Philip Orrell

Good evening, everyone, and welcome to our webinar this evening from Benenden Hospital. Happy New Year to you all! This is our first webinar of 2024, and we're covering a very interesting topic tonight on knee replacement surgery with robotic surgical assistance. My name is Phil, and I’m your host this evening. I’m joined by our expert presenter, Mr Alex Chipperfield, Consultant Orthopaedic Surgeon. If you haven't attended one of these webinars before, the format is as follows: The presentation will last around 20 to 25 minutes, and this 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 by using the Q&A icon on the bottom of your screen. You can do this anonymously or you can give your name, but we should let you know that if you do give your name, this session is being recorded for archiving. If you would like to book your consultation following the session, we'll provide contact details at the end of the webinar. I will now hand over to Mr Alex Chipperfield.

Mr Alex Chipperfield

Thanks Phil. Thanks very much, and good evening, everyone. My name is Alex Chipperfield. I’m one of the Consultant Orthopaedic Surgeons here and I’ll be talking about knee replacement surgery using robotic assistance included in this session so I’ll speak a little bit about myself and then the hospital here that we work in I’ll talk in broad details about the symptoms and signs and treatments for arthritis of the knee and knee replacement surgery in a bit more detail I’ll then go on to discuss robotic assisted knee replacement and what that brings to the field and how that can improve matters and then I’ll be around to answer your questions afterwards so to start with me so I’ve been a Consultant orthopaedic Surgeon for the last 13 14 years now I work here in Benenden as well as other hospitals in Kent I’ve been here since 2012, and I specialise in hip and knee surgery, predominantly hip and knee replacement surgery.

I’m not the only person who works here at Benenden; there are half a dozen of us here who specialise in knee replacement and knee surgery, and their names and pictures are all up on the screen for you to see here.

Knee arthritis: what are the early signs and symptoms? Well, there are a couple of pictures here. The one on the left shows what a normal knee looks like, with lovely smooth surfaces on the ends of the bone, and those smooth surfaces normally glide freely over each other as your knee moves. What happens when you get arthritis is that that lovely smooth coating starts to fragment, break away, and wear down, and you end up with rough, exposed, painful bony surfaces that will grind against each other and lead to pain, stiffness, and feelings of clicking, grinding, swelling, and inflammation around the knee in the early stages. those symptoms can be measured with what we call conservative measures so painkillers physiotherapy sometimes injections kind of thing there comes a point though that that those symptoms will increase things will deteriorate and you'll get to the point where you develop the later symptoms so you get pain not only when you're doing things but pain when you're not doing things as well so you can get woken up at night by pain in the knee the stiffness can limit your physical activity and it can have an impact on what you do or can't do you can get deformities of the knee where the knee will either bow or become more you become more knock kneed or bandy-legged depending on which part of the knee wears out more rapidly all of these things lead to an unhappy painful knee that restricts your quality of life and limits your daily activities.

When you get to that stage it's time to start thinking about treatments there are many different treatments for arthritis of the knee or other joints and they tend to depend on the severity of the symptoms or the impact that it's having on your life generally you with treating any condition like this you start small and build yourself up so the first kind of treatment options that you that you try would be non-surgical so not having an operation looking at physiotherapy to build up the strength and the support around your knee activity modification now what most people interpret that as saying well you can't do exercise or you can't do loadbearing exercise with an arthritic knee actually quite often it's the opposite exercise movement keeping everything around your knee as strong and supportive as possible can help support a failing joint and actually prolong the life of a war worn out knee simple painkiller analgesia, so over-the-counter medications that you can get, such as paracetamol or codeine, work very well as painkillers. There are also anti-inflammatory medications like ibuprofen and paracetamol, which can also help calm down inflammatory changes around the knee. These can be given as tablets or gels that you can rub on that will help some people find that strapping the knee or having a brace can support things and take a bit of pressure off and that can buy you a bit of time and help there are also injections that you can have into your knee typically there are two main types of injections either steroid injections which are very powerful anti-inflammatory injections that can help calm down a big swollen angry inflamed knee the other type of injections that you can have are things called hyaluronic acid injections which are much more of a lubricant or you know and the theory of that is to coat the rough edges and allow the inside of the knee to again glide more freely and these all these non-surgical activities either in isolation or combination can help people live with a worn out knee for many years quite happily eventually though you may well get to the stage where those measures fail or stop working and then you would consider surgery.

