Mirella Falcone

Good evening, everyone and welcome to our webinar on hip and knee arthritis. My name is Mirella, and I will be your host for this evening. Our expert presenters are Orthopaedic Surgeons, Mr Kumar Reddy, and Mr Mark Jones alongside Consultant Rheumatologist Mr Amit Saha. The presentation will be followed by a q and a session, if. So, if you would like to ask a question during or after the presentation please do so by the Q and A icon which is on the bottom of your screen, this can be done with or without giving your name. If you would like to book your consultation, we will provide the telephone number at the end of this session. Please note the webinar is also being recorded I will. Now, hand over to Mr Amit Saha and you will hear from me again shortly.

Mr Amit Saha

Thank you. very much for that introduction good evening.

Thank you very much for coming this evening hopefully by the end of this hour you felt it is all good out that you have spent learning about what we can offer and the benefits that the benefit may be able to give to you hopefully. Now, or in the future.

So, a very quick introduction my name is Amit Saha, Rheumatologist. I trained in London and in Sussex a decade and a half ago mainly based at Kings and guys and Ian Thomas's in London. I did their masters and dissertation with regards to disease activity rheumatoid arthritis I've been a sponsored education fellow in London when I was a trainee and that's led me to become a senior lecturer at Kent's only and the UK's newest Medical School the Kent and Medway Medical School based in Canterbury. Currently my day job is at NHS Maidstone and Tunbridge Wells where I'm a Consultant Rheumatologist. I was clinical lead but an expert colleague. Now, because I have taken up my university post. So, let us go to the next slide please.

So, simple introduction slide you can read this as well as I do, and this is just a very broad definition of what rheumatology does. It just basically deals with everything that comes with joints, bones, muscles, and soft tissues. You might ask yourself ‘how does that differ from orthopaedic colleagues?’ well, they're going to expand much more on what they do but the simple way how I teach it to my medical students is things that need a medical treatment e.g., drugs normally comes under my scope and things needs their clever achievements like joint replacement that my medicines can't work then my orthopaedic colleagues get involved and like I said this can be any part of the joints, bones, muscles, and soft tissues. Soft tissues, muscles and tendons can affect any joints and rheumatology will deal with any joints, but they can commonly affect the ones that you use most like the hands, wrist, hips. Next slide please.

So, just to carry on from the next slide. What is a rheumatic disease? Again, this is a definition you can read quite clearly here. Any clinical condition that causes pain, stiffness and swelling in the joints but also everything that surrounds it the tendons the ligaments the bones and you may be surprised at internal organs you can ask yourself why is a rheumatologist where I've always thought of you know I was dealing with joints deal with the internal organs well I'm sure if you haven't. I would expand on a little bit there's conditions such as lupus which is one disease which you probably have heard of and there's some much rare diseases called vasculitis. Now, lupus is an autoimmune condition that can affect any organ in the body, what quite commonly affects the joints initially and that's where it comes under the auspicious rheumatologist and these disease not only it causes joint pain, joint swelling but can because it can affect the whole body can affect any organ lungs the hearts the kidneys are brain causing seizures.

When I see anyone who comes with joint problems, obviously look if it's something like rheumatoid arthritis but more unusual conditions and this is where my expertise is and all my fellows would tell you  my expertise will come into play is to see if you've got one of these other more unusual conditions that you want to treat early to prevent long-term damage and finally osteoporosis mentioned here and I'll expand on that on that later slide. Next slide please.

Now arthritis, when people say to me ‘Doctor, do I have an arthritis?’ well arthritis is basically a pain in the joint so it can be anything for me it can keep to the joint the inflammation also advise it over overuse or autoimmune inflammatory arthritis where the body attacks itself, I've just included those two things but that's included in the first line there's huge amounts of arthritis as well there's two common in a way to simply divide it is things that are mechanical. The other one is autoimmune infrastructure arthritis again can affect these joints being a completely different mechanism. So, you haven't done any injury to your knee you haven't done any injury to your shoulder, but the body just attacks it it thinks this isn't my joint causes inflammation and thus causes pain and unfortunately this can affect everyone from children, babies in some very unfortunate cases it rises at the end of their life. Males and females are both affected but NHS England told you a lot of my conditions are more common women, and this is just down more due to simple hormonal issues which actually can cause autoimmune diseases to increase greater frequency and the sentences in both of them. Osteoarthritis or what you mean the similar pain stiffness and reduce mobility and it's my job with advantage to talking to you examine you and doing a few investigations to find out if it's just simple wear and tear which you can manage your pain control or refer to my colleagues or it's an autoimmune condition we have to like consider those much stronger drugs that can prevent your body attacking itself. Next slide please.

So, osteoarthritis. The straightforward way is that arthritis like I said just means just basically joint pain. Osteoarthritis is just worn and tear joint pain as you can see here the usual places are spine hips knees which are commonly used. So, we use knees triceps is it. So, commonly effective and only that because these joints are overusing become damaged this can actually cause the connective tissue by the tendons the ligands holding them to also become inflamed and cause a pain and sometimes it may not be the joint that's actually a huge problem it's actually the tenders and that's what we try to treat. Next slide please.

