Phil

Okay, once again. Good evening, and a very warm welcome to our webinar from Benenden Hospital. Tonight, the topic is treatment for hip and knee osteoarthritis. My name is Phil, and I'll be your host for this evening, and I'm joined by our expert speaker, Mr Raman Thakur, Consultant Orthopaedic Surgeon here at Benenden Hospital.

So, for the benefit of those of you who haven't joined one of these sessions before, there'll be a presentation from Mr Thakur, which will last around 25 min, and this will then be followed by a live question and answer session. If you have a question at any point, please feel free to submit it using the Q&A icon at the bottom of your screen, you're welcome to ask your question anonymously, or you can include your name.

We should note at this point that session is being recorded, so any names that are shared may be visible in the recording.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

So without further delay. I will hand it over to our expert speaker, Mr Raman Thakur.

Mr Raman Thakur

Thank you very much, Phil, for inviting me today, and a warm welcome to everyone.

Right, the topic I've been asked to talk about today is about hip and knee arthritis, diagnosis, management, and presentation.

I work as a Consultant Orthopaedic Surgeon, both in East Kent and Benenden Hospital. I have trained in orthopaedics back home from in Hyderabad, in India, and subsequently completed a training program in the southeast.

Finally, following the completion of the training, I attended a fellowship for hip and knee reconstruction in New York and have been working at Benenden since 2012.

I perform hip and knee replacements, robotic knee replacements and ACL reconstruction and knee arthroscopy surgeries.

We are going to talk about assessment of the joints affected joint what is hip arthritis and management options.

Similarly, with knee arthritis and risks associated with principally primarily surgical treatments, hospital stay and recovery, and some tools that might help individuals make a decision about whether surgery is appropriate for them.

So it all begins with coming to the clinic and hospital, finding out whether what is the problem, getting the diagnosis and finding out your options for further management.

So it requires a full history both of what is happening with symptoms related to the joint as well as your general medical condition. Then we follow that with an examination which would include examining your joint for movement, strength, and then obviously investigations. Maybe an X-ray or scans.

Once we have a completed assessment, then what are our treatment options, whether surgical, non-surgical, and physiotherapy.

If surgery is the option, then fitness for anesthetic would be the important thing which is performed as pre assessment prior to giving scheduling a date for surgery.

What is hip arthritis? Osteoarthritis is not the same as a rheumatoid arthritis. So rheumatoid arthritis is a systemic inflammatory condition which affects multiple joints that has a genetic predisposition and a strong family history.

Why is osteoarthritis is not necessarily genetic, but there is a strong familial history, and it probably is multifactorial, both genetic and environmental factors.

It presents predominantly in the hip, as pain and stiffness, and it may affect sleep may affect day-to-day activities, and if the arthritis is advanced. May patients sometimes report crackling or grating sensation on movement of the joint movements in the joint are restricted, pain, weakness may ensue, limiting the ability to walk any significant distances.

As mentioned. I said, the causes are either age related, wear and tear and injury predisposing injury sometimes how the joint has developed during the formative years, and osteoarthritis is strongly associated with obesity both in the hip and the knee weight bearing joints.

That is, a picture showing a healthy hip on the left, which has got smooth surfaces covering the ends of the bone, and on the right picture shows the arthritic hip, which shows that the surface layer is worn out, and there is irregularity on the surface, and the bone is exposed. Where, then, bone on bone situations can cause a lot more pain.

Treatment options, non-surgical options include management of the pain, lifestyle modifications, avoiding certain activities and positions which may reduce the discomfort and make life a bit more easier.

Obviously, modifications to footwear. Especially people have got a bit of hind foot problems, and things can sometimes help how they are walking, reduce the pressures on the joints, and therefore improve comfort and slow down progression of arthritis.

Cane can also help is a big help, especially using it in the opposite side of the joint of the hip joint affected. So if you've got a right hip problem, use the cane. On the left side is generally people.