There are several different operations that you can do depending on the severity of the disease or the particular distribution of the arthritis inside your knee. There are keyhole surgery operations that you can do; you can break the bones and realign them; you can try; and you know there is some experimental work about replacing lost cartilage to try and increase the cushioning in the knee, but ultimately the only definitive long-term surgical treatment for an arthritic knee that fails all other methods is a knee replacement.

There are lots of different types and brands of knee replacements; it's a very common operation. There are about 100,000 performances in the UK every year, and the results are overwhelmingly good. The average age for someone to have their knee replaced in England is 69, but that age is getting younger as people are becoming more demanding and more active lifestyles have led to knees sometimes wearing out a bit more rapidly than they would have done previously. There's a slight bias towards ladies having their knees replaced over men. It's about 55/45; that may well be just because women live a little bit longer. Another factor may be that women are more likely to have injuries around their knees, especially cruciate ligament injuries due to the anatomy, and that can lead to wearing out of the knee in later life.

As I’ve said, it's a good, reliable operation. The overwhelming majority of people who have knee replacements—more than nine out of 10—are very happy with the results, and it is an incredibly long-lasting, hard-wearing implant. the aims of knee replacement surgery are to decrease your pain and as a consequence of that to increase your mobility and restore the function to your knee balancing your knee correcting any deformity or major loss of movement is part and parcel of that there are like as I’ve said the age of knee replacement surgery is getting younger and with higher demand patients comes the expectation or the wish to get back to higher functioning higher impact sporting activities and more demanding high impact jobs and that proves can be a challenge for Surgeons and for implants so with these greater expectations you the drive is always to try and improve the outcome measures and the functional results following this kind of surgery.

Like I said, there are many different brands and different manufacturers of knee replacements, and they all have different brands. The one that we tend to use the most here is something called the Vanguard knee replacement, which is shown on the slide there. It's manufactured by a company called Zimmer Biomet, and the reason we use that is because it has the best combination of being a proven long-lasting, hard-wearing implant that also performs well on a daily basis. The ODEP rating, the orthopaedic devices rating, gives you an idea of how long these things last, and you know 15a is the best rating that you can get. The vanguard knee replacement tends to be fixed into the bone by using bone cement, which is a kind of grout that holds the metal parts of the knee replacement in place in the bone. This implant can be used with or without patella resurfacing, which is when you replace the undersurface of the kneecap as well. Surgeons are divided as to whether or not they routinely resurface the patella. There are some who never do it, and there are others that always do. I tend to replace the patella maybe eight out of 10 times. Generally, when I see a kneecap that has any visible signs of where I'm doing the operation, I will replace that as part and parcel of the surgery as well.

The operation itself takes around an hour and a half to do, and most people are in the hospital for one or two nights following their surgery. Initially, after the operation, you'll have a big bandage on your knee that gets taken down after the first night, and then we start getting you up and about and getting things moving. Your knee will be painful; it will be stiff, tight, and swollen after the operation, and dealing with that pain and that swelling is the biggest challenge.

In the early days, as far as your recovery goes, you will need pain medications. A lot of people feel huge amounts of benefit from ice therapy and cold therapy to help calm down the swelling, and the nursing teams and the physiotherapy teams will support your mobilisation. In the first couple of days while you're in the hospital, you will be discharged home normally on day two or day one. If you're really flying following the operation, when you go home, you'll be discharged on a pair of crutches and on the necessary pain medications.

You'll be supported in the community by further visits from to the physiotherapist and the first month or so is all about decreasing the pain decreasing the swelling increasing your movement and function as time goes by normally by the time you come back again to see me after about six weeks following your surgery most people are walking independently at that stage some people are using a single crutch when they're indoors their range of movement is improving and the dust is settling from the surgery but that first few weeks is tough is hard work as long once you get through that the results really start to pay off and you notice a big change the recovery itself though from this kind of operation does take weeks and months to get through I tell people not to make any big plans for the first three months because you may not feel ready to be doing most things until that stage but on the whole if you do what you're told if you brit your teeth and get through those early stages you know the overwhelming majority it it's a great operation that works very well.

