Louise King

Good evening, everyone. Welcome to our webinar on robotic assisted surgery for knee pain. My name is Louise, and I'm hosting this session. I'm joined by a presenter consultant and orthopaedic surgeon, Mr. Alex Chipperfield. 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 by using the Q&A icon, which is at the bottom of your screen. This can be done with or without providing your name. Please note that this session is being recorded. If you do provide your name, though. If you'd like to book your consultation, we'll provide contact details at the end of this session, and I'll now hand over to Mr. Chipperfield, and you'll hear from me again shortly over to you. Thank you.

Mr Alex Chipperfield

Thanks, Louise. Good evening, everyone. My name's Alex Chipperfield. I'm a Consultant Orthopaedic Surgeon here at Benenden, and I'll be talking to you today about knee replacement, knee arthritis, and robotically assisted knee replacement. Sorry to disappoint all of those people who are expecting there to be two of us tonight. It's just me in the end. So sorry about that.

A little bit about myself. I've been a doctor for 27 years now. I trained in London and the south-east of England as a junior doctor. I then went over to Australia to do a fellowship and then came back to East Kent in 2010, and I've been a consultant here and hereabouts ever since. For the last 14 years, I've been working at Benenden for the last 12 of those 14 years, and my specialist interest is in hip and knee replacements. So I spend all my days talking to people about worn-out hips and knees and replacing them.

So about this session, we are going to briefly talk about the signs and symptoms of arthritis in the knee. We'll talk about various different treatment options. Then we'll go through the process of what's involved with a knee replacement operation. What the process and the recovery are. Then we'll talk specifically about robotic assisted knee replacement that we offer here at Benenden, and then there'll be a question and answer session. So any questions during or after the talk? Please type them in, and I'll be happy to do my best to answer them.

So the first slides are about what the symptoms are of knee arthritis. Essentially, arthritis happens when the normal smooth coating on the ends of the bones, the articular cartilage, starts to wear away and degenerate and fragment, and you get to a situation where, instead of having lovely, smooth surfaces gliding over each other, you have rough areas that grate and grind and catch and grate, and so on, typically in the early days. These symptoms will be episodic. You might notice pain and stiffness first thing in the morning, when you get up. You might notice that with demanding activity, excessive movement, or carrying lots of weight, you find that your knee can be stiff. You can get grinding and clicking. You can also get swelling and inflammation of the lining of the knee joint and of the tissues surrounding it. So you go from a situation on the left, where you've got a lovely smooth surface, to one on the right, where things are starting to break down and fragment. The end stage of that is when the articular cartilage completely wears away, and you are left with what we call bone-on-bone arthritis. That's where there's no gap at all left between the ends of the bones, and the bones scrape against each other, and you can see that on the X-rays on the screen there. when you're getting into the later stages of arthritis. Your knee hurts when you're not doing things as well as when you are doing things, so you tend to get trouble. You get pain at rest as well as with movement. Your sleep will start to get disturbed, and the things that you could do you can do less of you can't run. You can walk less far. You have to start using walking aids to help you get by. Coupled with that tends to be deformity of the knee joint as well, and that deformity can be as a result of not being able to fully bend or fully straighten the knee or deformities either one way or the other, so you can go knock, knead, or or bow legged, depending on which side of the knee joint is more worn with the arthritis treatment of arthritis, essentially in the early stages, is non-surgical on the whole.

So the first thing that we try to do in the early stages is to try and live with the pain. Try and minimise the amount of symptoms that you've got. So if you're putting a lot of pressure on your joints because you're overweight, then it's quite good to lose weight and take some pressure off. If things are getting stiff and weak because of lack of movement. Then, seeing a physiotherapist to get your movement and strength back again will help painkillers. Painkillers are great in the early stages of arthritis and can make the difference mean the difference between you having a good night's sleep or not, or being able to complete a round of golf or not so simple over the counter. Painkillers and anti-inflammatory medications can be quite useful. Some people find that they benefit from strapping and braces to support and maintain the strength in the knee, and there are lots of different braces available on the market. Some are good, some aren't. Some people get on with it, some don't, and it's very much a case of trial and error. Finding the right ones that work for you. Once you've done that, that's the first level of treatment. The next level would be things that are slightly more invasive, such as injections into the knee. There are a few different kinds of injections that you can do to try and minimise or stave off the symptoms of arthritis. None of these are a cure for the problem, but they can turn something that's difficult to live with into something that's easier to live with. Typical injections would be things like a steroid injection or a lubricant gel injection or new types of injections that last a bit longer, such as something called ArthROSAmid, which is something that we use here at Benenden.

