Damien Gregory

We'll just wait a little bit longer while some of these participants arrive. They're just entering the room now, and we'll begin soon.

Right. Good evening, everyone, and welcome to our webinar here on treatments for hip and knee arthritis. Now my name is Damien, and I'm hosting this evening, and I'm joined by our presenter, Mr Matthew Oliver, Consultant Trauma and Orthopedic 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, please 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. Please note, though, that the session is being recorded. If you do provide your name, if you'd like to book your consultation. We'll be providing contact details at the end of the session.

So I'll now hand you over to Mr Oliver, and you'll hear from me again shortly over to you, Mr Oliver.

Mr Matthew Oliver

Thank you, Damien. Good evening, everyone. Thanks for joining this webinar this evening. I'm going to talk to you all about hip and knee osteoarthritis and its management.

So an introduction about myself, I'm a Consultant Trauma and Orthopedic Surgeon. I trained at St. George's Hospital Medical School, and I left there in 1998 and embarked upon basic medical and surgical training, ending up loving orthopaedics. So I went and did a higher surgical training rotation in the South East Thames area.

That finished up with a senior fellowship over at the University of Calgary in Alberta, Canada. I was there for a year and worked for four quite eminent hip and knee replacement Surgeons.

I returned to East Kent in 2010, and became a consultant orthopedic surgeon for East Kent hospitals with my main base. Being at the William Harvey Hospital in Ashford, and at the Kent and Canterbury Hospital in Canterbury. I started working here at Benenden in 2012.

I'm a reasonably high volume, hip, and knee surgeon, certainly doing slightly more than double of the national average that my peers do.

Next slide I have to click on it. I think that's it. It's a bit delayed.

So included in this session, they're going to be in five parts, really. So the first is all about hip arthritis, second about knee, osteoarthritis, third about injection options for knee arthritis.

Fourth part, all about the robot knee that the hospital here offers, and then I'll take a question and answer session after that.

So, starting off with osteoarthritis at the hip joint.

This is an incurable diagnosis. Unfortunately, but it doesn't affect everyone. There are some factors that predispose you to it. These are listed up here. The chances of getting it unfortunately increases of age, if you're a lady, if you're overweight, especially if you're obese.

All of the weight bearing joints. The hip, the knee, and the ankle are susceptible to being overweight.

If you've had an injury to your hip at any point, and this could be an inoculus injury that may have happened in childhood, or as a young adult, and you didn't really recognize it at the time. You just jogged it off. You can also injure it in a car accident or skiing accident. Something like that. There are autoimmune diseases that can damage hip joints, such as rheumatoid arthritis.

But these are rare these days, as most of these conditions are so well managed medically, with pills and potions.

We don't really see gout affecting hips either much these days again, because they're so well managed medically.

There are a few other rarer conditions that cause the hip to crumble away. One of them is called avascular necrosis.

That's when the blood supply to the femoral head is damaged, and it doesn't quite recover. This can be as a result of a hip fracture that has been managed conservatively, and a hip fracture that's been fixed, and then the ball of the femoral head gradually deteriorates, as the blood supply doesn't recover after the fracture.

It can also happen if you have some medical conditions, such as diabetes. If you're a heavy smoker, if you're a drinker, if you abuse intravenous drugs, if you've had chemotherapy, or it could happen idiopathically, where there's no rhyme or reason for it, but fortunately, avascular necrosis is one of the rare causes of degeneration of the hip.

How does it present? It starts off with just a little bit of a niggle in the groin. It just feels a bit stiff. You get a bit of startup pain. If you've been sitting down for a long while or first thing in the morning, and it might ache if you overdo things in the garden, or go for a long walk, and as the condition progresses you'll notice that the pain slightly increases and the stiffness increases, you'll have difficulty putting on your shoes and socks.

Bending down to get things off the floor, tying your shoelaces, etc. As it continues to progress. When you roll over in bed it will jar and wake you up and disturb your sleep. Your walking distance will gradually decline, and you won't be able to sort of do many athletic pursuits.

When it's really advanced you'll notice. You'll hear some funny noises coming from your hip joint. You'll feel it grating and cracking, and that means that you've certainly left it far too long before coming to see one of us.

Another thing that we notice with patients when we examine them is that the muscle bulk on either side of the leg differs quite considerably, as you don't use the hip as much, the excursion of movement is less, and therefore the muscles that the hip uses gradually waste away, and that is quite obvious to see.

So the treatment options there are several available painkillers are the first thing that people reach for the over the counter painkillers like paracetamol, non-steroidal anti-inflammatories like ibuprofen.

Then you can get some stronger ones from the GP, such as naproxen, which is a stronger non-steroidal anti-inflammatory or cocodamol, which is codeine and paracetamol mixed together quite strong painkillers that make you feel a little bit icky. Certainly the cocodamol can constipate. You make you feel drowsy.