Potential risks I’m not trying to put you off, but there are a few things that could be potential hazards of the surgery. potential pitfalls, and on this slide, what we've done here is we've divided those up into things that can occur during the operation, things that can occur early on during your recovery, and then later risks of surgery. the focus of this talk is about robotic surgery and one of the reasons why robotic surgery has come to the four is because knee replacement isn't perfect like I said you can see there are things that that can happen during or after the operation and the aim with the robotic surgery is to minimize the risk of some of these things from occurring so if we look at the injuries that can occur during surgery one of the things one of the advantages of robotic surgery is that there's less of a chance of injury to the ligaments or tendons that support the knee in the early during the recovery stage there's talk about stiffness and swelling and limping and again less trauma to the soft tissues around the knee when you're having the surgery Theoretically, this should lead to less stiffness and swelling in the immediate post-operative period. Don't get me wrong, it will still be sore and there is still swelling, but the theory is that with a robotic assistant, that will be less if we look at the late complications that can arise from knee replacement, things like fractured bones, things like dislocation, and things like implant failure due to the implants. Wearing out revision surgery in general, if you can find a way to place that knee replacement as accurately as possible, theoretically those longer-term complications or problems can be less, and that's where the aim of robotic surgery is, so the aim is generally to minimise the impact of the surgery to minimise the risk and to improve the early and therefore later outcomes of the operation.

This is a picture. This is ROSA, the robotic surgical assistant. This is the machine that we use here at Benenden to aid us with the surgery. This is actually only half of it, so the ROSA system itself consists of the robotic arm, which you can see on the slide. There's also a camera system and a camera array that are in the operating theatre as well, and it's these two machines working in harmony with each other that help you and me during the operation to improve the outcomes of your surgery.

So, like I’ve said, the aim and the benefit, or perceived benefits, of the ROSA system or the robotic system in general are to reduce the likelihood of the soft tissue injury around your knee, or rather, limit the damage to the soft tissues around your knee. There are studies that associate robotic surgery with less pain. You know, like I said, that it will still be a painful thing to go through in the early stages, so don't expect to have no pain. Even with a robotic operation, the potential for getting out of the hospital more quickly, getting back to activities more quickly, and having a better functioning knee afterwards is all you know, derived from the fact that if you have a more accurate operation done with less trauma around your knee, then you should bounce back more quickly. I just got to have a drink, sorry. How does the ROSA knee system work? There's a picture of me there staring intently into space, what I’m actually doing there is I’m looking at the screen there's one screen visible on the robotic arm it's in the picture there but then there's another screen on the camera array which I’m looking at so the system works with there are sensors and those are those blue things that you can see that are attached to the bone model that I’m working on their those are sensors that are attached to the bone during the operation those are picked up by the camera system and that then is that the position of your knee and the position of the surgical instruments are then calculated by the system to allow the robotic arm to make tiny adjustments in the movements of the arm when you're doing the operation.

So, a lot of people worry, and a lot of people think that the robotic arm is actually doing the operation instead of me. That's not the case. The robot ROSA is basically a tool that I use when I’m doing your operation; it allows me to make more precise cuts in the bone. The way it does that is by the robot, like I said, knowing exactly where the position to hold the cutting blocks is so that I can use that to make the cuts in the bone myself. So, it's me doing the operation at all times; the robot arm does nothing unless I tell it to, and all it does is move and position everything so that I can do the surgery more effectively and more accurately.

Essentially with ROSA there are or any robotic surgery there are two parts to two advantages to using a robotic assistant one is like I’ve mentioned the accuracy of the cuts and the accuracy of the placement of the implant but there's another part which ROSA has evolved from which is the planning of the surgery and what we what we call navigation in the old days we used to use navigation programs which used those sensors and used those cameras in order to plan the surgery in real time while we're doing it and what the navigation side of the robotic surgery does is it gives you three-dimensional real time information about the amount of deformity in the knee about the movement and about the balance of the soft tissues and if you're accurately mapping out all of those things at the start of the surgery and then at every single intervention or every single cut you make whilst you're doing the surgery you can then reassess that during and after the operation so that planning side of it as well as the execution of the plan allows you to in real time adapt modify and tailor the surgery precisely to the deformity or to the particular pattern of arthritis that you have yourself and that's the big advantage that I find with the robotic surgery is the planning and real time data capture that you have less of when you're when you're not using a robot to perform a knee replacement.

