislocation. If the arthritis is spread to all of the compartments, including the petal and other compartments, then it will be reasonable for one to consider a total knee replacement. You also have a petal joint replacement where some patients we see have isolated petal pain, mainly when they are coming downstairs. They struggle to come downstairs, and they have difficulty crouching and kneeling. They have to hold on to bannisters and do one step at a time. When there is isolated petal arthritis, it would be reasonable to offer them petal replacement. Then, with regard to the partial knee, I can show you here where you can see that only part of the knee, which is on the medial side, has been replaced, and on the tibial side, you can see a metal back tibia along with the plastic that is moving. This is what a partial knee looks like, and the other compartments are well left alone, as you do not see any arthritis in the lateral or petal compartments. With regard to total knee replacement, this is how a total knee looks. all you need to do is shave the articular surfaces of the arthritic bones at the end of your thigh bone called the femur and then you shape the femur for the knee replacement process and you put the femur in which is like a Vanguard knee replacement and also on the it side again you resurface the tibia and shave the articular surface off and then put in a TBL component so at the end of the bone you have the metal component which articulates with the plastic so this is how a  Knee replacement looks again you have got a cruet retaining where the cruet ligaments are being the posterior cruet ligament is retained when you call it a cruet retaining and if the crusades have gone if there's an increased posterior slope in the tibia then one can consider a posterior stabilized total knee replacement and there is also Replacements that are available and it'll be soon available at Benenden with regard to robotic  knee replacement surgery which AIDS surgeon in performing an replacement with the robotic assistance it'll be here and my colleagues are going to give another webinar with regard to robotic knee replacement surgery in January you're all welcome to join for this robotic knee replacement surgery which is coming soon then you got constraint totalling replacements and you got revision where we put the stems in to the thigh bone and the shin bone and make it stabilized and in severe deformities these are useful and also when the ligaments have failed like mainly the medial collateral ligament which is the chief stabilizer if they fail then one can consider a constrained total knee replacement you can see the Vanguard knee replacement this is the one that we use at Benenden this is I got good Survivor ship and the AEP rating of the Vanguard  knee Replacements is 15a would operating and it the 10year survivorship is about 97% these are basically cemented totally replacement and you can resurface the petal if there is arthritis in the pet or they can be done without the pet res serving We again have Cruciate Retaining and Poster Stabilised Vanguard. Total knee replacements, so with regard to the surgical process, what happens during the knee replacement surgery? One would have a midline longitudinal incision, and the disease joint would be replaced with your bony cuts. Once you have resurfaced the cuts, you can plan your replacement, as I've just shown you, by putting the femoral component into the thigh bone, and at the end of the shin bone, where it is the tibia fibula, you can insert the tibial component into this, so this is how knee replacements are performed.

So with regard to coming to recovery from a replacement surgery though on my slide it stays two to three days in hospital majority of the patients are discharged within a day or two especially the unicompartmental knee Replacements they are getting discharged within a day as the recovery is quicker and the patients prefer to be at home rather than hospital we encourage that and you'll have a large protective dressing on the knee and pain will be controlled with the regular pain medications and also patients do get in addition to spinal an electric Canal block to help with the pain and you'll be soon vised by our physiotherapist team and we've got an excellent team of physiotherapists who will help you regain your Mobility range of motions and function we also have got excellent highly skilled Team of nursing staff who looks after the inpatients on the ward that provide you all the information that you need and help you regain your mobility with regard to recovery from knee replacement surgery we only let you leave the hospital once everyone is happy that it is safe for you to do so and you are mobilizing independently with the help of crutch or frame that you've been provided with and you'll be shown how to safely go up and downstairs if you got stairs at home and after about a week most people can walk independently with sticks we encourage all our patients to take pain clears on a regular basis to help with the pain and uh there'll be some bruising around the Staples if you do not wish to have Staples and we can use dissolvable stitches following knee replacement surgery and regular exercise are quite important before and after surgery majority of the patients do complain of some numbness which is not uncommon after knee replacement on the outer aspect of your knee and some of them have got some medial pain around the top of the shin bone which is again not uncommon after 6 weeks one can resume driving short distances and you will have your appointment to be seen by the respective Consultants who has performed your surgery at 6ek interval and you any questions or concerns that you may have he will be addressing all those issues at 6 we interval one would assume for patients who had need replacement to return to normal activity after 3 months with regard to potential risks that one can anticipate There is a risk of blood transfusion when there is increased blood loss, and there can be a little fracture that one can come across, and there can be slight damage to the nerve of the vessel, and the ligament or tendon can be injured at the time of surgery with regard to recovery wound problems. I'm very pleased to let all of you know that infection rates in this particular hospital have been time and again proven to be less than the national average. The other one is a DVT, which can develop clots in the veins of your leg that can sometimes migrate into the lung and cause a PE. That's why everybody is given blood-thinning tablets or injections for a period of 14 days. You will also have Cal pumps in the form of flettons until you get out of your inpatient bed. Another one is stiffness and swelling of the knee, which is not uncommon, and one has to do regular exercises to get rid of the stiffness and improve the swelling. Late complications include infection and plant failure with regard to aseptic loosening, where the poly plastic that is being put in between the components can wear off and there can be delamination of the poly, which can contribute to loosening and may well require revision surgery. If the symptoms are getting worse, the others are fracture and dislocation, which are again very rare following knee replacements with regard to patients de support tools. it's an NJR surgeon's profile it is in the public domain any one of you can look into the surgeons how many a surgeon has performed or has performed over the years with regard to the knee Replacements or hip replacement surgery and there outcomes and the results so if is an out layer it would highlight in the NJR this is mainly not only to give you enough guidance and also it will also monitor the surgeons and also the implants that we're putting in nowadays if an implant is failing soon it would highlight that these implants are not very good and they would abandon these implants for further use so it is a tool that gives us Guidance with regard to choosing the implants and also with regard to long-term how the surgeons are performing with the regard to their joint replacement.