Now we've talked about the other types of arthritis. The inflammatory arthritis so, basically your body doesn't attack the knee joint it doesn't attack the shoulder joint because it recognizes it's your joint for example if someone else's joints got put into you and they have no drugs to prevent your body attacking it your body will recognize that joint is not being been on a foreign object and cause inflammation and try to get rid of it exactly what happens when you get an infection say in your nose your body realizes this infection wants to get rid of it produces a lot of mucus you feel Health you feel a temperature but eventually the body overcomes it and you recover and you carry on the problem with the joint the joint is stuck in there. So, it doesn't really matter if the body mistakes it thinks it's different it will keep attacking it until it destroys the joint and because it's attacking it just imagine if someone puts a corkscrew in your nose and you had a Perpetual cold all that mucus not going anywhere that's what happens in inflammatory arthritis new joints and that's why you feel. So, bad and because it's such an inflammatory condition you don't you get joint pain you get tiredness you sometimes you get fever you can get weight loss you can just feel very unwell and it's not like for example you can get similar pains rheumatoid arthritis but because of rheumatoid arthritis is persistent it occurs with or without risk day in day out throughout the night it make you feel very unwell I was untreated the joint's confused but not only that the joints you can lose bone when you lose bone it never comes back. So, you become functionally deficient. So, with limited arthritis you want to pick this up yesterday when you get the symptoms because if you treat it soon enough and early enough you can actually prevent all these things occurring. Next slide please.

Now we go to osteoporosis. Now, this is a term I'm sure you've heard lots of people in in the meat all the time but simple definition it just means that you have less density in your bone and if you look at this simple Slide the bone density on the right is normal there are holes but that's structured. So, your bones are not too heavy. So, if it were completely dense you would not be able to lift it even with all the muscles in the world. So, if it's a composite structure of air and Bone laid in a certain way to prevent to withstand Trauma from every day to Daylight or even simple fours but if you look at the femur which is the hip bone in the pelvis on the left hand side you can see they're much more air because there's less bone and just imagine if you felt which bone would be more likely to fracture. So, this is what's osteoporosis and sometimes the bone can be even thinner. So, it is just like there is some women they can be sometimes walking they go for pavement and suddenly they will fracture spine and you will see these women who have not been treated who've been caught too late bent over pixel fractures in the spine with a hip you'll know when you have a hip fracture. So, this is why osteoporosis is a very important disease to pick up early and to treat early. Next slide please.

There's a number of risk factors but these are the risk factors I'm supposed to compare any age for various factors but common is over 45 postmenopausal smoke or drink too much lack of exercise and low weight paradoxically in most diseases are used to tell doctors will tell you lose weight but this is a different because actually if you have a too much too little weight your body responds while producing less sperm for example if you a normal weight or your BMI for example touch Rays your body responds to that weight by actually increasing bone density. So, you're supposed to risk is lower unless your fracture risk is lower that's why National it's a weightless when they go up to space come back they can get quite thin bones and they have to do exercise if a space to keep their bones of getting too thin vitamin D deficiency but the biggest thing and this is where you blame your parents you blame your parents for many things but this thing you can definitely gain genetics is about 80 of the reason why if you've got osteoperosis is the reason you've got us raise is because genetics. Next slide please.

Now with regards to hypermobility, this is a term again you hear a lot of people say, and you are thinking why hypermobile joints makes you feel. So, painful well. So, you may have one or two joints that are a bit more flexible than others I hope that we have made a hyperbole Mobility means that your joints are much more flexible than other people and it is not just wondering it is a multiple drain. So, for example I'll give you an example that you probably could all do at home if you stand up and ask you to bend down the touch of toes half of you get down to your knees three quarters another quarter make it down to your ankles and the remaining people maybe it's such a toes and about one or two percent may actually be able to put their palms on the ground and that's actually what you call a hypermobile spine and this can be also the same with your elbows and your knees where actually it goes beyond zero degrees and you can actually bend it beyond the normal angle just like that and you ask yourself why does this cause pain well if you're actually overextending all the time you're doing things that your body aren't used to this constrained attendance it can constrain the muscles and can cause pain and unfortunately a lot of people who do have hypermobility just have the pain which we can manage with good focused physiotherapy to protect the drains there's a small minority that do have certain subtypes of hypermobility that can cause some significant side effects most commonly related to the heart and it's our jobs as we've been trying to decide which is the most potentially Sinister one someone with hypermobile have and consider Cardiology investigations. So, we can manage before it becomes a fundamental problem. Next slide please.

