Louise King

Good evening. Welcome to our webinar on hip a knee replacement surgery. My name is Louise and I’m your host for this evening.

Our expert presenters are Orthopaedic Surgeons Mr Matthew Oliver and Mr Richard Goddard. They'll be taking you through private hip a knee replacement here at Benenden hospital which we are a leading provider for within Kent and Sussex.

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 without giving your name and please note this session is being recorded if you do provide your name we will see that in the questions.

If you'd like to book your consultation, we'll provide contact details at the end of this session and Paul Pharo will be on hand to take book calls from our private patient team.

I'll now hand over to Mr Matthew Oliver and you'll hear from me again soon.

Mr Matthew Oliver

Good evening ladies and gentlemen, thank you very much for joining us this evening on this Benenden hospital hip and knee replacement webinar. I'm joined by my with my colleague Mr Richard Goddard and I’m going to talk to you about hip surgery and then he'll follow with knee surgery.

So, a little bit about myself, I was appointed as a Consultant in the NHS in 2010 and I started working here in 2012. I've been on adult reconstruction fellowship about hip and knee replacements in particular in Alberta Canada at the University of Calgary for a year prior to my appointment.

I perform double the national average of hip and knee replacements per year usually but with the pandemic everybody had a dive of their numbers we're getting back up to speed now which is excellent news, in the latest NJR report last year I found out that I’d had four hips revised in 12 years so that was quite pleasing.

Included in this session is hip replacement surgery and knee replacement surgery to follow. I'll be giving a brief overview about osteoarthritis at the hip, what's involved with the consultation and the diagnostics, followed by the treatment options, the surgical journey, your recovery and then a little bit of information about patient support tools. So firstly osteoarthritis is her entire condition it's hereditary to a certain extent it is usually of gradual onset can actually come on quite quickly in some cases there's no specific single cause it may be caused by trauma in your youth when you've had a sporting accident that you've just shrugged off as a bit of a groin strain it there are risk factors though that can lead to arthritis at the hip and already there's a familial link. Also being overweight and certain professions and sporting pursuits put more strain on the hip joint. Fortunately it's a treatable condition but it is incurable, there is however quite a lot of advancement in recent years about trying to preserve the human hip joint with various techniques these include using hip arthroscopy and trying to nip the problem in the bud by changing the shape of the joint by nibbling off bits of worn out bone or by repairing the the articular cartilage to a certain extent but once the the condition is taken hold none of those things really really you know they don't really work.

The average age for requiring a hip replacement is approximately 69. That's according to the national joint registry.

So the consultation process you have 20 minutes with us and it's really to get to know each other it's about developing the doctor-patient relationship which I believe is absolutely crucial for a good result it's an elective procedure and you choose to whoever to wish to have your hip joint replaced it's not like it's a life-threatening condition so therefore we have time to develop a relationship and that should hopefully get stronger throughout the journey starting off initially with a positive at the consultation, a detailed history will be taken to include your past medical history and the history of an injury your medication your allergies and any other concerns that you have. Some colleagues including myself occasionally use the Oxford Hip Score which is a validated functional tool to assess how bad your hip actually is it looks at 12 different everyday events such as walking up and down the stairs doing your housework getting up from the seated position and it scores the severity of the arthritis, this is quite useful in the patient that is undecided about what to do next and sometimes it's a barn door case the hip is completely worn out and the patient is in agony but quite a few on quite a few occasions the hip isn't too bad in the patient's managing so it gives us a score that we can then reference against and repeat the score say in three or six months later. Quite a lot of validated research has been done by the oxford group about when the ideal time to have a hip replacement is and the score was out of 48 and they were they reckon around between this a score of 24 and 26 is the ideal time to consider having a hip replacement because if you leave your hip to get too bad the muscles around the hips start to waste you become less active, your cardiovascular ability also declines and therefore recovery afterwards isn't as swift and the end result may not be as good as it could have been if it was nipped in the bud. Following from that you have a detailed physical examination an x-ray the pelvis may be required which we can accommodate for you on the day but quite a lot of the time patients come to see us with an x-ray already provided by primary care which is useful at the end of the consultation it is my aim to provide an individualized management plan for each patient.

