Mr Alex Chipperfield

Good evening, everybody, thank you for coming along today.

My name is Alex Chipperfield, I am an Orthopaedic Surgeon here at Benenden.

I specialise in hip and knee replacement surgery, and I'll be giving you the talk this evening.

Now, this we're trying something new tonight, this is a little bit different from our normal webinar format.

Normally, we spend the first 45 minutes, lecturing you about a particular topic, and then we have a bit of interaction at the end where we discuss questions and answers that arise during the time.

I've always found the Q&A section to be the most interesting and varied and hopefully helpful, so we thought what we would do this time around is focus much more on the Q&A session, rather than me lecturing you about a specific topic.

I've got some slides prepared that I can show, if we don't get any questions, or to help answer whatever questions do come through so please feel free to submit your questions.

There's a Q&A icon at the bottom of the screen, you can ask questions anonymously, or you can put your name as well, just to let you know that the session is being recorded and so the shared names might come up on the screen, and I might talk to you by name, just because it's easier than talking to someone anonymous.

The idea is this will run until about 7 o'clock, so we'll try and get through as many questions as possible, so try and keep them brief if you can, I'll try and keep my answers brief as well, and I'll try not to repeat myself too much.

If off the back of this, or just in general, you're interested in booking a consultation, we'll give you all the contact details at the end of today's session, so that we can so that we can, take things offline further.

Now, what I was planning on starting by was just talking about a few, topics that tend to get tend to get touched upon the most, while we're waiting for questions to come in, but having said that, look at my screen, we've already got plenty of plenty of things to start with, so what I will do is I'll start answering questions and take it from there, really.

So the first one, I'm going to use your name, Daniel, because Daniel, you got in there first, so special shout out to you.

Daniel asks, what is the criteria for a TKR?

So, Daniel, what we're talking about here, when you talk about TKR for everyone else, is a total knee replacement.

So a total knee replacement is surgery, that is performed for end-stage arthritis of the knee.

So, knee arthritis, here we go, there's a nice little video here, that describes what knee arthritis, or what shows what knee arthritis is.

So, here's a knee joint and once we get past the first bit, you'll see so what we're looking at here is the knee joint going into a knee replacement, but what it starts with here we go.

So you've got the knee joint, and the surfaces of the bone are lovely, smooth surfaces and what happens when you get arthritis is that those surfaces wear away and start to become hard and grate and grind instead of moving smoothly.

So the way that we counteract that with a knee replacement is that we make cuts in the bone to fit a knee replacement over it, and you can see the model of the knee replacement up on the screen there.

Obviously, this is a big operation, it involves a hammer and a saw and your leg, it's a permanent, irreversible thing to do.

So, it's a treatment for arthritis, but it's very much the last resort, it's what you do when all other measures fail.

So there's a whole ladder, or spectrum, of treatments for knee arthritis that you would go through before you get to the point where you can't live with it anymore, and it's a knee replacement.

Typically, we start with smaller measures, which are what we call conservative therapy so painkillers, anti-inflammatory medication, exercise, and movement.

Those are the kind of things in the early stages of arthritis that can take a knee that's bothering you and giving you trouble and turning it into one that you can live with.

If or when those simple measures fail, then we start to get more invasive, talking about injections, and I'm sure we will talk more about injections later on in today's session, so I'll just touch briefly on them now.

Essentially, injections are a more powerful way of delivering anti-inflammatory medication directly into the knee joint itself.

If injections fail, or if they work initially, but then start to wear off, then we start talking about surgery.

There are a few smaller procedures that we can do for knees to try and squeeze a bit more life out of a worn-out knee, such as keyhole surgery or joint realignment but ultimately, if all conservative measures have failed, if the smaller operations are either unsuitable or have been tried and you're still struggling, then it's time for knee replacement.

So, in a nutshell, a knee replacement is an operation for a worn-out knee that is symptomatic enough to be dominating your life dominating your life decisions, shrinking your world, stopping you doing from the things that you want to do, and you've tried all other measures, and you're still in trouble that's when it's time to consider knee replacement surgery.

Moving on from that slightly, we've got a question from Andrew here.

What is the process to assess a patient and determine what treatment is needed?

Well, that's where the consultation comes in, so what I suggest that anyone does is come along and see myself or one of my colleagues here at Benenden, who will meet you in the outpatient clinic and go through the whole consultation process.

Typically, what a consultation involves is taking a medical history, which is essentially a conversation.

We talk about what problems you're having, your symptoms and signs, onset, duration, what makes it better, what makes it worse, the kind of the history of the presenting complaint.

Also, when we're talking, we talk more about your general health, we assess your general health, fitness.

Other comorbidities, other medical problems, and that helps in the decision-making process.

If we're talking about surgery, we can decide whether or not it's appropriate for you to have surgery in a private hospital setting such as Benenden.

In addition to the verbal consultation, we would do an examination, which would be a physical examination of the joint in question, whether that be a painful knee or a painful hip so be prepared to be examined, be prepared to have someone look, feel, and move the joint, that is affected.