Most people find that far more helpful than using on the same side physiotherapy, and subsequently more interventional options could be a steroid injection if the pain is not managed with the previous measures.

Surgical treatment, obviously, when conservative treatment fails, the pain has become significantly intrusive, keeping people awake at night or becoming significantly intrusive, affecting work, then hip replacement would certainly be the most preferred option.

Hip resurfacing used to be done. It is probably coming back into fashion, but it is still experimental with newer materials, and it is not something that we are doing at Benenden Hospital. Hip fusion is mentioned for completion. But again, that is something which would be considered only if hip replacement has failed or is not an option.

So a hip replacement involves taking out the diseased part of the femur with the ball and replacing it with a metal pin which goes inside the bone of the femur. Along, and on top of that pin has got a ball which is the head of the prosthesis, and that articulates with a shell which fits into the pelvis, and on the inside has got a liner which for most patients is plastic high density, polyethylene with ceramic line head on the femur.

The idea is that the bone on bone situation is resolved, and therefore it will help with relief of pain from the arthritis, because the structure of the ball and socket is again round, and especially with arthritis, you get extra bone forms or deformity of the bone which restricts movement, and therefore with hip replacement.

Again, mobility is restored. Mobility of the joint is improved, reduces stiffness, and improves the ability to get back to normal activities and walking abilities again almost back to normal.

Hip replacements are classified variously, first in terms of the materials used. It could be metal on metal, metal, on plastic, ceramic, on plastic, ceramic, or ceramic. Those are the sort of options the most frequently used and commonly used. Option is ceramic on plastic, which seems to have as good a survival as the other materials.

Again, the second option of dividing hip replacements is how we achieve fixation of the prosthesis in the bone, and either it could be used as a press fit entirely, and allowing the bone to grow or in grow into the prosthesis, which is the uncemented method, and the second method is cemented where in bone cement is used as a grout filler to fill in and achieve primary stability in the procedure.

I think we will go on to the knee and talk about knee osteoarthritis. Again, the modalities of causes and symptoms are sort of similar, just the fact that the joint itself, where hip is a ball and socket joint knee is more a complex hinge joint and therefore, and also it's a more superficial joint.

A lot of people may notice swelling again, stiffness reduced activity, pain in walking, pain, on activity, distances, walking distances gradually reduced and associated with deformity, as the arthritis progresses in the joint.

The causes similar to the hip are related to age related wear and tear, or previous joint injury. Having had meniscal problems, ACL ruptures, further complex trauma to the knee, intraarticular fractures, all those can predispose patients to develop post-traumatic arthritis and it involves breakdown of the surface cartilage and the bone and rubbing on bone situation.

So that similar picture to the hip, you can see a healthy knee on the left and arthritic knee on the right.

Treatment options for knee arthritis are again similar, non-operative with working on pain, relief, weight, management, activity, modifications, physiotherapy braces and strapping can be performed. Sometimes, if patients have got one sided pain, an offloading brace can be used to take the pressure off the affected side and make it more comfortable, and then interventional treatment can be in the form of injections into the knee, which may be either steroid, Arthrosamid®, or hyaluronic acid. Injections are available at Benenden.

Surgical options involves if there is a significant deformity which may be causing significant loading on one side, and especially in a younger patient. An Osteotomy might help correct the alignment and weight bearing on the non-affected side relieving pain.

Arthroscopy may be an option in some patients where there is lining. The lining of the surface has got damage, and there are loose bits which are catching whilst moving the joint or loose bits in the joint, causing loose bodies which are causing locking and mechanical symptoms in those situations.

Then an arthroscopy can be beneficial in relieving some of their mechanical symptoms, and hopefully also help with pain and relief.

Cartilage transplantation is usually something that is possible with mainly focal small areas of where in the joint in arthritis. Unfortunately, that situation is bit far gone, and cartilage transplantation on its own will probably not be an effective solution.