If and when things progress and you get to the stage where all of those non-surgical means have failed or have stopped working. You then start thinking about coming to see someone like me, a surgeon, and seeing what I can offer as far as trying to minimise your symptoms. There are a few things that you can do around the edges of an arthritic joint to try and get more life and more time out of that joint. Whether that be small operations like keyhole surgery to deal with any loose bodies or rough areas, or try and get things moving a bit more freely. If the joint is significantly misaligned, then then you can do what's called an osteotomy, which is where you break the bones to realign the joint, to take the pressure off the most worn areas. There are surgical techniques designed to try and stimulate or transfer articular cartilage from worn parts, from non-worn parts of the knee to worn parts of the knee. kind of similar to hair transplants, where you take little plugs of hair from one part of your head and put them into another part. You can do a similar process inside the knee joint to try and cover up bald patches of arthritis. All of those things, again, are operations that are designed to help you live with what you've got. Ultimately, at the end of the day, if all of those don't work and your life is being made miserable by your symptoms, that's when you start thinking about knee replacement surgery.

I'm going to pause there for a second. There's a question come through from David, who is asking where the where that strap has come from because it looks more sophisticated than the one that you have seen, David. To be honest, I don't know where that particular one comes from. It's an image that they've used on the presentation. I would, you know, if you go to a medical device website or shop. Then they will have a selection of braces. This one looks like it's made of Neoprene. It also has metal hinges on the side. This is what we call a range of movement, Brace. It tends to be used more for supporting patients when they're recovering from surgery. That means that you have to restrict their movement. such as a ligament reconstruction operation rather than one that will take the pressure off things when you've got arthritis, so hopefully that answers that question as well as I can.

So knee replacement, surgery. It's a very common operation. We do. I do hundreds of them personally; every year at Benenden we do about a thousand every year. There's a lot that goes through the doors. There are about one hundred knee replacements performed every year in the UK. It's a common operation for people in later life. The average age is around 69 years old, but it must be said that the age where people are having knee replacements is getting younger and younger. When I started out it was patients in their mid to late seventies. Now it's in their mid to late sixties. I've certainly replaced people's knees in their twenties, thirties, and all the way up to knocking on a hundred. It's still later life. But getting younger There tend to be slightly more ladies than men that have knee replacements. It's about 55, 45, that split, and I think that's something to do with ladies tend to live a bit longer than men do, so there are more older women to operate on.  It is a hugely successful operation. It works really well. The overwhelming majority of people who have a knee replacement are very happy with the outcome. There are some things that can go wrong at some times, and I'll go through that a bit later on.  The other thing to say about knee replacements is that they are incredibly long, lasting, and hard wearing.  I was told by a patient today that knee replacements only last 10 years.  That's wrong. This slide tells me 80% of knee replacements last for 25 years.  Knee replacement, a modern knee replacement done properly will last decades after an operation. Well, they're to get rid of the trouble that you've been having, so it's to help with the pain. 

Once your knee doesn't hurt, then life just feels better. Full. Stop.  We try and aid mobility. So people who have a lot of restricted movement in their knees before surgery, or people who have deformity or instability in their knees. Then you can correct that with knee replacement or surgery that helps just restore natural function and realign the knee joint as well.  Those younger patients I mentioned, the ones that we're seeing more and more of through the doors. They tend to have higher demands. So we're looking now at trying to get back to people regaining the function so they can get back to sporting activities and high-demand jobs.  There are certain activities—certain sporting activities—that are slightly out of the comfort zone for most normal knee replacements.  Expecting to be able to play sets of tennis or run marathons following joint replacement surgery is unrealistic, but being able to indulge in exercise is absolutely standard for a normal knee replacement.  Roger on the screen has asked me if we're able to kneel after a knee replacement operation again. That's something that patients tell me all the time—that you're not allowed to kneel after a knee replacement.  I don't know who's telling them that, because it's certainly not me. Yes, knee replacements are strong enough to kneel on, and you are allowed to kneel on them.  I have many patients who are plumbers, carpet fitters, priests, people who spend a lot of time on their knees, and you can do that. after having had a knee replacement as well.  It can be painful to start with to kneel on your knee. You have a scar right down the front of your knee, and so it does. You can't kneel immediately, but it is certainly something that you can do with time following knee replacement. It's certainly strong enough. It won't mean that the knee replacement lasts any less time, fails early, or falls apart. 