I showed you half a dozen of us who all specialise in knee replacement surgery. All of us will be offering this service down the line. Obviously, it takes a bit of time to get trained up and to make sure that you're safe, comfortable, and confident with the system. Currently, as of January, there are three of us that have passed that final hurdle. Over the next few months, more of us will come on board with that as well.

Is the system right for me? There are a few situations where robotic surgery isn't the right thing to do and interestingly the biggest thing that I find the biggest reason why people might not be suitable for a robotic knee replacement is nothing to do with their knee or how their knee is it's to do with the rest of them and most importantly it's to do with their hip joint as I’ve said part of the robotic process is that real-time data gathering that planning of that an assessment of that movement of your leg during the surgery in order to accurately do that you have to have a hip joint that moves freely normally and reliably and so people who have very bad arthritis of their hip or who've had a hip replacement or who've got a condition that means that their hip doesn't move in a normal way or in a reproducible way they you tend to struggle gathering enough information to reliably use the robot when you're doing this surgery so I would say the number one reason for people not being suitable for a robotic surgery of the knee would be for a pathology around their hip that that prevents that gathering of that data obviously everyone is different and that discussion as to whether or not you'd be suitable for surgery is something suitable for robotic surgery is something that we talk about the consultation when you come along to talk about this with me or any of my colleagues.

The company has provided this video, which just shows a little bit of the movement of the robotic arm in more detail. It's a 90-second video, which I’ll just play here for you. Just so it'll just talk about you, you'll see everything moving, which will give you an idea of what things look like and also give you an idea of what the robot does and what the surgeon does as well, so I’ll just click, and press play for that, and I’ll stop talking for 90 seconds.

ROSA Knee is a robotic surgical assistant for total knees. Replacement: Your surgeon is specially trained to use the robot. The ROSA knee does not operate on its own; your surgeon is in the operating room the entire time, making decisions throughout your surgery. Your surgeon creates a plan for your surgery based on your unique anatomy. The robot 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 personalise your surgery based on your unique anatomy.

There you go, so hopefully that gives you an idea of how things move and how the robot moves during the operation. Get rid of that. The difficult decision, apart from whether or not to have a robotic-assisted knee replacement, is whether or not to have a knee replacement in general, and there are lots of different ways that you can come to that decision. The best way is to have a conversation with me or someone like me who can look at your particular set of symptoms, look at your level of function, and talk about whether or not it would be a realistic thing to do, whether you would benefit from an e-replacement, or whether it's either too early or, god forbid, too late to think about that operation. On the website that is at the bottom, the patient decision support tool is a very useful thing that allows you to use data that is provided by the national joint registry, which keeps and monitors every single implant that has been put in this country over the last 20 years. It's a huge data set, and what it does is allow you to put in your own symptoms and level of function, and it can tell you the level of improvement and the level of functional gain that you'd expect to see following a knee replacement, so that's a very useful tool. The other thing to think about is choosing your hospital and choosing your surgeon, and there are lots of different ways to do that. You can look at the joint registry to look at the surgeon's profile to see how many of these operations they do on a regular basis.

You can also look at review sites such as Doctify to take have an idea of the kind of feedback that that that we as Surgeons get from patients and also the kind of feedback that hospitals get so I would I would recommend that before you think about you know if you are thinking about knee replacement surgery number one I would go through that decision tool because I think that's useful and I would also look around for a clean high volume hospital that has low revision rates and low infection rates and I would look for a Surgeon that has good reviews but also a Surgeon who does this kind of operation day in day out if you're if you're kind of person Surgeon who is doing hundreds and hundreds of knee replacements every year or hundreds and hundreds of joint replacements every year that's what you want in your Surgeon you don't want someone who does one every now and again who does half a dozen a year or so you want someone who does this for a living if you see what I mean.

That's all that I have on the presentation here. Well, now is the time for the Q&A session, Phil. There are a few questions here; should I just go through them from top to bottom?

Philip Orrell

We've got some on the screens here. I can start answering them, and we can see where we go. Yeah, of course, so the first question we have is from Kay, and she says I was told I needed a patient-specific knee replacement due to a pin in the femur. I would like to know about any problems if the pin is removed after about 40 years. Also, if it isn't removed, how good are patient-specific replacements?