If it's if you're coming in with a hip problem, please wear underwear, I've had a few patients over the years who haven't, and it's a bit awkward and embarrassing when you're trying to examine someone's hip.

So, make sure you're wearing underwear, make sure you're dressed appropriately, and expecting to have part of your body exposed to have it examined.

The next thing that we would do would be to move on to specialist investigations.

Those are in the world of orthopaedics, those tend to be things like x-rays and scans, whether those be ultrasound scans, or CT scans or MRI scans.

We have the facilities for all of those scans to be performed here at Benenden, but if you have had any scans done recently in hospitals elsewhere, we can get them transferred onto our system here, which saves duplication and makes the whole process a lot smoother.

Once we've taken the history, the examination, and the investigations, then we can talk, as in a shared decision-making process, we can talk about what treatment options are available, what are the risks and benefits, the pros and cons of each of them, and at the end of that, we will come up with a treatment plan that is suited best for you.

Hope that answers your question, Andrew.

Anonymous says, how do I know that the pains I feel in hip or knee is actually arthritis?

Well, from what I've just said, it's my job to distil your symptoms down into a pattern of recognizable clinical signs and symptoms, and along with examining you and taking specialist investigations.

We'll be able to figure out which is coming from your hip, or your back, or your knee, or vice versa so that's all part of the process that happens during that consultation.

Beryl asks, what other medical conditions need consideration before a joint replacement is undergone?

Well, essentially, what we need to look at there is your general health and fitness.

We need to know whether or not it is safe for you to undergo an operation of whatever magnitude we're talking about, in this hospital there are different levels of medical problems that we worry about.

If someone, you know, the majority of my surgery is hip and knee replacements, and the majority of people who have hip and knee replacements are in the later decades of life, 50 plus.

It's not unusual for people over the age of 50 to have other medical issues as well, whether that be heart problems, or kidney problems, or lung problems, or blood pressure, or high cholesterol, or thyroid, you know, the list is endless.

So most people will come in to talk about their hip or their knee with other stable medical comorbidities.

Obviously, they need to be known about, but if they are stable and diagnosed, then the vast majority of those will not, will not prevent you from having elective surgery.

There are some undiagnosed complaints, or some unstable or critical conditions that may limit your suitability for surgery or limit your suitability for surgery within a private hospital and those are the things that will be discussed at your initial consultation and then further.

If we decide that we're going to proceed with surgery, you will then be assessed at the in a clinic called a pre-assessment clinic, which is focused much more on your general health, fitness, suitability for surgery, and optimization for the perioperative period.

Moving on, let's have a look, I've seen a question there's a question here from Raj, Raj asks for my opinion, please, on stem cell therapy for knee arthritis.

I'm conscious that this is a live session, and I'm being professional about this, my opinion on stem cell therapy for knee arthritis is that there is no proven scientific benefit that stem cell therapy gives any long-term relief from arthritis.

There is no evidence that it halts or reverses the arthritic process so my opinion is that if a family member or a friend came to me asking whether or not they should spend a lot of money having one of these treatments on their arthritic joint, my answer would be, in my opinion, no.

I'm not going to say any more than that at this stage, but I'm more than happy to talk at length in different forums.

Okay, we're trying to fit everything in at the moment into the sort of the preoperative stages, so I'm just sort of filtering a few of the questions that we've got.

So, I've got a question here from Robin or a statement, he says, my left knee is basically bone on bone but it isn't causing me huge problems at the moment I walk about 10 kilometres every day.

The consultant I spoke to has said only a full replacement makes sense which seems to him to be overkill.

I was wondering if there was anything I can do to maximise the time I have before to consider surgery?

So Robin, what would we dealing with there, and it's something that we see quite a lot, is there's a big difference between the radiological findings, so the x-ray appearance and reporting of what's going on with a joint, and the level of symptoms that that particular person is experiencing.

Quite often, I will have patients will come to me, and they will say, well, I've had an x-ray, and I've been told I've only got mild arthritis, but why does my knee hurt so badly?

Or the opposite, or in your case, Robin, where you say, well, I've got severe bone-on-bone arthritis, but I can still do everything that I need to get by.

So there's definitely a mismatch and what we're seeing, or what we're talking about here, is that the report of the x-ray is a radiologist or a radiographer sitting in a room in isolation from the patient that it is referring to, reporting on set radiological criteria as to the severity of arthritis whatever joint they're looking at.

So, you're looking at a radiological classification and diagnosis rather than a set of symptoms as to how much it is affecting you.

Generally the x-ray will say, do you know, all I want to see from an x-ray is, do you have arthritis, yes or no?

The severity of the arthritis is not the picture, it's the person, especially with something like bone-on-bone knee arthritis, surgically, your only option is a knee replacement.

Clinically, symptomatically, from the sound of things, if I were you, I would I would, yeah.

I would avoid having surgery, because although the x-rays look bad, you are managing.

Like I said before, the time for you to have an operation is when you can no longer live with the symptoms that you have and if you've tried other treatments, and despite that.

Your quality of life is being significantly affected, your decisions are being clouded by the or dominated by the symptoms that you're getting from the affected joint.