There are many different brands and types. of knee replacements that are out there, and most institutions or surgeons will have one or knee replacements that they offer to patients. that tends to be based on heritage, on track record, on whether or not, whether or not you know how long these things last.  The one that we use here at Benenden is something called a Vanguard knee replacement, which is a new modern-generation knee replacement. That is what's called a condoler knee, so it's more shaped like the bone that is removed, and the aim with that is for it to look and feel and act much more like a natural knee.  The other good thing about the Vanguard knee replacement is. It's of the longest, longest, hardest, wearing knee replacements. according to national joint registries.  It has a very good year-over-year survival rate, you know, right up there with the top knee replacement. So it is absolutely one of the best ones out there, which is why we use it.  The Vanguard knee replacement that we use is held in with cement.  Now, the cement that we use isn't actually cement. It's an epoxy resin that helps and acts as grout that binds. the implant to your bone, and that's the standard way of fixing a knee replacement into a person.  One of the things sorry.  One of the things that's not shown on those pictures up there is the kneecap.  The undersurface of the kneecap can be replaced during the surgery, and whether or not it is replaced tends to be down to the surgeon's preference as to whether or not they replace them regularly or how badly worn or not. The kneecap joint itself is. I find that I tend to replace the kneecap in about or out of knee replacements that I do.  But other surgeons may have different feelings about that recovering from a knee replacement.

So a knee replacement, like we've said earlier, is a big operation. It does require a hospital stay and an anaesthetic, and most people tend to stay in hospital either one or days following their surgery.  you, when, after your operation, you'll come out of the operation with a big bulky dressing, on which will be compressing your knee. That will be removed when you get back to the ward to allow you to start bending your knee and mobilising and getting things going. You will need pain relief following your operation, and that is given by the anaesthetic and by local anaesthetic that I inject into your knee while I'm doing the surgery, and then by initially very strong painkillers, afterwards followed by more regular painkillers that you go home with down the line.  Another good way of dealing with the pain that you get in the early stages. Following a knee replacement is ice packs. You'll have ice packs on the ward, and you can. You can get What's called cryocuffs, which are basically ice packs that are moulded to your knee, that are really helpful in the post-op period to help calm down the inflammation and tightness and swelling that you get following a knee replacement? Besides me visiting you after the operation and having lots of painkillers. You will also see the physiotherapists when you're in the hospital, and they will be the ones that help get you up and about and help you get the most out of the knee in your early stages, and they will also guide you through the first few weeks of your recovery in terms of exercises and getting the most movement and value out of your knee replacement.  There's also a highly skilled team of nurses up on the ward. One of the great things about coming somewhere like Benenden Hospital is that the ratio of patients to nurses is much lower or higher, depending on which way you look at it. What that means is that the nurses that are on the ward have more time to spend with each individual patient. They're not being pulled. to cover a whole ward, and you know that's one of the great things about here is that you'll find that everyone has more time to help you. to get through this, to talk you through it, to guide you through the early stages. There's always someone available who is very good to help. 

Once you leave the hospital, you can, you like, I said. Your length of stay is really determined by how quickly you get up and about and how good you're feeling and how well you fulfil all the discharge criteria.  Most. You only leave happy when you only leave hospital when you're when we and you are happy, that it's safe for you to be discharged; like I said, most people are pretty quick, and it's or nights you. When you leave the hospital, you'll go home normally with a pair of crutches. You'll be able to get up and down stairs. You'll be able to get in and out of the bed and in and out of cars, so you'll be able to transfer and cope and manage and mobilise in the real world. When you leave. Most people will get rid of their crutches or graduate from crutches to a single crutch to a walking stick over a timeframe of a few weeks. Which again really depends on how you feel the majority of people when they come and visit me. weeks down the line from their surgery. The majority of people are walking unaided. Some people might be on a crutch or at that stage. It really is down to you and how you're feeling over the next couple of weeks; it's all about... letting the dust settle from the surgery. You'll be taking painkillers. You'll be having ice therapy. You'll be working on building up the movement and the strength. Everything will be very swollen and bruised and tight, and it takes a bit of time for that to settle down.  Most people notice that after about a month or two the swelling is receding, and with that receding swelling you'll get more movement and more function with your knee. 

There's a question here from Stuart, which is relevant to that saying Will I gain full flexion and straightening following a knee replacement?  The answer to that is the range of movement that you will get following a knee. Replacement is. The majority of it is determined by what your movement is like before the knee replacement. If you haven't bent your knee properly for years. Then the chances of you being able to do that instantly after a knee replacement are fairly low.  Most people follow joint replacement surgery.  You have to work on your range of movement. It's not something that's handed to you. It does take time and effort on your part to get there.  The majority of people will get full extension flexion. Most modern knee replacements will flex to somewhere between and degrees.  What you won't get, or what is very rare, following knee replacement surgery is full flexion, and by what I mean by that is being able to bring your heel all the way up to your buttock. maybe once a year. I see someone who is exceptional who can get that kind of flexion. It's not normal, and don't expect that. But most people flexion to about degrees is what we aim for, and you know what you should be able to achieve. 