While the consultations going on in the back of my mind I’m doing all of these sort of the diagnostic workup really to work out in my head whether it's your hip that's the problem whether it's your spine or both or is it the muscles around the hip that are causing the pain the history and the examination is the key is key to working this out so I may require you to have diagnostic tests such as MRI of your spine MRI of your hip and sometimes an MRI hip arthrogram that's when an injection of contrast is placed into the joint to look at the arctic at the surface and the the the cartilage at the hip in more detail especially a structure called the labarum which can get torn especially in a young patient with pain.

After we've got all the investigations back, we then work out what what to do next if it's a spine and your hip is actually satisfactory I can offer you a cross referral to a Benenden Hospital spinal surgeon quite swiftly if you've got inflammation or bursitis this can be treated in in the first instance conservatively with activity modification, weight loss and analgesics. If it's a severe bursitis that that is not responding to these judgments, I can call upon the interventional radiology team here at Benenden to do an image guided injection and again if you can't get it under control with conservative congestion river into a radiologists can help.

Treatment options are therefore divided into non-operative and operative the hospital has a BMI cut off for surgery about 40 because a lot of show that the passion is at higher risk of complications if they're considerably overworked and also that that doesn't necessarily manage surgical combinations but aesthetic complications so you've been in you've been advised to do your best to bring your weight down to as close to 40 you can I deal like that before going ahead to surgery. The non-operative term is very similar to what I described already it's about painkillers weight loss management activity modification of light load bearing exercise occasionally a steroid injection or into the hip which is again provided by the radiologists here can help matters the caveat with the steroid injection though is that if you did wish to go ahead with a hip replacement we'd have to wait about six months because there is evidence to show that doing the hip replacement too soon after the injection can lead to an infection or increase the risk of an infection and then the final option is the total hip replacement the surgical journey really starts at the consultation process once we've decided that you need a hip replacement. I spend quite a bit of time informing you about the pre-habilitation and that means what I’d like you to do in the build up to the operation that that is to optimize your general health with nutrition exercise and just getting a little bit more active in preparation for the op I understand that you would be in pain but exercise is actually quite beneficial in in moderation the next step in the surgical journey is the pre-assessment clinic and you'll come down to Benenden for the day and meet the pre-assessment team which is a collection of excellent hard-working nurses and the consultant the knee for tissue you'll have a whole selection of blood tests taken an ECG heart tracing and then the other investigations that they seem that they deem necessary this is to pre-optimize you to get you in the best shape possible and I’m particularly interested in optimizing the management of diabetes because there's strong evidence to show that if you have poor diabetic control that also leads to a poor surgical outcome and an increased risk of infection it's important also to correct things like anaemia and high blood pressure and again the pre-admission team will either wash your jeep for help or in some cases we can ask the cardiologists here to help you with further tests like echocardiograms etc the hospital is fully involved with the rapid recovery protocol or heart recovery protocol for hip and knee replacements and has been for many many years and this essentially is a multi-disciplinary approach involving the consultant surgeon, the anaesthetist, the theatre staff, the nurses on the ward, the physiotherapists, we are all working hard together to ensure that you overcome the operation in the most effective and swift manner because the best thing for you is to get you home swiftly and out of hospital.

