Phil Orrell

Thank you very much for joining our webinar this evening, where we'll be covering knee replacement surgery. My name's Phil, I’ll be your host for this session and our expert speaker this evening is our Consultant Orthopaedic Surgeon, Mr Mark Jones. Just to give you an overview of the format of the session, Mr Jones's presentation will run approximately 40 minutes and this will be followed by a Q&A session and you can submit questions for the Q&A session at any time during the presentation or following the presentation and you can do this by using the Q&A icon at the bottom of your screen. I should point out that you can do this anonymously or you can give your name and I should mention that if you do give your name, we are recording this session. If you would like to book your consultation, we'll be providing contact details at the end of the session.

That's quite enough from me for the time being, so without further ado, I will hand over to our expert speaker Mr Mark Jones.

Mr Mark Jones

Hello, good evening, everyone. Thank you for attending this evening's webinar, so I’ll get on with my presentation. So my name is Mark Jones, I’m a Consultant Orthopaedic Surgeon here at the  Benenden Hospital and the session today is going to talk a bit about what to expect from a painful knee and knee arthritis going through the management treatment options of this and and mainly focusing on knee replacement surgery and how this will affect you as a patient and going through anything that you're you have any queries about at the end with any questions.

So, as I said I’m a one of the Consultant surgeons here specialising in knee surgery. I train or I was in Imperial College School of Medicine where and you know I undertook my undergraduate training, where and my surgical training occurs here in Kent surrey and Sussex region before I went over to Brisbane, Australia to do my specialist sub-specialist training in knee surgery particularly sports medicine and knee replacement surgery I now have a consultant post in East Kent Hospitals as a consultant there where I do my trauma in Margate and my elected work in Canterbury, sub-specializing in knee surgery and sports knee injuries.

To talk about the Benenden Hospital we're currently a leading provider of private hip and knee treatments in Kent and Sussex and we provide an environment that is clean and calm and hopefully will suit your needs. If you acquired any surgery here we have Consultant Orthopaedic Surgeons who will see you in clinic and operate on you and Physiotherapists who will see you pre-operatively and post-operatively through your your management for your knee conditions we've had very good outcomes in patient satisfaction rates on both the private websites and other app applications which rate our performance and we have a rapid recovery program with most of our patients who have knee replacement staying in for maximum of three days usually.

These are the group of orthopaedic surgeons who perform knee replacement surgery, as you can see all of us work here and and numbers which we we do on a regular basis.

Current numbers for last year, for these is just including our private patients the Benenden did 225 private knee replacements last year, which is one of the highest in the region they'll be second to the Horder Centre, this doesn't consider all the NHS patients we also do so this number is higher it's just not included in this total.

So what is arthritis and how does it affect you? Well, the arthritis is a condition early on where you start developing some stiffness in the knee you may start getting more pain in your knee depending on the activities you're doing the more impact work that you're doing and you may start noticing your knee clicks or grinds or scrapes and feels a bit rougher than it used to do and it can swell up when it does this and you may notice that the swelling causes even more stiffness within the knee.

The late symptoms of arthritis are that you get pain at rest you sit down and the pain doesn't go away you can't sleep at night time because of the pain or it wakes you from sleep and you start getting a bit of a deformity in the knee and this is because you wear out more of your cartilage and you're more because your knee becomes more angulated because of the the arthritis which is subsequently worsens your pain and symptoms and because of all of this you start walking smaller distances to try and offload this knee because of the pain. If you look at these x-rays here you can see on the left hand side is an x-ray of a normal knee and you can see the gap between the two ends of the bone indicating there's a nice area of cartilage and meniscus sitting in that gap which act which adds shock absorption and protection to the knee. On the right-hand side, you can see that because the cartilage has worn out, you have bone on bone arthritis, and this is ending stage arthritis requiring treatment if the symptoms are bad enough.