Most people are driving at or around the week stage.  It depends on which leg you've had operated on. It depends whether you've got an automatic or a manual car. Essentially, though, you shouldn't drive until you can control the vehicle. left leg automatic.  You'd be driving a lot more quickly than your right knee, because your right knee is the one that you have to be able to stamp on the brakes to do an emergency stop without hesitating, and people find that following knee replacement might take a bit of time. Like I said already, we meet you again at weeks, and most people will be discharged at weeks because everything is heading in the right direction.  If we have any concerns or worries. Then we carry on until the storm has passed.  Most people are back doing most things. around about months, and I certainly advise people, especially people with high-demand jobs, to say, you know, to take it from the outset. Say, you're not going to be at work for months.  You need that time to heal, recover, and build up your strength and confidence again. So take it.  That's what we have to say about the recovery.

I mentioned earlier that there are, you know, some problems that you can get following knee replacement. They've broken down the potential risks on this slide into immediate ones.  Early and late, which is as good as any, gives you structure to the answer.  So there are things that can happen during the operation. You can bleed. Everyone bleeds during a knee replacement. Sometimes you can bleed so much that you might need topping up with blood—a blood transfusion. in a normal elective knee replacement. The odds of needing a blood transfusion are about one in. It's quite rare.  You can get damage to your blood vessels, to your bones, and to your nerves during the surgery. Again.  Those are rare, but if and when they happen, they can be serious, so they are things that we do our best to avoid. But you can't guarantee that it won't happen.  Other soft tissues around the knee, so ligaments and tendons the things that you rely on after a knee replacement to support and move your joint. Sometimes they can be injured or damaged during the process and that can lead to problems later on with instability of the joint, which can lead to early failure or a need for revision. So these are big, bad, horrible things that can happen. Fortunately, they are vanishingly rare, but you do need to know about them. other things that can happen. You can develop infections. The infection rate at Benenden is incredibly low. It's very low when compared locally and nationally, but it's not. There are people that will get an infection, and if you do get an infection, it can be a very serious problem.  People can get blood clots.  We do. everything that we can to avoid developing blood clots or DVts in the leg, but that is a risk of surgery, and it can happen.  Blood clots in the leg are more of an inconvenience than anything else.  but blood clots in the leg. can develop into something more serious; they can break off and sit in your lungs, causing a blood clot in your lungs, which is known as a PE or pulmonary embolus, and those things can kill.  So again, very rare, but a real risk that has to be looked out for. other things you can. You know. We're talking about restoring function and mobility. Sometimes you don't restore full function and mobility, so you may be left with some residual stiffness or swelling, or a limp. other things that can happen at any point down the line. You might get in an accident and break the bone around a perfectly good joint replacement. That can be a reason why you might end up needing more surgery, and we touched on it earlier that artificial joints do eventually wear out, or can eventually wear out, and so you might end up needing revision, surgery, or a redo operation. If any of the parts wear out, or if they start to work loose, or if the bones around a knee replacement start to wear away and fail.  So I don't mean to put you off with any of those things. There are lots of different things that can happen during or after a knee replacement that aren't ideal, like I said before.  It's a good operation. On the whole, most people are very happy with it. If something bad does happen, we do everything that we can to try and make it right. But at the end of the day, there will be some people who go through all of this and end up with a result that's not as good as they or their surgeon had wanted.  So that's a fact of life, really. 

Let's talk about the robot. Now let's talk about robotic assistance knee replacement. with the previous slide.  I've spoken about the potential for damage during the operation. The potential for problems after the operation. Like I said, although this is an excellent operation, there is always room for improvement and there's, you know, people constantly innovating and changing and working at ways to try and get the best. out of a knee replacement.  One of the innovations going forward that we've been looking at is using robotic assistance during knee replacement.  Now, this is why it's important to state here that That doesn't mean that a robot does your operation.  This robot is not a smart, free-thinking device. It is basically a tool. It kind of looks a bit like the mechanical arms that you see on car production lines.  That are used to drill and position things on, and that's essentially what this tool does. It's a tool that helps me to perform the surgery in a more accurate way than a conventional knee replacement.

So what the robotic system does, it gives me more information about how, where, and what angle I'm making the cuts in the bone, and it allows me to fully assess the movement, the stability, and the function of your knee in real time. both before I make the cuts in the bone during and afterwards as well. So it's another feedback tool, another layer of accuracy and confidence that it gives me to allow me to try and get the best from your knee. Replacement.