So it doesn't matter what other people are telling you about how bad things look, it's all about how it feels, and functionally how you are and if it doesn't feel too bad, and you're functioning normally, and you can live with it, then do.

Talking myself out of a joint or talking myself out of a job, but there we go.

Moving on now, Pauline has got a, she asks, why are partial knee replacements done?

So time to get the props out, what I've got here, I've got a knee.

So this is someone's knee, and a knee joint is a single entity, but what you can do is you can divide it up into three separate areas.

Oops, the kneecap bit at the front, the medial compartment, and the lateral compartment and when you get arthritis, particularly in a knee, you can be in a situation where only one of the particular parts of that knee is worn out.

A total knee replacement, we showed you the video earlier.

Here's a model, a total knee replacement replaces all of the joint surfaces involved in a knee so the entirety of the end of the femur and the entirety of the top of the tibia.

If you are a person whose disease is simply isolated to the, say, the medial compartment of the knee, the inside part of your knee, then it would seem that you're throwing the baby out with the bathwater if you're sawing away the rest of the knee joint, just to deal with one isolated area.

So what you can do instead, you can do a partial knee replacement so here's a partial knee replacement, this is a medial unicompartmental knee replacement.

So what has happened here is that only the inside part of the knee has been replaced with a bit of metal on each side of the joint and a bit of plastic in between.

The lateral side, the outside part of the knee, is still you, and the kneecap joint, which has disappeared for the sake of ease, is also still you.

So partial replacements are done when only a single part of the knee joint is worn out the advantage of a partial knee replacement is that it's slightly less of an operation.

It still involves a hammer and a saw, but it's less of surgery than a full knee replacement but it's more importantly, you leave two-thirds of a natural or normal knee joint behind.

People who have a partial joint replacement tend to report that after surgery, once all the dust has settled, their joint replacement, their joint itself feels a bit more natural, a bit more normal, and a bit less artificial.

One of the issues that people tend to get with knee replacements in particular is that although they feel good, and they're very good at getting rid of pain and allow you to get back to most functions.

If you ask people, does it feel normal or natural, quite a lot of people will say, no, it feels artificial, you get less of an artificial feeling with a partial replacement rather than a full.

Not everyone is suitable for a partial knee replacement, you have to be properly assessed, prior to the surgery and also during the surgery to make sure it's the right thing for you, but it is an option in isolated single compartment disease.

The disadvantage of a pastoral knee replacement is that it may well be that later down the line the process that's occurred in one part of your knee that's led you to have that part replaced will occur in the rest of the knee joint as well.

Like I said, it is one joint, just one part of it is worn the rest of the knee can wear out later down the line.

You can get progressive degenerative change that affects the other part of the knee, and so you might end up in a position where you end up having to have your partial knee replacement removed, and a total knee replacement put in and what we do know from studying the results of partial knee replacements, full knee replacements, and conversions of partial to full knee replacements.

The results of conversion to partial, conversion of partial to full knee replacements aren't quite as good as primary partial primary full knee replacements.

Sounds better in my head rather than when I say it, but like I say, we can talk more about that in a consultation if needs be so I hope that answers your question about that Pauline.

Moving on from that, we do have a sort of a supplementary one from Paul, Paul says, I suffered an ACL injury 46 years ago and managed to avoid surgery so far but is it possible to avoid a partial or total knee replacement altogether.

So, an ACL injury is a cruciate anterior cruciate ligament injury.

The anterior cruciate ligament is one of these pink things that sits right in the middle of the knee, and its job is to stabilize the knee joint and stop it from abnormal movements.

If you've been walking around with a knee that has that has been ACL deficient for the last 46 years, the chances are that you will have developed some arthritis in your knee as a consequence of that.

Whether or not you end up needing an operation, like I've said, is down to you.

If your symptoms are bad enough, and you cannot live with your knee, then I would suggest that you start thinking about surgery.

You don't have to have surgery, but it's an option for you if you're struggling with the knee that you've got.

The reason this is a follow-on from partial knee replacements is that one of the criteria for people to safely have a partial knee replacement, particularly a medial unicompartmental knee replacement, this one as you can see on the model of this knee replacement, partial knee replacement, the cruciate ligaments in the middle of the knee are still intact.

So, generally, it's agreed that in order for you to be suitable for a partial knee replacement, you have to have a functioning cruciate ligament.

So if you don't have a functioning cruciate ligament, then you wouldn't be suitable for a partial knee replacement.

So in your case, Paul, 46 years post-ACL injury, if you are thinking about joint replacement, it will most likely end up being a full knee replacement.

I've got a couple of questions about injections, I've got three, three in a line here, one from Anne, one from June, and one from Beata, I think that's how you spell it, well say it and they're all about injections, so I think we'll I'm going to start talking about some injections.

June is the easiest question to answer, so I'll start with that one.

June says, I've heard of steroid injections for knee pain, but is there an equivalent for hip?

The answer to that is, yes, there is an equivalent, it's called a steroid injection.

So, yes, steroid injections, are commonly done into large joints with arthritis in them, and whether that be a hip joint or a knee joint.

Steroid the way that steroids, or the way that all injections work, is that they are anti-inflammatory injections.