So, I've gone through quite a few things but you might be thinking God it's quite scary but it's not scary it's only scary if you don't pick it up and you don't treat it and I see people day in day out vending NHS everywhere where we have a whole array of Diagnostics but they've answered the Divinity we can get diagnosis done very quickly and that is the advantage of being an abandonment in my opinion you can come to see any of us very quickly and get the Diagnostics very quickly and we do a whole array of diagnosis tests quite a few tests diseases can be will that ruled in with blood tests we've got x-rays on site we've got very experienced ultra-sonographers which are simple to use variously less expensive than the other modalities and risk-free because we're just losing sound waves but if we need other scans that ultrasound scan will not pick up we've got access to bonus scan CTS or MRI which is very useful for me and more importantly very useful for you but there's no point if we couldn't do anything with this well we can recommend and start a number of treatments and inflammatory and your aquatic drugs to help patients who need these issues and there's certain diseases such with regards to certain conditions osteopathic conditions fibromyalgia which I didn't mention was not in this slide which is a chronic pain condition not related to any automobile decision it's just how you places pain but can be affected by sleep and weight which we can also pick up and can recommend and there's certain things where my medicine will just not work or will not be good enough we'll have side effects but that's why we have close relationships with our orthopaedic colleagues who you're going to hear from which can do various other things that when medicine reaches Limitless social joint replacement surgery we can recommend Physiotherapy and in clinic we can quite easily inject a variety of joints which may not which will personally need for surgery. So, that is quite a quick run through of what we as a Rheumatology team we I work with two other experienced Consultants can offer with regards to picking up diseases investigating it and recommending or stroking treatment or do the appropriate referral if it is necessary. So, I am sure there will be lots of questions at the end, but I will let my colleagues Continue from here.

Mr Kumar Reddy

Hi, good evening, everyone. I'm Kumar Reddy, I'm one of the Orthopaedic Surgeons and Site Leads at William Harvey Hospital. I hope you all have a thorough enjoyable evening and thanks at the outset. Let me thank Mirella and Oliver Hall who have been instrumental in arranging this webinar and also thanks to my other colleagues Amit and Mark for joining the webinar which would give you useful information. I hope you'll thoroughly enjoy it. So, I've been here for the last 25 years, and my main special interests are doing hip replacements, knee replacements, partial knee replacements, ACL reconstructions repairs for sports injuries and also have been undertaking revision work including hips and knees. Next side please.

I'm going to be very brief with the presentation which would allow you all to raise some questions which we all would be more than happy to answer them. So, I will stick to me mostly into the hip replacement surgery today and osteoarthrosis and it has been very well defined and explained by Amit. So, I'll just go into briefly what is hip arthritis it's a common disease affecting in the body most commonly the knee and the hip joint surfaces which are normally covered in a normal individual with a smooth articular cartilage and they become gradually damaged and it becomes thin rough and sometimes you will have a bare bone where the article cartilage is completely destroyed. So, this is what it is and the most common causes or it is as we age as we get older, we do develop arthritis and there's a strong family history and sometimes an injury to the joint itself can cause after period of unaccustomed exercise or running. I've seen few young patients in the recent years where they've done London marathons and then developed a pain and divest where they lost the blood supply to the ball of the joint and developed secondary arthritis. The other conditions being rheumatoid arthritis, any inflammatory arthropathy can cause this type of problem. Next one please.

So, what are the main symptoms in general that people have to look for? It's usually pain and stiffness of the joint that it affects most often when I ask my patients who come to the clinic, I ask them whether they've got difficulty in cutting the toenails putting the socks tying the shoelaces getting in and out of the car getting in and out of the bath when I ask them they say doc I have not been having for the last one year I've just been having shower because I'm not able to get into the bath and these are the main history that you take from the patients and also it's very important for us to distinguish between the pain that is coming from the back or from the hip it's very important for the surgeon to know and people usually present with growing pain which is classical and sometimes the pain radiates from the hip down the knee and some of the patients it's not uncommon people present with knee pain if you fail to examine the hip you will get easily caught out. So, I have seen few patients and from other trusts saying that they have knee pain despite having a knee replacement and people have failed to examine the hip then when we examine and did the x-rays, and you can see it is very Advanced arthritis of the hip. So, majority of pain would be resolved once you do surgery in the form of hip replacement surgery. Next one please.

The treatment options being one is a modification of your lifestyle by reducing weight and doing some exercises to get the muscle tone and as Amit has clearly pointed out about other modalities of treatment mainly conservative, I'm going to stick with the hip replacement surgery. Next one please.

With regard to hip replacement and what is a hip replacement, the total hip replacement is a surgical procedure with the view to replace the joint the joint is made up of two parts one we call it a socket which is like a cup shaped bone in the pelvis and the head of the thigh bone which you call it a ball or the femoral head I hope I can show you here. So, this is the pelvic bone where you got the socket there which we're going to put the implant in which is the established shell along with the liner inside and you can see with regard to the ball of the head you can see this is the ball that's been replaced but this is this is how it looks like which is a tie bone at the end of the Thai bone you got a ball which articulates with the socket. So, there are several types of hip replacements which include resurfacing which we are not doing anymore and Benenden and other types of hip replacements or cemented hip replacements and uncemented hip replacements my practice largely over the 20 years have been uncemented protein Replacements where we in Benenden we use the time testis processes which have been tested for the last 30 years and most of the implant survivorship is about 99 percent these have been time tested again they've got very good develop rating and my bet is very important for one to know the bearing surfaces and there's a long-term survivorship the best bearings are going to be ceramic on ceramic however it's not heard of that we do come across some squeaking from time to time. So, my favourite bearing surface is ceramic on Crosslink poly bearing surface it eliminates squeaking and again it gives you long-term survivorship.