Tens machines. I guess they have a role to play. Anything to distract your mind from. The discomfort is probably beneficial to trial. Lifestyle changes. If you're overweight that needs to be addressed because you need to offload the joint by reducing the forces through it. That would certainly help.

As does holding a stick and the opposite side on the opposite side to the arthritic hip. That will help because you'll put the weight through the stick and not the sore hip.

Steroid injections. These are practiced. I'm not a keen. I'm not really a lover of these injections into the hip joint for a few reasons.

Firstly, there's a small risk of introducing infection into the joint of a steroid injection. Not only does it pierce the skin and go into the joint from a long way out. So it's a deep joint. It's got to go through several layers of tissue to get there, but also the injection itself can lower the immunity in the hip joint, and therefore it's recommended not to have any hip replacements for at least six months after one of these.

I've also seen on a few occasions that the steroid injection can bring the rapid demise to a hip, whether that's low grade infection, or just bad luck interfering with the joint cartilage and corroding it.

Who knows but I hold these in reserve ice packs and hot packs will help a bit shoe where I don't really think that makes much of a difference. To be honest with you. Just decent, supportive shoes should be all that you need.

There are some funky shoes and insoles that you can buy, but I don't think they're worth spending the money on. Personally, physiotherapy is very beneficial to an arthritic joint of any description, because an arthritic joint needs to be kept moving to keep the nutrition in the joint and the muscles around it optimal.

Even though it might sound counterintuitive. It's actually a very beneficial light load bearing physiotherapy. And when all of those things have failed and the bad days outnumber the good, you're into hip replacement, surgery, territory, joint fusion that is, it can be done. But the indications for that are extremely limited in the modern day and age.

Certainly that operation isn't carried out here at Benenden. That's the joint fusion.

Some data about hip replacements for you all. Interesting one in the top line there. And I think that's going to increase that number, as private hospitals help the NHS with the COVID-19 Waiting List backlogs

Because an independent private hospital really is an ideal venue to have a hip replacement, all the white noise of busy emergency admissions, trauma admissions, corridor medicine.

You don't need to concern yourself about that in an independent hospital. It's a calm, clean environment. To come in and have a tyre change effectively is a pleasant place to come for a big operation, and I think the independent hospitals are working collaboratively with the NHS.

Also with private medical insurers and that's why that's been a quite a big increase in the number of procedures.

So over a 100,000 hip replacements are done in the UK last year. It's quite an impressive number, and it will continue to increase.

Hip replacement, surgery is second, best operation in the world it says, up there behind the cataract. I didn't know it was the second best.

I do know from a very famous paper that was published many years ago about quality life adjusted years. That's a fancy term given to describe how much an operation would give your quality of life back to you after it's been evaluated, and the top four operations are
cataracts number one, because I guess if you can't see that's pretty miserable.

Number two is a cardiac surgery, bypass, grafts, and stents, because without your heart you don't really have a life. Number three is a hip replacement, and number four is a knee replacement.

I can understand that as well, because if you can't walk, your quality of life is pretty poor. So all those four things together consistently outscore all of the other procedures that are done for people on the whole, to give you your quality of life back.

So what is a hip replacement? It's made of two parts or three actually is a cup or a shell, or an acetabular component.

That's part number one that's press fit into the pelvis into your own natural acetabulum. After we ream it up to make sure it all matches and fits neat and tidily. Inside the cup goes a liner and the liner can be made of either plastic or ceramic.

Then that articulates with a ball or femoral head, and that's even made out of metal, cobalt, chrome, or ceramic, and then there's the stem, the femoral stem, and that can be made out of titanium or cobalt chrome depending. If it's an uncemented hip that's press fit into the femur, or a cemented hip that is glued into the femur with bone cement.

When do you need to consider hip replacement? This is a very good question.

Really, there are lots of different tools available to help validate that for someone who's undecided. The one that I like to use is called the Oxford Hip score.

It scores you out of 48, and the lower the score, the more likely you'll need to have a hip replacement. The research that's been done on it shows that if you score around 24 to 28, that's the ideal time to consider having a hip replacement.

If you score below 20, then your hip is already considerably arthritic, and you're already considerably disabled, and the recuperation following hip surgery won't be as good as if you had it when it was only moderately arthritic.

Because the amount of points that you can gain on the score after you've had your hip replacement is partly determined by how arthritic the hip is prior to having the hip replacement.

So that's quite a useful tool. So I would say, when the bad days outnumber the good when you've trialed all the conservative things, and when your quality of life is poor, most days you're limping, you can't enjoy life. That's when you should probably consider having a hip replacement. I certainly wouldn't recommend leaving it. So you need to use a wheelchair.

Briefly talked about this already. These are the two types of hip replacements commonly performed in most hospitals around the world. There is a 3rd type, the resurfacing hip replacement, but that's very much restricted in its use to certain cohorts of people, and it isn't performed here at Benenden.

So on the left hand side, the one with the pink ball on the top or femoral head. That's an uncemented hip replacement. It's coated in hydroxyapatite, or a porous coating, and your own bone recognises it and grows into the stem over a three month period.

