Louise King

Good evening, welcome to today's webinar on hips and knees. I'm from Benenden Hospital and I’m your host, Louise King. Today's speakers - as you can see on the screen - are Mr Alex Chipperfield, a Consultant Orthopaedic Surgeon at the hospital and Mr Kumar Reddy, Associate Specialist Surgeon at Benenden Hospital. The presentation will take approximately 30 to 40 minutes and then we'll have some time afterwards for a Q&A session.

You can ask questions throughout the webinar, and we'll answer them at the end. Ask them through the Q&A button at the bottom of your screen or perhaps the top and you can do this by giving your name or anonymously. At the end of the session, we will have a phone number to ring where our lovely private patient ladies, Chelsea and Karen, will be there to answer. Just to remind you that this session is being recorded so if you wanted to ask a question and you didn't want your name to be seen then do that anonymously. So now I’ll hand over to Mr Chipperfield, thank you very much.

Mr Chipperfield

Good evening, everyone. Hello and welcome to our talk. My name is Alex Chipperfield. A little bit about me before we start, I have been a doctor in the NHS for 25 years now. I trained predominantly in the Southeast of England, before going over to Australia to spend a year perfecting hip and knee surgery. After that, I came back to Kent and took up the post of a consultant here where I’ve stayed for the last 12 years. Mr Reddy and I have been members of the orthopaedic consortium here for the last decade or so and I'm a member of the hip society. My specialist area of interest is primary and revision hip and knee replacements.

Here's Mr Reddy as well who along with many other accolades is also a member of the American academy of orthopaedic surgeons. Again, he has an interest in hip and knee replacements as well as soft tissue knee surgery. We'll meet him later though.

A little about Benenden Hospital; the original hospital site opened in 1907. It started off as a sanatorium for postal workers. The Benenden Healthcare Society was formed around 60 years ago off the back of that, and the next major expansion happened in 2017 where the hospital was almost rebuilt. So that's the picture of the main entrance and you can see there now is an impressive new building along with three brand new cutting-edge operating theatres. Over the last few years, it's become a centre of excellence for orthopaedic surgery especially hip and knee replacements, and we perform around 900 joint replacements here per year. This is data from the national joint registry, these are 2019 figures which are the last normal year before the pandemic figures and so this shows the figures for England alone. So around 100,000 hip and knee replacements are performed annually in the UK generally performed on slightly more women than men. It is a 60/40 split, and it tends to be on patients who are in their late 60s, early 70s, although we have seen the average age for joint replacement surgery falling quite dramatically and a large proportion of my patients are significantly younger than that.

The way I've structured my talk today is I'm going to try and answer some of the commonest questions that people ask me when they come to see me in the clinic, so hopefully that will mean that I won't have to answer these questions when you come to see me for real.

The most common first question that people ask is: do I need a hip replacement? The answer to that I give is ‘well you tell me’, and really what I mean by that is that the need or not for a hip replacement really depends on the effect that the arthritic hip is having on every aspect of your life. Your quality of life, the typical kind of symptoms that people get from an arthritic joint, number one is pain. It tends to be fairly typical groin pain that's where the hip joint is right deep in the front of the groin and a lot of people think that their hips are more to the side or to the back, but essentially right at the front in the groin that's right on top of the hip joint. That pain doesn't just stay there though it can radiate, and it can go around into the buttock and down the thigh all the way down into the knee as well. Besides pain, people tend to have stiffness and difficulty getting down to cut their toenails or to put shoes and socks on and that can restrict your daily activities. Another issue that people get is feelings of instability and their hips will click or lock or simply just feel untrustworthy and if you put all those things together, the pain, the stiffness, and the instability, well that leads to a general loss of function. So, you find that your sleep is disturbed, your walking distance decreases, and you no longer can enjoy your hobbies, activities or work and all of these things lead to a decrease in your quality of life. Ultimately, there will come a point where your life is being so significantly affected that all you can consider is surgery and that essentially is when you need a hip replacement.