So part of the disease process when you get arthritis, is that you develop inflammation of the lining and of the structures that surround that worn-out knee and steroid injections, or all injections, work by calming down the inflammation that is wrapped around that joint.

Now I would say I spend half my life dealing with people's knees, half my life dealing with people's hips.

Injections into knees tend to be a lot more common than injection into hips and the reason for that is it's a simpler process.

Injections into knees, on the whole, we'll talk about one exception to that, but on the whole, injections into knees, we do in the outpatient clinic.

So, your knee joint is a joint that is very accessible, it's close to the surface, it's easy to get to, and it's easy for me to inject whatever substance I would like into your knee joint in a clinic situation without any fuss, without any need for any other specialist equipment or any drugs, any other drugs going into you.

Your hip joint, however, is very deep inside your body, in order to inject steroid or other anti-inflammatories into the hip joint, I need a needle that's about that long and I need you to lie very still while I put a needle that long directly into your hip joint.

People tend to wriggle when you do that in the outpatient setting, so hip injections are done under either heavy sedation or full anaesthetic in an operating theatre, and in order to guide the needle deep into the hip joint into the right place, I use an x-ray machine as well.

So, rather than doing something in five minutes on the couch in the clinic, injecting someone's hip is a much more involved procedure that involves you coming into hospital for the morning or the afternoon, you go to sleep, and I inject your hip joint in the operating theatre.

So, yes, it is possible, and we can inject anti-inflammatory steroids, or cortisone, or lubricant gels into your hip joint but it takes a bit more than with the knee joint.

So that's the first question, I said that was the easy one, and I went on talking about it for a while, so I'm sorry.

Next one is from Anne, who says, I've had several hyaluronic injections on my knee, which have worked brilliantly.

The last one left me in agony for around four weeks, should I risk another one?

So, I've mentioned steroid injections into the knee or the hip, steroid is one of the anti-inflammatory things that you can inject into people's bodies.

The problem with steroid is that number one, they're short acting, so they wear off and number two is that there are side effects associated with steroids themselves.

They're very powerful anti-inflammatories, but they have other powerful effects on the body as well and people can get symptoms and side effects from steroid injections, from multiple steroid injections.

Ranging from small things like brief changes in mood, or pain associated with it, to worse things like trouble with their blood sugars going out of control, or brittle bones, or developing problems with hormones or skin.

Having multiple high doses of steroid isn't a good thing, so other anti-inflammatory injections could be considered as well, and one of those is the one that Anne has mentioned, something called hyaluronic acid.

So, hyaluronic acid has lots of different trade names, which you may have heard of the typical ones are things like Durolane, Octenyl, Monovisc, Synvisc.

All of these things, if you read the packets, they're all this thing called hyaluronic acid.

So, hyaluronic acid is another type of anti-inflammatory that you can inject into someone's joint.

It only has an effect on the environment within the joint, so you don't get the systemic side effects that you can get with steroids, so they're a good alternative to steroids.

Again, they tend to provide short- to medium-term relief, they don't they tend to last for weeks and months, not years but because they don't have any other side effects on the rest of you, they are things that can be repeated.

They do still have side effects, and most of those side effects are localized, so you can get pain around the injection site, you can get infections, you can get bleeding in and around the joint that's being pierced with the needle and you can get a localized inflammatory response, what's called a synovitis or inflammation.

So, perversely, an injection designed to try and alleviate inflammation can sometimes aggravate and provoke it and it sounds to me, Anne, that that's probably what happened to you with your last injection.

Just because it happened once doesn't necessarily mean it could happen again but it might do.

So, you're not more likely to develop that reaction next time around, but it might be worth finding out the brand that you had, and switching brands, or, dare I say, having an injection by a different person the next time around.

So changing what is injected, or who or how injects it, may well change things up a bit, so that's Anne, that's your question.

Then, Bhatia, who's name I couldn't pronounce, and I still hadn't, asks about the different type of injection.

Here we go, I've got arthritis in both knees, had Austenil, which is one of the hyaluronic acid injections but this time, it didn't help as before.

I'm on the waiting list for a steroid injection, that's another one we talked about and then she goes on to do the interesting bit.

There is a drug advertised called Arthrosomething, are they better than Austenil? NHS won't touch me.

Sometimes the pain is so bad, I want to chop my legs off.

Well, that's horrible and hopefully we can avoid that.

So, the arthro-something is Arthrosamid® and Arthrosamid®.

Was one of the things that, I was prepared to talk about if we didn't have any questions, because Arthrosamid® is a new treatment for arthritis in the knees, and it is incredibly popular.

I've been sitting, talking to people in clinic all day, I've seen 28 patients today in my clinic, and at least half of them I've spoken to about Arthrosamid® in some way, shape, or form.

It's incredibly popular so like I said at the beginning, when I started talking about injections, all injections are anti-inflammatory agents of some description.

What differs between the different anti-inflammatories is their mechanism of action their duration of action, and the side effects that they have and essentially, What you want from an injection is one that is effective.

One that is long-lasting, with minimal side effects and of all the injection options that we have currently available, Arthrosamid® is the one that ticks most of those boxes.