The same with the shell that's got porous or hydroxyapatite coating on it, and the bone grows into that on the right hand side, the shiny one with the light brown head, ceramic head on the top. That's this, the cemented hip replacement. It's highly polished, because, as the the stem sinks slightly into the cement, it actually becomes more stable, more stable construct.

So what's involved? It's an operation that's performed under spinal anesthetic with sedation. Where you're numbed from the waist down, you're placed in the lateral position, lying on your side for about an hour or so. An incision is made to access the hip joint, and there are various different approaches that are used to access the hip.

The most common two are the direct lateral approach and the posterior approach.

I would say that if your surgeon is a high volume surgeon performing either of those two approaches, then they're both absolutely fine to do the job, and should give you a good, well functioning and recovering hip.

There are some novel approaches through the groin or the anterior approach, some of which use X-ray. There's a steep learning curve with those, and they're not routinely practised.

But it's important to keep an open mind as technology evolves. It's a couple of nights in hospital. If you're flying, you can sometimes go home the next day and there's a scar that you'll have on the side of your hip, which is about 10 to 12 centimeters long, sometimes shorter, or sometimes longer, depending on what access is required to do the job.

There's a picture of post-operative X-rays. The patient, the two hip replacements in situ there has had cemented femoral stems. They're the highly polished, shiny ones that you saw in the image before the patient has got

press fit uncemented acetabular components with large ball ceramic heads, and the picture on the right hand side is the uncemented hip replacement where the stem is, press fit into the bone, and rested on the pedestal there with the collar to give it initial stability while bone grows into it.

Your recovery. This hospital very much supports the rapid recovery protocol which has revolutionized joint replacement surgery over the last 10 to 15 years. When I first started, orthopedic patients used to be in hospital for seven to 10 days after these operations.

Now they're out and about within a day or two, and sometimes they can be discharged on the day.

so the name of the game is to get you up, and walking as quickly as possible with physiotherapy support, you'll start off with a frame for a few minutes, and then rapidly progress to crutches. You'll be shown how to do the stairs, and once you're deemed safe by the physios. They'll discharge you and arrange for you to have some outpatient physiotherapy.

Once you've left hospital. As I said earlier, you'll be in hospital a couple of nights, sometimes just the one. And we'd like to try and get you back to relative normality by about six weeks.

In reality, it's more like six weeks to three months and you'll gradually progress from crutches to a crutch to a stick, to hopefully nothing in that timeframe.

This is a timeline for the recovery. First few weeks it will be sore. You'll have bruising up and down the leg from the buttock all the way down to the little toe. It will go all the colors of the rainbow, and the leg will be swollen. Sometimes you can have some minor weeping from the wound. If it's excessive weeping, then you need to let us know.

You'll be provided with enough painkillers to get you through the first few weeks, and we'll also arrange for you to be followed up with physiotherapy, either here at the hospital or in your locality.

First six weeks you're supposed to lie on your back. You can't drive your car, and you have to avoid getting into awkward positions and sitting on low, slouchy sofas.

By six weeks things start to return to normal again. You'll be able to drive your car. Sleep. However, you like. One thing I would avoid at that period of time, still is to sit on really low slung seats and be careful not to internally rotate your leg too much.

By about three months you should be able to get back to playing golf, going for a swim, riding a bike, doing most things that you like to do.

There's a picture of a scar from a hip replacement that looks like a direct lateral approach the posterior approach. Scar is slightly more on the buttock.

As you can see from the writing there. The vast majority of patients are very comfortable after hip replacement surgery. Once it's settled down, it's been described a little bit as a Christmas card operation.

We're fortunate enough to have gratitude from our patients who send us cards most years for Christmas, thanking them for the operation, as always, very well received, and the aim of the game is to ensure that the hip is as comfortable as possible, for as long as possible.

There are risks with this operation, though you can see from the X-ray. This hip is not lined up properly. The ball has popped out of the socket. That's a dislocation.

There are several reasons why this happens. first of all, there's the surgical ones. Fortunately, even though we try our best sometimes the components are put in slightly, inaccurately, or they've changed position once they've been fitted very uncommon, but it does happen. Sometimes the patient doesn't follow the rules and cuts corners and puts themselves at risk.

Most of the time we can relocate the hip under sedation or a brief anesthetic, and if you're really careful, it may not happen again. But if it was to recurrently dislocate, then that means that revision surgery is very likely to be required.

Unfortunately, but very uncommon. Other risks are blood clots in the leg and the lung. That's why we send you home with a month's worth of blood. Thinning pills to take loosening of the joint means it gradually wears out with time. But modern implants are lasting 20 plus years these days without any any trouble.

We've got to make sure we get your legs the right length. We're usually within about a centimetre or so of that, and you won't recognize that we do all that we can to avoid infection.

The national average across the UK for an infection of a hip joint is about 1/2%. Benenden will be scoring much less than that. It's an ultra clean place, with very, very high standards of hygiene and cleanliness.