The next thing people often want to know is what is a hip replacement made of. This picture here shows a set of instruments surgical instruments that I generally use to put in a hip replacement. So, you can see there are lots of different parts and tools that are used during the surgery. The hip replacement itself is essentially what you're recreating is the ball and socket joint of the hip and that tends to come in four parts. So, the socket is made of a shell and a liner that goes into that shell. The ball part of the ball and socket then goes into that socket and there's a stem that goes down inside the thigh bone that keeps the ball in the right place. Those four components are made of different materials, the shell and the stem of the implants are generally made of metal and that tends to be titanium. The liner of the socket and the ball that goes into it, they can be made from lots of different materials and they’re the combination of that is determined by the demands that you're going to put through that joint and basically tailored to give you the best kind of hip replacement for what you need. Hip replacements can be held in your body in different ways. Generally, they are either cemented or uncemented and the cement there refers to the special substance that is used to help bond the metal into the bone. The decision as to whether or not you use cement in a hip replacement is based on the design of the hip replacement that you're using and also the quality of the bone. You're implanting the hip into the lifespan and all of these different combinations together contribute to the lifespan of a hip replacement which generally these days with modern materials is several decades.

Often people ask about the length of stay in hospital and what the hospital journey will be like. This is a typical picture and essentially the first time we meet will be when you have been referred by your GP or advanced practitioner into the outpatient’s department. We will take a history and we will examine you and do basic tests such as x-rays and come up with a diagnosis and a treatment plan if at the end of that treatment plan the outcome is that you wish to proceed with surgery. You will then have another appointment to have a pre-assessment clinic. At that stage you'll meet an Anaesthetist and a Physiotherapist, and you'll go through the typical MOT basically to make sure that you're fit and it's safe enough for you to proceed with surgery at Benenden Hospital. You'll then be admitted on the day that you have your operation and go down to the operating theatres and have it done. I'm afraid there's not much time for rest we get you up and about immediately. If you have your hip replaced in the morning, you'll be walking on it in the afternoon and if you have it done in the afternoon, you'll be standing up early evening. That means that when you when you wake up the next day you already have the confidence that your hip replacement is strong and solid, and you already know that you can walk on it and get going. You'll be discharged home when it's safe for you to go and typically the length of your stay for hip or knee replacement surgery here is two nights. When you're discharged home, you'll often be given general precautions just to take things easy and not go too crazy with your brand-new joint for the first six weeks or so.

The next thing to talk about is when can you do things again. When will I be able to walk, drive, ride a bike? Everyone is different but these are the top ones that people ask and I'll just quickly go through and give you an idea when you can be walking, like I said, on the day of surgery. So that's pretty quick. Driving, it depends on which leg you've had operated on, what type of car you've got. If you’ve had your left leg operated on and an automatic car, you'll be driving pretty quickly. If it's your right leg or your driving leg, then generally what we tend to say is that you need to be able to perform an emergency stop before you can drive, the average length of time is somewhere between four and six weeks before you feel confident to be behind the wheel again. Riding a bike, most people will be riding a static bike at around six to eight weeks and then out on the roads if that's what you like generally about three months skiing a lot of people enjoy skiing. It's ski season at the moment and I tend to tell people that if they've had a hip replacement then they shouldn't go skiing that year they should skip a season and then go back to it the year after. Golf, most people find that they're back on the golf course hitting a ball within about two to three months, but I advise that they go and speak to their golf pros before getting back to it. Having sex, ideally you should wait until you leave hospital and generally when you feel comfortable to do so. Normally, it'd be around a month or six weeks until you can travel again. Really when it comes to traveling what we're talking about here is air travel. The risk of air travel close to surgery is that it puts you at a higher risk of developing blood clots and so it's good to leave a certain amount of space between surgery and flights. What we tend to say is that you should avoid flying if you can for the first six weeks following a joint replacement like this and then between six weeks and at three months, we suggest that you stick to a short haul flight so four hours or less. After three months then you're free to do what you want getting back to work really depends on your job and how accommodating they are. I tell people to be prepared to be off work for two to three months, but individuals vary.