So, the implants I can show you is which is a uncemented protein replacement which has been coated with the hydroxyapatite which is called a type 1 collagen this encourages your natural bone to bind it like a glue which we call it a Osteo integration. So, it is made of titanium. So, and you got a head which is this is a ceramic head, and which is like this this is a ceramic head, and this goes on the top of the trunnion, and you also have metal heads in place where you can put the metal head on it. So, the metal heads have got they also have got good long-term survivorship but it is inferior to ceramic on Crosslink poly the main reason why one has to offer a hip replacement is once all the conservative methods of treatment physiotherapy anti-inflammatories exercises everything failed to improve his symptoms the next ultimate is to be considered for a hip replacement surgery my aim is to get rid of your pain and to improve your quality of life if one does not have pain this is not the surgery that one could offer.

So, what can be expected from a hip replacement I thought hip replacement will provide a large reduction in pain in majority of the patient nearly 90 to 95 percent it allows the patients to have a better sleep and they can resume their normal activities including sports like Golf and some of them have gone back to tennis and it also improve your quality of life.

So, the conclusions are you may benefit from a hip replacement if severe pain limits your everyday activity you find it hard to walk any distance without any pain you can use a walking stick or a crutch if that does not relieve the pain then the next option is for a hip replacement it has to be confirmed both on the clinical examination findings and also on your radiographic appearance sometimes it's extremely difficult to see most often though you see arthritis distinguished on the radiographs sometimes it is not as obvious then one need to do necessary investigations in the form of MRI scans to see whether this is significant matter that would warrant for a hip replacement next one please

I have talked to you about cemented and cemented and the bearing surfaces which I have explained to you what the bearing surfaces are metal plastic ceramic in detail. Next one please.

We also I also have been using short stems in patients who are young patients with a very tight narrow medullary kennel the reason why I use it is recently the studies have been done in Imperial College London and Professor C who does quite a lot of research has done a gate analysis in patients with short stems and it is published that people with who have short stem hip replacements have got improved functional outcomes when compared to standard stems and in addition to this my life becomes much easier if I do a short stem in young patients who are 50 and below the reason being it is only a very short stem and also revision surgery later on when it comes necessary it would makes the make the surgeon's life much easier as all you need to do is put some flexible Osteo tones to just seal the bone from the outside integration of the stem just proximally and it's your life becomes much easier in taking the short stem out so I tend to use them in younger patients and yeah with regard to the complications the common complications or infection but which one would write but fortunately the infection rates are much lower and in Brandon we are very proud to announce that the infection rates are much less than the national average and you can develop deep in thrombosis or pulmonary embolism that's why people who undergo hip replacement surgeries will have either clexane which is a low molecular weight Heparin or a riverox ban or apixaban five milligrams twice daily for a period of 35 days and the hip can dislocate sometimes I mean where the ball can come out of the socket and cause a dislocation and again it's a rare entity very rare probably one person one in a hundred which is again a rare entity in and again one can expect legal and discrepancy one leg can be slightly longer or shorter than the other we tend to normally measure the leg lens during surgery and make sure that this is not a common occurrence the next thing is there can be some damage to the nerve or the vessels again it's a rare entity there can be a very prosthetic fracture and these processes after a period of time can become loose and cause either aseptic loosening and where we might have to redo it again. So, all these complications put together is less than five percent got a good success rate of we normally give them about 95 percent regarding hip replacements.

With regard to recovery and approaches I normally do by poster approach and I preserve the pyriformis which is a sparing approach and we do it minimal invasive incisions of less than 10 centimetres and once we do them and patients are allowed to get up and walk either the same day in the afternoon or very next day with the help of physiotherapists and they resume their exercise program the very next day usually majority of patients that they stay is about a couple of days in the hospital and then once they're safe once the physiotherapists are happy with their walking and exercises they can be discharged home safely and they'll be followed up in the clinic in six weeks and they will have x-rays post-op before discharge.

Again with regard to National joint registry, this National joint registry is important, all our details have been put in the format and we send it to National joint registry where it collects information on the joint replacements both hips knees and shoulders from hospitals in England and Wales the registry will help to find out which are the best performing implants and the most effective type of surge it also enables the surgeon to look at their complication rates or if somebody is an outlier then National joint registry would write to the chief executive or the trust about their increased number of complications if there any. So, it monitors the Cyanogen as well and we can monitor ourselves and the patient outcomes. So, normally in my practice I do about 350 to 400 joint Replacements a year and all the years have done at least several thousands of these types of replacements Thank you. I will pass it on to Mark.

Mr Mark Jones

Good evening, everyone. I am Mark Jones; I would like to record the sentiments of everyone. So, far thanking you all for turning up to this presentation today. So, my I'm a consultant in East Kent hospitals working mainly in Margate Hospital in Canterbury I've I got back off Fellowship about two years ago just over a year ago from Brisbane where I learned all about sports knee injuries and surgery for knee and I'm currently a faculty of surgical trainers at the Royal College Association of Edinburgh for the teaching that I do.

