Damien

Okay, so good evening, everyone, and welcome to our webinar on treatment for hip and knee osteoarthritis.

Now my name is Damien, and I'll be hosting this session, and this evening I'm joined by our presenter, Mr Alex Chipperfield, Consultant Orthopaedic Surgeon.

Now this presentation will be followed by a question and answer session. If you'd like to ask a question during or after the presentation, you can do so using the Q&A icon, which is at the bottom of your screens.

Now this can be done with or without giving your name. But please note that the session is being recorded. If you do provide your name.

If you'd like to book your consultation, we'll provide pricing and contact details at the end of the session. So I'll now hand you over to Mr Chipperfield, and you'll hear from me shortly. Over to you.

Mr Alex Chipperfield

Thanks, Damien.

Good evening, everyone.

As Damian said. My name is Alex Chipperfield. I'm an orthopaedic Surgeon here at Benenden Hospital. I have been a doctor for knocking on 30 years now, and I specialize in hip and knee replacements. I spend about half my time replacing people's hips and half my time knees.

So this talk, when we're talking about both of them works quite nicely for me.

A little bit about my background. I studied medicine in London. I qualified in 1997. I then trained in orthopaedic surgery in the South East of England, and then performed a fellowship in Sydney, Australia. I came back in 2010 and started as a consultant in East Kent, where I've been working ever since.

I've been working here at Benenden for the last 13 years, and not only am I a Surgeon here, but I'm also now the medical director here, as I said, I specialize in primary and revision, hip and knee replacements.

Forgive me tonight if I sound a bit muffled. I'm just getting over a cold, so I'm sorry about that.

Moving on, what we're going to talk about in this session. We're going to talk a little bit about the consultation and assessment that you would go through when you come and see someone, me or someone like me here at Benenden.

I'll then talk about hip arthritis, the diagnosis and treatment of that. Then I'll do the same with knee arthritis as well.

We'll move on. We'll talk about general things, about risks and recovery and patient decisions, support tools, and then there'll be an opportunity for a question and answer session at the end.

As Damien said, if you if you click on the Q&A icon, you can enter in a question whenever you want, they will pop up on the screen. If anything comes through that I can answer immediately. That doesn't interrupt the flow. I will do so.

If not, then we'll discuss things at the end of the talk so hopefully you'll find what I've got to say interesting or useful to a degree.

So starting with what happens when you, when you first come to see me or one of my colleagues here at Benenden?

Well, initially, what we have is an outpatient consultation and in that in that consultation we will or I will take your medical history, listen to your symptoms and the signs and the things that have brought you there today.

I'll then examine the affected area of the body, whether that be the hip or the knee or both. We'll look at the range of movement, the function, the strength of that limb.

We will do some basic investigations, such as X-rays. If you haven't had any X-rays done prior to our meeting. If you have, or if you've had some scans, then we will go through those. We will talk about what those X-rays and scans show.

Off the back of that we'll come up with a diagnosis, and we'll devise a treatment plan. Whether that be surgical or not. We'll talk about what your different options are to deal with the problem that you've come with.

From the end of that we may well be talking about an operation, and we'll briefly talk about whether or not it's safe or appropriate for you to undergo that kind of surgery in an institution like this.

So it's more, it's getting to know each other. It's diagnostics. It's coming up with a plan and talking about whether or not you want to go through with that plan.

Starting with hip arthritis, just to give you a brief overview of what is hip arthritis. Well, it's when the hip joint the ball and socket joint at the top of the leg. When that starts to wear out or degrade or disintegrate, or gets injured in some way.

As a result of that, the commonest symptoms that people get tend to be pain, loss of movement, and loss of function.

Now, pain related to hip joints very classically tends to be pain, that you feel right in the front of the hip in the groin.

In the early days, and especially in younger, more active people, they tend to misdiagnose themselves as having a groin strain or a persistent muscle injury that won't go away when really the underlying problem is the joint underneath that's beginning to wear out.

So you can get groin pain. You can get pain in the lateral thigh, or radiating round into the buttock as well. That pain can also radiate down the thigh bone into the knee, and it's not unusual for people with hip arthritis to only present with pain lower down in their leg in their knee.

Along with that pain, people notice stiffness and loss of function in that hip.

The early signs that people would get when it comes to loss of function, of a hip joint would be difficulty getting down to your shoes and socks, so, tying your shoelaces, putting your socks on cutting your toenails, that kind of thing can be difficult, and a struggle in the early stages.

Lifting your leg to get into a car can be a struggle or getting up onto bed that can cause a pain as well.

Along with stiffness and pain you can get grating and grinding and clicking sensations in a joint. They tend to be fairly late on when it comes to hips.

When you can start to feel a hip grinding and grating. It's a fairly, you know, far gone hip joint.

You may notice that functional things like walking distance decrease. You may also notice that your sleep is being disturbed, and when you start to get pain when you're not doing anything rather than pain with extreme activities, that's the time when you really need to start seeking help.

What happens at a very basic level. Your hip joint is a ball and socket joint, and that ball you have a lovely, smooth ball that glides effortlessly in a smooth socket, essentially with arthritis, those smooth surfaces start to deteriorate and degenerate, and they become rough, so, instead of gliding, they catch and grate and grind and creak and seize up.

Not only do you get that, but then you also get inflammation of all the tissues that surround the hip joint or the knee joint, so the lining of the joint gets very inflamed and angry.

You get a lot of extra fluid that can be produced as well, and that can lead to pain and stiffness and swelling around the joint.