So how do we treat knee arthritis? Well, it really goes down two pathways, the first pathway is the non-surgical pathway, and this includes activity modification, avoiding those high impact activities which you do which flare your knee up or cause more pain. This can be a problem sometimes, people are still having to work and still have to go up and down ladders etc and this can be a problem to act to modify these activities it is about trying to do activities which are protected for the knee these include cycling, swimming and those activities are non-impact. Weight loss has a huge part in treatment options for knee arthritis, the knee takes a huge load through it on every step that you take. One of the examples is as you go up and down stairs the knee actually loads about five to ten times your body weight, so even small amounts of weight loss will have a huge benefits to you in terms of your pain relief physiotherapy is key to try and maintain the strength and range of motion around this knee to stop it from deconditioning and having problems later on after the operation. Simple energies here is key and nice to release guidelines in the last couple of years about what kind of painkillers should be taken, we're moving towards the painkillers such as co-codamol and anti-inflammatory such as naproxen or ibuprofen which help with pain relief to try and dampen down the pain within the knee. Strapping of the knee with braces or even corrective braces which correct the alignment can be used and this helps offload the knee or unload the knee and they can be prescribed by your doctor to try and aid with some of this pain relief and get you to the physiotherapy and activities as normal and finally we move on to injections which again are encouraged by NICE guidelines, steroid injections are the main ones indicated for arthritis according to NICE guidelines and these are injections into the knee which take away the inflammation of the knee and the pain so that you can get using this knee trying to build up the knee with physiotherapy and help with the weight loss. There are other injections available and here at Benenden we offer duralene which is a hyaluronic acid injection, it's a high molecular weight injection which acts acts as a shock absorber in the knee and lubricates the knee joint, so that your knee arthritis is slightly more bearable and it dampens down the effect of the inflammatory process that arthritis causes.

There are surgical treatments for arthritis that are not just replacement surgery, we can correct the alignments. As we discussed earlier knee arthritis causes your knee to change shape and as a result you start putting more weight through that damaged compartment, this causes your knee to become either bowlegged or knock kneed and actually in surgery we can correct this with a procedure where we actually break your bone and correct the alignment to make it either straight or slightly on the opposite way to where it was going in the first place so that you can offload this damaged compartment and help with your knee pain. There are arthroscopic techniques where if you have catching symptoms within your knee because of loose flaps of cartilage we can just shave these off, micro fracture can give a little bit of relief but actually it's probably going more out of favour now in terms of the treatment of cartilage disorders within the knee and because it affects your issue with cartilage transplantation later which can be referred on to other centres which are cartilage specialist centres and our local one is Stanmore where you can have transplantation of bone and cartilage into defects, if they're small enough. And lastly you can have knee replacement surgery, which is what we're going to focus on today in terms of the management options.

Knee replacement surgery is a very common operation that occurs within the UK and about 100,000 are occurring every year in the UK at the moment. The average age is somewhere around 68 or 70 and the majority of patients who have it and just are females have a majority of their procedures at 56 percent. Patients do really well after knee replacement and they do have a health improvement in 94.5 percent of patients and research seems to suggest that 80 percent of knee replacements can last for 25 years, however this does depend on the use that it has, the age that it goes in and other issues which can affect the wear and tear of the knee replacement itself. So the question is do you need a knee replacement? Well knee replacement surgery is indicated for patients who have bone on bone arthritis in their knee, once you have bone on bone arthritis if you need it all then depends on the symptoms you're getting do you have this, does it affect your quality of life and if it does and you have osteoarthritis the bone or bone arthritis or rheumatoid arthritis is another condition or if you've had significant traumas of the knee causing severe fractures and exposing underlying bone or severe ligament injuries leading to ongoing instability, then you are certainly suitable for consideration of a knee replacement. What of the aims of this knee replacement for you? Well the main aim is to improve the pain within the knee so that you can then increase the mobility and you can start getting back to normal day-to-day function you can start walking around without ongoing pain and you can sleep better and you don't have rest pain, this helps restore function and also in certain circumstances we do a realign the leg mechanical axis but actually this is surge independent and patient dependent and sometimes we will still maintain some malalignment in the knee as we feel that this is maybe your better or this is your natural alignment and this is what we try and restore. In younger patients you'll have slightly higher demand to for work and sports we try and get them back to those as well and I certainly don't tell patients that they can't do anything after a new replacement as long as they're willing to take risks that the more you do the higher impact stuff you do the more likely this is to wear out or if you had a big injury you could fracture around the implants.

So, there are different types of knee replacement, certain patients with certain types of arthritis are suitable for a half knee replacement, as you can see here on the left side of the screen. A half knee replacement can either replace the medial side, which is the inside of your knee, the outside of your knee the lateral compartment or the patellofemoral joint as an individual uni-compartmental knee replacement and again this is specific to the type of arthritis and the patients that present with those that can those conditions. A standard knee replacement is is the one that you see on the on the right and this is the more common one, this is for those patients who have another arthritis throughout their knee and wouldn't do well with a half knee replacement we can use standard instrumentation which is the most common type of procedure performed and this is where we put instruments around the need to try and get the alignment, we make our cuts around the knee according to your normal anatomy and we put the knee replacement in. Computer navigation is becoming more topical, it's research is being done to show computer navigation and potentially robots in the future are the way forward in terms of how a new replacement is performed, certainly in Australia the computer navigation outcomes the patients who have computer navigated surgery at 10 years have probably got better reported outcomes in terms of their their prongs which is the the patient outcome scoring system in in all age groups and this may convert into the outcomes following robotic surgery but certainly the long-term outcomes aren't there yet. Some patients though do require constrained total knee replacement and these are for those patients who have who acquire revision surgery, if they've got severe deformities that lead to ligament laxity or failure and these patients need a little a little bit more constraint from their knee replacements so that it can function without dislocation or giving way.