So the surgical journey continues with admission on the day the operation is usually carried out under spinal anaesthetic with sedation so you'll numb from the waist down and you can be completely sedated or you can actually be completely awake it's your choice most people prefer to be fast asleep we try to avoid using general anaesthetic because spinal anaesthesia is much better at lowering your blood pressure to reduce bleeding and also has been shown as excellent afterwards the first few hours after the operation you're very comfortable indeed it is also been shown to reduce the risk of blood clots in the leg and the lung the operation usually takes about an hour or so and you'll be away from the ward for about two to two and a half hours in total once you get back to the ward you'll be closely monitored post-operatively by a dedicated nurse in your own private room and you usually stay for a couple of nights it's possible to go home the same day if the morning is if the operation is done first thing in the morning and all the stars align and everything's perfect it is certainly possible to go home on the day after as well but the usual duration of stay is two nights you we aim to get you fully weight bearing on your new hip on the day of surgery once the spinal anaesthetic has worn off and the the the physiotherapists will usually visit you twice a day so if you're ops in the morning you'll definitely get a visit from the physio in the afternoon.

The first day postoperatively you'll have a comprehensive check with the resident medical officer and the nursing staff you'll have blood tests taken and an x-ray of your pelvis will also be arranged it would be expected that you should be mobile on two crutches at this stage and it would be hoped that you'll be practicing the stairs on the first day by lunchtime or beyond you should be dressed in your own clothes sitting out for quite a long period of the day some patients though on the first post-op day do have what's known as a vasovagal episode which is like a faint this is due to the spinal anaesthetic and it's quite common and the nurses and the doctors on the ward are very skilled at dealing with this this. It may mean that you'll have to spend a little bit extra time in bed just to wait for that to to wear off usually it's completely gone by the second day so as I said earlier if you're doing really well and all the stars align and you tick the check boxes it is possible to go home in the afternoon on this first post-operative day. Day two more physiotherapy is provided if you haven't been discharged and this is usually the case if you've had a as if you've had one of the vasovagal episodes on the first post-op day when you do go home you'll be supported over the telephone and you can ring at any time to the ward where the nurses will be available to log your call and if they can't deal with your inquiry they'll get hold of one of the surgeons, you'll go home with a four-week course of an anticoagulant to take by mouth a tablet called rivaroxaban and follow-up will be arranged for you to see your surgeon at six weeks. If outpatient physiotherapy can be set up for you on discharge that is a real bonus and I'd certainly advocate that because that really does put the icing on the cake and makes it a good hip replacement into an excellent one, it's really important that you keep up with the exercises and meet up with a qualified physio at least weekly to make sure you meet the milestones, it also reassures you that everything's going to plan you have to stick to the hip precautions in the first six weeks and in my practice that simply means I'd like you to sleep on your back for the first six weeks not drive your car for the first six weeks and be extremely cautious when you bend down to pick things up from the floor. The physios will show you exactly what that means and what that entails before you go home after six weeks we can relax nearly all of the precautions if all goes to plan at the six week postdoc follow-up you'll come back to the clinic and some people will come from far afield and it'll be great to to try and make the most of the trip to Benenden and we quite regularly arrange for you to have a check-up of myself and have physiotherapy on the same day that would be the gold standard I checked the wound I'd like to see that you'd be mobile for crutch or a stick occasionally patients walking without any aids at all you should be safe to drive again and as I said earlier we can start to relax the hip precautions at this stage.

All operations carry risks fortunately they're rare but but we you need to be made aware of them and as part of the initial consultation a lot of time is spent going through the informed consent process listed here are some of the the ones that they aren't common but they're the ones that happen most frequently so infection in a place like Benenden it should be extremely low indeed because it's an elective centre with laminar flow air ultra-high clean theatres and hygiene is of the utmost priority. We don't have any mix of cases, there's no trauma cases there's no medical cases there's no bowel surgery cases or anything like that near the joint replacement patients, so that's quite reassuring really so infection really should be closer to zero, but the average nationally is about one percent. You can get blood clots in the leg, in the long as I alluded to earlier so it's important to get mobile quickly it's important to take the anticoagulants you can get a nerve injury sometimes that's some numbness down the leg very rarely you can get a foot drop, most of the time that resolves within about three months. Very rarely the hip can dislocate in the early postoperative period, if it occurs whilst you're in hospital with us which is incredibly unlikely but not impossible then it will require you to go back to theatre to have it relocated, if it occurs in the community out of hospital and especially if you live out of area is likely you would need to go to your local NHS hospital for support but please let us know so we can deal with it afterwards, there's a small risk of the leg length discrepancy and of course the implants do wear out eventually but the modern hip replacements these days should last at least 20 years, everything being equal.