Mr Alex Chipperfield

Okay, difficult to tell you about your exact case because obviously you I’m only speaking in general terms what I don't know is where in the femur the pin is whether you know that kind of situation essentially though in the old days before navigation or robotic surgery when one of the first things that you do in order to make try and make your knee replacement as accurately as accurate as possible you put a rod that goes inside the thigh bone to give you the axis of the thigh bone and all of your measurements are taken from that rod if you have something inside your thigh bone that it stops you putting that rod in then that can make life difficult and so that in that kind of situation you would use a navigation system or a robotic system such as ROSA to negate the need to put a rod down inside the femur if the rod so if the pin in the femur is simply obstructing the surgical technique then there are ways to modify your surgical technique to get around it if that rod is so prominent that it means that you can't put a knee replacement in because the metal's in the way then you might have to remove that first having an implant in your leg for 40 years and then trying to remove it is not a benign thing to do to someone and it can you it has its own unique set of circumstances so I think in your case what I would suggest is that you come along we look at your x-rays we look at your knee and we talk about the feasibility of doing the surgery if we can do the surgery without removing the rod then ROSA would be ideal for that if you'd have to remove the rod first then we we'll talk about that as well that's about as good as I can give you at the moment without knowing more about your case but hopefully that helps.

Philip Orrell

Okay, next question: have you come across plasma injections as a treatment for a knee problem?

Mr Alex Chipperfield

Yes, I have, so I spoke about two different types of injections. I spoke about the steroid injection and the hyaluronic acid injection the reason I didn't speak about the other kind of injections which is things called prp or plat platelet rich plasma is because unlike the steroid or the hyaluronic acid there isn't strong scientific evidence that a prp or a plasma injection has any benefit in the medium to long term when it comes to either halting or reversing the arthritic process inside someone's knee so plasma injections are out there the there are people who are huge advocates of that but I’m afraid at the moment there isn't enough objective scientific evidence for me to recommend that you spend your hard-earned money on an experimental treatment there we go.

Philip Orrell

Okay, thanks. Tim asks, Would I be able to jog on a treadmill after recovering from knee replacement surgery?

Mr Alex Chipperfield

Yes, given time, the first thing is that the early stages of the recovery from a knee replacement are all about building up the strength and movement in your knee. If you're the kind of person who goes to a gym and has a treadmill, then you may well also be the kind of person who has an indoor bike or a static bike. Most people find that in the early stages they get more benefit from being on a bike than on a treadmill as regards to improving the movement and strength around their knees. Once everything is settled in and the recovery phase is over following a knee replacement, I have no issues with people walking long distances, either indoors or outdoors, whatever they want. If you're talking about using a treadmill as a recovery tool from the surgery, they probably have other things that are a bit better than a treadmill, such as a bike, but in the longer term, once things have settled, I have no objections to that at all.

Philip Orrell

Okay, our next question comes from Sarah, who asks, Are the replacement joints still made mostly of metal?

Mr Alex Chipperfield

Yes, is the short answer. The longer answer to that is that yeah, knee replacements on the whole are made of a combination of metal and plastic, and that gives the combination of something that is hardwearing and strong enough to function as a knee for many decades but also soft enough to give some cushioning to allow more movements. There have been some advances in the different types of metal, and there are some manufacturers that cerise their metal or coat their metal in other substances to try and make them even smoother, longer lasting, and harder wearing. There has also been some research into developing ceramic knee replacements because ceramic hip replacements are a fantastic innovation. There hasn't been the same kind of innovation when it comes to knee replacements. Ceramic knee replacements are yet to be proven. Metal knee replacements are the mainstay of treatment, but there are, like I said, different coatings on that metal that can theoretically increase the lifespan of the implant.

Philip Orrell

Okay, thanks. The next question comes from Andrew, who says, Is it okay to elect for knee replacement because I’m finding hill walking and other outdoor activities increasingly difficult and painful as opposed to impossible? I have a damaged, displaced meniscus leading to bone-on-bone on the medial side.