Treatment options, so typically once a degenerative process has started, once a joint is worn out, that process, you can't stop it. What you can do is try and mitigate it, to try and find ways to live with the symptoms that you have.

So if your number one symptom is pain, then, taking medication to alleviate that pain will be a first logical step. So, taking painkillers, whether they be anti-inflammatories, such as Nurofen or ibuprofen, or painkillers, such as paracetamol or codeine.

They can. They can help take the edge off things, allow you to get a good night's sleep, or to get around a round of golf, or to do whatever you need to do without too much intrusion from your painful joint.

You can talk about lifestyle modifications, really I'm not really keen on that telling people to slow down or stop doing the things that they enjoy doing. Well, what's the point of living? In that case, you know, the whole point of a joint is to allow you to move.

Joints are stimulated by movement and kept healthy by exercise, so restricting your movement or stopping your exercise, will just compound the situation rather than make things better.

So lifestyle modifications, such as changing your footwear or using a stick to walk is one thing, stopping doing the things you enjoy doing in order to avoid surgery. That's a decision that I wouldn't necessarily suggest that you should make.

Physiotherapy has a role, especially in keeping muscle, strength, and flexibility and movement, and allowing you to make the best of a worn out joint physiotherapy again can help you live with what you've got. It will not grow you a new joint, but it will make the best of the one that you do have.

You can consider injections into hip joints as well as knee joints. We'll talk more about injections when we talk about knees. You can do injections into hip joints.

Typically, that will be a steroid injection to calm down the inflammation around the hip joint. It can be useful, in the short, to medium term not a permanent or long term solution to problems.

Ultimately if you cannot live with your symptoms or find any other way to deal with them, you're looking at surgery, and the main form of surgery that you'd be looking at would be hip replacement.

The slide mentions hip fusion. Fusion is an operation of the past. Really it was a salvage operation for young people who were too young for hip replacements in the days when hip replacements didn't last long enough or weren't good enough.

These days it's an operation that you never see so ultimately. You're looking at joint replacement surgery.

As I mentioned earlier, your hip is two bones. When they articulate against each other. You've got the ball, which is the top of the thigh bone. You've got the socket, which is the part of the pelvis that it articulates with a hip.

Replacement replaces both of those elements. So you refashion the socket and you replace it with a metal shell that has a lining inside the ball. You replace that ball with an artificial ball that is affixed to a stem that sits down inside the thigh bone as the as the picture demonstrates.

So there are four components to your hip replacement. You've got the shell and the lining of the shell that make up the socket. You've got the ball and the stem that make up the femur side.

The aim of the surgery is to get rid of your pain, to restore your movement and function, and improve your ability to live your life and enjoy the life, and get back to doing the things that you want to do.

There are lots of different types, brands of hip replacements. There are lots of different materials that your hip replacements can be made of essentially, what we do is we would recommend the most suitable hip replacement for you, for your lifestyle, for your activity.

But really, what you want is one that functions well, and that lasts an incredibly long time. That's what it boils down to.

There's a question that has come up on the screen about how long does a knee replacement last?

I'll answer that there's well, just in general talking about. Sorry I need to go backwards instead of forwards. Talking about joint replacements in general hip replacements, knee replacements, modern joint replacements last four decades.

It used to be in the old days that the main reason for someone to have further surgery on a joint replacement is because the joint had worn out.

Those days are gone with modern materials and modern techniques. Reasons for revision of joint replacements is no longer because the implants fail, or where it can be for other reasons, so such as dislocation, broken bones, infection, that kind of thing.

So most hip replacements will last an incredibly long time. There is still a risk with any joint replacement that you might require surgery afterwards. But typically that surgery would be for a reason other than the implants wearing out.

I mentioned steroid injections in the past. We've got another question here about after a steroid injection into a joint. How long it take? How long will it take before surgery to replace that joint can take place?

That that has been asked about a knee, but the answer applies to both knees and hips generally the advice is that you wait at least six months between having had a steroid injection into a joint and having that joint replaced.

The reason is that steroid injections bring with them a slightly increased risk of developing an infection following a joint replacement.

That risk is at its highest in the early stages. So you want enough time to have passed to minimize that risk.

So typically what we try and do is, we say, well, if someone's had a steroid injection you want at least six months of clear water between that injection and the surgery, if at all possible.

If you're struggling, if you're desperate, if you really cannot go on, then obviously we could proceed with surgery, but it does slightly increase your risk of infection.

Moving on now to knee replacement. Okay so what is knee arthritis? Well, it's a similar process to what's going on inside the hips. So what happens with arthritis of the knee is that the normally lovely smooth surfaces that glide over each other, and the ends of the bones, the end of the thigh bone, and the top of the shin bone.

Again they start to degrade, start to wear out and start, to grate and grind and catch and again the lining of that joint will become angry and inflamed, and cause pain around it.

Again, it tends to be a degenerative condition that is related to age. Most people, most typical people who suffer with arthritis of the hip or the knee tend to be in their sixth or seventh decade of life.

But we have noticed that people's joints are wearing out sooner these days than they were previously it can be related to injury can be related to occupation, family, lifestyle, other illnesses or diseases can have an effect on the joint, but the typical pattern is a degenerative one. That is a wear and tear type picture that comes with age.

So the symptoms that you tend to get again would tend to be pain, stiffness with loss of function swelling, and again later on with symptoms as more and more things start to wear away and degrade, you may start to develop deformity and pain at rest and night time again.