The knee replacement we use here in Benenden is called the vanguard knee replacement, it's a product produced by a company called Zimmer Biomet and looking at the current ODEP rating which is the national ratings for how implants survive is the highest implant we've got is 15a out of the vanguard system. The 10-year survivorship is very good, and this is 96.4 percent at 10 years should survive meaning that only 3.6 percent will have been revised at 10 years. It's a cemented implant which means that we put we secure it into the bone with cement which acts as a bit like a grout within the knee itself and we sometimes do the patella and we sometimes don't and again the research doesn't seem to suggest which one we should be doing and it all depends on the patient's symptoms and the findings are intraoperative surgery and sometimes a surgeon has a preference about which one they prefer.

So what happens during your knee replacement surgery? Well, apart from obviously your you have the anaesthetic, and this can be as a general anaesthetic, spinal anaesthetic or even a block which blocks the nerves around the knee to make the knee numb and this is all in conversation with your anaesthetist. Once you're in surgery we take your disease joints and we we put on jigs onto the bottom of your bones to make our cuts so that we can basically soar off the arthritic area of your knee and then on top of these sawn off areas we put in our knee replacement components, our femoral components and our tibial components and put and there's a plastic spacer in between which allows that need to move freely and then occasionally we put a plastic button on the underneath the kneecap as well and these are all secured in place to the femur, to the tibia and to the patella with cement.

Most patients in my experience here stay in only one to two nights, those who do really well will probably go home the next day but majority of patients here are probably staying two days. Occasionally patients will stay in three days if there's problems getting home, pain isn't controlled or they're taking a little bit more time to get up and about with physios. You'll wake up with a large protective dressing on your knee with a waterproof dressing on underneath, the big wool and crate bandage usually comes off the day one or day two, leaving this waterproof dressing on underneath which needs to remain on for a couple of weeks to let the wound heal. Your pain will be controlled by the doctors on the ward who manage your painkillers and make sure they're liaising with you and the nursing staff to make sure pain is under control and the physiotherapy team will get to see you hopefully on the first day as soon as you wake up to try and get you up and about and around the ward so that we can get you as independently mobile as possible as quickly as possible and we've got very skilled nurses here at the  Benenden who will look after you and who understand your recovery process after a knee replacement.

Once you go home, well we only send we only discharging from hospital when we feel it's safe to do so and this is in conjunction with physiotherapy input as well as the nursing input. You'll go home with frames or crutches depending on what's safest for you and what the physios feel is going to keep you safe at home and you'll be shown how to go up and down stairs after about a week you'll most likely be able to just walk independently with just the sticks you've been given and these gradually wean off over the next six weeks. First couple of weeks after new replacement is a very painful operation, you will be on painkillers, but we do want you to take those painkillers and not be too proud and because it is a very painful operation. You will have bruising around the knee which is very common and some of us use some people use staples to close a wound which you'll be able to feel or or even see underneath the dressing. You should in these first two weeks be doing your exercises that the physio has given you to try and get this knee moving as quickly as possible to try and prevent long-term stiffness and to try and improve this muscle musculature around the knee as quickly as possible. By about six weeks you should be now walking at home and briefly outside and you probably have weaned off the the sticks or the frame that you've been using, you may even be able to drive a short distance depending on the knee that's been replaced and the pain and how you've recovered and at six weeks this is when you'll see the surgeon that's done your operation so they can make sure that you're getting on okay but your range of motion is improving and your pain is getting better. By three months these are when patients start feeling the benefits of the surgery they can see the light at the end of the tunnel the pain is getting better the mobility is improving and it's starting to return to normal activities, getting back to work for those patients who work and they're starting to do their normal exercises. There are risks to any surgical procedure, there's risks can occur at three time periods during the knee replacement either during the surgery, during the recovery period of the surgery or even later on. During surgery you may lose some blood we make a big cut in the knee, and this can bleed and so sometimes you need a blood transfusion either during the surgery or in the recovery period afterwards whilst you're an inpatient. Because we're cutting soft bone and putting hard metal implants into a slightly softer bone there can be a fracture to the bone or bone injury, there are nerves and blood vessels ligaments and tendons surrounding the knee and these can also be damaged with a saw blade at the time of surgery. During recovery period you can have problems with the wound, these wounds can break down and become infected and you can get an early infection in the in the knee. Blood clots can occur in your calf which can go up to your lungs and that can be a significant problem in terms of it can cause significant breathing difficulties and in the worst-case scenario can lead to death. To prevent this, we do give medications to thin your blood to try and prevent this but obviously we we do this in conjunction with you to find out your risks of the blood clots before the operation. You will in the first few weeks walk with limp and this does gradually get better as your pain improves the stiffness improves and your strength improves and you will have stiffness and swelling in those early few weeks which does hopefully get better and progresses up to about the 12 to 18 month stage the stiffen the range of motion gradually improves. Later on after a new replacement you can get a late infection which again would require further surgery, over time implants can can fail they wear out and they get what's called aseptic loosening where the plastic within the knee causes an immune response in your body which causes the bone to break down and wear out and cause loosening of the implants requiring revision surgery. It can also fracture around the implant at a later stage, either requiring a fixation with metal with plates and screws or even revision surgery where we replace the knee replacement. It can dislocate so knee replacements that have mobile bearings or the ligaments become loose the whole knee can dislocation require revision surgery later on.