Mr Alex Chipperfield

As I mentioned earlier the people people's demands people's expectations following knee replacements are increasing all the time and you know people want to be able to get back to their normal activities such as hill walking and being outdoors that kind of thing and the decision as to when do you proceed to knee replacement when is enough that decision is a very difficult one to make you know you're struggling to do that but you still can do that kind of thing in in the old days people used to wait until they couldn't do that or could barely walk across the room before they before they decided to go down the surgical route and part of that was that knee replacements tended not to last too long or the early versions of knee replacements were mechanically not quite as refined as they are today the decision that you make as to whether or not it's time to have that operation is the simple question is whether or not you are prepared to live with your knee the way it is everyone will have a different level of activity or lack of that they happy with before they proceed with surgery I would, you know, have a conversation with your surgeon as to what your expectations are. What I wouldn't want you to do is be promised something that can't be delivered by a knee replacement, but if you're realistic about your outcomes, if you've got bone-on-bone arthritis, then it certainly would be an option as to whether or not it's the right time for you. That's a discussion to have with your surgeon next time.

Philip Orrell

Okay, moving on to a question this person asks, when is a good time to think about returning to a manual job? Would it be best to wait three months?

Mr Alex Chipperfield

Yes I well I tell people especially people who have a manual job that you will need time to recover from this it is a big operation regardless of whether or not you use a robot you need time to heal and recover and what you need in that time is to be focused you need to be selfish you need to be focusing on yourself you need to be you need to be dedicated to your recovery and what you don't need is people with unrealistic expectations on you about when you're going to get back to work if you tell people that you're going to be off for six weeks work will expect you back at six weeks and you'll be putting yourself under a lot of pressure to do that and you may not feel ready or right to do it especially with a with a manual job if you're job involves a lot of lifting carrying or you know difficult or atypical movements then you are going to need that time to recover and heal so I tell people be very open from the outset say I will see you in three months and even then it may well be that you'll need to gradually return to work either on partial duties or lighter duties until you build up the full amount of strength and confidence in your knee.

Philip Orrell

Okay, thanks. The next question comes from Linda: do you perform partial knee replacement?

Mr Alex Chipperfield

Yes, I do, and nearly all of us who perform knee replacements here also perform partial knee replacements. That service isn't currently offered with the ROSA robotic system, but it is something that hopefully within the next year to 18 months they will be introducing, so yes, we do it using conventional methods to perform those operations, and both myself and lots of my colleagues here perform that, so yes, it is an option, but not with ROSA just yet.

Philip Orrell

Okay, thanks. This person asks if I’ve had injections in both knees and hips that suddenly became much worse, so looking at the surgery, I’ve subsequently been told that I now need to wait six months before surgery. Is this right?

Mr Alex Chipperfield

I presume they're talking about the time between having an injection in your joint and having a joint replacement afterwards. Steroid injections are one of the types of injections that you can have into joints. There is some scientific evidence that if you have an operation rapidly following a steroid injection, there is a slightly increased chance of you developing an infection following the joint replacement. That evidence seems to suggest that the safe window is sometime around six months onwards. Different surgeons will feel comfortable with different levels of risk. There are some surgeons who say if it's within three months of an injection, they're not happy, but any time after that is fine. I think 6 months as a minimum after a steroid injection is a sensible thing to do to minimise the potential for infection. An infection in a joint replacement is a catastrophic event, and anything that you can do to lower the risk or minimise it, then I would suggest that you follow that if you've had a different kind of injection, such as a hyaluronic acid injection, then there's less evidence that that can increase the risk, so that might be something that you need to discuss with your surgeon in more detail to get a bit of clarification.

Philip Orrell

Okay, thank you. Moving on, is there a difference in the length of time for ROSA and non-ROSA surgery?

Mr Alex Chipperfield

Yes, we've been focusing on the good things about robotic surgery, but there are some bad things as well, or some things that are different, and one of the things that you consistently see is that robotic surgery does add time to your operation. Typically, most knee replacement operations take about an hour or so to do using robotic surgery. There are extra steps in the operation, whether it's the placement of the sensors, the gathering of the data, the planning and processing of that, or the movement of the arm, which is slower than a human arm. As you could see from the video, all of these things do add up, and so typically, it would add about somewhere between 20 minutes and half an hour to the length of your operation.

Philip Orrell

Okay, thank you, Robert. I had my left knee replaced in 2021. Having the staples removed was the most painful part. Afterward, could stitches be used instead?