Again, we've got similar pictures here before and after healthy knee worn out knee similar to that of the hip from earlier.

Treatment options, what can you do? Again, we talk about finding ways to minimize the symptoms that are coming from your worn out knee trying to help with the pain, to maintain movement, to support the knee.

So painkillers, physiotherapy straps, and braces to try and alleviate some of the pressure from the knee, or to prevent or mitigate any deformity or loss of function.

Injections, there are lots of different things that you can inject into someone's knee steroid injections I've mentioned earlier and there, there, you know, there again, are a common thing that you can do in hip, in knees as well as hips.

Arthrosamid® is another treatment that I'll mention in the next slides. That's only indicated for knees at the moment. I'll talk about that a bit more in the slides ahead.

Other surgical options, if we're not talking about injections. Well, if a joint is deformed or misaligned. Then sometimes you can perform what's called an osteotomy, which is where you break the bones to realign the bones, to take pressure away from a worn out part of the joint and put it through a healthier part of the joint.

There are some conditions related to arthritis that can be helped with keyhole surgery or arthroscopy.

There's a lot of work currently being done on trying to transplant cartilage from healthy areas of the joint into unhealthy areas, or try and take cartilage from one person and implant it into another.

At the moment, although some of the early results are hopeful. That's still fairly experimental surgery, and certainly nothing that has proven long, lasting benefits.

Moving up the surgical ladder, the next step would be either a partial knee replacement or a full knee replacement, and we'll talk about those things in the upcoming slides.

I mentioned Arthrosamid® earlier on, Arthrosamid® is a new treatment that we've been offering over the last year or so here at Benenden. It's an injectable therapy into the knee.

The difference between Arthrosamid® and the other injections, such as steroid or the lubricant gel injections into the knee is that Arthrosamid® is a much longer lasting treatment.

Typical steroid or gel injections may give you a few weeks or months of relief. They're very good for an emergency situation, or, in the short, to medium term, to dampen down some of the symptoms associated with arthritis.

But the problem with those injections is that the symptoms then recur. It's not a good idea to have multiple steroid injections in a short period of time.

So Arthrosamid®, the reasoning behind it is to give an injectable therapy that gives long, lasting relief, that gives you relief for years rather than weeks and months.

And in patients where Arthrosamid® is suitable, then it is a viable long-term option. Again, the aim is to reduce the stiffness, the pain, and swelling around a worn out knee.

Now it's very important to note that Arthrosamid® does not cure knee arthritis. It does not grow you a new knee. It does not have any impact on the worn, articulating surfaces, the skeleton of your knee.

Arthrosamid® acts on the lining of the knee joint, and if you have a lot of inflammation and swelling and pain of the lining of the joint. Then Arthrosamid® will help with that. If you look at the slide that's on the screen there, the area that's circled, the area that Arthrosamid® is acting on is the synovial membrane, the lining of the joint. It's not those articulating surfaces that are wearing away.

So I will see a lot of people in clinic who want to know if they're suitable for an Arthrosamid® injection and it really boils down to whether or not you have inflammatory symptoms.

So if you have a lot of pain surrounding your knee joint, if you had a lot of swelling and fluid surrounding your knee joint, then the chances are Arthrosamid® will help.

If you don't have much in the way of swelling or inflammatory symptoms. If your symptoms are much more pain and stiffness and deformity of the joint itself then Arthrosamid® may not be of benefit.

My advice is have a consultation with me or someone like me, and we'll talk about whether or not it's suitable.

In people who it is suitable, it's a fantastic treatment, but it's not suitable for everyone.

The other thing to say about Arthrosamid® is that it does take a little bit of time to incorporate the lining of the joint. It does take a bit of time to work.

They’re short acting injections,  one of the things in their favor is that they work quickly as well as only working for a short period of time.

Arthrosamid® rather than working in days and weeks. You look at weeks and months for it to work typically after about a month. But it can be three months before you feel the full benefit from it, but when it does take it lasts for years.

The Arthrosamid® injection process is different from a normal steroid injection that you would have in the clinic environment.

This is done as a day case procedure in the operating theatre environment. You're given antibiotics an hour or so before you have the injection.

It's done under local anaesthetic, and I use an ultrasound machine to guide the needle into the correct area inside your knee. Once I find that the needle is in the correct area, I inject the anaesthetic to numb the inside of your knee joint.

I drain off any extra fluid, and then I inject the Arthrosamid® into your knee joint. From there we allow the Arthrosamid® to incorporate, and, like, I said, that can take a few weeks to feel the full benefit from it.

You're given an exercise regime. We recommend that you take things easy for the first 72 hours and then build up your activity and exercise as guided by the rehab program.

I've already spoken about other injections that we perform in the outpatient clinic, whether they be visco supplements or lubricant injections, or steroid injections as well like, I said, the good thing about them is that they are quick and inexpensive and easy to do.

The bad thing about them is that they may not be as effective or as long lasting as Arthrosamid®, but they're another option that we can talk about at the time of consultation.

Moving on to knee replacements. Knee replacement, although it's a big operation, it is a common thing to do. We perform, there are about 100,000 knee replacements performed in the UK every year. About a thousand of them are done here at Benenden.

We do a lot of joint replacements every year, a lot of knee replacements. So they're a common operation. They tend to be performed, on the whole, in people, in their sixties and upwards. But, like I said earlier, that age for surgery is getting lower and lower.

Ultimately, age is one consideration but the real consideration is whether or not your symptoms are bad enough, and that doesn't matter if you're 30 or a hundred, if the time is right to have your knee or your hip replaced. Then the time is right.