So how do you decide who or when to have the operation? Well we all have NJR profiles, so the NJR is our National Joint Registry and this is where all of our data regarding our joint replacements are kept it shows the numbers of joint replacements we do a year, which shows where we're doing them, what age group of patients we're doing them on, how high risk these patients are and our our one-year mortality rate it shows. So you can first of all pick your surgeon by going onto our profiles on the NJR and finding out which surgeon you want to do it you can go on to the private healthcare independent network which has a database of all of the the surgeons doing the procedures and the outcomes and also around and the outcomes from the  Benenden and you can go on other review sites such as Doctify which will allow you to review doctor and so and Hospital profiles to see see what their outcomes are and how other patients have got on with those surgeons.

So, it now comes to the end of the presentation and leaves time for some questions that you may have, and I’ll try and hopefully answer as many as I can, but I’ll hand you back to Phil who will try and coordinate that. So, thank you very much for listening and I’ll speak to you with some of your questions.

Phil Orrell

Okay thanks Mr jones and thank you for some excellent insight into the various conditions and treatment options available.

So, we will now take some questions from our attendees.

So, this attendee asks why my knees hurt when I’m lying in bed resting?

Mr Mark Jones

So, the problem with knee arthritis is that the knee has bone on bone arthritis which basically means that the underlying bone is not protected by cartilage anymore, now the bone has nerve endings and nerve fibres, and it also is a honeycomb structure which can become bruised, and you can bleed into this area. So if you do weight-bearing tasks during the day and you've overloaded the knees during the day, then your knees are painful at night because you've done too much and that knee is bruised and it's painful and those nerve fibres just underneath the cartilage are causing that pain for you and that's that's shows an end stage arthritis where patients get knee pain at night or at rest and it means that they're usually pretty bad and require a knee replacement at that stage or at least some intervention.

Phil Orrell

Okay, thank you. This attendee asks, I’m in my early 60s and already had one of my knees replaced. I have pain in my other knee that hasn't got better from injections meaning that I rely heavily on my new one standing still is this safe to do or should I seek to get surgery as soon as possible?

Mr Mark Jones

I mean it's safe to do, I think if you failed now steroid injections on on your bad knee and your and you know the risks and the implications of having a knee replacement which you obviously do having had the other one and it's done well for you then I certainly would seek advice fairly soon from a surgeon to have a discussion about whether first of all whether your arthritis is suitable for a knee replacement and if it is then you know have a discussion about that knee replacement option. But it certainly is safe to stand on that leg and take pressure through it this knee replacement can take quite a lot but obviously the more you wear it out over the years the higher the chance of revision surgery later on.

Phil Orrell

Okay, thanks. This person says, I’m having a full knee replacement on July the 29^th, I know that this will give me a stronger good as new knee, but could I ask are the things I used to be able to do such as kick a ball, run, kneel down I will not now not be able to do in the future once I’ve recovered?