To finish off my presentation there are several patient decision support tools available and these are increasing in figure and in number over the last few years so you've got the national joint replacement registry surgeon's profile where you can look everybody up who does hip and knee replacements to see their general figures where they operate and their numbers and their volume there's the private health care network where again you can get information about surgeons and where they work and then there are various review sites that you can look at patient reviews to make help you with your decision making process.

So, I'm going to hand you over now to Mr Goddard, one of my colleague who's going to talk to you about knee replacements and knee surgery over to you Richard.

Mr Richard Goddard

Thank you, Matthew, that was a really interesting talk and very informative. My name is Richard Goddard, I specialize in knee surgery. A bit of background about myself I trained as a medical student at the University of Leeds I then did some moved down to London did some research into knee surgery and ligament reconstruction and did a master's degree at the University of London and did my senior surgical training in the Southeast Thames rotation.

Foreign so I'm going to talk to you about knee replacements similar to hip replacements it's a very common operation the main indication is for wear and tear osteoarthritis the other conditions that knee replacement is considered for include inflammatory arthritis which tends to be more of a medical condition you may have heard of rheumatoid arthritis conditions like gout can also affect the knee joint the knee is more prone to injury especially with sporting injuries skiing football you name it you can damage the cartilage in the knee and damage the ligaments of the knee when you're younger and sadly this predisposes the joint to becoming arthritic we'll also see people with fractures around the knee joint and this again damages the integrity of the knee joint and even though surgery is often done when to treat a fracture often it leads to arthritis in the future the goals the names of a knee replacement are similar to what we've heard Mr Oliver talked to us with the hip it's pain relief of the painful arthritic joint to restore the anatomy the alignment and the function of the of the leg and the knee joint and importantly increase increased mobility and the functionality try and get yourselves back to doing the hobbies activities daily activities that you enjoy we're also now seeing a lot higher demand and younger patients with severe arthritis of the knee and this adds more challenging problems to how we deal with an arthritic need a younger patient.

So knee replacement is a very common operation our national joint register highlights approximately a hundred thousand are performed in the UK most years that obviously dipped a few years ago due to the covid pandemic the average age of a knee replacement is similar to a hip fluctuates between 65 and 68 years of age slightly more common in female patients and over 94 of people on studies and questionnaires and and health scores reports a significant increase in their health and improvement in their well-being it's to be noted this isn't a hundred percent not there's not one operation that's 100 successful but the vast majority of people have good benefit from a knee replacement. How long do knee replacements last the technology is getting better I'd probably say that hip replacements on average do better than knee replacements I usually quote an average expectancy of a knee replacement is between 15 and 20 years but this is probably a conservative estimate where studies and joint registers show approximately 80% of knee replacements can last up to 25 years.

Most of the surgeons here at Benenden use the vanguard knee replacement which has a very good survivorship over 96% at 10 years, it's got a long heritage of a successful knee replacement which was the AGC the vanguard's predecessor and over 85% of these AGC knee replacements were lasting 30 years, so we're hoping the vanguard will be similar if not better. It can be cemented or uncemented but commonly a cemented implant is used here at Benenden and the surgeon will decide during the operation whether or not to resurface the the patella the kneecap and there's various options for the knee replacement to be more stabilized if a patient has more severe arthritic deformity.

So what are the symptoms of arthritis of the knee early on? It may not be too severe you may just find a bit of aching and stiffness in the morning pain on demanding activity perhaps long walks or sporting activities than you may become painful often on the medial or the inside of the knee some patients report the sensation of clicking and grinding instability of the knee locking giving way and the knee become can become swollen after activity as the arthritic process progresses the symptoms often become more severe patients describe severe daily pain pain with standing start at pain getting out of the chair, getting out of bed and this progresses to pain at rest and pain at night and patients often report being woken in the middle of the night with pain in their knee. Commonly as the arthritis progresses patients notice a deformity which may be that the knee becomes bowed or some patients become knock-kneed.