Typically, slightly more women than men have knee replacement and hip replacement surgery. I think that's mainly to do with the fact that women tend to live a bit longer than men, on the whole.

Again, the aim of a joint replacement, whether it be a hip or a knee is to get rid of the pain. That's the number one aim off the back of pain relief. You get better function, you get better mobility.

You get a more mechanically stable and balanced knee, and that will allow you to get back to most of the activities that you want to do. It's not carte blanche to do everything.

You will find that there are some activities, high impact activities that require a lot of pivoting, twisting, deep flexion movements that you may not be able to get back to after knee replacement, but those kind of activities if you can do them, you shouldn't really be considering knee replacement anyway.

So you know you won't lose that, because by the time you're thinking about joint replacement, that's not something that you'll be doing anyway.

The knee replacement that we use here is called a vanguard knee replacement, manufactured by a company called Zimmer Biomet. The reason we use that knee replacement is because it is a tried and tested knee replacement that performs incredibly well and lasts an incredibly long period of time.

With a knee replacement, people think that what it involves is cutting away the entire knee and replacing it with a big lump of metal and plastic. It's not quite the case.

What we do with knee replacement surgery is we make cuts in the bone, but we resurface the bone, we shave away the curved and worn ends of the bone, we reshape them so that they can fit a metal implant over the top.

There's a little animation that's coming up now, that explains, or you know, allows you to visualize that. So here is the normal knee, and then you see the worn out part and then the cuts that we take, making the bone just to reshape and bevel the ends of the bone, and we then replace them with curved metal on the top of the thigh bone, flat metal on the top of the shin bone, and a piece of plastic in between that acts as a cushion or a balance to allow things to move.

So that gives you an idea of what knee replacement surgery involves, it's a bit longer than that, but that gives you an idea of what it is.

Sometimes you don't have to replace the whole of someone's knee. Sometimes you can replace just part of their knee, if only one compartment of your knee is worn out, and there's no other damage to any other structures that support or move your knee. Then you may well be looking at a partial knee replacement.

These are X-rays of a medial partial knee replacement, which is the commonest kind of knee replacement to do.

The reason for considering partial rather than full knee replacement. It is that it is a slightly less of an operation, still, a big thing to go through. But it's slightly quicker recovery.

Functionally, people who have a partial knee replacement tend to do a little better, tend to feel a bit more normal, bit less artificial in their joint after a partial knee replacement.

So, if suitable, certainly an option, and something that we do a lot of again here at Benenden Hospital.

Another new tool that we have. There's a picture of me with my friend ROSA. ROSA stands for Robotic Surgical Assistant.

So ROSA is a tool that I use here at Benenden to allow me to perform knee replacement surgery more accurately than a conventional knee replacement.

At the moment ROSA is only available for total knee replacements. There is an upgrade, a software package that is coming that's going through FDA, and approval at the moment, health and safety approval.

All being well, that will be something that we will be bringing for partial knee replacements towards the end of this year. So it's an option for partial knee replacements in the medium term. It's not something that's available just yet. We're yet to see it in action here.

If it is something that that works as well as the total knee replacement, then it will be something that we will offer here at Benenden Hospital down the line at the moment, though I only offer that for total knee replacements.

The benefits of the robotic assisted system are that in theory you'll have slightly less pain and a slightly quicker recovery following your knee replacement there’s more potential for accurately balancing the soft tissues, to plan and execute that plan with more accuracy than without the robot.

The robot doesn't do the operation, that's still me. The robot is a tool that I use in order to plan the surgery, to guide the cutting blocks, to allow me to make accurate cuts in the bone, and then to assess the precision of the cuts that I've made afterwards.

Again, there's a there's a little animation here that will demonstrate what ROSA does, and how it helps me do my operation.

There you go, so that was a friendly American man taking you through what ROSA does. Like, I said, it is a it's a tool that I use. The implant that I use is the same.

Whether or not I use the robotic assistant the theory behind it is to enhance accuracy and speed up recovery. Short term data seems to indicate that that's the case.

What we don't have yet, because this is new technology, we don't have evidence that it makes knee replacements last years or decades longer than conventionally implanted knee replacements because the technology hasn't been around long enough for that.

I've spoken about benefits of joint replacement surgery. There are also risks involved as well. Some of those risks can happen during the surgery.

Joint replacement, whether it's a hip or a knee is an operation that involves a knife and a hammer and a saw, and your leg. There are other structures other than the bones, and those other structures can get damaged or bruised, or stretched or injured in some way during the surgery, whether those be muscles or ligaments, or tendons, or nerves, or blood vessels.

So there's always potential for injury during an operation. There's also worries about infection. You can develop problems with your wound or infections afterwards.

Benenden Hospital, the infection rate here is incredibly low when compared to national average or compared to local other hospitals.

I'd be lying if I said there were never any infections at Benenden, because everywhere has infections. But the risk of infection in this particular environment is much less than average. So that's good.

There's a risk of blood clots after joint replacement surgery. There are two main types of blood clots that we talk about one is a blood clot in the leg called a DVT. That can be a pain can be an inconvenience can make your recovery a bit longer or a bit more complicated. But

isn't life threatening.

Blood clots that sit in the lungs called a PE or pulmonary embolism, they can be much more medically threatening.

We do a lot before, during and after an operation, to minimize the risk of blood clots.