surgeries and lastly with regard to knee replacement robotic surgical assistance so it is everybody is catching up on robotic knee replacement surgeries and as you all know about 3 million Replacements are being done in a year throughout worldwide and out of which about 11% or being done with robotic assistance this at the end of the day your surgeon is still in charge and this robotic robots will help the consultant perform total need replacement surgery with an improved precision and it gives a better alignment and U Precision when undertaking the knee replacement surgery we do not know still the long-term outcomes but we hope the long-term survivorship and the outcomes can sign significantly improved by doing this robotic  knee replacement surgery You will have a very detailed webinar with regard to the surgeries that are coming up soon, which is scheduled to be on the 9th of January at 6 p.m. Thank you all for listening to me. Now I will pass it on to Phillip.

Philip Orrell

Thank you, Mr Reddy, for that insight into the patient journey. We can now take some questions from our attendees.

So, this person asks, Would having a partial knee replacement be better for younger patients? I'm in my early 50s and would need a revision later in life.

Mr Kumar Reddy

Yes, the answer to that question is certainly yes if you are 50 or younger, I believe, and if you have isolated unicompartmental arthritis, mainly in the middle compartment, as evidenced by the x-rays, and with regard to prerequisites, it is ideal. One should have an intact anterior cruciate ligament, and there should not be any arthritic changes in the lateral compartment of the knee. Also, your knee should not have a fixed flection of more than 10°, and the knee flexion should be more than 100° in the case of the unicompartmental knee. Replacements if one were to consider and also the surgery in the long term because you distribute several million seconds of stress when compared to a 75-year-old, it would also be certainly reasonable to consider any replacement as with the distribution of load and millions of cycles of stress, the joint replacement would wear off, and doing a knee replacement later on is a much easier way to do than doing a revision in a total knee where we need to put stems into both the bone and the shin bone.

Philip Orrell

Okay, thank you. This person asks if it is advisable to build up the knee muscles before surgery.

Mr Kumar Reddy

Yes, 100%, you need to because your knee is defunctioning because of the pain, and wasting you get if you don't use the knee is quite a mark at wasting of the muscles, and this is quite vital, and it's a very important question that you've asked, so for all patients before knee replacement surgery, I would encourage them to do strengthening exercises within pain limits so that they would have a better function following surgery.

Philip Orrell

Thank you. The next question is about average. How long does the operation last for a total knee replacement?

Mr Kumar Reddy

By and large, most of us do knee replacements in less than an hour. I have not been using tka for the knees for the last 20 years, so it has proven to be better pain relief when compared to people who use tka, but in the long term, it should not make any significant difference, so by and large, most of the knee replacements or partial knees are done in less than an hour.

Philip Orrell

Okay, thank you. This person asks, Would I be able to go back to work on my feet most of the day after I've fully recovered?