So, what is osteoarthritis of the knee? It goes through various stages but if if one was to look inside the normal knee joint the cartilage surfaces would be lovely and smooth and have the appearance of a billiard ball the arthritic process causes damage to the smooth cartilage of the knee and the cartilage becomes crumbly and flaky and then becomes more like the surface of the moon crumbling away and this is grade three or moderate arthritis and then severe grade 4 arthritis is where the cartilage fully peels away from the bone and crumbles away and patients have exposed bare bone and then the bare bone can touch together which we call severe bone on bone arthritis and it's this stage four arthritis when most patients would be in need of a knee replacement.

So, what are the treatments of osteoarthritis of the knee? Similar to hip arthritis, we try other non-surgical treatments first so if if patients do certain activities which cause pain activity modification is important avoiding for example running jogging and trying more activities that don't load the knee joint as much such as cycling and swimming weight loss is important if your weight and BMI is higher than we would like. Physiotherapy is useful to strengthen the muscles and ligaments around the knee which can help the arthritic pain, we should try simple pain killing analgesic tablets either bought from the chemist or prescribed by the GP and some patients find knee braces supports and strapping helpful but not all injections can be tried which can be a steroid injection as we've heard can be used in the hip joint and often if appropriate surgeons may try a hyaluronic acid or duralene injection which can be done here at Benenden and put simply this is a biological oil which is injected into the knee joint trying to lubricate the arthritic joint it must be noted that injections probably are not a a great and effective treatment for severe grade four bone on bone arthritis that can be tried if we're trying to avoid surgery surgical treatment is commonly a knee replacement that in younger patients and if appropriate we may try to correct the alignment of the joint which is called an osteotomy keyhole surgery can be tried to try and debride and stabilize the cartilage and micro fracture techniques to try and encourage cartilage growth again these are often tried in younger patients where we're trying to avoid major surgeries such as a joint replacement and probably worth mentioning but is very experimental at the moment and not many centres are having success undertaking it cartilage transplantation that this is probably the future of orthopaedics and it's basically watch this space.

So prior to knee replacement surgery it's important to get as healthy as possible we've heard Mr Oliver explain the importance of this with the hip joints and it's the same here with the knee joint so good control of pre-existing medical conditions such as high blood pressure and especially diabetes to help reduce the risk of effective complications. Losing weight to get the BMI to an acceptable level which here at Benenden has to be below 40. Pre-habilitation gentle exercise physiotherapy things like cycling and swimming non-load bearing exercises are good to improve the muscle strength around the knee, you would then come to the hospital for pre-assessment clinic to see the nursing team for blood tests, health screening and see the consultants in these tests to discuss the various anaesthetic techniques available, commonly as spinal anaesthetics commonly used for hip replacements.

So, after the operation, it's similar to the hip replacement on the day of surgery you're closely monitored on the ward, medication given to manage pain, sometimes if one is feeling nauseous and sick after the anaesthetic then this is controlled early. Mobilization on the day of surgery once the anaesthetics worn worn off would expect a patient to be helped out of bed, sit in the chair perhaps walk a few steps with help with the physios and nurses with either crutches or walking aids and start to exercise and move the knee joint. It's very important with a knee replacement to get the knee joint moving, get the knee fully straight and get it flexing and bending beyond 90 degrees as quickly as possible. Patients usually stay for two nights but if we do incredibly well may go home after the first day and check x-rays and blood tests are performed to make sure everything's looking okay after the operation.