Whether that be talking about enhanced recovery, tailoring our anaesthetic, mobilizing early, using mechanical and chemical means to minimize the risk of blood clots. There's a multimodal approach to minimize the risk of blood clots. But again, sometimes blood clots can happen.

People can develop a limp during or after an operation. Sometimes that can persist most of the time. It goes away as your tissues heal as the muscles recover, and you build up the strength and confidence again.

Swelling, I would say, is not a risk. It's a fact associated with joint replacement in the early stages you will have swelling and bruising. That swelling and bruising will settle and fade. But it will be an issue in the early stages.

late problems that we talked about where we, you know, things can wear out. Things can break things can loosen things from fall apart.

Although joint replacement is an incredibly safe, reliable, successful, and dependable operation, sometimes the outcome isn't as good as we hope.

The overwhelming majority of people who have joints replaced are very happy with them, but you have to go into surgery appreciating the risks as well as the benefits.

Talking about time in hospital after you'll be admitted to hospital on the day of your operation, either in the morning or the afternoon, depending on where you are on the operating list.

Most people who have a joint replaced here at Benenden will either be in hospital for one or two nights. So you come in on Monday. You go home on Wednesday.

We have you standing and walking the day that you have your operation you'll be discharged home normally, when you go home you'll be fully weight bearing, but you will be on a pair of crutches.

You will probably get rid of those crutches after about three or four weeks, depending on how confident and how strong you feel afterwards.

You'll have physiotherapy whilst in hospital, and also physiotherapy, either locally or here at Benenden as an outpatient following your operation.

You'll be brought back to clinic. I will review you again at about six weeks post-OP.

There's a question on the screen asking how long after a knee replacement, will I be able to drive.

The average time for driving is about six weeks but that really is down to you. It depends on which knee you have replaced and what kind of car you've got.

But basically you have to be able to control that car. So if it's your right knee that's replaced in order to control the car, you have to be able to stamp on the brakes to do an emergency stop. When you can do that safely without hesitation, you can drive.

That tends to be about six weeks.

If it's your left knee that's replaced, and you've got an automatic or an electric car that left knee doesn't left leg doesn't control the car. Basically, most people will be able to get back to driving a bit sooner as soon as they can sit comfortably for long periods of time.

So it may well be that after a few weeks you're driving your automatic car with your left knee replacement, right knee replacement may take a bit longer. Same rules apply to hips.

I've touched on recovery a bit, but you know, in the early stages. You will need painkillers. You will have swelling. You'll have some bruising, and it will take a bit of time to build up the strength and confidence following that.

The first six weeks is all about letting the dust settle after that, from six weeks onwards. It's all about building up the strength, the confidence, the stamina, the movement, and getting back to your normal activities.

It's a gradual process. Everyone is a little bit different. Everyone's journey is a little bit different. There's no right or wrong, as far as that goal goes.

I've spoken a lot about me. I'm not the only Surgeon here at Benenden, there are half a dozen of us here.

I perform hip and knee replacements, and like I say, I've been doing that for a long time. I do about half and half and I do hundreds of each every year.

I have colleagues here, Mr Goddard and Mr Jones, who only specialize in knee joints and knee replacements.

There are other colleagues, such as Matt Oliver, Kumar Reddy, Raman Thakur, Bill Dunnett, who perform hip and knee replacements, the same as I do.

Deciding once you've decided that you're going to have a joint replacement deciding where to have it done, and who by is difficult.

If you're not part of a health environment or health system. It's very difficult to decide

who to go with.

There are more and more, ways online that can help you decide. So there's a platform called Doctify, which is a rating system where people that have had surgery, that had experience with Surgeons and with institutions get to give feedback and rate their Surgeons.

That's, I was going to say, that's my Doctify rating. My Doctify rating is 4.99, not 4.98. It's better than that. So you know, we'll update that later on, we'll get the guys to update it. But so ratings, rating platforms like Doctify or top doctors.

Iwantgreatcare.com. There's lots of patient driven satisfaction platforms out there that will help you make that decision.

Whether or not you like the look or sound of someone, or somewhere where you're deciding to have your operation.

The other place I would recommend is looking at the National Joint Registry, the NJR. So the National Joint Registry is an incredible database that's set up 20 years ago that monitors, every joint replacement that is performed in the UK. It monitors implants, but off the back of monitoring implants it also gives you an idea of Surgeons and institutions.

So every Surgeon's data is visible on the National Joint Registry, and you can type their name into the NJR. And look at important things like how long, how long do implants last. But more importantly, how many does a particular Surgeon do every year? Where do they work, and what are their outcomes like?

So you want a Surgeon that has good outcomes, whose operations last a long time, and who does high volumes of joint replacements.

If you're looking at someone online, and they say they do five or 10 knee replacements every year. Not sure about that. I would look for someone who does hundreds of knee replacements every year. Someone who's done that for decades. That's what you want. You want the experience and there are tools on the Internet that will help you find those people.

This is an example. This is kind of the high level data that you get from the NJR. That gives you an idea of how many joints are replaced. The demographics of the people, the reasons why they're replaced. It also gives the average age and body mass index of people that have joint replacements.

There's a there's a question here from Mrs Barber who I won't mention your age, but it says what is the preferable weight and BMI for knee replacement, surgery?

BMI, for those that don't know is a ratio between how tall you are and how heavy you are. So it looks at your weight and your height, and it comes up with a number.

Healthy gives you a BMI of around about 25. The heavy, if you, if you get heavier and heavier. Your BMI goes up. Someone whose BMI is over 30 or 35 is getting towards the overweight, and then obese.