Hip replacement surgery is a fantastic operation, and the outcomes of hip replacements are highly successful. They change your life for the better. There are risks involved with any invasive procedure, those risks are rare, and we do our best to minimize them but they are real and if you do get a problem then it can be quite difficult to get through. We anticipate problems and we make provision to try and stop them from happening, but sometimes they can. The typical kind of things that can occur is you can bleed you can lose blood and sometimes that means that you need a blood transfusion following your surgery pretty rare. You know around 1 in 20 people might suffer what might require a blood transfusion. I've already mentioned blood clots when it comes to air travel, and they are a risk following joint replacement surgery. Any surgical wound can get infected and an infection around a joint replacement can be potentially disastrous. This is a picture of me performing a hip replacement you can see I'm wearing a space suit there. Now that is not just for my protection that's for your protection to prevent any contamination during this surgery.

Other problems that you can get are more specific to hip, than knee replacements. Dislocated hip replacements can pop out of joint. If you do too much or are very unlucky, we can change the length of your legs during the surgery as well. Then there are other things you can get damage to the bones or to the nerves. Hip replacements and artificial joints in general don't last forever and another risk of a joint replacement is it may eventually wear out or work its way loose. But generally, like I said with modern implants that's something decades down the line.

Apologies for the wounds here. Another thing that people ask immediately after surgery is what's happening to me. There are three hip replacement incisions here none of these are from my patients, but these are all normal post-operative appearances of wounds you will expect your wound in the early days to be a bit red and a bit itchy, raised, lumpy and tender and that's all normal and part and parcel of the healing process. Another thing that you can get with the bottom left picture there is that you will get bruising and swelling in the leg following surgery. Generally, that bruising, and swelling will come out over the first few days and then with gravity it will sink down your legs. So typically, people who have a hip replacement may notice a week or ten days later that their knee gets a bit tighter and more swollen. As the bruising and swelling sinks down the leg due to the effects of gravity and again that's a completely normal part of the recovery process.

You can get cramping of the muscles of the soft tissues around the joint if they are moving in ways that they haven't moved before or not used to because your hips are stiffened due to surgery. Then it takes a little time for the strength and stamina of those muscles to return.

There are many different resources on the internet that you can look at when it comes to making a decision about hip replacements or knee replacements. This is one that I found that is very useful; the web address is jointcalc.chef.ac.uk.

This is a patient decision support tool that has been made in conjunction with the national joint registry and what this does is this allows you to personalize the potential benefits and risks of joint replacement surgery tailored directly to you. So, you go on to the website and you're presented with a functional scoring questionnaire and questions about your age, weight and general health. From that, it will produce a personalized chart that will allow you to visualize the benefits very easily to your quality of life and mobility that this kind of surgery will give you. It will also give you a personalized idea of the length of time the joint replacement will last, the revision rate and the specific risk rate to you and I find that's a very useful tool to look at. I would recommend that if you're considering joint replacement surgery that you take a look. That is enough of me talking for now, I think. I'm happy to answer questions going forwards at the end but I'll now hand you over to my colleague, Mr Reddy, who talk to you about knee replacement.

Mr Kumar Reddy

Hi, good evening, everyone, thank you for joining our webinar at Benenden Hospital and thank you very much Alex for introducing me earlier. I would like to keep it very brief, and, in a nutshell, I would like to explain to you - do I need a knee replacement?

Osteoarthrosis is a disease process which affects the joints, mainly the weight-bearing joints like hips and knees and most often women are more affected. This is the most common type of joint disease which we come across in day-to-day clinics. Next slide please.

My colleague has already given you the data about how many knee replacements are done and with regard to national joint registry as you can see more than a quarter of a million total knee replacements are being done between 2017 to 2020. Obesity is one of the common causes of people being affected with joint arthritis especially with the knees. 1.3 million total replacements have been registered in the joint registry for the past 17 years. Next slide please.

So, when it comes to the anatomy of the knee, the knee joint is made up of the lower end of the thigh bone. I hope you can see the picture, so this is the lower end of the thigh bone which is joined by the shin bone and in between the two joint surfaces you can see the menisci which act as shock absorbers to the joint. This is connected by large ligaments. One is the anti-cruciate ligament and you've got collateral ligaments on either side. This one is the lateral collateral ligament and the medial collateral ligament on the other side. This will also be joined by sesamoid bone called the petaler which articulates with the trochlea on the top so that's what this knee joint is comprised of.