Here we go. So the benefits of a robotically assisted knee replacement. We spoke about soft tissue injury. If your cuts are more accurate, or if you're not moving the knee in abnormal ways, try and get the conventional instruments in and around the knee. When you're performing the surgery, there is less of a risk of damage to the soft tissue envelope that surrounds the knee. So there's a less likelihood of damage to the soft tissues, either ligament, injury, or just damage in general. Just sort of postoperative trauma resulting in pain and swelling. So there is some evidence that robotic assisted surgery gives you less pain and swelling immediately after an operation than a conventional knee replacement.  Now don't get me wrong.  A knee replacement, whether you use a robotic assistant or not, is still a big operation to go through; it still involves a hammer and a saw and your leg, and it is a painful thing to go through.  That pain may be less with a robotic knee, but it will still be there and that kind of goes on to the next point, where it says, robotic surgery is associated with reduced pain. potentially. If you have a knee in the early stages that is less painful and less swollen, then it may mean that you leave the hospital more quickly. It also may mean that your recovery in the first few weeks and months is a little bit more rapid, which means that you may get back. You may hit those early milestones. quicker than you would with a standard knee replacement.  Better knee function after your surgery. I think what we mean by that is that the function of your knee replacement depends on the implant that you have and the accuracy with which it is put in.  So if you have a knee replacement, the best knee replacement that you can have put in as well as it can be, then your knee will function as well as it is designed to do and that's what we're talking about with the aim, with robotic surgery.  Whether, when you come and have your knee replaced here at Benenden. Whether you have a robotic assisted knee replacement or a conventional knee replacement, the implant that you have will still be the same. You will still have a Vanguard knee replacement.  It will. Yeah. So it's another. It's a tool to put in the knee replacement that we use, as well as we possibly can. 

How does it all work? Well, the ROSA actually comes in two, there’s separate parts to the ROSA. It's quite bulky. There are big machines, both about the size of a washing machine, that come into the operating theatre. That we use during the surgery. The first one is a camera array, and so what that is is a big pair of eyes that sits in the corner of the room, and that will be looking at your knee; more specifically, it will be looking at sensors that I attach to your bones as part of the operation. I attach sensors to the thigh bone and the shin bone. Those sensors via the camera allow the computer with the robot to determine exactly and precisely the location of your bones and joints in real time and space to calculate the angles that we make the cuts with and the accuracy.  So one part of the robot is the camera. The other part is the mechanical arm, the robotic side of that. That's another machine on the other side of you, which is guided by the cameras and the sensor arrays to position the cutting jigs and the alignment rods accurately on your skeleton, so that then I can perform the surgery.  If your knee moves. Then the robotic arm moves with it. You'll see a video in a minute that demonstrates that, probably better than I can say it.  Before when the replacement is performed, we fully assess the range of movement, stability, function, and deformity of your knee, and from that map that we produce during the beginning of the operation. We then plan and assess your surgery afterwards. So we use your data.  your individual data and the D structure of your knee as well as the movement in space to plan the operation.  Great detail during the surgery itself.  Does the robotic arm perform surgery? No, it only moves when I tell it to move; it only moves. to a certain position, and then I have to do the operation. guided by that position. So it is still me doing the surgery, or one of my colleagues.  The job is to put the alignment guides in the right place, which I then make the cuts from.

A question that people ask, and there's here that I can see at the bottom, saying, when do you decide not to use ROSA.  The flip side of that is Is the ROSA system right for me? The answer to that is, everyone is a little bit different. There are on the whole, if you are having a knee replacement, the majority of people who have knee replacements will be suitable for a robotic assisted knee replacement. There are certain things that come into play that make that allow people to make decisions whether or not they're going to opt for the robotic knee replacement. One of them is cost. It's more expensive than a conventional knee replacement. So that comes into play. The other thing is that at the moment here, robotic surgery is not available for NHS patients. It is only through insured or self-funding patients. So those are the criteria, so cost is a factor.  There are exclusion criteria. There are types of arthritic knees that aren't suitable for robotic surgery. One of the main ones is not actually to do with the knee joint but with the joint above the hip joint.  Like I said to you at the beginning, with the robot is actually a camera and sensors that detect your movement and position of your leg.  If your leg is immobile, or if the positioning of the leg is erratic. Say if you have a fused hip joint, or if you have a hip that has been replaced but is failing so unstable or unreliable or moving in an inconsistent way then that means that the data that the robot gets is inconsistent and unreliable, and so it doesn't produce accurate results. So people who have instability or lack of, or complete lack of movement of their hip above the knee replacement would be ones that are not suitable for robotic surgery.  There are certain connective tissue diseases and disorders where the kind of knee replacement that we would need to put in would be something above the standard knee replacement, and robotic assisted surgery at the moment in this hospital doesn't work with revision surgery.  or more enhanced, highly stabilised knee replacement implants The other thing that I would have to say no to at the moment, but will change. is partial knee replacement surgery. So the way things are at the moment. The software and the hardware that ROSA currently offers only work with total knee replacements.  We do do quite a lot of partial knee replacements here as well, where you just replace half of the knee joint rather than the whole thing, and the thing that I'm most excited about with ROSA coming up probably in the next few months, although you can never tell exactly with timelines, is that the upgrade to the robot will be that we will be able to start offering partial knee replacement surgery with robotic assistance as well, and that, I think, will be really helpful.  It's not on the table. Now, please don't come to the clinic and ask about it, because it's just not there.  You'll get plenty of notice from the marketing team and from us when it does become available. Sometime next year is about as accurate as I can say about that. But if you want to speak more about whether or not you'd be suitable for a robotic assisted me, then that's what one of the consultations will be for I spoke about.