So potential risks again with knee replacements a vast majority of knee replacements go without any complications. During surgery there's a risk of excessive bleeding and one may need a blood transfusion on the ward the day after the operation that this is fortunately not common and quite rare these days, there can be damage to the bone perforation of the the femur or the tibia or very rarely fracture. There can be injury to nerves causing numbness and again severe nerve injury is rare but you can if a nerve is injured you could be left with a foot drop similar to hip replacements. During recovery we closely monitor for wound healing problems, infection, we give you anticoagulant tablets for two weeks to prevent blood clots in the leg DVT and blood clots in the lungs which can be occasionally serious and life-threatening. Late infections are again fortunately rare and knee replacements don't last forever they're artificial made of metal and plastic and are prone to wear loosening and subsequent failure and if this happens after 15 to 20 years, you may need a second operation to redo the knee replacement.

So there are many different types of knee replacement you can have a partial knee replacement if the arthritis just affects one side of the knee joint, commonly this is the inside and here at Benenden we use a number of partial knee replacements commonly an Oxford knee replacement more commonly the arthritic process affects more than one part of the knee joint maybe the inside structures and also the kneecap joint and then a full knee replacement is is necessary which is the more common technique used and the then more complicated knee replacements for specialist indications such as severe deformity and previous ligament injuries and failure.

So this poor chap here on the left with an arthritic knee has become quite severe and we can see he's got severe deformity of both knees with what we call a very small alignment is is gone very bow-legged and this type of deformity usually needs more surgical ligament release to correct the deformity and we have to use a more stabilized knee replacement which can be done and is commonly done here at Benenden.

If one ignores the arthritic process, it's never a good idea. The joint can become more disfigured and worn and this patient left the arthritic knee to get very bad and we can see the clinical photograph shows a very severe deformity which we can see on the x-rays required a more complicated knee replacement and this is what we need to try and avoid so even if patients don't wish to have surgical intervention. It's a good idea to have a surgeon check your joint every year or every two years to examine the joint examine the ligaments perhaps take new x-rays to make sure there's no complications arising.

Just to mention, knee replacements are commonly not linked together, they're not a constrain joint but occasionally we need to use a hinge which where the top and bottom of the implant is linked together. Commonly this is for revision scenarios and patients with complicated medical problems, bone loss and severe deformities.

With a knee replacements, we're trying to obviously cure the arthritis cure the pain we're trying to correct the deformity and restore the individual patient's alignment and the clinical access to what it was prior to the knee replacement and there is a number of techniques that surgeons can use to try and achieve this this goal.

Patients are generally getting younger and rightly so having increased demands with respect to sports occupation and just higher expectations of what their joint replacement should enable them to do and we're seeing younger patients present with severe arthritis and it's not uncommon for me now to see patients in their late 30s and early 40s with severe arthritis who may sooner rather than later need a knee replacement.

Different surgeons use different techniques but one we occasionally use here at Benenden is the signature technique in my mind this lends itself to patients with severe deformity perhaps abnormal anatomy like previous fractures and malalignment issues which the signature replacement can help overcome and achieve better alignment.

So commonly with a normal knee replacement, one would just have x-rays taken in clinic with the signature replacement we need to do a detailed MRI scan of the hip, the knee and the ankle and this allows a computer program to help help the surgeon determine how much bone to take and how to correct the knee joint, it must be stressed however that not all knee arthritis are not all patients need this extra surgical planning and the vast majority of patients we see a non-signature standard knee replacement is the correct choice.

What signature does is create specific guides that fit the individual patients that the actual knee replacement that is implanted is exactly the same as one would get without signature.

So the results of any knee replacement should be accurate component sizing and positioning recreation recreation of the normal alignment of the the knee joint where possible and usually an excellent on table range of movement it must be stressed that most of us at the end of a knee replacement get an excellent range of movement of the joint in theatre and then it's down to the individual patients with their exercise regime and physiotherapy to maintain a good range of movement both in hospital and then at home.

That's all I've got to say about knee replacements we can see here all the excellent surgeons that perform both hip and knee replacements here at Benenden. Now both Mr Oliver and myself will be happy to answer any questions that you may have.

Louise King

We have quite a few questions so I will go through these quite briefly. How does having a bone graft as well as a total hip replacement effect recovery Mr Oliver?