And then coming to knee replacements if there is damage in one part of the joint an option could be a partial knee replacement which could be either on the medial side or the lateral side, or indeed the kneecap joint, patellofemoral joint.

If the arthritis involves two or more parts of the knee, then most of us would recommend having a total replacement.

So talking about steroid injections. I'm sure majority of people know about it. If there is anybody wanting specific information, we can do that. Arthrosamid® is something that is new drug introduced to the Uk market about a year or two ago. It is

a non-biodegradable hydrogel polyacrylamide, which is generally about 2.5%, and the rest of it is water.

It is an only approved injectable that stays for a long time within the lining of the joint, and hopefully, if it has been effective for patients, then the treatment expectation is that it will give benefit for a much longer period than other substances, like steroids or hyaluronic acid, which are usually cleared by the body.

Idea is to help reduce the stiffness, reduce the pain, and improve function.

The difference between Arthrosamid® and steroids can be that it always takes much longer for Arthrosamid® action to manifest itself, and may take anywhere between four weeks to up to four months before this full effect is manifest, and patients have significant relief of symptoms and pain relief in most recent studies is being shown to be maintained, for up to three to in the most recent study. Up to four to five years is done.

The procedure for Arthrosamid® injection is done as a day case procedure, oral antibiotics are given on admission, and usually it needs to be an hour at least before the antibiotics are in the system and the injection can be performed. Local anaesthetic is used to help make it comfortable and ultrasound guided.

The procedure is done under ultrasound guidance, and any fluid that is there in the joint as an effusion is drained, and local anaesthetic is injected, and then the Arthrosamid® itself comes as one Ml. Syringes, six syringes, and they are injected into the knee.

Advise post-surgery is to rest the knee for 72 hours and avoid strenuous activity for two weeks followed by a structured rehab program which is being developed by the company, and will be given to the patients at the time of the injection.

Other injections we talked about the steroid injection and the durolane. Both are done as outpatient procedures and steroids can help delay knee replacement for up to six months, and can be repeated two to three times a year.

The important thing to understand with steroids is, if you are contemplating knee replacement surgery, then it is probably in your best interest to avoid multiple injections, because one it does. It is a natural hormone in the body, it can affect other organs, and, secondly, it can increase risk of infection in the joint.

So any injections with a steroid or hyaluronic acid, or Arthrosamid®. We recommend a gap of at least six to nine months between the injection and knee replacement.

The durolane, which is hyaluronic acid, is formed as a single injection, and it replenishes the normal dwindling hyaluronic acid in arthritic knees and helps with lubrication reducing friction reducing inflammation in the joint, and thereby helping pain, relief, and

reduction of swelling in the joint. The company recommends that the injection is not repeated for a minimum of six months, and the effects can last up to a year. It can be repeated if it has been successful.

If so, if conservative treatment has not been effective or not appropriate. For whatever reason, then, and the pain and disability are severe, then the option is knee replacement.

As mentioned on the slide between 100,000 to 120,000 knee replacements are performed in UK with an average age of both hip and knee replacements, about 68 to 70, and there is a higher incidence of the ladies in both hip and knee.

Arthritic conditions the idea is to relieve pain, improve alignment, access and restore function and mobility in the joint.

The knee replacement we use in total knee replacement we use is a vanguard knee, which is marketed by Zimmer Biomet and has an ODEP rating of 15A which 15 means 15 years as a track record and a stands for the high performance and 10 year. Survivorship of this prosthesis, as in the national joint registry, is 96.4%. It is a cemented replacement. We use bone cement as grout to achieve fixation of the prosthesis to the bone, and where the kneecap is in the front of the joint, it depends on whether or not it is being severely affected, and where then we can replace that with a plastic under surface to your normal kneecap.

So from outside it will, you'll notice that the kneecap still is your own.

This as a video, I believe, let's see a knee replacement.