Damage to nerves and blood vessels can happen. The big one is the sciatic nerve can get bruised, especially through the posterior approach, and one can get a foot drop, it usually recovers, and we would provide you with a splint to keep your foot at 90 degrees to the shin bone while it recovers.

Fracture can happen. So we have to be careful when we do the operation. And you must be careful. You don't have a fall in the early postoperative period and revision is sometimes needed. If fractures happen, infection happens, dislocation happens, and so on.

So that's the osteoarthritis of the hip and its treatment moving on to knees.

Now it's very similar, but it's just a different joint, really. The knee joint there healthy one on the left, unhealthy one on the right.

First sign is stiffness starts to hurt when you push yourself, you might hear it making some funny noises, usually coming from the kneecap, as the cartilage is no longer pristine as it runs up and down on top of the femur and you may notice your knee's a bit warm and swollen and puffy.

As it progresses, you get pain at rest after activity, it throbs, disturbs your sleep. You may also notice that the knee starts to change shape. It can become bow, legged, or not kneed, and you won't really want to do too much walking. It'll just be too sore to weight bear on.

Treatment options for osteoarthritis at the knee similar to the hip activity, modification to offload the knee weight loss. If you're overweight, that's absolutely crucial, you can really slow down the progression of osteoarthritis of the knee. If you lose a lot of weight.

Physiotherapy is important, for the reasons mentioned earlier, to keep the muscles around the knee as strong as possible, and to lubricate and the joint, and to give the joint nutrition, it needs to be exercised, otherwise it will just stiffen up and become a peg leg.

Painkillers as before, simple ones going up the pain ladder, using the Gp. For cocodamol. Non-steroidal anti-inflammatories.

Knee braces. This one here is an off loader Brace where you can jack out the side of the knee that's worn out the most to try and stop the femur and the tibia touching. They have some benefit and work well for a while, but there's nothing that one can do to stop the progression of the arthritis, unfortunately, and eventually they become ineffective and then we move on to injections.

There are three different types of injections, and all of them have a different action. Really, this is a little bit about synovial pain which is important to learn about, to understand how Arthrosamid® hydrogen injections work which I'll talk about in a minute. So the synovium is a lining that we have around our knee joint and in a healthy knee.

It helps provide nutrition for the structures within the knee, helps provide an optimal amount of synovial fluid. When the knee is damaged the synovium becomes inflamed and produces too much fluid, and in that fluid there are chemicals that cause stiffness and discomfort and burning. They're chemical, inflammatory mediators.

Basically if the synovium remains damaged, the chemicals produced can actually be counterproductive to the articular cartilage that remain and speed up the demise of the knee.

So this Arthrosamid® with hydrogel injection that the hospital offers now works effectively by combining at the synovial lining at the knee and switching off those inflammatory chemical mediators and calming it down again.

So it reduces the joint stiffness, reduces the pain, and helps to a certain extent lubricate the knee. So it enhances the quality of life of the patient.

It purports to be effective up to about four years in the free studies that are ongoing. Analysing this in real time. You can see and research about them on the Arthrosamid® website.

So it's a day case. It's done under local anesthetic. It takes about 20 min, half an hour to do. You have to come in an hour or so before to be given antibiotics. You have two antibiotics to take. Once they're in the system, we proceed. The knee is cleaned, and then local anesthetic is infiltrated as seen.

Here we use an ultrasound to detect where we need to put the the needle. It goes into the super patella pouch, which is a space underneath the quadriceps tendon just above the kneecap and once we know we're in the right place, we inject six syringes of one milliliter each of hydrogel Arthrosamid® through the same needle.

The needles removed, the wounds, cleaned up, the plasters placed on the knee, and that's effectively it. It's important to have a restful 72 h or so after the injection, because the knee feels stiff and hot for a while, and uncomfortable, and the manufacturers recommend that you don't do anything too strenuous for the first couple of weeks.

There's a dedicated rehabilitation program that you'll be advised to follow in the brochure that comes with the injection, and it's available online. And it starts off with basic exercises and progresses to advanced exercises, to really put the icing on the cake and make the most of this treatment.

It's not for everyone, and it's important to look at the indications for use of Arthrosamid®.

So it is a game changer for osteoarthritis of the knee, and it has multiple roles to play. I think, first of all, it's useful for the patient that is relatively young, who has an arthritic knee.

But it's too good to really force the issue and say, you know, you need a knee replacement, because we know that knee replacements don't last forever, and in the younger generation. Their expectations won't be met by a knee replacement.

Your natural knee will always be the best knee you receive, so we want to try and keep that ticking over for as long as we can.

So the first cohort of patients is hopefully going to help out are the younger generation forties, fifties, sixties, and in that cohort of patients that seems to be where Arthrosamid® has the best response rate.