Mr Matthew Oliver

It just depends on what kind of bone graft has been done before I’d need to have a bit more specific information but if there wasn't a bone graft in place before when you have your hip replaced sometimes you do need to have these are holes in the socket of your pelvis filled with bone and we usually use your own bone to do that we would be aware of those cysts on the pre-operative x-rays and that would be the only real indication for using bone graft in a primary hip replacement usually.

Louise King

Thank you, next question. This person has suffered for a while with hip pain but they are only 51 which is obviously quite young for replacement is it better to try and wait or could it cause other issues by leaving it?

Mr Matthew Oliver

I think I would definitely advise the patient to get their hip checked out just to get a baseline on how severe it is because there's lots of evidence to suggest if you catch the arthritis reasonably early and replace it with the symptoms are starting to be intrusive and the the outcome is usually better. What you don't want is for the hip to continue to grumble on and then suddenly get worse and then take the patient literally off their feet which has happened quite significantly to lots of patients in the covid pandemic due to the access into healthcare so I would definitely recommend that the patient gets it checked and seen by a sensible orthopaedic surgeon I assume that would be the same for a knee replacement as well.

Louise King

Okay, this person says they're in their late 50s and their job requires them to be on their feet most of the working day. If they had a knee replacement, would this still be possible afterwards?

Mr Richard Goddard

During the initial consultation we often discuss the patient's occupation and expectations usually after a knee replacement it's very painful for the first six weeks there's six weeks no driving so most manual occupations that require a lot of standing vast majority of people would be off work for a good two to three months maybe back at two months doing light tutors lighter activities by three months I'd be expecting most patients to be able to get back to most normal manual occupations however those that involve lots of kneeling it may be difficult but we usually don't promise that it will be comfortable to kneel that if kneeling is important at around the six week stage it's a good idea to start kneeling on something soft like a cushion on the sofa on the bed and then progressing to kneeling on a foam mat on the floor but not all knee replacements are comfortable to kneel upon and probably only kneeling for short distance for short periods of time. With respect to walking and standing up all day probably at three months still a bit uncomfortable at six months more tolerable but it can take a good nine months to a year for knee replacements to be tolerable to stand and walk for prolonged periods such as working all day.

Louise King

Okay, this one doesn't specify what type of replacement they just say with a metal replacement would it cause an unusual sensation during cold weather.

Mr Matthew Oliver

I'll say in my couple of lines there's no doubt that some patients have come to see me saying when the the temperature drops or it's a particularly damp day they have the sensation of something feeling a little bit cold in their leg because it doesn't have a blood supply and especially a knee replacement is very superficial not so much of a hip replacement the hip replacement most of the time they forget that it's there once it's all healed up.

Louise King

This person asks can you run after a knee replacement, they're thinking a weekly five to ten km

Mr Richard Goddard

The answer to that is yes and no so as I've tried to allude to, having a knee replacement isn't a quick overnight recovery it takes a good six weeks to get over the worst of it probably by three months I'd be expecting someone to be doing exercise in the gym perhaps cycling or swimming. I wouldn't recommend running on a knee replacement even though people do but certainly give it time, give the ligaments time to settle down if one wishes to run, I'd probably leave it for a good six months to nine months after the knee replacement but my general advice would be to try and avoid running where possible.

The knee replacement is made of metal and plastic so the the weak link is the plastic liner and these are tested in the lab on on sort of simulators and robots and they only last for so many millions of cycles if one was to run 10k every week then that's using many more cycles than someone who's just simply walking on it activities such as cycling and lower risk with a knee replacement and I usually try and advise my keen runners to take up cycling after knee surgery, thank you.

Louise King

Can you please advise how hip replacement how a hip replacement is affected if you've already had knee replacements?