So, knee surgery I have the easiest presentation to do because the knee is the most important joint in the body, and everyone is already explained to your kind of what arthritis is. So, I don't need to go necessarily down that route to explain all that again but knee replacement surgery is basically where we replace the damage after the arthritic surface of your knee with a knee replacement and this can either be part of the knee replaced there's a uni compartmental knee replacement or a full knee replacement with a total knee replacement and we really only recommend knee replacements for those patients who have failed the non-operative management and we'll talk about why during the presentation. So, the symptoms that I see when patients come in who need a knee replacement they are those patients who have arthritis most of the common is osteoarthritis the degenerative joint disease from wear and tear throughout the years and it affects the knee because it is a weight-bearing joint the majority of patients who get this are around the age of 65 and most patients who have knee Replacements in our current joint registry are around the age of 70 when they get the knee replacement and it does affect women more commonly than men and we've heard about the reasons from Dr Sahar previously.

So, this is a bit of an example of a knee replacement with kind of what it looks like and the arthritic joint beforehand if you can see here with the joint you can see that we'll look at the normal joint in a minute but this is the anatomy of the knee it's made up of four joints it's made up of the medial side of the joint which is the inside of your knee the lateral side of the joint which is the outside of your knee you've also got the articulation between the small bone the fibula and the tibia and then you've also got the patellofemoral joints which is another problematic joint it has made up of many ligaments and what we are talking about when we talk about arthritis is damage to the articular cartilage which is the lining of the bone within the joint and this can be due to problems with ligaments or the meniscus during your life which could lead therefore to degeneration and damage to this cartilage.

So arthritis is an inflammatory is a non-inflammatory arthritis it's a degenerative joint disease but actually it is inflammation within the joints you get inflammation from wear and tear from debris within the knee you get damage to the cartilage the cartilage over time loses elasticity and becomes more fluid field and then over time this cartilage wears out and you then lose the joint space and the way I like to describe that is it's like a flat tire you slightly you lose the air in your tires you become slightly wonky and your knees start deforming and then they start causing more wear and tear because you're overloading certain parts of your knee and then this leads to other changes in the bones such as new bone formation you get thickening of the bone you get cysts which cause swellings and this causes all the pain and the knee that you get osteophytes things that cause pain within the knee are the osteophytes these are new bits of bone which form as a reaction to the arthritis you get increased blood supply but it congests within the bone because of the pressure and that causes pain feels like a dull toothache you get inflammation of the synovium this is the into the synovitis where you get swelling of the knee joints and this fluid in the knee joint can also then cause stretching of the joint capsule and that causes pain itself and again you can also as Kumar has mentioned if an important knee examination is actually an examination of the hip and the spine above it because this can also cause knee pain when actually you don't have any arthritis there are other reasons meniscal tearing can cause pain joint contractures as well. So, I mentioned earlier about the knee. So, on the left x-ray you have a normal knee joint with a good space between the two areas of cartilage between the fight the fibre and the femur and the shin bone the tibia whereas on the right-side hand side you have got a very worn-out compartment of the knee on both sides but this outside part more so we talked about risk factors throughout it's the same as the hip joints it's the same as what Dr Saha was talking about Rheumatology but in in for kneeing osteoarthritis mainly it's age weight does have an effect because it has you overload the knee a lot more trauma you know if you overload the knee or you have big trauma to the knee soft tissue knee injuries sporting injuries and this does lead to arthritis later on and family history and then there's other causes which can cause it as well but they're less common.

The symptoms do progress and most patients come in saying they've had many years of pain but some things tipped them over the edge at that point of coming in to see us where they just say it's just become more unbearable over the last six to 12 months usually and it's it usually that is it's causing pain at rest or it's causing pain at night time patients have trouble mobilizing long distances anymore they can't go for long walks and they get this pain which just causes they just can't get rid of and despite painkillers then it can become unstable if the ligaments become injured during the arthritis or because of the more deformity that you get and the idea of any treatment of arthritic joints particularly knee joints is you can treat them either surgically with non-in with invasive procedures or non-invasive.