How does it work? Here is the mechanical arm. There is someone's hand guiding that cutting block towards the knee joint. There's a little film from the company here that explains that in a bit more detail.

ROSA Knee, a robotic surgical assistant for total knee replacement. Your surgeon is specially trained to use the robot. ROSA Knee does not operate on its own. Your surgeon is in the operating room the entire time and making decisions throughout your surgery. Your surgeon creates a plan for your surgery based on your unique anatomy. 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 we go, lovely.  If you're thinking about having a knee replacement, there are lots of people that you can talk to and ask lots of resources out there. One would be. Come along and speak to me, or someone like me here at Benenden, and we can take you through the whole process. Before that, I would suggest. So one of the things that I look at if people mention other surgeons to me who I don't know who they are. The first thing I do is go to what's called the NJR. Which is the National Joint Registry, and all of us joint replacement surgeons are registered with the National Joint Registry. If you look on their website, you can see a surgeon's profile and why; that's important. That will tell you how many knee replacements or joint replacements that surgeon does, how long they've been doing them, for what kind of patients they operate on, and what kind of results that they get. So it's very useful. Typically, you want a surgeon. who is experienced, who does many joint replacements every year and has done many joint replacements a year for many years, so that kind of information is available via the NJR website, and it's worth having a look at.  There are lots of different hospital and doctor review sites. Doctify is the one that Benenden Hospital uses. Take a look at Benenden's profile on that. Take a look at my profile on that. The results are good, and the reviews are real and genuine and very flattering. So it's worth looking around with. Those.  The joint registry also offers a decision-making tool. which is quite good. It uses the data from the NJR to try and predict the likelihood of you being happy with your knee replacement, and how long it will last, and all this kind of stuff Go onto that website, have a look type, all your data in, and it's a useful thing useful tool in the build up to thinking about knee replacements. 

Another thing that you can do is you can come along and say hello. You can come to a clinic appointment here at Benenden. The other thing that you can do is come along and see myself and Mark Jones, another one of the knee surgeons here at Benenden we're doing and a live face-to-face event at the Spitfire Cricket Ground in Canterbury in two weeks time this time weeks, the 3rd of December.  It's a free event. You can book a place via the Benenden website.  Come along and say hello! You can meet myself and Mark. ROSA will not be making an appearance. She is locked in a broom cupboard here. She doesn't leave the hospital, but you'll get a chance to grill us and talk to us in more detail about everything ROSA and knee related at that point. So come along. It'd be nice to say, Hello. 

Now is the Q&A session. I've done a few already. We've got about 15 to 20 minutes, so I'll do my best to work my way through them. So, Louise, what have you got for us? 

Louise King

Okay, we have a question from Roger. I think it was relating to a slide quite early on. He was wanting to expand on cartilage replacement. 

Mr Alex Chipperfield

I can. But I'm not going to. The reason I'm not going to is because it's not a thing that we do here at Benenden, and it's not really related to knee replacement or ROSA, which is what most people are here to talk about. I can be more than happy to talk to you about it. from a clinic appointment, it? But just to give you a heads up, like I say, we don't do it here at Benenden. There are some surgeons who perform it, some who don't. I don't perform it.  I don't believe that the results that you can get from that are as anywhere near as long, lasting, and reliable as ones that you can get from joint replacement. So I'm not the right person to come to for cartilage transplantation. But I can take you through things, and I can give you a few names of people who I would recommend if you wanted to go down that route. 

Louise King

Thanks. Okay, we have a question from Christine, she says. Will she be able to swim breaststroke after knee replacement? 

Mr Alex Chipperfield

I don't see why not. It does take time to get back to swimming. You're not going to go rusty or sink if that's what you're worried about most people. You can get into a swimming pool once your wound is watertight, and once you start to regain some of the movement, breaststroke is one of the more complex knee movements that your knee would have to go through. It does involve flexion as well as rotation of the knee, and most people find that.  You know it'll come later. Some people never get back to doing breaststroke and end up. Stay with front, crawl, or back, crawl.  It's perfectly possible.  It needs a well-functioning knee replacement to get to that point, and it's not something that you will do the first time you get in a swimming pool. 