So, Arthrosamid® is different from other forms of injection in that once you inject it into someone's knee, it remains there permanently and the way it does that is it binds with the lining of the knee joint, it calms down that inflammatory response, and it locks it in, and it prevents the lining of the joint getting angry and inflamed anymore and like I say, it's the only injectable that has that effect that is permanently within the knee once it's there.

So, that has the effect of minimizing, or reducing, or in some cases, eliminating the inflammatory response that people have around an arthritic knee and that will vastly decrease the symptoms coming from an inflamed, worn-out knee.

It's slightly different in that it takes a bit of time to work the mechanism of action is different.

Like I said, it binds with the lining, It's not an it's not a chemical, drug, as such, it's a mechanical thing that binds and takes time to work.

So, a chemical drug, like a steroid, works as it gets absorbed into the lining, and it works within hours, days, but it wears off very quickly.

Arthrosamid® takes time to build up to full effect, although some people feel benefit within a few days or weeks it can take up to 3 months before you get the full effect.

So it does take longer to kick in, but once it is there, it's there, and, you know, the evidence that we've got at the moment is that if it gives you relief, it will give you relief for years.

I'm the reason I talk to so many people about Arthrosamid® is, from what I've said, it sounds too good to be true, you know.

An injection that you have once, that lasts forever, that means you can avoid having a knee replacement sounds brilliant.

In some people, that is genuinely the case, but the problem is that Arthrosamid is not suitable for everyone.

Like I said, it's anti-inflammatory, it works on the lining of the joint, it does nothing to this stuff.

So all the bits that you can see on this model, the articular surfaces, the bones, that move and support and form your knee joint are not affected by injections.

Everything about the everything that's affected by the ejection is the things that are wrapped around the knee getting angry and inflamed.

So if you're one of those people that has arthritis of the knee, who doesn't have a lot of inflammatory symptoms or inflammatory signs, then there's not very much for an injection of whatever kind to be effective on.

So, first thing people ask is if they're suitable for an Arthrosamid® injection, well people who respond well to injections tend to respond well to Arthrosamid® injection.

So if you've had a good response in the past to either a steroid or a hyaluronic acid injection, then it may well be that you're suitable for Arthrosamid® if you've got severe advanced arthritis with no inflammatory symptoms, then you're not going to be suitable.

Consultation, physical findings, examination, that's the way we find that out, that's a brief bit on our throws mid.

Hopefully, that will answer a few questions about that.

Moving on now, Andrea has got a question.

I'm trying to find a nice picture, here we go, knee replacements, here we go.

Andrea asks, what happens if you have a nickel allergy?

So this is a picture of a knee replacement, and you can see that the majority of knee replacements, the majority of the implant this stuff is made of metal and typically, the metals that are used in knee replacements are alloys of cobalt chrome and one of the metals that form part of that alloy, that mixture that forms the metal that goes into your knee, is trace elements of nickel and there are some people who have an allergy or an intolerance to nickel.

The way you would know that is if you get irritated by costume jewellery or, you know, that kind of thing.

If you have a surface reaction to some metals, then it may be that you have a nickel allergy.

If that is proven by going through allergy testing, then, it's advisable that if you're having a joint replacement, you have you avoid one that has nickel elements to it.

So, there are knee replacements that are manufactured, that do not contain nickel, and in people with proven nickel allergies, or people who have, a response to certain metals, then we can proceed with a nickel-free implant.

The reason we don't do that with all patients is that nickel-free implants are incredibly expensive, they're much more expensive than standard implants.

There is no advantage in a nickel-free implant over a normal implant unless you are intolerant of nickel.

So, it's not standard practice, but we have them, and they are available, and it is something that can be done for people with a proven nickel allergy.

I've got two questions, they're both from June, actually, they're both two sides of the same coin.

They're talking about hip replacements here and what June asks is, what are the downsides of hip replacements? But then she also asks, what are the success rates of hip replacement?

So I'll answer them both, let's find a picture of a hip replacement that I can use While we're talking about it.

Hip replacement, where are you? Up top, here we go.

So here's a couple of hip replacements, there are lots of different types of hip replacements, these are different brands and different design philosophies behind them, but essentially a hip replacement, like a knee replacement, is when you replace the articulating surfaces that are worn out and diseased because of arthritis or trauma or another condition.

Essentially, a hip replacement is a ball and socket, rather than sliding surfaces that glide over each other, such as a knee, but that's the design.

Hip replacement is the second most successful operation that people can have from a quality-of-life point of view, the impact it has on someone's life in a positive way.

Like I say, it's the second-best operation that you can have, the best operation that you can have, as far as life-changing goes, is cataract surgery, also provided by Benenden, get in touch if you want one, not performed by me.

Cataract surgery, being blind and then being able to see, and having all that done under local anaesthetic as a walk-in, walk-out procedure is a neat trick.

Next, down on the list, as far as satisfaction goes, is hip replacement.

So, June, what's the success rate of hip replacement?

The overwhelming majority of people who have a hip replacement are absolutely delighted.