So, non-pharmacological or pharmacological and I will break that down for you now. So, the non-surgical treatment I always like to break this down into the non-pharmacological treatments the pharmacological and the lifestyle changes the most important thing is it unfortunately is activity modification you have an arthritic joint which is painful because of wear and tear and overloading this weight-bearing joint causes more pain. So, chain activity modification does improve pain and improve outcomes however we need to have treatments such as heat and cold changing the temperature of the knee can help with pain relief decreasing the load through this knee. So, weight loss can help not carrying heavy bags or Carrier bags in either hand can also help offload this knee and exercising by increasing the strength in your quadriceps and your hamstrings can function as a floater of the knee and acts as a shock absorption so that you don't overload this damaged cartilage as much and that's where physiotherapy comes in pharmacological treatment include analgesic medication paracetamol simple energies such as paracetamol and ibuprofen moving up to more complex codeine-based medications if you're really struggling with pain but we do try and avoid these because it does cause problems with pain tolerance we can also talk about intra-articular injections and these usually come within two formats either steroid injections which we can give mixed in with a local anaesthetic which helps with some inflammation within the knee and helps you do your Physiotherapy and your exercise so that you can have your weight loss and get back to a point where your knee does not take as much weight through and is a bit stronger and we can also use hyaluronic acid injections such as duraline which we offer here at the Benenden which acts more like a lubricant within the knee and lines this damaged cartilage. So, that you can have a little bit better friction-free movement throughout the joints and offer some pain relief we have mentioned lifestyle changes. So, changing your activities that you do a bit of weight loss and all of this from my point of view MSA patients should never do stuff that they enjoy but to get fit and to get strong it is minimal impact exercises such as swimming and cycling so that then if you do want to go for your very short run or your little game of tennis you've got the strength in your quads and you've got the fitness to do that but it's more for enjoyment rather than to get fit from and we can also look at knee braces which can correct some of the deformities within knee arthritis to offload the damaged area.

Surgical treatments arthroscopy in my opinion plays very little role in an actual kind of an end-stage arthritic knee occasionally there may be a loose body which is knocked off which causes acute locking of the knee and we can go in with a camera to remove this loose body and help with those symptoms we can debride loose articular surfaces but again if there's enough if it's bare bone exposed this is not really going to help and actually an arthroscopy can sometimes flare up the arthritis you've already got and make it worse and it's from my point of it's not usually indicating in the arthritis. Now, it does mention implantation of cartilage here this is a very kind of subset of patients who have very isolated areas of arthritic change within the knee which you can actually do cartilage transplantation on but it's probably not for the vast majority of patients or surgeons in that matter. So, the surgical treatment really is a replacement of the arthritic joint, and this can either be through a half or partial knee replacement or a full knee replacement.

Now, the half the partial knee Replacements include replacing the inside of the knee. So, the medial unit compartmental knee Replacements replacing the kneecap. So, the patellar femoral joint Replacements replacing the outside of the knee. So, the lateral unit compartmental knee Replacements or occasionally you can even replace the patella and the inside which can be a medial bicarb bicompartmental but it's that's not that one's not performed here at the Benenden it's more the other three that would be and then if you're not suitable for a unit half knee replacement then you have a total knee replacement which is this picture and this replaces all the surfaces but I do have to stress that not everyone replaces the kneecap because in a normal tote a knee replacement if the kneecap is normal then you don't always have to replace it and the outcomes are just the same so there are complications to all surgical treatments which is why you have to have a knee replacement when you're ready and unwilling to undergo these complications potentially the risk of infections it can be either a superficial infection just in the wound which can be cleared up with some antibiotics but what we dread are the Deep infection within the knee joint themselves this is around in your lifetime about a one in two percent risk from having the knee replacement to not having the knee replacement basically persistent pain knee Replacements are painful they're not like a hip replacement they are more painful post-operatively and take a lot of time to get over and actually there's a lot of patients who do have persistent pain after a knee replacement and the way I always consent my patients is that I will say to them eighty percent of patients at a year are happy with their knee replacement they will tell their friends and they'll say I'm glad I had this done unfortunately we then have that other 20%. So, 15% patients will they'll be unhappy with their new replacement but they won't be worse off they'll still be better than they were preoperatively but they won't be as good as they were expecting and again a slightly silly way of explaining it but it's like playing the lottery and expecting to win 100 million pounds and you come away with a hundred pounds maybe you're better off but you're not what you're expecting and sometimes that's on an expectation thing rather than anything else and then unfortunately five percent of patients after a near placement can be worse off and that can be either due to a big complication which is known about or persistent pain which we cannot get to the bottom of and unfortunately these patients are very unhappy with any replacement and there's not much in terms of treatment that we can do apart from getting them under the chronic pain team but if you have a completely complication free knee looking at the national joint registry data it should last at least 15 years if not more and actually most knee Replacements we're putting in today have very good outcomes and we would hope they'll be lasting 20 or 25 years depending on anything that's gone on obviously here at the Bennington hospital we offer knee Replacements as a treatment and we make sure we assess you to make sure the knee replacement is correct procedure for you we go through the shared decision making process we're going through the consent process of both non-operative and operative treatments because actually that's important that you understand the risks of both continue with the non-operative measures if we can help you with that. So, looking at other options physiotherapy bracing steroid injections during injections and when you finally think that this is the treatment you want we can offer the surgery as well for a knee replacement and we have a rapid recovery Pro school and that we get we have we pay patients have the correct anaesthetic which means that they have a quicker recovery post-operatively and this just reiterates that over 80 should have a good outcome after their then their surgery but recovery can take 12 months. So, do not expect it to be completely like a hip replacement at six weeks that you will be running around near placement patients do take longer to recover.