Louise King

David mentions Wacko, and he had a knee operation, and that was marvellous. How does the ROSA compare? 

Mr Alex Chipperfield

Oh, Wacko! I presume you mean Mako rather than Waco. 

Louise King

That would make sense.

Mr Alex Chipperfield

Lets mention Mako, because that's right. So as I said, there are lots of different brands of knee replacement, and each of those companies that manufacture replacements manufactures robots that assist that surgery as well. So Mako is A is a different kind of robot, manufactured by a different company, which goes with an implant, a different kind of knee replacement implant.  Mako was one of the first robotic systems on the market and initially, that was the one that everyone went to. in the last few months. The number of robotically assisted knee replacements performed by ROSA has outperformed Mako. So now ROSA is more popular than Mako as far as knee replacement surgery goes.  I'm glad that you had a good result from a robotic assisted knee replacement. Whatever the brand or make, that's good to hear. 

Louise King

Alan asks what type of anaesthesia is used. A full or epidural?

Mr Alex Chipperfield

And the answer to that is both. Most people, most knee replacements here at Benenden and electively in general, are performed under what's called a spinal anaesthetic. So that is when you have an injection in your back that puts the lower half of you to sleep. On top of that, most people will have some sedation as well. Heavy sedation that's put into a vein means that you, you know, won't be fully awake.  You won't be completely anesthetized. But you will be asleep.  So most people, unless you really want to know what's going on.  You won't hear, see, or feel anything about what's happening. 

Louise King

Val says she's having a hip replacement in December but also probably needs a knee replacement, as it's clicking all the time, although not terribly painful. Should she do something about this at the time of surgery? 

Mr Alex Chipperfield

There's not much you can do at the time of the initial surgery. The best thing that you can do is get through your hip replacement. If your knee on the same side is giving you pain, then you may well find that having your hip replaced can help with making your knee feel a bit easier because people do get pain referred down from their hip that they feel in their knee.  So quite often when I see patients who've got arthritis in their hip and their knee as well. We start at the top. that helps with the pain coming from the hip. It can also make your knee feel better. if you end up needing your knee replaced as well. Most people tend to find that they need about months to fully recover from one big operation before they have another one. So I would say. get through the first one. Don't worry about the second one until the time is right for that.

Louise King

That answers Olivia's questions too, if you need both knees replaced, how long do you leave between doing them? I imagine.

Mr Alex Chipperfield

Yes, so I would suggest months you can do both knees at the same time. I do hundreds of knee replacements every year. It is rare that I do bilateral, simultaneous knee replacements. I probably do that once a year. as opposed to the fact that I do one at a time. You have to have a very unique set of circumstances to have a bilateral, simultaneous knee replacement. It's a huge thing to go through, and most people aren't suited, so I would have one done. Give yourself a good time to recover, and then have the second one done.

Louise King

Rajesh says, What material is the replacement joint made of?

Mr Alex Chipperfield

Go back to this slide because there's a picture of it somewhere.  I want pictures of me where we go.  Here we go. So there are parts to your knee replacement of them are shown there. The other part that's not shown. There is the kneecap. So, the main bits are metal. There's a curved piece of metal that fits on the end of the thigh bone and a flat piece of metal that fits on the top of the shin bone. That metal tends to be cobalt, chrome, or titanium.  Then there is. There are bits of plastic. One is the curved piece of plastic that fits between those bits of metal, and the other piece of plastic is the patella button or the resurfacing that we put on the underside of the patella, and that plastic is highly cross-linked polyethylene.  So the answer to your question is highly cross-linked. Polyethylene and cobalt chrome.  The cement, like I said, is an epoxy resin polymer as well. So there you go. Those are all the different bits. 

Louise King

Thank you, Calvin said. Is it recommended to take any exercises prior to surgery in order to assist the recovery process? 

Mr Alex Chipperfield

Yeah 100%.  So when you've had your knee replaced, in order to get the best out of it.  You have to rely on everything that's wrapped around that knee.  You have to rely on the muscles that move your leg on the ligaments and tendons that support and help mobilise things, so the stronger you are before an operation, the more movement, and the more flexibility you have before an operation, the quicker and better your recovery will be afterwards.  So whatever you can do to keep your knee as mobile and strong as possible, basically, you want to come into the operating theatre in the best shape of your life in order to maximise the speed and ability of your recovery. So yes, absolutely.  Keep as strong and healthy as you possibly can before. 

Louise King

I think relating to that. Michael says, How long do you think it'll be until he's able to do some gentle line dancing, I assume, after a ROSA knee replacement?