So the arthritic condition shows as brown that what's happened in knee replacement, shaping the surface of the bone, and then putting the prosthesis and use securing that in place with bone cement and then the prosthesis bone.

The metal glides on the plastic, and because of that the pain from the arthritis is improved. Knee replacement is one of the most painful operations we do so important for people to understand that it is important to understand that pain control is essential and to be able to rehab well and get good outcome from following the knee replacement surgery.

This is a slide showing the partial knee replacement on the inner side of the knee, where you can see the situation is bone on bone, and here it has been replaced on the inner side with metal and plastic, and I have got some props. I will show them to you, and that is what a partial knee replacement looks like.

On the inner side metal and plastic are in between. Working on the inner aspect. That small bone is fibula on the outer aspect of the knee.

So that is a partial knee replacement and that is a totally replacement where, as shown in that previous animation the shape, the bones have been shaped, and then a well fitted implant put on the femur, similarly on the tibia.

shave the bone, and then put in a prosthesis where the keel goes into the bone, and then use bone cement between the bone and the prosthesis to get that fixation.

The options of knee replacement surgery at Benenden Hospital include the conventional as well as robotic assisted systems. So it is the system we use is the ROSA knee which goes with the vanguard knee. By Zimmer Biomet, it helps mainly with implantation and soft tissue balancing of the knee, and therefore helps with reduced pain possibility and chance of an early and less painful recovery in the early phase, and reduce soft tissue dissection and injury potentially may result in a shorter stay in hospital.

What is the difference between a robotic versus a conventional replacement? Obviously to get the alignment in a conventional replacement, we have to use rods into the bone to work off that and get our alignment and cuts on the femur side as well as on the tibia side.

We again use rods, either on the outside or the inside of the bone to help with our alignments and then release the tissues, whereas in a robot we use sensors, we have got a couple of pins to add onto the femur and into the tibia, and then the sensors are attached and the robot then reads where the limb is in three dimensional this thing and guides the placement, especially whenever there is movement of the leg.

The robot automatically adjusts for that and helps the surgeon oriented. If there has been a change in position, the robotic arm itself is guided by the surgeon, and the surgeon is still doing the operation as well as the decision making. It is not the robot doing the surgery.

So that is just showing the pictures of the robotic arm coming in, and it is giving us a clue about the angles and the position, and then we PIN it, and then the surgeon makes the cards.

ROSA knee is a robotic surgical assistant for total knee replacement. Your surgeon is specially trained to use the robot. ROSA Knee does not operate on its own. Your surgeon is in the operating room the entire time and making decisions throughout your surgery.

Your surgeon creates a plan for your surgery, based on your unique anatomy helps to ensure the plan is executed as intended.

ROSA knee uses a camera and optical trackers to know where your leg is in space. If your leg moves, the robot can tell and adjust accordingly.

ROSA knee provides your surgeon with data about your knee. This helps to personalize your surgery based on your unique anatomy.

Hopefully, that has given a flavor of what is achievable using different techniques and we come to the risks of surgical intervention in the form of joint replacement, and we have divided these to just clarify during surgery during recovery and late onset complications during surgery.

Obviously there is risk of damage to tissues, particularly if you look at how the knee sits there, you have to move this kneecap around and then do the surgery, and obviously concerns of damage to the bone, the nerves, and the vessels which sit behind ligaments and tendon itself during the recovery concerns with wound infection or delayed wound, healing, oozing, and more commonly blood clots, either in the leg or embolism to lungs.

Ongoing pain may cause limp along with some weakness of the muscles from the arthritis. Obviously, that will take a few weeks, in most cases, to start settling down. Ongoing stiffness and swelling.

Both of the joint as well as the whole leg can be seen, and it is important to address that with advice from the therapist and surgeon.

Late complications include failure of implant due to either wear or loosening and periprosthetic fractures which may involve the area of the prosthesis, and subsequently require surgical intervention and revision. Surgery and dislocation may happen early in the postoperative phase, especially with hips.