So, what happens is the joint gets inflamed and, in the process, the smooth cartilage which is covered by the end of the bones of the joint becomes thin and it becomes rougher. It may lead to areas of no cartilage at all, leading to bare bones which ultimately cause significant amounts of pain that would affect your quality of life. Next slide please.

With regard to pathophysiology, which is a disease process, you get osteophytes in the joint surfaces at the end of the thigh bone or on the shin bone which is the tibia. There will be a vascular condition, increasing pressure inside the bone which we’ll call a marrow edema and there will be inflammation of the synovium leading to synovitis which is again inflammation of the tissue inside the joint. Next slide please.

You can look on the left-hand side where the joint surface on either side is maintained and you've got tibiophenol joint space. On the other side, you can see complete obliteration of the joint space, with prominent table spines and also osteophytes, leading to osteoarthrosis of this joint.

The risk factors, as you can see on the slide, there's aging, obesity and trauma which can lead eventually to arthritis and strong family history of arthritis can also be a factor in giving rise to arthritis. Reduced levels of sex hormones also has been studied and it is one of the indications of a risk factor for this type of arthritis. The other factors include metabolic diseases, blood disorders, neuropathic diseases, bone disorders, and previous surgeries in the form of meniscectomies, which can lead to where the shock absorber effect has gone from the knee. That may ultimately lead to osteoarthrosis and crystal deposition like gout pseudo. Gout can also cause a lot of pain inside the joint leading to arthritis.

Next slide please. One of the symptoms or indication for a joint replacement in my book is pain. I don't do a joint replacement for loss of function and unless there is unremitting pain where all the conservative methods of treatment have failed to significantly improve your symptoms. Then you need to have a combined decision with your GP and with your consultant surgeon and the family needs to be involved. This is a major surgery and this needs to outweigh your benefits against risks.

Normal symptoms include: progression of pain over several years, your activity becomes less, your walking distance gets considerably reduced, you'll be waking up at night causing sleep disturbance at night, and the joint becomes contracted and you can get a reduced range of movements in the knee, people can develop deformities, either fixed flexion deformity, where you would be unable to straighten the knee and also you can have a bowed legs or knock knees. Next slide please.

The treatment essentially is non-invasive or invasive treatments. Non-invasive is either non-pharmacological, which would be your physiotherapy and also doing some simple exercises at home, also eating healthily and generally modifying your habits. Pharmacological, is basically taking some painkillers and anti-inflammatories, in the form of naproxen, along with some omega which lines your stomach so that you don't develop any oscillations. Invasive is largely joint replacement, you can see it's important to have an education with regard to osteoarthrosis about how it affects your joint and the pain relief it can give. Heat and cold can sometimes help in relieving the pain and so can weight loss because the joints are being loaded by the weight. If you can relieve the weight, it would immensely help the joint and exercises are quite important that you need to do on a regular basis. With pharmacological aspects, I've already outlined, with regard to anti-inflammatories. Sometimes steroid injections can help and hyaluronic acid injections where we give an injection that would help regenerate the cartilage. But we do not have enough strength on the studies to show that it would be the long-term benefit. Lifestyle changes which include weight loss, physical activity, stretching exercises, low impact exercises, like swimming and cycling, rather than running or doing high impact activities. A knee brace also can help in relieving the pain and discomfort. Next slide please.

Surgical treatment. My colleagues and I here, we don't personally do arthroscopic surgery for osteoarthrosis. We do them occasionally in young patients where there is patchy bone loss and MRI scans reveal an osteochordal defect localized and osteochondral defects with bare bone. In that circumstance, we make a micro fracture to encourage the joint to form new cartilage.

There is a 20 percent chance of people getting worse after arthroscopic surgery and that is one of the main reasons why people do not do orthoscopic surgery for osteoarthrosis. Next slide please.