Mr Alex Chipperfield

Yes, so there are two ways that you can close a wound following surgery. One is with staples or surgical clips, and the other is with stitches. Typically, the stitches tend to be dissolving stitches that sit just under the surface of the skin. The advantage of a dissolving stitch is that it doesn't have to be removed. Removal of surgical clips is normally a relatively painless thing to do, but some people struggle, and some people have. You know, every now and again, people hear horror stories from people who, with nurses or other people removing those clips, have really struggled to do that, so typically I tend to try and avoid using staples for knee wounds if I possibly can. The exception to that, though, is that if the skin over the knee is very thin and delicate, sometimes it doesn't; it's not thick enough or strong enough to support a dissolving stitch, in which case I do have to use clips. I find that probably about a quarter of the knee replacements that I do end up having staples. If you were to come along and have your knee replaced by me and you tell me the story of how horrible you found the clips being removed, I would do everything that I possibly could not to use them, but if your skin is incredibly weak and fragile, then we might have to do that. But the one thing that we could change would be the person removing those clips, so instead of going where you had the bad experience last time, I'd be more than happy to do that myself or have one of the nurses here do that instead, so either way, we should make things a bit more pleasant.

Philip Orrell

Okay, thanks. This person asks if I was due to have a knee operation last February. I was scared and did not go ahead. I’ve trained in the gym, and I’m coping. Can a knee become too damaged to have a knee replacement?

Mr Alex Chipperfield

Theoretically, it could realistically happen in the modern world, wouldn't it? There are two things that you think about: one, will everything wear away so much, and will there be such a big furmety that a standard conventional knee replacement is, you know, no longer sufficient? That can happen very rarely in people who haven't, you know, people who've been for whatever reason avoiding coming for an operation every now and again. You end up needing to use a slightly more advanced kind of knee replacement, one of the ones that you might typically use in a revision operation or a redo operation where there's often quite a lot of bone loss. You can use them in a primary situation. If the bones have eroded dramatically, it's really rare for someone to go that long in this day and age in the modern environment. The other part of the equation is the muscles and the joint, the ligaments and tendons around the knee replacement. if you leave things for a very long period of time knees can stiffen and can weaken you can still do the operation but then you rely on those stiff weak muscles and tendons to move the knee afterwards so people who leave things too long from that point of view can often struggle with their with their recovery or it can take longer to recover because they're starting from a much lower base point so you working hard in the gym to keep your muscles as strong and supportive as possible number one it can give you a bit of a helping hand and help delay the surgery which is what it sounds like with you but secondly if you do come to having a knee replacement in the future then you will be at an advantage by having those muscles around your knee as good as they can be that will make your recovery a lot more quick.

Philip Orrell

Okay, thank you. Dawn asks: Is the replacement joint hyper that will allow me to continue with yoga?

Mr Alex Chipperfield

All knee replacement knee replacements are artificial joints made of metal and plastic and none of them can form none of them perform as well as a completely normal knee that doesn't have any disease in the fine movements that involve pivoting and twisting knee replacements will not do the other thing that most people find is that very deep flexion of the knee so getting to the stage where you are sitting on your heel so you're bending your knee so far back that you're sitting on your heels that is very rare to see someone who's had a knee replacement be able to do that most modern functioning knee replacements with a good result you will get to around 120 or 130 degrees flexion but to get to the level where you're sitting on your heels you won't achieve that with a knee replacement and to be perfectly honest if you can do that you probably shouldn't be thinking about a knee replacement in the first place if you've got that kind of movement then you know the it you would it would imply that the disease is not at the advanced level where you would benefit from a knee replacement anyway.

Philip Orrell

Okay, next question: I’ve been diagnosed with osteoporosis. Would this affect the clinical decision to do a knee replacement?

Mr Alex Chipperfield

No, although people are getting younger for their surgery, it is still an operation that you do later in life. In those people, you know, average ages late 60s and early 70s, and with getting older, you get other problems as well, so we're used to operating on people who have multiple medical problems, and as long as they're stable and controllable, then we can perform the joint replacement surgery. We're also used to operating on people whose bones are a little bit weaker as part of the ageing process, and with osteoporosis, you do have to take more care during the surgery. You also have to consider the fact that this knee replacement is cemented, and one of the advantages of using a cemented implant over an uncemented implant is that it can help restore a bit of strength or solidity to bones that might otherwise be weaker, so having osteoporosis wouldn't normally stop you from having a knee replacement. In fact, a lot of people who have knee replacements will have a degree of osteoporosis, which is just part and parcel of being slightly older.

Philip Orrell

Okay, thanks. The next question is I’m 43. Am I too young to consider surgery?