It gets rid of their pain, it changes people's lives for the better, it stops you feeling old, it stops you being limited, and it opens up your life again and the majority and the great thing about hip replacement is that it's reliable, dependable, and the results you get are instant.

People, day the same day of surgery, or the day after, say their pain is gone, and they feel better already.

It's really incredible to be able to do it, and to see the impact it has on people but You ask also, what are the downsides.

It's an invasive procedure, it's a big operation, it involves a hammer and a saw and your leg.

There are risks associated with the surgical process, and there are risks that you can problems that you can develop afterwards as well and not everyone who has a hip replacement is delighted with it.

Fortunately, adverse events are very few and far between, but they do happen, and complications are real and can be horrible for people who go through them.

We do everything in our power before and during an operation to make sure that the process runs as smoothly as possible and is as risks are as minimal as possible but despite that, things can go wrong.

Bad things can happen, the headline kind of risks that people can develop following joint replacement, hip replacement in particular.

Bleeding, you can lose blood, blood clots, you can get a blood clot either in your legs or in your lungs.

Plot clots in your legs are an inconvenience, can be painful, can be troublesome, but not life-threatening blood clots in your lungs can be life-threatening, so a lot of what we do before and during and after an operation is designed to minimize the risk of blood clots.

The anaesthetic you have, the way that you're brought the way that you're mobilized, the drugs that you're given after surgery are all designed to minimize the risk of blood clots, but you can still develop them.

Infection, infection is an absolute disaster, if someone gets an infection deep within an artificial joint, that often means multiple further operations.

It can mean that you have to remove the infected joint.

Leave someone without a joint for a while and then go back in and replace everything.

Revision surgery for deep infection around a knee replacement or a hip replacement is horrible.

We operate in sterile environments, we give you high doses of antibiotics, I wear a spacesuit when I operate to prevent the risk of contamination, we make sure that you're not bringing any bugs into hospital with you but there are, you know, infections still happen.

The infection rate at Benenden is significantly lower than the national average but infections can still happen, and when they do, they can be a catastrophe.

Broken bones, damaged nerves, all of these things can and have happened, can happen again.

Dislocation is something that is more common in hip replacements than knee replacements, but knee replacements, in particular partial knee replacements, they can dislocate too.

Dislocation is when the joint comes out of socket and again, if patient has a dislocation, it can be painful, a terrifying experience.

Most of the time, if it's done if it happens early on, it can be dealt with by relocating the joint and nothing further, but some people end up having to have furthermore invasive surgery, and again, that can be a horrible thing to go through.

So all of these things can happen, have happened, and will happen again if you want me to put you off having a hip replacement, I can, and I will.

But all of these risks are real, but small.

The overwhelming benefit for the majority of people is far better than the risks far outweighs the risks.

So, it's a great operation, works very well, but it's not without problems, I don't want to talk more about them because, you know, I'm meant to be talking about happy things, not bad things.

Gillian asks, I've been told I have osteophytes, will these be removed when I have my hip replacement?

So, osteophytes are little spurs of bone that form around a diseased arthritic joint.

I'm seeing if I can here we go the picture of the arthritic hip doesn't actually show any osteophytes.

Let's see if we've got a picture of an arthritic knee, nothing's just coming up in to my immediate view, so I'm sorry about that.

Osteophytes are little spurs and rims and ledges of bone that form around a diseased joint.

It's a body's defence mechanism to try and share the load in a painful joint.

Typically, osteophytes tend to interfere to some degree with the function, movement, flexibility of a joint, and they are one of the first things that you remove when you're performing a joint replacement in order for the replaced joint to be able to move and function as normally as possible.

So the answer to that is if an osteophyte is interfering with the function of the joint, they will be removed.

I'm conscious of the time, I've been talking a lot and we're coming into almost the last well, we're in the last 15 minutes, so I'm going to try and go through,

Let's have a look at what I can talk about a thing that I often get asked a lot, hopefully this is a quick answer, a baker's cyst.

Trevor asks, is a Baker's cyst a byproduct of osteoarthritis?

Short answer, yes.

So people come to me saying that they've got a diagnosis of a Baker's cyst, I tell them they don't have the Baker's cyst is not a diagnosis.

A Baker's cyst is a sign or a symptom of something happening with a knee joint.

So what a Baker's cyst is, is when you get a swelling that is filled with fluid that bulges out the back of the knee.

Everyone's knee is lubricated by fluid, that fluid is produced and absorbed by the lining of the knee joint.

If your knee is upset, angry, irritated, inflamed, then your body's response is to produce more fluid.

So you get a buildup of fluid inside someone's knee joint, and that fluid builds up, and the pressure builds up and up and up, and everything gets very tight and stiff and swollen and painful.

One of the release mechanisms is that there's a weak spot in the back of the knee joint, and that fluid can build up and then get forced out the back of the knee.

When it gets forced out of the back of the knee, it's called a Baker's cyst so a Baker's cyst is a sign of a problem with the underlying joint itself.

The commonest cause of Baker's cysts is arthritis in the knee joint, but there are other causes that can cause it as well.

So it's best to have your knee investigated for what is causing the Baker's cyst it may well be arthritis, but it could be something else as well.