So, with regard to surgical treatment, you can see there's a partial knee replacement. But again, one has to be aware of the limitations and the indications for a partial knee replacement. Patients need to be isolating with an isolated unicompartmental disease, either medial or lateral, and one should have an intact anterior cruciate ligament. There should not be any joint contractures and the range of movements have to be beyond 110 degrees of flexion. These are the indications that the partial knee replacements have become more popular in the recent past and people are favouring more towards partial knee replacements. The reason being, your kinematics are maintained, and your ligaments, we do not take off the ligaments unlike in total knee replacements and the recoveries are much better, when compared to the total knee replacements. I do them mostly for an overnight stay and patients can be discharged the same day. If I do one in the morning, they can go home in the evenings. When I do them in the morning, or if I do them in the afternoon, the very next day they go home with an exercise program. The next one is when the joint is affected both on the inside and the outside, then it needs to be a total replacement when all the conservative methods of treatment like exercises, physiotherapy, painkillers and injections have failed to significantly improve the symptoms.

I just would like to show you what the knee replacement consists of and what it is made of. It is made of an alloy. This is the femur where it goes to the end of the thigh bone and it is made of cobalt chromium and nickel. People who are allergic to nickel have got the nickel-free implants which are made of niobium. In the shin bone you’ve got the tibial implant which is a metal again and it goes on the bone, inside the bone. On top of it you’ve got a plastic which is a highly cross-linked poly-bearing surface with chart grades with your thigh bone by implant. So sometimes we might have to leave this kneecap when it is evaluated and when people have a lot of pain I do tend to replace the kneecaps when the kneecap is totally worn out.

Regarding the complications, the most fearful complications or infections is a persistent pain and clots that you can develop in the leg that can occasionally migrate into the lung. We do give blood thinning tablets for about 14 days for knees and 35 days for hips. Next slide please.

So, with regard to the knee replacement and secondary care at Benenden Hospital there has to be a detailed clinical assessment by your consultant orthopaedic surgeon whom you're going to see. It has to be a shared decision which needs to be made by yourself and when all the other methods or moralities of treatment have failed to improve the symptoms. Operative treatment options need to be discussed depending on the clinical symptoms and the radiological appearance of the joint. There's also rapid recovery protocol which my colleague has already discussed with all of you with regard to length of stay and the physiotherapy treatment that you need to recover. This is the exercise program that you need to follow when you've got home.

With regard to patient reported outcomes, the large studies have shown that more than 80 percent of the patients have stated that their result was excellent or very good and there's about 15 to 20 percent of the patients who are not very happy with the knee replacements. The recovery most of the time takes about three to six months and in about five to ten percent of the injuries this can be prolonged and it can take up to 12 months. Next slide please.

With regard to dissatisfaction rates, in the literature it has been reported to be at about 15 to 20 percent and all over the world and even in the expert hands where they've done thousands of knee replacements, these are the reported dissatisfaction rates. I always tell my patients that nobody in this world can give a god-given sneak and match a god-given sneak, unless it's really, really painful we can help you in getting the pain away by doing the joint replacement.

In conclusion, an appropriate referral has to be made by your GP, or you can come and see us at Benenden Hospital when all your methods of moralities of treatment, which include physiotherapy and all other treatment modalities, have failed to improve your symptoms. It is about managing your expectations and you need to carefully discuss with your consultant, whom you're seeing, with regard to making your view about going ahead with surgery.

I'm happy to take any questions at the end of this. Thank you very much for listening to both of us.

Louise King

Thank you, that was really interesting both of you. We have quite a lot of questions, so let's see how many we can get through in the time. The first one is for yourself, Mr Chipperfield. They say their hip is painful when they walk up, or downstairs and they can no longer do Pilates three times a week. The hip isn't painful when they're sat down but it is when they're trying to get up, and it's - you know - they struggle. They've had physiotherapy but they've been discharged because there's nothing else they can do. Is it too soon to think about hip replacement?

Mr Alex Chipperfield

Like I said, every level of symptoms that you're prepared to tolerate and live with before you undergo surgery is very much a personal choice. Everyone varies even between sides or between hips and knees as to what they can put up with. From the sound of things, you are on the road that will eventually lead you to a hip replacement. The question as to whether you finally make that final thing is very difficult to say without having made an assessment. It may be that there are other interventions that we can do that might make a difference, that might buy some time, that may well help you live with your pain or help your pain become much more minimal so that you can carry on doing the things that you enjoy. I would suggest in the first case that you need to be seen and assessed and investigated by someone such as me or Mr Reddy here at Benenden. Then we can see if there are any alternatives. Ultimately, a hip replacement really is the last thing that you do but - if there are no other options and you find your current level of activity unacceptable - then that would be the way to proceed.