Mr Alex Chipperfield

No, in my book, age doesn't matter; what matters is the level of function of your knee, the symptoms that you're getting, and whether or not that's having a severe enough impact on your life to be thinking about surgery. I’ve done new replacements on people in their 20s and people in their hundreds and everywhere in between essentially what it boils down to is whether or not you are ready for that surgery at 43 you're not too young unfortunately but the younger you are when you have this kind of operation there are certain elements of this operation that are become more relevant to you so the fact that a knee replacement is incredibly long-lasting and hard wearing and last decades is a good thing but if you're planning on living another 40 years it you know the chances are that it may well get to the point where your knee replacement wears out before you die so the risk of the implant wearing out in your lifetime is higher the younger you are when you have an operation the alternative is to wait until you can guarantee that it's going to last you the rest of your life which is fine but what do you do for the next 20 years until you get to that age so really it's all about a balancing the pros and cons of this surgery like I mentioned about the decision making tool earlier in the talk that will give you if you type in your age your height your weight your activities and your symptoms that will give you a very realistic idea of how long that knee replacement is expected to last age is not age is one factor but it's it won't it wouldn't be the only determinant as to whether or not you have your surgery.

Philip Orrell

Okay, this person asks, Do you use a general anaesthetic or a spinal injection?

Mr Alex Chipperfield

Both typically most people who have knee replacements have what's called a spinal anaesthetic which is where you have an injection into your back which will put your legs to sleep the good thing about that is that it stops you from feeling anything during the surgery but it also gives you pain relief after the operation as well which is quite important in the early stages because it's painful on top of a spinal anaesthetic most people elect to have some other form of anaesthetic as well normally what we call heavy sedation so most people who have their knee replaced will be asleep from the waist down with the spinal anaesthetic they'll also have sedation on board as well which means that they won't hear see or feel anything about what's going on you'll be asleep or unaware of what's happening if you want to be completely wide awake you can you're not going to see anything during the operation either way because there will be drapes masking the knee from the rest of you so you don't get to see anything unfortunately if you want to be as you can be if you don't you won't be sometimes for many different reasons a spinal anaesthetic might not work or take in in which case you will have a general anaesthetic where you go fully to sleep either way you won't know what's going on.

Philip Orrell

Thank you, okay? Moving on to the next question, are all knee joints standard, or can a joint be made to measure depending on the circumstances, for example, leg length?

Mr Alex Chipperfield

So no there are custom built knee replacements that are can be tailored you based on scans of your knee beforehand they can be manufactured in order to precisely fit your knee they are prohibitively expensive and overwhelming number of cases unnecessary knee replacements don't just come in one size they don't just come in left or right or small medium or large each of the components that makes up your knee replacement so the femoral component the tibial component the patella if you're having that the plastic that goes in between each of those comes in multiple different sizes of one millimetre difference and so when you're having a knee replacement then and again when you're planning that with the ROSA or with any other system and when you're doing surgery yourself everything is being measured so you we have a selection of 25 different femoral components There are 25 different tibial components. 25 different polymers of all different thicknesses 25 different patella’s All of these things are available, and the implant that you receive is tailored to you in real time during that surgery, but it is tailored to you by choosing the best implant that we have available and building one for you specifically. Like I said, it is time-consuming, overwhelming, and overwhelmingly unnecessary. It tends to be used more as a sales technique than as an actual benefit to you in the long term.

Philip Orrell

Okay, thank you. Unfortunately, we've run out of time for any further questions. I’m sorry if we didn't get around to answering yours, but if you've provided your name, we will answer yours via email.

Mr Chipperfield Can you just move to the final slide, please? So, as you can see on screen, we are offering an exclusive attendee offer, and you receive 50% off your initial consultation. As a thank you for registering for this webinar, you will receive a call back from your dedicated private patient advisor. You will receive an email tomorrow with the webinar recording some treatment information, pricing, and updates on news and future events. If you'd like to discuss or book your consultation, our private patient team can take your call tonight until 8pm or between 8am and 6pm Monday to Friday, using the number listed to the right of your screen.

After this webinar, you will receive a survey, and we'd very much appreciate you filling out that survey. Your feedback obviously helps us improve future events.

Our next webinar is on hip replacement surgery, and you can sign up for that via our website.

All that remains for me to say is that, on behalf of the team here at Benenden Hospital, I’d like to say thank you for joining us today. We hope to hear from you very soon.