If you look at the average BMI for patients to have hip or knee replacement surgery. You can see that on average, those patients are overweight. People who have knee replacements tend to be a little bit heavier than people who have hip replacements. So the average BMI for a knee replacement is 30 BMI for a hip replacement is 28.

One thing that BMI is a very good predictor of is whether or not you are at risk of developing complications during or immediately after an operation.

And so a lot of hospitals, particularly private hospitals, will have an upper limit of BMI which they find acceptable. And that's not because you're too fat, but it's because of the risk. The medical risk of complications associated with a BMI at a certain level.

So hospitals will have a cutoff. The cutoff at Benenden hospital planned joint replacement surgery is a BMI of 40.

If your BMI is above 40, then we cannot offer you joint replacement surgery here at Benenden.

We can offer other treatments, and those treatments, such as injections or other different therapies, that will be able to help you live with your worn out joint until you are able to get your weight down to a safe level.

we can do so. You can come and see someone. You can talk about options. We can talk about treatment. We can instigate some of those treatments, but when it's coming to joint replacement surgery, you have to have a BMI of less than 40 in order to have your joint replaced here at Benenden.

Other NHS institutions, those that are prepared to take on a higher risk those that have intensive care facilities on site they may accept a higher BMI, but you will find that most actually all private hospitals will have a cutoff.

Each one will vary a little bit like I said, the cutoff of Benenden is a BMI of 40.

It's now time for the Q&A session. I'll leave this slide up, which also gives you an idea of the costs of the treatment that's involved.

I'll start with one that I think, I answered earlier, but I'll try and be a bit more clear, which is, why does Arthrosamid® not work for some people?

The reason for that, like, I said, is that Arthrosamid® acts on the inflamed, angry lining that so that that surrounds a worn out knee joint.

So and it's very good at dealing with problems that come from that.

But people with arthritis may or may not have problems with the lining of their knee joint, and if they do have problems with the lining of their joint that could be a large part of their symptoms, or a small part of their symptoms.

So the people who Arthrosamid® are the most benefit for are the people who have inflammatory symptoms, and who those symptoms are a large part.

The problems that they're feeling. People who don't have inflammatory symptoms, or people whose inflammatory symptoms are minimal, then Arthrosamid® has to have something to act on, and if it's only acting on something that is a very, very small part of the reason why your arthritic knee is giving you trouble.

Then that's why it won't work for you. Hopefully that clarifies things and answers that question.

I'm just going to scroll through because the ones at the top I've answered I've got a question about steroid injections when the first steroid injection wears off. What should you do next?

That really depends on when it wears off. If it wears off after a few weeks, then you've got to look at some other form of treatment.

If it gives you a nine months or a year of long, lasting relief then, if appropriate, you could consider repeating that steroid injection, I said. You can't have them that frequently, but you can have them on an annual basis if appropriate.

If you have a steroid injection that wears off after a few days or a few weeks. Then why would you repeat something that hasn't worked the first time?

So, I would suggest have another consultation. If appropriate, you might be suitable for another steroid injection, or another form of injection. If not, then it might be time to start talking about the next level of treatment that would involve surgery.

I've got another question about injections. I've had n stride in the past. Is Arthrosamid®. An option?

N stride is a different kind of injection. It's not something that we offer here at Benenden, and it is not something that has been part of my practice for the last five years or so, and the reason is that it's an injection that that we hoped would make a significant difference. But it's not something that does.

It involves taking blood from a patient processing that blood to take out some of the healing proteins that exist in people's blood, concentrating them down and injecting them into people's knees.

When it first came out, it was thought to be a useful and effective treatment to try and halt, or even reverse the process of arthritis.

The more evidence there is out there that it really doesn't seem to make much difference in the medium to long term. It's not something that I would recommend people consider these days.

Is Arthrosamid® an option. If you've had N Stride in the past, there's nothing to. There's no contraindication to having Arthrosamid®. If you've previously had n stride, what I would do is have a consultation. See if you're suitable for n stride.

Do you have to wait until your hip is at a severe stage before having a hip replacement?

That depends on what you mean by severe if you're saying does the arthritis look severe on an X-ray?

Well, no, because interpretation of an X-ray is just what someone thinks when they're looking at an X-ray and all an X-ray really tells you is whether or not you have arthritis.

Severe in my book is whether or not your symptoms are severe. If your symptoms are at the stage where it's having a significant impact on your quality of life.

If it's stopping you from doing things, if it's shrinking your world, dominating your decisions, and if other treatments that you've tried have not helped then it's time to have a joint replacement.

So in that way, yes, it is worth waiting until your symptoms are severe. If you get the occasional twinge of pain in a joint that will catch you every now and again. But 99% of the time your joint is fine and you can do. You can live a normal life and do most of the things that you want to do.

Why would you even consider a joint replacement? It's a destructive, irreversible thing. No, don't have one, only have one if you can't live with what you've got anymore.

Can you please comment on what the recovery is like for a knee replacement, for example, can you climb stairs post-op / need a carer? How long is recovery on average?

Yes, you can climb stairs after the operation. It's one of the basic things that the physios in hospital will show you how to do before you're discharged. So yes, you'll be able to get up and down stairs before you you're sent home from surgery.

Will you need a carer after this operation. No, people worry that if they live alone they'll struggle after joint replacement.

Most people are able to do most things when they are discharged, you will be able to look after yourself. You won't need help washing or dressing.