There's also a role to play for those who have chronic medical conditions, where major surgery, such as a knee replacement, would put their health at risk, such as severe renal impairment or cardiac issues, and several patients in their seventies and eighties have had Arthrosamid® to calm their knee down and get a better quality of life. So it has a role to play across the generations.

But it's important to note that the pickup or success rate does drop off as one ages in the over 70 s. It's supposed to be around 63%. So the odds are still in your favor, and you would still most likely get some benefit from it.

Side effects are minimal. There's always a risk of infection of any injection and, as I said earlier, there's some mild joint pain and swelling lasting for a few weeks.

It doesn't work straight away. You have to be patient. It takes up to 10 to 14 weeks to reach maximal effect.

The next injection that's available here at Benenden is durolane, and this is provided for using your membership. They Arthrosamid® you get 10% discount, but you have to fund the rest of the cost. Durolane is included in your membership, and you can have one of these injections for every two year cycle.

It's done in the outpatient setting under aseptic technique and it's essentially a lubricant that's injected in the knee, a bit like Castro Gtx in your car. Hyaluronic acid is a natural acid that's found in all of our joints, but as we age, the concentration of the acid reduces

its primary goal is to provide some nutrition and lubrication to the articulating surfaces, so the idea is this, injection gives you a real high concentration sort of booster.

It takes a few weeks to work, and it reduces friction between the worn out surfaces and therefore reduces pain. It's good and quite effective in the mild to moderately arthritic knee, and it can be repeated. And I've noticed a trend in recent years, where I have a cohort of patients, return to see me just before the ski season, so they can go on the slopes in relative comfort.

It's not always effective. But, as I say, some return for further injections and then the final injection again, that you can have for your Benenden membership is the tried and tested local anaesthetic steroid injection again.

Done as an outpatient. I wouldn't recommend having any more than two to three a year. There's a risk of infection with these injections, and you would have to delay having major surgery, such as a knee replacement for at least six months following this injection. These are quite commonly carried out by primary care practices as well.

So the treatment options, once those injections don't work anymore.

You can correct the alignment of a knee, if it's a bit wonky, and your rest of your knees in good shape, and you're relatively young. That's called an osteotomy, not performed here at Benenden, only usually done in some specialist centers quite high morbidity having the shape of your knee changed to offload the bit that's taking the beats, and there's a lot of recovery and a lot of rehab.

So think carefully about that one, but if done by a high volume chap, and successfully, it may stave off needing a knee replacement for many years.

Arthroscopic techniques. Only a few really exist for an arthritic knee these days, you know, just having it done to relieve pain is a sham procedure now, and will only give you minimal benefit, and sometimes can make things worse.

But there are a few indications, such as a loose body that's making your knee lock. We can fish that out, and the arthritic knee will function better, and you'll be fine again if you have an unstable cartilage tear. That's also an indication to do an arthroscopy to snip that out.

And also microfracture techniques not practiced that commonly. Now. But that's when we drill little holes into very isolated areas of cartilage loss in the hope that fibrocartilage grows over the cracks. You have to be non-weight, bearing for quite a while and the recovery afterwards is quite intensive and not always successful.

So yes, think carefully about that one, and then you've got cartilage transplantation and stem cell therapy not available in the mainstream, but at specialist research units like the World National Orthopedic Hospital in Stanmore and a few private hospitals.

You can consider having stem cell therapy to try and regenerate the cartilage loss. Very novel, and not usually covered by private medical insurance and very expensive.

Certainly, worthwhile thinking about. If you're in your thirties and forties, and you've got an isolated defect in the bone a small one, I'd certainly consider getting in touch with the Royal National Orthopedic Hospital in Stanmore, which is the closest unit to where we are to see whether the patient would be amenable for that treatment.

Then the final option is the knee replacement.

It's a common operation, just like the hip. About 100,000 are done a year. Average age is about 69. Most patients are female. Most patients are significantly overweight, unfortunately, and most patients get a good reported health outcome afterwards.

80% of the knees now are going for a good 20 years with the latest implant technology.

The aim is to provide you with relief of some pain, improve your mobility, and restore your function and realign a Bendy leg if it's a little bit bowed or not need. But the overarching aim is to relieve pain. And similarly, the overarching reason to offer someone a knee replacement is unremitting pain.

We have to be careful with the younger patients, the 50 to 65 year olds, because they still have an engine of a 21 year old and want to do crazy things, and the knee replacement isn't really designed for that. You can, however, get back to relatively high function, like riding a bike, playing golf, playing doubles, tennis, swimming. You can even go skiing at your own risk. So you know, if everything goes to plan, you can still do quite a few things.

The one that we use here is the vanguard knee replacement made by Zimmer biomet. It's been around about 15 years or so, and it has the highest ODEP rating of 15.

A ODEP stands for orthopedic devices, evaluation panel. And it's an independent organization that evaluate all of the implants across the board, hips, knees, shoulders, etc. And to get 15 a. That essentially means that there is independent orthopedic literature, stating that the survivorship of the implant at 15 years only 5% or less have needed to be revised for any cause.

and you can see from the next stat that it has a 10 year survivorship of 96%. So it works.