If people are not careful about how they position the joint and follow the rules with do's and don'ts. The risk of dislocation reduces as the recovery progresses.

Hospital stay at Benenden is usually either one or two nights, and if the surgery happens in the morning, then ability to be seen by the physiotherapist and get up and going the day of surgery obviously help with discomfort, and mentioned about the swelling so important to keep it elevated and keep the exercising, so reduce any swelling of the foot and ankle as physiotherapy will advise regarding a range of movement strengthening as recovery progresses.

Most people are able to discard their walking age by about six weeks so in terms of recovery, walking indoors about a week, 10 days wounds to heal two weeks. Most people are able to discard their walking aids by six weeks and start driving, and 90% of recovery happens in three months. Full recovery may take anywhere from three months to a year.

As mentioned, two weeks painkillers, visible bruising, physiotherapy exercises, and then six weeks back to driving, and a six week is also the mark when the surgeons would most likely see the patients back in outpatients three to six months, as I mentioned, feel the benefit of surgery, start returning to normal activity and continue rehab.

These are our hip and knee surgeons, who are specially trained in performing the procedures, both conventional and reporting.

And you mentioned about the patient decision support tools. PHIN is Private Health Information Network, where you can get idea for about the surgeons, as also on the National Joint Registry. To do your due, diligence and review sites such as Doctify, can help again in making that decision about choosing your surgeon.

Mentioned about this briefly earlier, as I said, hip and knees roughly between 100,000 and 120,000 knees in 2023, and average age is roughly around that same 67 to 69, and a higher percentage of ladies compared to men.

Majority of the indication for joint replacement is osteoarthritis, and about 14% of knees are suitable for a partial knee replacement and the incidents performed, and I think with that I will finish the presentation.

I'll pass you back to Phil, and then I'll be happy to answer any questions.

Phil

Thank you, Mr Thakur, for talking us through the various treatment options available, so we can move on to your questions.

We're obviously delighted to have a significant number of you attending this webinar, but it does mean that we have got quite a number of questions to get through. We'll do our best to cover as many as we can today. It would be helpful if you could try and keep your questions brief, and then hopefully, we can get through as many as possible.

So this first attendee, I think this is a two part question. Really, they offer two bits of detail in two separate questions.

Hyaluronic acid injections, carried out locally in Hampshire, have had no effect. An X-ray shows that I have severe osteoarthritis in both knees and very little cartilage, so bone on bone is it worth trying Arthrosamid®?

Mr Raman Thakur

So it is important to understand that if the symptoms are quite severe.

and if the pain is limiting most day to day activities. Walking distances are severely restricted, and they and it is affecting sleep and the arthritis, as you mentioned, is severe then maybe the right option in your case could be any replacement. I think the most important thing will be to have it assessed, and then decide what are your options.

I've done Arthrosamid® injections in people with severe arthritis only when they felt and they wanted not to go for surgery. So, and I have had mixed results. I've had one or two patients who haven't had good benefit, but on about 60% or 70% have had 70 to 80% improvement in symptoms, despite the severity of arthritis, so it does need a proper assessment. See what sort of arthritis, what is the pain generators in your individual case and then understand what might be the right treatment option, and then deciding whether or not you want to try something different, because that obviously is a shared decision, making process with full understanding to the implications of intervention.

Phil

Okay, thank you.

Our next question comes from Linda, who asks, what is the success rate for keyhole surgery for a meniscal tear in the knee.

Mr Raman Thakur

So, Linda, that's a very important and a useful question, I believe, because a lot of people have a tone, meniscus on an MRI scan, and once that is been mentioned or reported, then the common perception is that it needs to be followed by surgery.

I think what is important to understand is what has caused this meniscal tear. If there is a clear cut, definite injury, and subsequently mechanical symptoms related to that and locking or giving way with typical pain localized in the region of the meniscus. Then surgery to address the meniscal tear might help the situation.