Mr Mark Jones

Very good question. So, I always explain to patients I don't ever say you can't do something with your knee replacement the point of doing the knee replacement from my point of view is that you get back to things that you want to do. There are things though with a new replacement you find harder to do, so certainly people find it hard to kneel down you've got a large scar on the front of your knee and some people don't like kneeling on that scar because it is a bit painful and irritable and so they may not want you may not want to kneel on it after the operation. Kicking a ball there's no reason if you find you're able to and you've got the range of motion to do it and the strength in your in your quadriceps then you should be able to you know people go skiing with new replacements they jump out of planes and they do get back to activities it's just it's whether you can with your knee replacement and how the how you recover in terms of stiffness and strength but it's certainly nothing in that I would say you should avoid doing if you want to do it.

Phil Orrell

Okay, sounds very reassuring. This person says, what is the maximum range of motion post-op?

Mr Mark Jones

Yes, that's a very good question as well. So knee replacements are mechanical devices and actually we're not going to give you the range of motion you once had as it as a child, because if we do that the the knee replacement can actually dislocate and it can impinge and cause more wear and tear, so majority of the time it depends on your pre-operative range of motion as well. If you have a really stiff knee pre-operatively then there is a higher chance of having stiffness after the operation in a reduced range of motion we'd always hopefully get you more range of motion than you currently have but because of this sort of scarring to the soft tissues it can mean that you still have a fairly stiff knee would hope to improve that by 10 to 15 degrees in both extension and flexion but if it's really stiff then sometimes that can be a problem. In the ideal world we'd get most knees fully straight and to about 120 maybe 125 degrees if we could.

Phil Orrell

Okay, thank you. This is an interesting one from an attendee called Claire who asks how long after the operation would I be able to manage a flight to Australia?

Mr Mark Jones

Okay Claire, so what we suggest after a big operation like a knee replacement which puts you at higher chance of blood clots is that you don't do long-haul flights for the research suggests six weeks, you still have a higher chance of blood clots compared to the average population who would be flying to Australia, but also that that risk doesn't really go down to zip to the same risk until about three months also the fact that sitting down for long periods of time when you need bent and doing the mobilization around airports I think if you looked at around the three-month stage I think that would probably be around the earliest that I would suggest a really long all flight to Australia.

Phil Orrell

Okay, thank you. This attendee says I have quite bowed legs will this cause an issue?

Mr Mark Jones

No, so we're very used to having bowed legs when it comes to doing knee replacements because it's the general disease of arthritis. It's the most common deformity we we address, majority of surgeons will make you make your legs straight again which actually will give you a little bit of a leg length discrepancy if we do one at a time because we straighten the leg and it's a bit longer, when I do knee replacements I probably leave you in a little bit of bowed leg because I think that's probably your natural anatomy but I certainly wouldn't do it to the same level as you're in at the moment if it's really bowed I’ll just give you a slight bowing of your knee so that you get back to your normal amount and that's me that you had before your arthritis progressed, but it doesn't cause a problem in the knee replacement though.

Phil Orrell

Okay, thank you. This attendee says I have a missing ligament following a serious sports injury nearly 60 years ago, would this be an issue from knee replacement?

Mr Mark Jones

It depends on the knee ligament, if it's the ACL within the knee then no because actually in most apart from half knee replacements we chop out the ACL as part of the operation, if it's the PCL which is the one at the back in the knee then it wouldn't affect your knee replacement, it would just need to be known to the surgeon because they would change the implant type. It would need a little bit more constraint, but it wouldn't affect your outcome in terms of surgery. If it's one of the ligaments on the outside of your knee and it's unstable still then it would it wouldn't affect your your knee replacement in terms of having the operation but it certainly would affect the implant you have because if it's a ligament on the outside of your knee would need a more highly constrained implant which is called a hinged knee implant so that we can keep keep the stability back in that knee, so it all depends on the type of ligament that's been injured and and the findings that the surgeon found on the examination in clinic.

Phil Orrell

Okay, thank you. This lady asks, can I have a corto steroid injection pre TKR?

Mr Mark Jones

Yes, so it's a very common thing that we see patients in clinic who need some immediate relief from their knee pain or who aren't ready for knee replacements. So we give corticosteroid injections at the time in clinic, the only caveat to that is that if we give you a steroid injection, we would not do the knee replacement for three months and that's because of this higher risk of infection following the steroid injection in that three-month period, but the research shows that after three months that risk decreases back to normal.

Phil Orrell

Thanks. Next question is, does having osteopenia affect outcomes and timing?