In the early stages, you may need help with logistics, especially things like that involve driving or transport. So food delivery, that kind of thing you might need help with getting to and from hospital or physio appointments. You'll need help with.

But you won't need someone living in your house. People who make those arrangements before surgery. Typically they just end up getting in each other's way and getting under each other's feet, so you won't need a living helper or carer.

How long is recovery? Recovery is a gradual process that is different, for different people takes weeks and months.

Most people are back doing most things. After about two or three months everyone's journey is different.

Everyone's milestones are different. So it's very different to. It's very difficult to give you a specific answer for that.

I've got two questions here. One is, do hyaluronic acid injections work? The other is, what's your view of Ostenil or durolane injections?

The reason I can club those together is that Ostenil and Durolane are both trade names of hyaluronic acid injections.

Those are the lubricant, the gel injections that I touched on earlier. Do they work? For some people they are beneficial, they help with inflammation, they help things move a bit more freely and smoothly inside someone's knee.

They tend to have the same kind of profile as a steroid injection as in. They work fairly rapidly, but they wear off after months.

The good thing about Durolane, Ostenil, hyaluronic acid. These are all the same kind of injection. The good thing about them, compared with a steroid injection is that they don't have the same side effects that steroids can have on the rest of your body.

So they are things that can be repeated slightly more frequently. But again, my advice would tend to be if you're looking for a repeated injection after only a few weeks.

My suggestion is that an injection, another injection isn't the right thing. If you're if you get good relief for a decent number of months following these injections, then they are sustainable and repeatable.

But if it's days and weeks, then you're looking at the wrong thing.

Is there anything to lose by having an Arthrosamid® injection? Yes, cost money, so Arthrosamid® is expensive. It's a couple of thousand pounds, it says up on here. Guide price from 2,565.

So the first thing is that if it doesn't work you will have spent that money without any benefit.

That's the main thing. Apart from that, the risks with Arthrosamid® injections are the same as risks with anyone sticking a needle in you. So a potential for bleeding, bruising, a potential for a flare up of symptoms in the early stages, and a very, very small risk of infection.

So yeah, there are. There are slight risks associated with it. But the biggest risk is

disappointment, you know. If you build yourself up for this injection to be a miracle that's going to suddenly make you forget that you've ever had a worn out knee. If it doesn't do that, and if it's cost a lot of money, then it will be disappointing and costly, but those are really the only the only risks.

Can both sneeze be done at once. Is there a limit of BMI patient considered for this treatment.

Having both or having a knee replacement is a big operation to go through, and it's a big thing with a long recovery.

Having both knees replaced is a much bigger operation, higher risk and longer recovery, longer time in hospital.

I do hundreds of joint replacements every year, and I've been doing that for decades once a year or less I will do a bilateral knee replacement.

So it is rare that I come across a patient whose needs are equally as bad that they must be done at the same time but at the same time someone who is strong enough and healthy enough to go through that double operation.

So it is possible. It is not very common. It is higher risk, there isn't a limit with BMI when it comes to as opposed to just the normal limit of not above 40.

But typically high. BMI is associated with other medical problems, having both knees replaced at the same time you need to be in top condition. So typically those patients would have a lower BMI.

It's not something that's done routinely. It is something that is possible but it would have to be a discussion on a person by person basis. It's not common.

I'm 53, and do. PT I presume is physical therapy, or could be personal trainer three times a week and walk dogs, and I've been diagnosed with severe arthritis in my knee. Would Arthrosamid® be suitable?

Well, again, the first thing to say is that severity of arthritis. There's a difference between what it looks like on an X-ray and how it's impacting your life if you're able to walk the dogs, if you're getting up and about, if you're doing, if you're seeing a personal trainer three times a week and working out in a gym and exercising then I don't mean to belittle your symptoms, but it may well be that those symptoms aren't severe.

It may well be that your X-rays look terrible, but you're managing to cope and live your life well with that so well done? If you are, would Arthrosamid® be suitable for you in that situation.

If you have a large inflammatory element to your symptoms, then Arthrosamid® would help. If you don't have that inflammatory synovitic set of symptoms. Then there isn't a target for Arthrosamid® to work on.

Best thing to do, have a consultation. Come and come and have a come and have a talk and we'll discuss. We'll discuss it.

I had a steroid injection mid-march. How long would I have to wait for an Arthrosamid® injection?

As I said earlier. One of the risks with injection is infection. One of the risks of steroid injection, in particular, is infection.

We suggest that you wait six months between steroid injection and joint replacement. We also advise that you wait six months between steroid injection and Arthrosamid® injection? Again, because of an increased risk of infection.

Why do you not use ROSA for all operations?

Three reasons for that. The first is availability, we only have one, ROSA, so it can only be used on one person at a time.

We have three operating theatres here, two of which at any one time are performing knee replacement surgery. So there aren't enough ROSA’s to go around to do ROSA surgery on everyone. So that's number one.

Number two is what's more than three reasons. I'll just keep going until I get bored or you get bored.

Number two is time. ROSA surgery takes longer than conventional knee replacement, surgery.

I like to think that I'm pretty good at ROSA surgery. I've done the most robotic operations here at Benenden. I do it as part of my routine practice. I know what I'm doing. I've got over the learning curve.

But even in my hands, in a normal operating session I'll be able to perform three conventional knee replacements in that same timeframe. I can do two robotic knee replacements.

So time wise, I can't do it every on everyone, because it would mean that the waiting list would get out of control.