It is important for me to point out also that about 65% of patients who have osteoarthritis may have a meniscal tear which is possibly being there as part of the wear and tear in the joint, and is not necessarily the reason why patients are in pain and just addressing the meniscal tear in that group of patients, especially if the arthritis is much more severe, and bone on bone may not actually benefit them, and particularly if they are meniscus being the cushion is the only thing. Keeping the bones apart, we go in and address and shape the meniscus tone meniscus then it might actually cause a situation where the bone may start rubbing more on the bone, and patients may not be particularly happy or slightly worse off after surgery, so it does involve.

Important point is assessment and discussion as an individual in whether or not it can, like our keyhole surgery can help in that situation.

Phil

Okay, thank you. Our next attendee asks what happens to the kneecap in knee replacement surgery.

Mr Raman Thakur

So just bring that prop back. So I think it will give us a bit more clarity. The kneecap normally is moved off to the side. I don't know why the kneecap is missing in this thing, but generally think that the kneecap is there which is enclosed in the tendon.

If the we shave the under surface of the kneecap and replace it with plastic on the inside, so from the outside, the kneecap is still the individuals.

Phil

Okay, thank you.

The next person asks, I suffer from pain in both knees due to osteoarthritis. This significantly affects my sleep during the day. I still have some pain, but I'm able to walk normally. When does surgery overtake my lack of sleep and associated issues?

Mr Raman Thakur

I'm trying to understand and I, if correct me if I'm wrong. But I think you're saying that because the sleep is affected is that a sufficient reason for you to go down the knee replacement route.

I think it requires a complete assessment. It requires to be understood how and what is causing your pain. Whether or not the arthritis is severe, and whether it is impacting on your day to day lifestyle, and as it in in arthritis, you do get also waxing and waning of symptoms just like a cycle of moon. You get full moon, new moon, and phases of moon.

It is not as regular as the moon cycle, but you do get phases where it can be quite severe for a few days or a week or so, and then it can settle down, and you may have situation times when you say, I don't have much in way of pain. I'm able to do a lot more, or you may have my situations like yourself, where you're getting pain at one or the other time, whether it is night time or with activity, and other times you're able to perform.

So I think that is bit to understand that sometimes it is very difficult to judge and make that decision as to whether or not the timing for surgery is appropriate and if you are able to perform to a decent level, then maybe it needs re-evaluation as to whether a non-surgical option or an injection might be able to tide you over that episode of exacerbation, and whether it can get you back to your normal baseline so that you can still function without rushing in for a joint replacement.

Phil

Okay, thanks.

This next person asks, how common is it to have osteoarthritis in the hip and knee on one side only might one cause or exacerbate the other?

Mr Raman Thakur

Absolutely, and I think the important point is to understand. Sometimes patients come with only pain in the knee, and when you examine them, when you evaluate them.

You actually find out that their hip is extremely stiff. It is painful to move, and then, when you start examining them, they do admit to having some groin pain, and when you further evaluate them with X-rays and all the arthritis in that hip is quite severe, so I've had patients who have come in with painful knee and ended up having a hip replacement and being happy with the outcome of surgery.

Arthritis in the hip on one side, arthritis on the knee on the other side, is actually quite a very difficult situation to live with, because one can aggravate the other.

Usually, if arthritis is there on one limb, both involving the hip and the knee, majority of us would try to address the hip first and then address the knee, unless it is that very clear cut that the knee arthritis is a lot more worse than the hip. Then obviously the knee surgery would precede the hip replacement.

Phil

Okay, thank you.

The next person asks, what is extensive calcification in the knee?