Mr Kumar Reddy

Normally, it takes about 3 months. We say about 3 months is the ideal time for one to go back to work, so up to 3 months if it's a sedentary job, you can go back after 6 weeks. If you're standing up all day long, up to 3 to 4 months, we should be allowed to accommodate your symptoms.

Philip Orrell

Thank you. This is quite a long question. I'm happy to repeat bits of it. It's sort of two questions rolled into one. This person asks, I have recently had a cortisone injection into my knee for my osteoarthritis. An MRI scan showed I have severe patellofemoral osteoarthritis, an osteochondral defect, and meniscus meniscal tearing. Is there a minimum time after a cortisone injection before a knee replacement can be carried out?

Mr Kumar Reddy

Ideally, one should not recommend cortisone because it is anti-inflammatory, and ideally, one should not be rushing into doing knee replacement surgery for a minimum period of time. I would not do any replacement if one had an injection for a minimum period of 3 to 4 months, so I think one has to be aware of this. If he has significant relief, then it indicates that he definitely has severe arthritis, which has given some pain relief, but with these steroid injections, one needs to think that these are temporary and they're not a permanent cure.

Philip Orrell

Thank you. They say that they're 74 years old, and is it too soon to consider a knee replacement? How bad should one's knee be before considering knee replacement?

Mr Kumar Reddy

I would always ask the patient how bad the pain is, if the pain is severe, if it is affecting his sleep and quality of life, and if he has tried physiotherapy and some painkillers because one cannot keep taking pain painkillers the rest of their lives because it can affect their kidneys and stomach, so it would be reasonable for one to be considered because he is 74 years old. If the pain is immense, it would be reasonable to offer any replacement, provided there is x-ray evidence of severe arthritis.

Philip Orrell

Thanks. The next attendee asks, Do I understand correctly that the vanguard has only a 10-year validity period?

Mr Kumar Reddy

The slide shown was for 10 years, but vanguards have been on the market for the last 25 years or more, and about 85 to 90% of these knee replacements have a 20-year survival rate.

Philip Orrell

Thank you. The next person asks, Are all knee replacements conducted on the spinal block?

Mr Kumar Reddy

The majority of the patients are recommended to have a spinal and a block, but again, at the end of the day, our anaesthesiologists have an excellent team of anaesthesiologists who can talk to the patients at the time of surgery, so some of the patients are very apprehensive about having a spinal. They would like to be put to sleep and not hear any noises, but our team of excellent anaesthesiologists can give them some sedation for them to sleep, and they also regard this as safer than having a spinal block. That's how the majority of the knee replacements are done, and hip replacements are being done at the end, but again, it's down to the patient's choice. One always respects patients, wishes what they prefer, and then goes along with the patient's great thank you.

Philip Orrell

Thank you. This person asks: Is bilateral knee surgery done in the same sitting, and how effective are injections, and do they affect the surgery?

Mr Kumar Reddy

bilateral total replacements it is not a thing that it is that we have inherited in in United Kingdom we always do one replace M at a time the reason being of the risks outweigh the benefits because the risks being one will be in significant amount of pain and also the risks of DVT and Pulmonary embolism are higher it is done in States and in Asian countries like in Singapore and India but we are evidence based so it is in the best interest of the patients that we do not do or carry out Replacements at the same setting so if you had steroid injections it would certainly help temporarily so one could have a knee replacement and also an injection into the other knee which is affected and you can defer the surgery for a minimum period of four to 6 months before we considered on the other side thank you

Philip Orrell

Thank you. This person asks, and I cycle after surgery, so they're asking how flexible their knee joint would be. Can I cycle after surgery?

Mr Kumar Reddy

Yeah it is a good question so again with regard to cycling one would encourage people to do exercises and one you got good range of movements your knee is flexing to about nearly 120 so it is reasonable for you to get back to cycling but I would go with the physiotherapist on their assessment and also speak to the respective consultant who has performed the surgery and they can measure how much flexion you have got and if you got good flexion then I see why not you should not be cycling so most of my patients they go back to cycling after a period of 3 months so I would recommend the person to ask to engage a dialogue with the physiotherapist and the respective surgeon who has performed their replacement surgery thank you

Philip Orrell

Thank you. We have a few sporty people on tonight. It looks like somebody is asking about the possibility of playing tennis after a new replacement. I assume the answer would be similar to the previous

Mr Kumar Reddy

Yeah, I mean Impact Sports. I always tell them that this is an artificial joint that is subject to wear and tear. The more you stress it out, the poly will wear, and it creates poly debris, which contributes to loosening. Idly, I do not recommend it, but some of my patients have gone back to playing tennis, and they have also gone back to playing golf within 6 weeks, so ideally, I would not recommend it. But if one were to play gentle tennis, not very high-impact or high-intensity tennis, it's absolutely fine after 3 months.