Mr Matthew Oliver

If you have an arthritic hip there's no doubt that you'll be in pain and you'll have stiffness and sometimes even though you've had your knee replaced successfully the pain from the arthritic hip can be radiated or referred down to the knee so it's quite common to go ahead and have a hip replacement after having had the knee replacement and the outcome is usually very successful. The caveat to that is the patient who presents in the opposite way they come to see you with pain in their knee but they've actually got an arthritic hip and when you tell them that they don't need a knee replacement they can't quite understand it because they don't have any pain in their hip it's usually a sign that the hip is extremely worn out and has stiffened up and the pain instead of being felt in the joint the hip joint goes to the knee.

Louise King

What is the recovery time scale for a partial knee replacement?

Mr Richard Goddard

I'd probably say have in your mind similar to a full knee replacement, but usually partial knee replacements make the milestones a few weeks and possibly months quicker, so the pain isn't quite as severe and the swelling is not quite as severe. It's still a big operation, no driving for six weeks, probably six weeks to two months off of off of most occupations and usually by three months most people with a partial knee replacements are doing slightly more walking and activities than a total knee replacement. By nine months to a year they've both evened out and both are doing about the same but generally speaking partial knee replacements recover a few weeks quicker than a total knee replacement.

Louise King

I'm afraid I just have so many of them but not enough time. This person says they understand the older the patient greater risk clotting and by that and that by having a general anaesthetic is the risk is somewhat smaller? This person's 80 years old and would want the risk to be as small as possible. What is the criteria for determining whether an epidural would be appropriate?

Mr Matthew Oliver

So, first of all there would be a spinal anaesthetic, epidural anaesthesia is slightly different and we spoke about it in our talks that the the spinal anaesthetic does reduce the risk of blood clots all the precautions are taken right from the start really in the initial consultation we have to complete a a risk assessment for venous thromboembolism and that is very comprehensive and it's without doubt that the hip or knee replacement would be considered high risk of blood clots hence we offer the the oral anticoagulant for four weeks for a hip and two weeks for a knee. Also there are other adjuncts available so the patients would come back from theatre with devices that squeeze the patient's calves while they're in bed before the spinal anaesthetic wears off to keep the circulation going around. There are other smaller versions known as a foot pumps that squeeze your feet, the patients find them very annoying because they make a little noise every five ten minutes but they that they they do the job and they are usually discarded on the first post-operative day. Once the patient gets more mobile, some patients can also if they're high risk have anti-embolism stockings applied we don't use them routinely here at Benenden but they are available on request and of course it's important to keep well hydrated to stop your blood getting too sticky.

Louise King

So, the final question is how long does it take to get back to normal after a knee replacement and therefore how long should you wait for having a second knee replaced?

Mr Richard Goddard

I'd probably say on average at the three-month stage most patients would say they're happy they've had their knee replacement. The pain is better and they'd notice they can walk a little bit further and they can get back to their activities. At three months the knee replacement still may be a little bit achy and a little bit swollen or a little bit stiff, you must carry on with working hard with the exercises and usually it takes a good six months further, around nine months to a year to the knee replacement to fully fully settle down and all the little niggles go away. When to have the second side replaced is really when the patient feels ready, if they're able to function and get back to normal activities to get the muscle strong then that's often a good idea without rushing. If the arthritis isn't too severe waiting around six months to a year is about normal. If I see someone who has a very severe arthritis of both knees such that wheelchair bound or house bound, at the six week stage if they're doing well we'll then start planning the second operation.

Louise King

Okay, thank you very much both of you.

I'm sorry if we didn't answer all of your questions, if you've provided your name, we will do so via email either tonight or tomorrow.

If you'd like to discuss or book your consultation, Paul from our Private Patients team will be available this evening to take your call for another hour until 8 30. Just use the contact details on the screen. Also, you could call that number from 8am to 6pm Monday to Friday to speak to someone and book a consultation. We're offering a special discount for joining this session the 50% discount is on the screen with the terms as well.

Once we close this webinar, you will receive a short survey and I'll be really grateful if you can spare a few minutes to let us have your feedback, it really helps shape future events for our patients. Our next webinar is on Monday the 30th January on gynaecology, just take a look at our website to sign up to that.

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