Mr Mark Jones

Not really, no. So, we in a lot of our age group population there's a lot of osteopenia because actually the knee is painful, you get a lot of disuse osteopenia because of you're not using it as much as you did. Now we know about this, and the implants are fairly good, and we put them in with cement so they should they'll be stable. There is obviously a higher risk of fracture around an implant if you've got weaker bone but hopefully once you put the implant in and you start mobilising more this will hopefully strengthen the bone a bit and it will remodel as bone does, so if you're using it more and you're putting more weight on it because it's pain-free then this is actually protective.

Phil Orrell

Okay, thank you. Next attendee asks, at what stage in the degenerative process is it best to operate, how do you know when the time is right?

Mr Mark Jones

So, from a surgical point of view, the the knee replacement has to be done in someone who has really bone on bone arthritis on weight-bearing x-rays. If you've got bone on bone arthritis then you then the only surgical option really then is is an arthroplasty or maybe a an osteotomy, if you have got mild or moderate arthritis in that degenerative process and the weight-bearing x-rays that the surgeon gets to you does not show that there's bone on bone arthritis, then you're probably not suitable at that time for a knee replacement or knee arthroplasty and there are maybe other options available which again could be discussed with your surgeon depending on the the disease and the disease progression and your symptoms.

Phil Orrell

This guest asks you spoke of the various risks post-surgically, what percentages do these have?

Mr Mark Jones

So, they're all fairly minor, so if the consent form when you go through it with this surgeon, the risk of blood clots is is probably around five percent of symptomatic blood clots, infection again is around a similar risk. We know that knee replacements wear out and the risk of it wearing out is again it depends on many factors but if we look at again the NJR is a good place to look at for this you can look for revision rates in certain knee replacement so you could and it will also give you a breakdown for revision surgery in certain age groups and certain genders and so you can actually break it down into almost percentages for particular people. But they're all fairly minor issues and again it's about having that discussion with your your surgeon because there are factors which increase your risk of complications, so patients with diabetes or with previous skin complications, previous blood clots would all have a slightly different risk compared to the average and so when you see your surgeon and they go through the risk factors with you, it'll be worth speaking to them if you've had other problems or previous blood clots because they will then be able to highlight the higher risk of blood clots in you and the protection that we can have.

Phil Orrell

Okay, thank you. This attendee Russell asks, do you have to have one knee operated on a time?

Mr Mark Jones

So, there are surgeons who will do bilateral knee replacement, it's I mean I don't see it I haven't seen it in this country personally, but it does happen and there are surgeons who will do. The the reason why it's not done very often is because it's a very debilitating operation anyway, it's painful and actually you find it difficult to mobilize even having one leg done let alone two on top of that the risks of having bilateral knee replacement do increase so your risk of infections, risk of blood clots all go up and go up to a point where you feel that the risks are maybe unacceptable. Along these lines if you have one knee replacement then actually not doing then a knee replacement for another three to six months reduces those risks and so you then get back to a normal level of risk following about six months after the first knee replacement. So yes, you could have a bilateral knee replacement in certain circumstances it is done but they usually done in patients who are have no other medical problems are maybe slightly younger so can deal with the physiological hits that you'll get from having big surgery and willing to accept it, willing to accept the higher risks. But we don’t do it at Benenden, sorry.

Phil Orrell

This next question is, is the hyaluronic acid injection suitable for someone with end-stage osteoarthritis?

Mr Mark Jones

Yes, I think if in my personal experience it is probably better in those patients who have mild to moderate arthritis because I do think that those patients will have significant bone or bone arthritis it's got limited parts of play but again it's about the discussion with patients in clinic if you really insisted you don't want an operation you want to try something else to try and manage your pain then I think it does have a role and it certainly would you know I would be worth trying if you didn't want to go down the surgical route and you wanted an option of an injection and a high duralene is probably out of the the hyaluronic acid formulas is probably has the best outcomes in terms of the the research.

Phil Orrell

Next question is, if one is experiencing slight pain and has bone on bone arthritis, does it make sense to opt for early surgery to get it over with whilst you are younger and presumably fitter?

Mr Mark Jones

Yes, so I don't think it is actually. I think knee replacements are for those patients with bone on bone arthritis with significant symptoms of pain and and issues of mobility, the problem with a knee replacement is it is a very painful operation, so if you're substituting mild pain for then severe pain post-operatively you don't then do as well because you're in a lot more pain and you'll not use that knee, you'll get stiff knee and then the outcomes of having a stiff knee if there are can be quite poor so I would say that patients who have a knee replacement should have the bone on bone x-ray changes and significant symptoms to justify to having a knee replacement personally.

Phil Orrell

Okay, thank you. This guest asks, if I have a partial knee replacement is it possible to later to have a full replacement if needed and how many times can this be done in one knee?