We've mentioned this and went with dissatisfactions those patients those 20 patients who don't do as well tend to be younger patients and it's probably it is the expect managing the expectations of these younger patients who have a pain from me who want to get back to working to doing stuff but they necessarily it is a mechanical device you need which may have trouble with. So, overall if you come to see us at the venison you'll have an appropriate referral and you'll come and see one of our one of our hip and knee surgeons who will be more than happy to see you regarding your hip or knee pain we'll carefully select the right patients who will do well from a knee replacement and will help manage your expectations and treat you non-operatively in surgically depending on your wishes and what our advice would be. So, these are our consultants here at the Benenden who everyone here offers both hip and knee Replacements except for I think me and Mr Goddard who both just only do knee Replacements, but we will be more than happy to discuss with you in clinic or further questions today about that procedure.

Mirella Falcone

Thank you very much Mr Mark Jones, Mr Kumar Reddy and Mr Amit Saha. That was an interesting presentation and very informative.

So, I will take some questions.

The first question is, my father is 87 and struggles with hip pain is there an age limit to having a hip replacement and with the risks be higher?

Mr Kumar Reddy

I'm happy to answer that question. Age is not a factor if they what I look at it is if a patient has lived up to 85 they would be extremely good and strong enough to live up to that age for me that pain and quality of life is the most important things and we've got an excellent team of honesters where they would assess the patients and make sure that they're safely being discharged. So, for me it is that pain and quality of life and it is not that I have not done I have done in 90/95-year-olds here and in fact 95-year-olds have put a 60-year-old to shame because he is walked out of the hospital the very next day after hip replacement.

Mirella Falcone

Can both hips be done at the same time if they are both giving you problems i.e., pain and loss of mobility?

Mr Kumar Reddy

Certainly not because the risks outweigh the benefits because the risk of thrombosis and Pulmonary embolism significantly increase if you do bilateral hips. So, that is why in UK, we do not engage ourselves in doing bilateral hip replacements for most all the patients I always do one at a time at three months and three to four months interval we can go back and do the other hip.

Mirella Falcone

Thank you. Next question I have a medial tear in my left knee and recently my right hip has been giving me problems especially if I knock my leg. I am active but I have given up walking far because of the pain is it possible my right hip is compensating for my left knee?

I think it's a bit of a mixture for Mr Mark Jones and Mr ready.

Mr Mark Jones

I think when you get any knee pain, or any hip pains other joints start taking the brunt of that load and. So, if you've got a medial meniscal tear that is causing pain you are going to walk with a slightly different gate which is then going to overload the other hip and I think yes it could be but again it would be it'd be one of those things that we'd have to look at you in clinic and actually assess both your hip and your knee because actually you may have two pathologies you may have right hip pain which is arthritic pain and you may have a meniscal tear on the other knee and you know we that's I think that would be the nice thing about coming to see us here at the Benenden we would have that kind of time to see you to see both joints and have that understanding that we can investigate that as well if that's what's causing problems.

Mr Kumar Reddy

Yeah, I absolutely agree with Mr Mark Jones who has explained. I think it's very important for one to be assessed clinically to examine the hip and the knee and it's not uncommon where people were complaining of knee pain most of the time and then their hip gets into trouble and all they need is a clinical assessment and a simple x-ray of the pelvis to see whether they've got any Mark degenerative changes that is affecting the hip.

Mirella Falcone

Thank you both. The next question is I am sixty-two and have bad playing in both my knees especially the right knee would you ever replace both sides at the same time if. So, what would be the recovery compared to having it done separately?

Mr Mark Jones

So, I think it's again echoing what Kumar said there has been in the past and probably in other countries a bit of a push to do bilateral needs I think the risks do go up considerably in bilateral knee Replacements and I think that that risk does outweigh the safety that I you know I would put my patients through so I think actually I would do exactly the same as Kumar he does with his hips I would stage the procedure do the worst knee first make sure you get over that and recover from that and then three six months later depending on how that recovery is because it's not as quick as hip replacements then go and do the other the other knee I don't know what because Kumar is also a knee surgeon I don't know he has any thoughts about that but bilateral knee Replacements do they're extremely painful there's a high risk of blood clots high risk of infection and reduce range of Mobility is a big problem post-operatively. So, I I would not do them yes absolutely I mean my rub stamp Mark Jones who has said very nicely.

Mirella Falcone

Thank you. question from Richard is physiotherapy often effective in your experience.

Mr Mark Jones

Yes, I because I think the whole point of the non-operative route is it's that offloading of that degenerative knee and physiotherapy is not going to make that knee x-ray or the knee arthritis any better but what it does is it gives you the strength in the quads and the hamstrings the muscles in the hip to actually when you're putting your foot to that floor is to take some of the impact it's like playing sports and you know controlling a football you need to take the impact of that football when you're when you're controlling it. So, it doesn't just bounce off it's the same as when your foot hits the ground if you don't have the cartilage or the meniscus in your knee you need other things to help take the shock absorption and one of that is the muscles around the hip and knee can do that and I think it's not as I say physio is not going to cure your arthritic knee but it will make the pain slightly more manageable they'll help with range of motion which will make your post-operative recovery better and also the better your muscles are preoperatively the better the conditioning are and then the better that the easier is to rebuild those muscles postoperatively to which then will make your knee replacement hopefully better long term yeah certainly physiotherapy is beneficial to most of the patients especially in arthritis when they do not like the exercises where the pain gets exacerbated I would generally advise my patients to stop and then to be reassessed again because when you got arthritis when you try to move the joints because of the increased stiffness it'll get more painful that's when people complain of that physiotherapy is not been beneficial but it's worth trying physiotherapy first it will give you build up your muscle tone and strengthens your muscles which is quite important even after search.