It doesn't mean to say they don't go wrong they can get infected. You can fracture the bone around it. And there are other things that I've mentioned earlier with the hips that also apply to the knees.

It's cemented in place. You can do a patella resurfacing, or you can leave the patella as a native patella that is, down to the surgeon's preference. I'm a selective patella resurfacer. If there's cartilage loss on it. Certainly in a younger patient, I would advocate having a patella resurfacing because you know that the arthritis is only going to progress, and five, 10 years down the line the knee replacement will start to hurt.

Then subsequently another operation might be required, whereas if you're in your late seventies early eighties, and there's just a touch of arthritis on the kneecap, it's probably best to just leave the kneecap alone recovery from a knee replacement

Again, You're in hospital for a couple of days in a private room. You'll have a dressing on your knee. It'll be bandaged from groin to toe for the first 24 h, and it's unwrapped in the morning your pain will be controlled. Using the rapid recovery protocol again with spinal anesthetic sedation, and then nerve blocks injected around the knee.

In some cases this will be topped up by medication and ice packs that the nurses will provide for you. You'll be visited daily by the physios that will go through a drill with you to get you up on your frame, and then crutches and show you the importance of knee bending exercises.

You won't go home until it's safe to do so, and it's absolutely super important to have physiotherapy arranged after you leave. It's much more important to have Physiotherapy for this operation than it is for hip replacement. You should really ideally check in with a Physiotherapy once a week to make sure you're hitting all the milestones, otherwise the knee can get stiff, and it's really hard to backpedal once it stiffens up

First couple of weeks. Well, actually, the first six weeks is going to be sore. It's like going to hell and back, really, for the first six weeks it is one of the most uncomfortable procedures, and you just have to grit your teeth.

Get the ice packs on the go. Make sure you take the painkillers regularly. It's so sore because it's quite a superficial joint, and you've got a big wound over the front, and you've still got to bend the knees. You've got to do the exercises while the wound's healing.

But it is no pain, no gain. Basically. Eventually the bruising settles, the pain settles down, and by about three months. You're starting to feel the benefits of the operation.

But some people say it can take up to a year to 18 months to fully recover. Certainly, that's been my experience. Some people fly through and super by three to six months. Other people take longer.

It doesn't mean to say anything has gone wrong. It's just that you take longer to recover.

These are the risks. So all of these are the same, really as hip replacements. There's one to add, that's patella tendon injury. It's very uncommon, but very debilitating happens once in a blue moon, where the kneecap tendon is pulled off the knee, it has to be repaired, otherwise you can't straighten your leg afterwards and the repair means that the leg goes in a splint for eight weeks, which stiffens up the knee replacement but and that means extra hard work with the physios afterwards.

So moving on to the Rosa. This has been here at Benenden now, I think, nearly a year or so, and it really is a game changer if you wish to have the latest technology to help perform your knee replacement.

So it is a robotic assistant that helps the surgeon personalise the knee replacement to the individual and improves the accuracy of the implant positioning the implant. The bony cuts needed to shape the bone to fit the implant. It also helps to balance the knee replacement, so it feels stable throughout a range of motion, and all of these things can be checked before we even put the real knee into the individual. That's what's really clever about it.

Also, if you have the my, the ROSA knee replacement, you get automatically signed up to the my mobility app which is like having a physiotherapist in your pocket. It sounds a bit daunting, but actually it's fantastic.

It gives you exercises on a daily basis for a whole year after the knee replacement that you follow the online videos. And if you don't do it, it will send you a reminder and nag you till you do it. Also using apple watch technology or an ipad or an iphone. It will count the number of steps you do. It will calculate the range of motion, and it will show you if you're hitting your targets or not, and if you are really struggling.

It will flag it up to your surgeon, and you can actually communicate with your surgeon via the my mobility app remotely so the benefits of the ROSA knee system.

I briefly alluded to it, but the other benefits are that there's less surgical dissection required. The incision is slightly smaller. We don't need to drill a massive hole down the canal of the bone, the femoral bone to fit the standard conventional jig.

So on balance it probably should recover quicker and should have less pain, not guaranteed. But certainly I've noticed people do recover quicker, having had a ROSA knee replacement.

And if you're in less pain and more mobile, faster, then it offers the opportunity to have a shorter stay in hospital if necessary, you know, if achievable.

So how does it all work? So essentially, it's the setup is the same as a standard knee replacement.

He had the same anaesthetic. It's the same implant. It's the same surgeon, the same scrub team. The only thing that's different is that the rows of robots in the room with a clinical specialist from the company, and what we do is we open up the knee as usual.

We fix once we've done the approach, we then fix two tracker pins into the tibia and two tracker pins into the femur, and these communicate with the robot.

Once these pins are in, we do some registration of the main landmarks, such as the femoral head center, different parts of the knee, your ankle, and so on, and it builds up a three dimensional picture of your knee in real time, or of your whole leg. Actually.