Mr Mark Jones

Okay, yes. So the problem with the uni-compartmental knee replacements are that you only replace parts of the knee and that means that the rest of the knee can develop arthritis, just like your other part as being a part of me that's been replaced and has and if that happens then you get this progression of arthritis which then needs revision surgery and it can be done in a couple of ways. The majority of these half knee replacements which form progressive arthritis will then be converted to a full total knee replacement. However, certain surgeons with certain arthritic pictures may replace another compartment as a uni-compartmental knee replacement and actually replace so then you've got two uni-compartmental knee replacements within the knee depending on the disease that you've got and again that's discussion with your revision surgeon at the time. But it the risk of having further surgery after a uni-compartmental knee replacement is about 14 percent at 10 years and so those patients tend to progress their arthritis and require further surgery of some kind.

Phil Orrell

All right, thank you. This person asks what is the difference between a standard knee replacement and a signature replacement?

Mr Mark Jones

So, signature knee replacement is a custom-made implant and it's not the the whole implant's not custom made but the cutting jigs because the customer made for the patient. They were certainly evoke a few years ago where it was deemed that this was maybe a better option for patients because you were getting a CT scan of their lower leg and you were getting the cutting jigs to be made for that patient and there was certainly a high number put in particularly around the region and I think the reason why they're not used as much anymore is because I don't think in terms of the outcomes they justify all the extra imaging and the cost compared to a normal standard instrumentation of a knee replacement in that it didn't show much benefit and so that's why it's not used in standard practice it can still be used in deformity so those patients have had previous fractures of their tibia or their femur can still have a signature knee implant as it means that our normal instrumentation is not able to be done and so we need another technique which can be by a signature or it can be by computer assisted navigation or computer assisted surgery, including robotic surgery which you know can be done in places and I think that's what's changed why signatures not as commonly used anymore.

Phil Orrell

Thank you. I think we may have touched on this aspect in another question, but this person asks how long you have to wait between knees replacements?

Mr Mark Jones

So, I tell patients that because it takes about three months to get back on your feet and I think the risks of blood clots infection and it does increase but it's still increased up to about the three-month stage I tend to suggest that if you've come in about both your knees then I see you at the six week stage if at that point you've you can see the light and you think actually my knee replacement I’m glad I had it done which is in you know a lot of the patients, then I will then probably put you on the list at that point to be done at the six month stage. From my point of view I think it means that you then have another six weeks to get to that three month stage where hopefully you're doing well and it also then gives you three months to then rehab both your legs so that you're in conditioned as possible in the best possible way for your next knee replacement at the six month stage.

Phil Orrell

This person asks, I’ve been advised that having too many steroid injections can be a problem if I then need to go down the surgery route, how many would be too many?

Mr Mark Jones

It's a difficult question, I think it depends on your circumstances. I certainly don't think we should be giving more than two steroid injections a year the risk or the problem with steroid injection is the first one is always the best one and so every injection you give after your first injection has a diminishing effect and so they work for less time so they work for less time plus you've still got the risks of infection from giving the injection and also steroid injections can damage cartilage, it causes what we call chondrolysis which is actually the cartilage cells die and so if you had remaining cartilage in that knee and you give years and years’ worth of steroid injection you will eventually lead to further arthritis. However, as long as there's no infection from the steroid injection there's no real limit on it, if it still benefits you and the risks and the benefits still outweigh the risks and you and you still decide you don't want an operation, then I would still go ahead because it won't affect the operation down the line, unless there's a an infection from the steroid injection which then would complicate your knee replacement but that would could happen after the first one or after the 100th one.

Phil Orrell

Okay, thanks very much. On a similar topic, this person asks I’ve suffered acute pain for over three months in my left knee and x-rays show acute osteoarthritis and I’m waiting assessment for surgery. Is it worth trying injections in the meantime to see if this helps and maybe delay surgery?

Mr Mark Jones

It depends what it means by acute arthritis, so there can be conditions where you get an acute collapse around the knee, which and that's because of what we call avascular necrosis of the bone and what happens is you suddenly get collapse of the bone leading to damage to cartilage and in that situation I don't think a steroid injection is justified because actually you want your bone to heal and harden and so I think you need to see it if you I don't quite know what could be a diagnosis of acute arthritis is but I certainly would be slightly worried by the term and I’d want a surgeon to see you first about that before considering an injection if it's being called acute on a radiological on a report.

Phil Orrell

Okay, thank you. This guest asks are there any benefits in taking colonel to rebuild cartilage?