Philip Orrell

Okay, thank you. This person asks and excuse my pronunciation on this one. Do you do injections of hyaluronic acid?

Mr Kumar Reddy

We do we have hyaluronic acid injections which is a type 1 collagen these benefit the patients with the arthritis and when then patients are allowed to have when they called the membership they're allowed one injection on their membership and also NHS patients also we can give they need to get a e referral for these injections as and they can give steroid injection but not THX or PRP injections we have not been giving it pen right than this person says I had my knee replaced at the beginning of August I am pretty mobile but my knee and lower K not sure what they're referring to their lower K is still a little bit swollen and I still get odd aches will my knee eventually get back to normal so first of August is only about 3 months down the line so yeah so ideally want to get an Optimum benefit it can take up to 6 months in certain individuals and majority of the patients though they recover between 6 weeks 3 months the optimum benefit one could get is about 6 months so I would recommend this person to continue with exercises with a view to strengthen the quadriceps muscle which is the extensor muscle with a view to improve his extensor mechanism and quadriceps function so idly if you still have got major issues then I would certainly get in with the surgeon who has performed the surgery.

Philip Orrell

Thank you, next attendee. He says I'm 74 years old and had a total knee replacement in 2012. I have rheumatoid arthritis, and lately this knee has been feeling stiff and starting to cause me pain. Does this mean I may need a revision?

Mr Kumar Reddy

No it's only very short period of time so one need to have a diagnosis it is important that he's assessed thoroughly and one need to have a diagnosis after an assessment why this is causing him severe pain stiffness and whether there is something loose mechanically that is happening he should have a plain radiographs to see whether there's loosening or not and people can then get on and do CT scans and also he should have routine blood test as a standard routine practice because some can be secondary to low grade infections so one need to rule out all these things and if all these measures failed to improve the symptoms it would be reasonable to for him to be considered for an orthoscopic surgery with the view to see whether there is any delamination of poly or not before one can embark on revision surgery You need to have a specific diagnosis before we put patients through a major revision or total replacement. That's what I would sincerely recommend.

Philip Orrell

Mr Tendi asked what the recovery would be from the patellofemoral joint replacement. I mean,

Mr Kumar Reddy

This is an isolated joint, which is a petal replacement, and the recovery can vary from 6 weeks to 3 months, so for any knee, including partial, the recovery is quicker when compared to standard total knees, so I would still say between 6 weeks and 3 months.

Philip Orrell

Okay, the final question I think you may probably refer back to earlier answers, but this person says I'm a keen Walker. Will I be able to resume walking a distance of, say, five miles?

Mr Kumar Reddy

following knee replacement surgery Yes, you can walk up to five miles, but listen to the knee. If the knee is not liking it, I think you should reduce it a bit. But people who had knee replacements after a period of six months resumed their normal activity levels.

Philip Orrell

Okay, thank you very much. We have come to the end of our attendees’ questions, so Mr Reddy, please can you move on to the last slide in the presentation if you don't mind? Yes, thank you. So as a thank you for joining this session, we're offering, as listed on the screen, 50% off the value of your consultation. Accord back from your dedicated private patient advisor and an email tomorrow with the recording of this session and further information, as well as updates on news and future events. If you would like to book your consultation following this webinar, our private patient team can take your call until 8:00 p.m. tonight, or you can call back between 8 a.m. and 6 p.m. Monday to Friday, use the number listed on your screen to the right of your screen. Following this webinar, you'll receive a survey, and we'd appreciate it very much if you could fill out that survey when this session closes to improve our future events with your feedback. Our next webinar we have scheduled is on treatment for enlarged prostate, and you can sign up for that via our website. I realise that we are finishing a little bit early today, but all that remains for me to say on behalf of Mr Reddy and the team here at Benenden Hospital is that I'd like to say thank you for tuning in this evening, and we hope to hear from you very soon.