And once that's done, we can actually see your leg on the computer screen, and we can put the knee out into full extension, and can see exactly how deformed it is, how much fixed flexion you've got, how much varus or bowing you have, and we can test the laxity and the stiffness in the ligaments.

Once we've recorded that information at 0 degrees 45 degrees and 90 degrees of flexion that is placed into the computer, and it generates a preoperative plan that we then stand back and have a look at and work out what we need to adjust to give the patient the best knee replacement possible. We can adjust the position of the implants, the level of the bony cuts to produce a balanced knee replacement.

Once we've balanced all the figures if you will, and we're happy with it. We then proceed to actually performing the knee replacement, and the ROSA cutting arm comes across.

and it fixes onto your bone. It only fixes where the plan wants it to fix. If we fix it in the wrong place, an alarm goes off, and we have to reset it and fix it where the robot planned. Knee cuts need to be. We then cut the bones, and the cut is invalidated against what the robot set preoperatively.

If the cuts are fine, we move on to the next step, and once we've done all of the bony cuts we then fit the trial knee replacement into place, and then go for another knee State evaluation to see if our preoperative plan has been mirrored with the trial implants and whether any tweaks need to be done, such as removal of extra bits of bone or soft tissue release to just to perfect it and balance it properly once we're happy.

With that no further bony resection is required. Essentially the robot is defunct, it goes to sleep for a while, and we put in the real knee in the usual standard fashion.

Once the real knees in, we can then go back and do a final knee state evaluation, using the robot. If we wish just to make sure it matches up with the trial bit late to change things at that stage. But you can adjust things slightly. You can't do anything with the implants, but you can certainly do a little soft tissue release and things like that just to perfect it. And then the pins are removed and the knees closed up in a normal fashion.

Yeah, does the robotic arm perform the surgery? Nope. The surgeon performs the surgery throughout the whole procedure. But the robotic arm is there to improve the accuracy of the bone cuts.

Is it right for you? You'd have to meet with your surgeon. Nearly always the ROSA would be an excellent adjunct to providing you of the best quality knee replacement you can get for yourself.

There are a few indications where it's not a good idea, such as extreme deformities that require more constrained knee replacements.

Is this the video? I think it might be. Yeah, I'll just play this briefly to show you. It's like a minute or so long.

So in a conventional knee replacement we don't have that luxury we have to go by feel and tactile feedback. We don't have the opportunity to validate anything that we've done once it's done, it's done. Whereas with the robot ROSA system. You can check every step, and, if necessary, adjust every step.

So just to finish off. There are some patient decision, support tools that are available to help one decide when the time's right to proceed. And also you can get information about your surgeon from the National Joint registry. There's a public sector available that you can look up.

And you can check out the hospital as well on the private healthcare information network, and Benenden has been signed up with the Doctify initiative now for a few years, and this has several thousands of feedback, and they look like they put my figures up there, too. It's very nice of you guys.

So this is the question and answer session now, and these are the latest prices. I believe.

Damien Gregory

Yes, no, absolutely. Yes, thank you, Mr Oliver. Also for covering so many subjects.

Mr Matthew Oliver

I take a sip of my drink, now.

Damien Gregory

Yes, good, you refresh quickly while I start reeling out some of these before we finish. So we've got Nicola is asking. This was actually relating to hip surgery. It's how do you actually determine the size of the joint to use.

Mr Matthew Oliver

So from the X-ray which is taken the clinic here we can template it with the implants that we intend to use. You have to calibrate the X-ray first, and once that's done, we can superimpose on your X-ray the hip femoral stem and the socket and it will tell us roughly, the size is going to be. It's either that size the size below or the size above most of the time. It's the size that you've templated, and then, when we're in surgery, we have trial instruments that we use to make sure that we get the most precise fit.

Damien Gregory

Grand. Thank you, Carol, also relating to hip surgery. So Carol practices ballet and wants to ask whether she'll be able to fold her legs post-surgery, and if so, when she'll be able to do that roughly.

Mr Matthew Oliver

Yes. So after six to eight weeks has passed, you can return to nearly all activities, and Yoga Pilates ballet and things within reason can certainly be enjoyed. You can cross your legs. You'd have to be careful with extremes of movements. I wouldn't recommend doing things like the splits or similar extreme flexion, extension maneuvers, but most things you can do.

Damien Gregory

Thank you. We've got an anonymous question here relating to robotic surgery, and you might know this abbreviation. Is it possible to still have this with Af. Would that be a familiar.

Mr Matthew Oliver

Atrial fibrillation.

Damien Gregory

Thank you.

Mr Matthew Oliver

Yes, yes, for certain. As long as your AF is controlled with medication. And that's not a contraindication to having knee replacement, surgery.

Damien Gregory

Lovely. Thank you. We've got Denise asking Arthrosamid® and durolane injections an option, if you've already had a partial knee replacement, but now have issues with the other half of the knee.