Mr Alex Chipperfield

Let's assume.  My experience. There's not much gentleness about line dancing. There's lots of hurling people around and swinging around. I could be wrong, but that was the last one I went to. That was a while ago. The answer to that is, it depends how gentle or not you want to be; like, I said, most people think the first month or weeks are about recovery and getting strength and movement back. The next few weeks are all about regaining and improving function. So I would say that you probably won't be in a state to be dancing with any particular grace or skill for the next few weeks. Anytime. After that, I would expect things to. You'd be able to start doing more and more. with the ROSA, with the, you know, hopefully, with the potential to bounce back a bit more quickly. You might get back a few weeks earlier, but you know I wouldn't make any big plans for big events for the st to months.  Thank you.

Louise King

We have questions based around physio. So what amount is included in the package of a ROSA knee replacement, and also if you were to have physio but you have the operation in Kent, but you live further away. Can you have physio more locally? 

Mr Alex Chipperfield

Yes. So the second question, physiotherapy is provided here at Benenden. I appreciate that lots of people come from further afield, and trekking backwards and forwards for physio is not appropriate in some cases.  So yes, there are, Benenden approved. Physios local to you that you can go to, or you may have someone that you already know, local to you that you trust, and that you have used before the Benenden approved. Physiotherapies can be accessed via Benenden society via head office in York.  I would suggest that you make plans for that. before you have your surgery, because all of these things take time to arrange.  Don't leave the hospital and expect to be able to arrange your physio for the next week. It doesn't work like that, so make these plans beforehand.  If you find someone local to you that you trust that is not on the Ben and approved list, then that would be something that you would fund for yourself, but you know, on the whole, that tends to be money well spent. How much physio do you get? You tend to get sessions, I think, which is what is provided. here, and most people find that that is what they need and what they find.  The other thing is that you.  The physiotherapist will be assessing, guiding, and progressing you. But there's so many resources out there about what you can do to help to get the best to progress and get more movement and help, whether that be online via Facebook communities or by arthritis charities or on YouTube videos or knee replacement support groups. There's loads of stuff out there, loads of exercises that help you progress and get better.  Another thing that I haven't mentioned is that there's a digital companion to knee replacement, especially robotic knee replacement, that we offer here called My Mobility, and that is a smartphone-based app that monitors your post-OP progress but also will give you suggestions and guidance for physiotherapy and rehab afterwards. So that's something worth looking at and using as well. 

Louise King

Just one more question. So we're running out of time. Do you give Herperine?  Heparin, heparin. Sorry, heparin.

Mr Alex Chipperfield

One of the risks of knee replacement that we mentioned earlier is developing blood clots.  One of the ways that we try and minimise the risk of developing blood clots is by giving medicine to try and prevent blood clots or thin the blood. Heparin is one of those medicines.  Heparin is that the way that medicine is given. It is given by an injection.  So heparin injections are something that the patients have to do on themselves, and we give a course of heparin with a knee replacement for days. So a heparin injection means that you would have to give yourself injections one every day following this operation.  Most people tend to not like the thought of injecting themselves or not want to do that. So what we tend to give, or what I tend to recommend and give, is a different kind of blood thinning agent, one that doesn't have to have an injection but one that's a tablet, and it's a tablet called Rivaroxaban.  So, and we give you that for days instead of heparin. So you don't have to inject yourself. It's a tablet you take once a day, and it has the same same effects to try and minimise the risk of developing blood clots after surgery. 

Louise King

Right. Thank you. Thanks for going through all those questions, and thank you everyone for sending in very interesting questions. Would you mind moving on to the last slide? Please. 

Mr Alex Chipperfield

It here, somewhere.  So, yeah.  Don't forget to come and see us in Canterbury. There you go. Another plug for that.  Is that it? That's or the next one.

Louise King

One more.  There we go!  Okay, so as a thank you for joining us in this session, we're offering % off the value of your knee consultation, which is a. really reasonable offer, a callback from your dedicated private patient advisor, an email with recording treatment, information and loyalty reward points, and, of course, any news on future events. 

After this event, you'll be sent a survey. We'd be really grateful if you could complete that. So really helps shape our future events and give feedback to our brilliant consultants like Alex.  If you would like to discuss or book your consultation, our private patients team can take your call until 8.30 this evening.  Or in the week from 8am to 6pm using the number on the screen.  We have many more events and webinars coming up on ROSA, including the face-to-face one plus hip surgery, ENT, and varicose veins. They're the rest of the events this year, and you can book up those up on our website. 

So on behalf of myself, Alex Chipperfield and our expert teams at Benenden Hospital, I'd like to say thank you for joining us today, and you'll hear from us very soon, so thank you and goodbye.