A couple of questions, one from Andrew, one from Shirley, how long do replacement knees last, and typically, how long will a knee replacement last?

So two birds with one stone here, joint replacements in general last an incredibly long time.

In the old days, in the 60s, 70s, 80s, when hip replacements and knee replacements were in their infancy, when the materials that they used were fairly basic.

One of the main reasons for people to end up needing further surgery on a joint replacement is because the bits wore out.

Typically, what you talk about with a knee is it may well be that the plastic in between the two bits of metal, that plastic, that polythene, used to wear out, and you'd end up needing to replace a joint.

Something interesting has happened in the last decade or so within the advent of better materials of friendlier, couplings, or the advent of bio ceramics, better plastics, different contours, and shapes of the implants.

What you found find now is that implants wearing out is no longer the commonest reason why people might need surgery on an artificial joint.

So yes, things can still wear out, but it's much less likely so these days the combination of other is a lot more than some, something wearing out.

So the other could be things that I've touched on, like broken bones, dislocation, infection, progression of arthritis, other symptoms.

I mean, all these other instability other indications could mean that you end up needing further surgery on a joint replacement in your lifetime, it wearing out can still happen, but it's a lot less common.

People who have a knee replacement or a hip replacement in their mid to late 60s, which is kind of the average age for people to have this kind of surgery.

you can pretty confidently say that the chances are, if they end up needing another operation, it's not because things are wearing out, it will be for another reason.

So, people in their seventh decade, if you have a modern joint replacement done well, and you don't get any complications, chances are it'll last you the rest of your life.

We're into the final 10 minutes, let's see if we've got, here we go, this is the bit I was dreading.

I didn't want this presentation to be everyone just sitting here watching me scrolling through questions so I'm sorry about that.

One thing here we go anonymous here, oh no, there was one anonymous, we've got another one here, Andrea as well, so I've got Andrea, and I've got an anonymous, so I've got more than one person, which gives me a good thing to talk about.

Andrea asks, what is the advantage of a robot-assisted knee replacement?

One of the other things that I commonly talk about in these kind of talks is robotic-assisted knee replacement.

So, let's spend the last 10 minutes talking about that so there's a picture of me looking happy, leaning on ROSA.

ROSA stands for Robotic Surgical Assistant.

So, ROSA is the machine, the robot, that I use when I'm performing robotic-assisted knee replacements.

So, when you perform a knee replacement what you have to do before you put the implant in is you have to make cuts in the bone, and those cuts in the bone have to perfectly fit

the implant so that everything goes into place so these cuts need to be the right size and depth and angle to give you the best fit with your implant to give you the best functioning knee replacement, to give you the best results when it comes to function, satisfaction, pain relief, and longevity and there are lots of tools that you use when you're performing a knee replacement in order to make things as accurate as possible.

ROSA, robotic assisted surgery, is another tool that we use to enhance the accuracy, when we're when we're doing a knee replacement.

So, when you have a knee replacement here at Benenden, regardless of whether you have a robotic-assisted or a conventionally performed knee replacement, you end up with the same implant done by the same surgeon.

This bit, this is the same, the difference with a ROSA is the tools that I use when I'm doing the operation.

So, robotic-assisted knee replacement, essentially what happens is, during the operation, I map out you’re the three-dimensional anatomy and range of movement and stability of your knee replacement of your knee, while I'm doing the surgery.

That data is then fed in real time into the robot and the computer, which then guides the robot to place those cutting blocks that then I use to make the cuts in the bone in the most appropriate ways to accurately improve the stability, the range of movement, the placement of your knee replacement.

Once that is done, the other part of the robotic system is that you then assess that stability, that movement, that function, before you then go to implant the definitive implant.

So, it's real-time assessment, planning, execution, and feedback that you get there are many more data points that you get with robotic assisted rather than conventional knee replacements.

The theory with that, is, that you get the best possible accuracy and alignment of the implant.

It's slightly less invasive, as in, some of the tools that you use with a conventional knee replacement mean that you have to make slightly bigger cuts or drill into bones that you don't have to do with a robotic knee.

So there's theoretically less pain, better stability, quicker recovery, it's still a painful operation, regardless of whether or not you have a robot but the recovery what I've found since we've started so, we use robotic-assisted knee replacements here, probably in about 10% of the knee replacements that we do.

Of the robotic-assisted knee replacements that have happened here, I've done about half of them so I've done lots of these here, I know what I'm doing, and I'm comfortable and happy using the robotic assistant.

At the beginning, I was a little bit sceptical about the benefits, I thought, well, what can a robot teach me? I do thousands I've done, you know, tens of thousands of knee replacements in my lifetime.

I do hundreds every year, and I've been doing that for decades what can this new machine teach me that I don't know already? But the answer is it, you know I tend to see people with robotic-assisted knee replacements, in the early stages, they tend to do better.

So, they recover a little bit faster, a little bit quicker, they reach their milestones a little bit earlier on.

So, I definitely see an improvement in patients, in their function, pain and movement.

In the first two to three months, people with a robotic-assisted knee replacement tend to do a little bit better a little bit earlier.