Mr Matthew Oliver

That's an interesting question. Actually, I certainly wouldn't recommend having a steroid injection. If you have half a knee replacement in place just in case it causes an infection.

But with regard to Arthrosamid®, that doesn't have steroid or durolane in, if done, restrict aseptic technique. Having counselled the patient about the risk of introducing infection by using the needle into the knee.

I don't see why you can't do that. To be honest, I've never done that, but I don't see why you can't. I certainly wouldn't recommend putting a steroid injection into a knee replacement 100%. No, to that.

Damien Gregory

Okay, interesting. And Min asks whether her osteoporosis would affect knee replacement.

Mr Matthew Oliver

So if you're treating your osteoporosis with vitamin d and calcium and supplements, and you're on a bisphosphonate, then usually osteoporosis isn't a contraindication to knee replacement surgery. If the bone in the tibia, it's the tibia that is the tricky one, because that's the bit that has to take your weight through it. If the bone is quite soft.

Then the tibial component can have a stem fitted on it. So we've got a knee tibial component here, and the traditional way of fixing it in is to put cement around here and on the keel, and then cement on here and down here, and then you leave it in place for it to set. If the bone here is like honeycomb and very soft and spongy, due to osteoporosis.

Sometimes this stem needs to be elongated to go further down and cemented to give a more robust construct. But normally, osteoporosis doesn't cause a problem.

Damien Gregory

Okay, thank you. So we we touched on hip surgery. But Tim was asking with the ROSA procedure, Is that done under a general.

Mr Matthew Oliver

So ROSA procedures done under spinal anesthetic. With sedation. It can be done under a general anesthetic, but it is much preferred to provide a patient with spinal anesthesia for joint replacement surgery, because it gives you excellent pain relief. For several hours afterwards it reduces your blood pressure, so you don't bleed so much, and it reduces the risk of deep vein thrombosis. So it's all win win with a spinal anesthetic.

Damien Gregory

Yes, okay, lovely. Thank you. And Joanne asks, is there an equivalent knee score to determine when it's the right time for surgery? I don't know if that's a.

Mr Matthew Oliver

I think there might be. Actually, there's the Harris hip, score, the Harris knee score the hospital for special surgery knee score, and there might. I think there is an Oxford knee score. Actually, you know, I've never used that. It's hips. I've used it for.

Damien Gregory

Right? Okay. Okay, Grand. Oh, sorry that I'm losing track of that one, because we sort of answered that one.

Joanne asks if it's still possible to have knee injections, if you are obese, or with a high Bmi.

Mr Matthew Oliver

Yes, that's not a problem using the ultrasound scan. It helps us to accurately position the needle in the right place and because the knee is a reasonably superficial joint. If we weren't to use ultrasound and do the other two injections in the clinic, we have a very, very high chance of hitting the spot successfully, so no obesity is not a contraindication.

Damien Gregory

Okay, fantastic. And yes apologies David. I think I missed your question at the beginning. He wants to know your opinion on Glucosamine and Chondroitin Capsule.

Mr Matthew Oliver

Yes. So the glucosamine and Chondroitin sulfate have been around for about 20 odd years. Now there is reasonably robust scientific evidence behind glucosamine in slowing the progression of osteoarthritis.

The big study that I remember from when I was doing my exams quite a few years ago now was carried out, I think, in Wales. I think it was Wales. And the study basically had two arms to it, those on Placebo and those on Glucosamine and those on Glucosamine actually delayed their knee replacement. They wanted to come off the waiting list.

So that was a positive finding, though, conversely, there's very weak scientific evidence to show it has any effect at all. So I've always recommended to ditch that, and just take pure glucosamine supplements.

Damien Gregory

Lovely. Thank you. I tell you what, we'll take one more just because we can combine these two, and that is how soon after can we have an Arthrosamid® injection after some unsuccessful previous steroid injections.

Mr Matthew Oliver

I think you can. I think you should wait about probably four months, and then I think it would be okay to go ahead.

Damien Gregory

Okay, Grand, thank you. Right. We'll leave it there then. Now, if there are some still questions unanswered. If you've left your name, what we'll do is we can answer your emails, answer your questions via email.

If we can just move on to the last slide.

So as a thank you for joining this session. We are now offering 50% off the value of your first consultation. If you're using Code Ortho 50, you'll get a call back from your dedicated private patient advisor an email with a recording treatment, information and loyalty reward points and update on new and future events.

We'd be really grateful if you could complete the survey at the end of the session to help us shape future events. If you'd like to discuss or book your consultation, our private patient team can take your call up until 8pm tonight, or between eight and six Monday to Friday.

You have more events and webinars coming up on Hernia repair cosmetic surgery, shoulder pain and cataract surgery. And you can sign up to those via the website.

So on behalf of Mr Oliver and the expert team at Benenden Hospital. I'd like to say, thank you for joining us today and hope to hear from you soon.

Thank you.

Mr Matthew Oliver

Thank you. Bye-bye.