Mirella Falcone

Thank you. next question I have needed a knee replacement for a while I work from home on a computer. So, no need for much movement how long would it be until I could return to this type of job?

Mr Mark Jones

It will be it is usually you are looking at the idea is getting back to a job after a new placement is looking at the painkillers that you are taking. So, you need to be able to be do the job safely there's nothing stopping you from getting back to your job as soon as you're discharged from hospital but it all depends on what your job is and how safe you think you're going to be you need to be able to do your Physio and your rehab at the same time and also if you're on stronger painkillers such as morphine based painkillers when you go home that can make you a bit clout bit fuzzy in the brain you know that and it may not you may not be able to do your job as well usually around I would say let the wound heal for a couple of weeks and then maybe get a bit of recovery going four to six weeks for something like that from a desk job and people who drive for their jobs have to struggle a little bit more because they have to get in a car and getting in a car after a near replacement usually depending on which leg it is takes about somewhere between six to 12 weeks but again that depends on the knee you're doing and what kind of car you drive okay.

Mirella Falcone

Thank you. Mr Mark Jones just three more questions to go. So, one from Steve should one seek a diagnosis earlier rather than later it is always important to have a diagnosis.

Mr Kumar Reddy

So, it is crucial to have an early diagnosis it does not hurt anyone. So, it is very important for those patients when they are experiencing pain to be assessed early and then to have a formal diagnosis can I yes, I can jump in on that as well I think from my point of view a lot of my practices need preservation surgery. So, it is trying to prevent patients needing a knee replacement by treating them earlier and younger. So, meniscal repairs ligament surgery the same as Kuma we do ACL surgery we do the meniscal repairs and you can also do other management options of knee arthritis such as osteotomies which is actually correcting the alignment of that bone which then will hopefully progress the time but you it takes you need to need that knee replacement. So, the sooner you get the diagnosis the better because there are more options available usually.

Mirella Falcone

Okay. Thank you very much. Question here regarding osteoporosis with osteoporosis can it ever improve with lifestyle changes, or will it continue to get worse without treatment

Mr Amit Saha

Yes, this is for me you think of that question yes most of the time because there is a strong genetic basis and there is the underlying cause it will generally get worse. For example, if you're extremely underweight for best medical reasons and this is coming more younger people anorexia or you drink excessively or smoke excessively or smoking at all at any level really obviously if you produce this will help with regards to your osteoporosis risk factors but generally depending on the degree of severity it wouldn't have a huge degree in most of the time you probably will need some treatment but the reason I've been probably in giving it not very definitive answer it depends on. So, many factors it depends on all sorts of risk factors how thin your bones are and then just the Judgment course sometimes with most of the guided between us. So, if I was going to do something I say you can do lifestyle changes but most social process if it's significant enough needing treatment the lifestyle changes Jenny will not alter that fact.

Mirella Falcone

Okay. Thank you very much Mr Amit Saha. Last question, I've had a radiologist's report which says I have severe degenerative changes in both hips do I have to have surgery on both hips not together and are there things you can do before that stage injecting something into the joint.

Mr Kumar Reddy

If you've got pain and if it is affecting your quality of life and if radiologically if it says that you have got severe arthritis in both the hips the only permanent solution you're looking for is the hip replacement surgery and if you want a steroid injection people can give cortisone injections into the joint but they need to be in the fluoroscopic control where you put the needle in and the fluoroscopy injection die and then make sure that the needle is in the joint and then you can inject but I have to reiterate that these are temporary measures and sometimes you can lose blood supply to the Bone and the hip the ball of the head can crumble. So, my advice is if you got severe arthritis as a permanent solution to improve the pain to get rid of the pain and to improve the quality of life you need hip replacement surgery, and it needs to be done one at a time not both. So, once we do one hip you should be able to transfer the load onto the other hip and the pain in the other hip naturally eases for a period of time then once your pain gets worse again, we can do another side but not both at the same time.

Mirella Falcone

Okay. Thank you very much. That's all the questions we have for this evening. So, I am sorry if we did not get to answer all your questions if you have provided your name we will do. So, after the event if you would like to book your consultation please do contact us on the name on the number on your screen Emma from our private patients team will be available to take your calls until eight o'clock this evening or between eight to six pm Monday to Friday we are offering an attendee discount for this session which with the terms on screen you will receive a short survey and I would be very grateful if you could spare a few minutes to let us have your feedback our next webinar is on 21st of November on private GP services. So, on behalf of our expert presenters myself and the team at Bennington hospital I would like to say thank you very much for joining us this evening and we hope to hear from you soon. Thank you very much and have a good evening.