Mr Raman Thakur

So you're talking about deposits of calcium into the knee, which is called chondrocalcinosis. It also sometimes goes by the name of pseudo gout, just like gout. It presents with sudden onset of swelling pain and limited movement in the joint and X-rays

typically show a soft tissue swelling, and on the X-ray you can see deposits of calcium into the cartilage in the joint, and people sometimes are in so much pain that the surgeons and the orthopods will aspirate the joint to get fluid out and test it under the microscope, and then that shows that there are no evidence of infection but crystals seen on the aspirate, which confirms that it is deposits of either calcium in pseudogout or uric acid in the gout. So that is a chemical arthritis. But it may also coexist along osteoarthritis.

Phil

Okay, thank you. The next person asks, is there an age limit from knee surgery?

Mr Raman Thakur

My oldest patient for hip and knee replacement was 95, so I don't think there is a chronological age limit. What is important is how fit are the individuals, and how good are they medically to be able to have and sustain the surgery as well as the rehab following the surgery.

Phil

Yeah, okay, thank you.

I feel that this question might need a bit more context. But the person asks if I'm having a minimally invasive total hip replacement in September. I live on my own will. I need to get carers in?

Mr Raman Thakur

So I think the important point is, certainly. Discuss that with your surgeon. In most hip replacements there will be some restrictions on what you can. You can't do how long you can be up and about, and how much you are able to do all on your own. So in general, all of my patients, I advise them that they will need support for the first two to four weeks, depending on their progress following surgery. So that is what I would typically advise the patients.

Phil

Yes, okay, thank you.

We did answer this one during the slides. But it's probably worth reiterating the answer to this one, how long does it typically take to recover from a knee replacement?

Mr Raman Thakur

So, as I said, the stay in hospital is usually one to two nights, and the wounds take about two weeks to heal, and most people progress with physiotherapy, and are able to discard their walking aids by about six weeks. Post surgery driving is again, after six weeks and recovery. Most of the recovery happens in that first three months, and full recovery may take much more longer.

Phil

Okay, thank you. This next attendee, Patricia, asks, do you use the anterior incision or Rottinger approach procedure for hip replacement?

Mr Raman Thakur

No, I personally do not use that. I do my hip replacement through posterior approach.

Phil

Thank you.

This person, asks my doctor, has recommended an X-ray of my knee, but also recommended physiotherapy. Is there a danger prior to diagnosis of the knee problem of physiotherapy not being helpful?

Mr Raman Thakur

I think. Obviously, that is a possibility.

But if your doctor has examined you and thinks that Physio might be something that will help with maintaining your mobility, helping with pain, or swelling control, then I think that is a reasonable intervention whilst waiting for X-ray.

But certainly, if there is aggravation of pain, or it is not helping, and the pain is getting worse. Then it needs to be re-evaluated, and I'm sure the physiotherapist, if they are evaluating you, they might turn around and say, No, no, let us wait for investigations, so if they feel that it is not something, they are confident that they can help. Then I'm sure they will tell you that.

Phil

Okay, thank you.

This person asks, can osteoarthritis of the knee be mistaken for sciatica?

Mr Raman Thakur

There is a lot of overlap with the with symptoms coming from one part of the body and affecting the other, and I do see a proportion of patients who come complaining of pain around the hip, pain behind the knee, actually being related to pressure on the nerves in the spine or around the hip, and causing, as you say, sciatic type pain. So nerve root entrapment can do that more.

Typically it is a burning type. Pain, it usually affects the whole limb, and it can be again more often associated with pins and needles or numbness in the leg, and may sometimes be associated with some weakness in some muscle groups in the knee, in around the ankle or the knee. So if you have any of those features associated with your pain, then certainly something to be examined, evaluated, and assessed and, if required, investigated with MRI scans and things to exclude that sometimes people who have problems clear cut arthritis in the hips and knees can also have back symptoms, and I've had situations where I've had to recommend patients to have a steroid injection into either the hip or the knee, and then see how much of the pain is relieved from that or a local anaesthetic injection, and how much pain is being relieved, and that can give you an indication.