Mr Mark Jones

I think it certainly isn't a NICE recommendation and NICE obviously is our governing body that looks at all the research to look at cost effectiveness of treatments that we use in the in the NHS and I think from my point of view it probably hasn't got a cost benefit, however I would always say that you know sometimes things work and things work for many reasons, for placebo reasons, for a small chance that it may work and I think if you get benefit from it there's always you know I don't see a problem it's certainly not going to harm you probably and I don't think it's necessarily got the research to back it up but I think if it works for you then it's not going to do any harm.

Phil Orrell

Right, thanks. The next question is, I had a heart attack 14 years ago an extent fitted does this increase the risk factor?

Mr Mark Jones

It does so your risk after the operation or during the operation will be slightly higher obviously with a stent you would want to be seen by the anaesthetic team preoperatively to have a full pre-op assessment to make sure your heart tracing was normal and make sure everything you know was optimized as possible pre-operatively it certainly wouldn't deter us from an operation if we went through the risks and benefits with you and you and we had a kind of agreement that this was the best out best best treatment for you but it would obviously it would put you at slightly higher risk of an adverse event it would still wouldn't be a high risk but it would it would be more than the general public with normal heart function.

Phil Orrell

Okay, thank you. Next question is, my knee is grinding is this something I should be worried about, I’m only 60?

Mr Mark Jones

Yes, knees grind and click and clunk all the time and it's whether they're painful when they do it. A grinding painful knee is different to a normal a non-painful grinding knee and I think if you have a painful knee that grinds then yes you probably should see someone because that grinding could be the start or the even the end of the arthritic picture which is then grinding and causing pain and then we can start treating that and giving you a diagnosis. So, I if it's causing pain the grinding, I would see someone. If it's causing discomfort and and affects your quality of life.

Phil Orrell

Okay, thanks. This person asks what the usual time frame from consultation is to knee replacement?

Mr Mark Jones

So on the Benenden, if you if you're a Benenden Member and you're coming down that route, I think it's it depends on the surgeon's waiting list and obviously every surgeon has a slightly different waiting list in terms of how long you're going to wait for that but I don't think it's any more than three months I don't know the actual numbers actually I don't know if Phil has any numbers but we can always get back to you but the waiting list coordinators here would know and we can always let you know what that wait would be but it's certainly again it depends on the surgeon you've seen and what their waiting list is on when you get done but I don't think it's much more than three months.

Phil Orrell

Okay, this this person's given their name so we can can get back in touch with them with that information.

This person asks, how soon after surgery could I have hydrotherapy?

Mr Mark Jones

So, as long as the wound is healed I don't really have any problem with that kind of management so the womb takes two weeks to heal at the two-week stage you then see your practice nurse and they check that the wound is healed they remove any stitches or clips that need removing and then it probably needs about two more weeks just to let everything mature a little bit more before you sit in a pool but I think around the four to six week stage I wouldn't have any issues of you getting an abort as long as you're wounded healed it covered over there was no scabs and there was no signs that it could get infected by going to a public hydrotherapy pool.

Phil Orrell

All right, thank you. This person asks I had my first steroid injection on the 28th of June just a few days ago, I rested two days as advised, I thought all was positive but disappointed that each day the old pain seems to be creeping back. What do you advise?

Mr Mark Jones

So if you did see initial benefit obviously most steroid injections get given with a local anaesthetic so for the first six to eight hours you will see some benefits that then wears off and then the steroid does take about 48 to 72 hours to to start kicking in but can take up to about a week before it it starts working and I certainly have seen patients who come back and actually say it took me about two weeks before it all started working, so I wouldn't lose too much hope but obviously if it doesn't have any benefit and actually the pain just starts getting worse and worse than I would contact the secretary and see if you can get seen sooner because obviously it's a management option that hasn't worked for you but I’d give it a little bit more time and just see how you're going.

Phil Orrell

Okay, I think we have exhausted all the questions. So, if you'd like to discuss or book your consultation, our Private Patients team is here until 8.30 this evening, or you can call them between 8 and 6pm Monday to Friday.

We're actually offering a discount for joining this session for seven days and the terms are listed on the screen, and you will receive a short survey after this session and obviously we'd be very grateful if you could let us have your feedback on the webinar. Our next webinar will be this time next week and it will be covering hip replacement surgery, so we'd love you to join us for that and you can sign up to that on our website.

All that remains for me to say at this point, on behalf of Mr Mark Jones and the whole team here at Benenden Hospital, I’d like to say thank you very much for joining us this evening and we hope to hear from you very soon. Thank you and goodbye.

Mr Mark Jones

Thank you.