Thirdly, not everyone is suitable for a robotic assisted knee replacement. There's a there are a group of patients whose particular conditions, or whose legs or whose other parts of their body are unsuitable to perform robotic knee.

And number four, which is probably the biggest reason is cost robotic assisted knee replacement comes at an increased cost.

What that means is that only people who can pay that increased cost are the ones that can have a robotic assisted operation at the moment until prices come down. That's going to be the case.

We perform a lot of joint replacements here that are funded by the NHS, NHS do not routinely fund robotic assisted surgery at Benenden or anywhere else in the South East at this point.

And so NHS patients, their funding doesn't cover the cost of robotic surgery.

Some people's insurance policies will cover the extra cost, but some don't. So increased cost, increased operative time. Not everyone is suitable and it's not available for everyone simply because of logistics.

Those are the main reasons that I can think of off the top of my head. There are probably some more.

Another question from you. You have AF, and you're on blood thinners. How does that impact on the operation?

Most people who have knee replacements or hip replacements are older people. Older people tend to have comorbidities, and a common comorbidity is AF, or atrial fibrillation, or an irregular heartbeat.

People who have AF are commonly on blood thinning treatments. So it's something that we see very often in the cohort of patients who end up having joint replacements.

It doesn't have an impact. You have to stop your blood thinners in the build up to the surgery, but it doesn't stop you having that surgery.

We manage the blood thinners before, during and after the operation, and we put you back on blood thinners the day that you've had your operation. So yes, we need to be aware of it.

Yes, there are certain precautions that we take, but it doesn't prevent you from having your joint replacement.

I've got a question here. How do you decide whether a hip replacement will be done anterior or posterior, please? I've heard that anterior is better.

If you've heard that anterior is better, you've heard that from a salesman, not a Surgeon. That's a controversial thing to say. So I'll get that out of the way.

What Debbie here is talking about and what we're talking about when we're talking about anterior or lateral or posterior, is the surgical approach that you use

to get in to put in the hip replacement.

The commonest forms of hip replacement. The commonest approaches in the Uk are posterior anterolateral, then anterior.

Each of those approaches has risks and benefits associated with it the majority of decent hip Surgeons in the UK. Who are high volume. Surgeons with good outcomes use a posterior approach.

And the reason they do that is because it gives the best combination of access to get in, to do the operation properly and safely, and the least amount of damage to the muscle and soft tissues around the hip.

Anterior approach is very popular in America and it's very it's a very popular marketing tool and the reason for that is that going in through the front of the hip.

As I said, with posterior approach, there's a balance between exposure being able to do the job properly, and recovery afterwards.

Anterior approach, people recover quicker in the first three, two to three weeks after an operation, people who have an anterior approach.

If they don't have any problems, they recover more quickly. So anterior hip Surgeons will show videos of patients after three or four days, walking around doing well.

Those patients after six weeks are the same. Those patients, after six months or six years, are the same as other approaches.

But you do get better, quicker, with an anterior approach. So maybe that's what they say when they're talking about it being better. What they don't say when they're talking about anterior surgery is the downsides of anterior surgery.

So the exposure, the ability to do your job properly, the complication rate is higher with anterior approach than posterior.

When I'm talking about complication. I'm talking about periprosthetic fracture, implant malalignment.

Catastrophic complications that require further surgery. They're all higher in anterior approach, and they all happen earlier in anterior approach than posterior approach.

That's why it's not something that we do here at Benenden. Personally, if you were my family or a friend, I would advise against anterior approach.

If you find a Surgeon who has decades of experience, of anterior approach, who no longer, who can demonstrate that their fracture weight, their early complication rate is similar to, or better than, people who do, a posterior approach. That's fine.

But if you're dealing with someone who dabbles in it, who's starting about it, who's starting to learn about it, or who's heard about it on a talk somewhere and wants to try it on you. My advice would be, avoid it.

There you go.

That's a nice controversial one last question, because I've been rabbiting on too much. There's a few more questions here. There's another 30. I could be here all night.

We'll do our best to answer the questions that haven't been answered during the session afterwards.

I've got one, unfortunately, is from anonymous but they've said you've spoken about using a robot to perform knee replacement, surgery. Do you use a robot to perform hip replacement surgery?

The answer to that is no, not yet. As I've said with ROSA we use ROSA for full knee replacements. Lter on in this year, if the technology looks like it works, we will be doing partial knee replacements, using the ROSA at some point down the line.

There may be a ROSA for hip replacements, but we don't have any firm date or time for that.

In the meantime there is a new technology that I'm looking at with regards to hip replacements. It's not robotic assisted. It is AI driven, navigated, planning surgical assistant.

That may well help with the planning accuracy, positioning, assessment of hip replacement surgery in the same way that ROSA does with knee replacement surgery. It's a system that I'm excited about, I'm seeing in a month or two's time, and if it is something that is viable and useful. It will be something that we'll be offering to patients here at Benenden later on this year.

It's not something that's available now, and it's not really something I should be talking about at this stage, but I'm too excited about it not to talk about it. So it is hopefully a system that will be coming in later in the year.

All the advantages with the machine learning. AI assisted computer driven accuracy, planning assessment of your hip. So I'm looking forward to it hopefully in the next couple of months you may be listening to me. Talk about that in more detail on one of these sessions, but that's all I can say for the time being.

Damien

Sounds good. Sounds exciting. That's me done for now, right we've saved. Let's save your voice box. Lots of interesting options there. So thank you. So yeah, we do have quite a few other questions here. So if you've left your name, we'll we'll get those answers over to you via email.

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Thank you.