If you have clear cut arthritis in the joint as to how much benefit you may get from a joint replacement or other intervention on the joint. And if that shows that my pain, 70% or 80% of the pain is gone, then you know that that is what the benefit one will get from having had a successful procedure performed to help with the replacement. So we do use sometimes injections as a diagnostic.

Apart from also, sometimes therapeutic reasons, especially when people have got multiple sources of pain.

Phil

Okay, thank you. A simple question, but probably quite a common one. And let's assume they're referring to conventional TKR, how long does a knee operation take?

Mr Raman Thakur

In most situations, a conventional knee replacement would be about an hour to hour and a half. Obviously, if there is a bit more complexity with deformity and things like that, then it can take another half an hour extra.

Phil

Okay, thank you. Heather asks, can hip replacements be carried out with a spinal block?

Mr Raman Thakur

Majority of my patients have a spinal anesthetic and something to keep them sedated so that they are much more comfortable during surgery. So yes, spinal anaesthetics or beyond 90% of my patients.

Phil

Okay, thank you. Our next question comes from Martin, who asks once you've had a partial or title knee replacement. Can you have another one in the future and the end of the lifespan of the original operation?

Mr Raman Thakur

So yes, in a short answer, but there will be a lot of things that will determine what and where things will progress. One of the reasons why partial knee replacements fail is progression of arthritis in the rest of the knee. So in most of the time, when a partial knee replacement fails, then it is converted to a total knee replacement.

Obviously, if there has been a specific reason why there is a problem whether it has come loose one bit or something. Then sometimes I've been in that situation where we have just gone on and revised a partial to another. Partial, and patients have been happy. But again, totally replacements can be revised.

If they have been due to instability or aware of the processes, it may require a much more constrained processes. But yeah, the surgeons can tell you that in most people it can be revised both partial and total.

Phil

Okay, thank you. This next attendee asks how long after a total knee replacement. Is it safe to fly?

So here at Benenden Hospital, and I think most places will also say the same, and there is nice guidance on it. We recommend that patients do not fly for six weeks on either side of the surgery.

That means before and after for six weeks to reduce risk of blood clots in the leg as well as pulmonary embolism.

Phil

Okay, thank you.

This person asks, can the kneecap be lined without knee replacement?

Mr Raman Thakur

So if you're talking about whether you have got a problem with petal tracking and secondary to that, you're having problems either with dislocation or altered anatomy causing pain. Then yes, I do do realignment procedures for kneecap to bring it back into place and reducing risk of dislocations.

But that is not usually a part of knee replacement surgery. I have had situations where kneecap has dislocated after joint replacements, and we have tried similar procedures to help with alignment of the kneecap.

Phil

Okay, I'm afraid we've run out of time for any further questions, but thank you again for for all your questions as you can appreciate. We had a vast amount this evening and if you have provided your name, we can follow up on your question via email.

As a thank you for attending this evening.

If I can just move to the final slide. Mr Thakur.

Mr Raman Thakur

Oh, oh, sorry.

As you see on the screen there, as a thank you for attending this evening. We can offer you 50% off your treatment consultation for a limited period and you will receive a call back from your dedicated private patient advisor.

You receive an email with the recording of this session treatment, information and loyalty reward points and updates on future events and health news.

You will receive a short survey at the end of this session, and we'd really appreciate it if you could take a moment to complete that. It does help us to inform future webinars and tailor them to your specific needs.

If you'd like to speak to someone or book your consultation, our Private Patients team are available until 8.30pm this evening, or from 8am to 6pm Monday to Friday, and the contact number is on your screen there.

We also have upcoming webinars on a range of topics, including urology, hand surgery and varicose veins. You can find the details for those and sign up on our website so that brings our webinar to a close and all I have left to say is on behalf of Mr Thakur and all of us here at Benenden hospital.

Thank you once again for tuning in, and we hope to hear from you soon.

Mr Raman Thakur

Thank you, Phil, for having me, and thank you all for attending.

Phil

Thank you, and goodbye.

Mr Raman Thakur

Bye-bye.