Whether that translates into longevity of an implant, whether that means that your knee replacement will last 25 years instead of 22 years, only time will tell.

Robotic surgery hasn't been around long enough to be able to give you scientific evidence from that, but in my experience, With a robotic knee replacement, people do seem to get better a bit quicker.

So it is an option here it's not available to everyone, there are certain inclusion and exclusion criteria with robotic surgery.

There's some conditions, some particular problems that you can have with an arthritic knee that mean that robotic-assisted surgery is not suitable for you, it's not available for NHS-funded patients here.

It is more expensive than conventional knee replacements, so it does come at a premium as far as price goes, but it certainly is an option, and please feel free to come and talk about that in a consultation with me at some point down the line.

I've got one minute left, I'm going to scroll right through to the end of the questions, and I'm going to see if there are any questions that are unusual, or that I haven't you know, I want a question that no one's ever asked me before, so let's see if I can find any of those.

I've got one question here, could you comment on plate-rich plasma injections?

I refer you to my earlier answer on stem cell injections, in that platelet-rich plasma injections for the treatment of arthritis in a hip or a knee joint, I wouldn't recommend it.

No scientific evidence to suggest that that'll give you any long-term relief.

Is Arthrosamid® a very advanced type of Flexi, which I find does help my knees? No, Arthrosamid Flexi is a I believe it's a cream that you can buy that you can rub on that can help people in the early stages of arthritis and with pain and inflammation.

Arthrosamid® is, a, like I said before, it's a permanent, implant that binds with the inside lining of your knee joint and calms down the inflammation so no, it's not.

It works in a completely different way, and has a much more robust scientific, body of evidence behind it.

I've answered that one about robots and my last one is going to be Heather Carter, because Heather says, if you have severe Paget's disease in your knee, is there any point in having Durolane injections twice, if twice worked, but not the third time?

Padgett's disease is a metabolic disease of bone that affects the actual structure and makeup of the bone itself.

Paget's disease doesn't normally affect the joint, so people with Padgett's disease aren't more or less likely to develop arthritis, but people with Paget's disease can develop arthritis.

If you have Paget's disease and arthritis the joint replacement surgery can be more difficult, riskier, because that Paget's disease means that your bone can be harder, perversely harder, and softer at the same time.

It can be more vascular, so the you can the operation itself to replace a worn-out joint is more difficult, and there are particular risks involved.

So it's nice to think of alternatives to joint replacement if you have Paget's disease.

One of those alternatives that we've already mentioned, hyaluronic acid, Durolane is one of the trade names of hyaluronic acid.

So, Heather asks, is there any point in having Durolane injections if twice worked, but not the third time? The answer to that is yes and no.

The Padgett's part is irrelevant, the fact that it hasn't worked the last time is more relevant.

There comes a point in the natural history of arthritis disease when it doesn't when injections don't work anymore, when either you don't have much of an inflammatory element, or the mechanical problems caused by the worn-out joint dominate the inflammatory side of things.

So it may well be that having had a treatment that worked in the past that no longer is working, it may well be that it's time to think about the next level of treatment.

So I would suggest a consultation to see and discuss how you are down that level.

I've overrun my time, I'm sorry I can thank you for all the questions and the interaction.

Like I said, this is my favourite part of the talks, hopefully you found that useful, that we've, you know, been able to, sort of jump and skip from one topic to another.

I found it interesting, and hopefully you will the same, if I haven't got to you, I'm sorry.

If you do feedback that this is a useful thing, then it may well be a format that we use more of in the future.

If there's a particular question, that hasn't been answered today that you would like to answer, well take advantage.

So, what we have here I can move on to my final slide here, if I can get my mouse to work.

Here we go so here is the offer as a thank you for attending this, this webinar, if we haven't covered your questions, and you provide a name, we can follow things up with email.

If you would like to come and see me or someone like me, I'm not the only person who works here, then you get 50% off the value of your consultation for a limited time.

So if you ring up the private patient's advisors, they'll be able to guide you through that process.

There are people here manning the phones for the next 55 minutes tonight, if not, you can ring up between, you know, in working hours, Monday to Friday, to book your appointment and discuss and take things further.

I mentioned cataracts as, as part of my, my talk, there's a range of other treatments and procedures that are provided here at Benenden.

The webinar series is not just talking about hips and knees, there are other things, upcoming topics that you might be interested in.

hand surgery, varicose veins, liver disease, there's eye surgery, there's, there's prostate surgery, there's urology, there's gynaecology.

There's a rolling program, so it may well be that something piques your interest.

Please dip into the webinar archive that we have on our website and also keep an eye out for further events as they come up.

That's my PR bit done as well, my corporate responsibility, I think, is done.

Once again, thank you all for joining me tonight, hopefully you found some answers helpful.

If you'd like to talk further, you know where I am, I'm always happy to talk at length, for anything that you might want to talk about but on behalf of all of us here at Benenden tonight, thanks for coming along, hopefully you found it useful.

I'm going to end the session now, but please feel free to follow up via any of the routes that we've, gone through, so that's it from me but If I can I might ask Oli to end the session now.

See you again soon.