Louise King

Thank you. Okay our next question is regarding the knee. They've had osteoarthritis in the knee for several years now. Is it inevitable the patients like myself will eventually need surgery? Thank you and this from Sue.

Mr Kumar Reddy

Right. If someone has already had treatment in the form of physiotherapy and having taken painkillers (because one can't keep on taking painkillers the rest of their lives because it can upset their kidneys and it can cause gastritis and you can absorb the stomach) and if one has gone through all the other conservative methods of treatment, then it's time again for them to be clinically assessed by either Mr Chipperfield or myself or wherever they would like to go to see the Consultant. And they need to have a weight-bearing radiogram to make sure that there is a radiological appearance of advanced osteoarthrosis. And one would need to make a decision and then it has to be agreed by both parties that you would certainly benefit from any replacement surgery.

Louise King

Lovely thank you. Okay I'm going to go over to the chat now and answer Christine's question. This is for you, Mr Chipperfield. With a hip replacement, how big is the wound, question one. Then should x-rays be taken within a particular period before the op and finally if they want the hip replacement done early August when should they see you?

Mr Alex Chipperfield

Okay I'll go in reverse order there, I think. If you want a hip replacement in August that depends on how you want to go about it. Generally, you can get your hip replaced either on the NHS or privately - either insured or self-funding. Waiting times, you know, you only have to open a newspaper or listen to the news to know that waiting times are long at the moment on the NHS. If you wanted an NHS hip replacement to be performed in August, I suggest you start asking for it about two years ago!

Generally, the waiting times for private or self-funding patients here at Benenden is around a month to six weeks on the whole, that kind of time frame. Now before the surgery, you know, the process that you have to go through starting with the referral and then the initial consultation and the pre-assessment leading up to the operation, I'd suggest that you start maki ng inquiries around three to four months before you were planning on having the surgery which would be April May time as far as I can work out in my head.

How big is the incision for a hip replacement? The answer to that is it's as big as it needs to be, to do the operation safely and properly. Generally the variable factors tend to be the size of the leg; if you have a big leg then quite often you need a bigger incision in order to get down into the into the hip joint itself. There are occasions when you can perform the operation through very small holes, but an old surgical colleague of mine once told me that wounds heal side to side not end to end so the size of the wound is generally not as important as the operation that's been done, though it averages about six inches.

Now I've forgotten the first question! Sorry, x-ray. X-ray, yes, number one you'll need an x-ray for diagnostic reasons. Number two you'll need an x-ray as I perform a hip replacement on your x-ray before I before I ever perform it on you. So I will need to have an x-ray that I can run through my computer system - my templating software that I have - that allows me to perform the surgery, so I get an idea of the sizes, the angles and the positions of the cuts that I will be making in order to perform the operation. As with any journey, if you're going to start a journey you want an up-to-date map and - with an x-ray - I tend to ask that patients have an x-ray within six months of their operation.

Louise King

Thank you. Okay we've an anonymous attendees question, Mr Reddy, and they are allergic to some metals such as some watchstraps, buckles or jewellery, surgical steep and hypoallergenic metals too. If they go for a private hip replacement how will the allergy issue be dealt with?

Mr Kumar Reddy

One question of pre-assessment is whether they're allergic to nickel or not. When it comes to the hips if - I'm allowed to answer, Alex - they are made of titanium. And we will not have any major issues with regard to hip replacements because you put in a ceramic head which articulates with a highly cross poly bearing surface and there shouldn't be any major concerns. With regard to the knee, of course, there are - if people are allergic to nickel - then we need to think of getting nickel-free implants, which we do in Benenden like niobium where they're completely nickel free. I've put it in - both myself and my colleague Mr Chipperfield have put in - quite a few niobium implants in the past and we are yet to see any allergic reaction to those ones, so those people who are allergic to these types of metals they need to have niobium implants.

Mr Alex Chipperfield

Can I add to that? Absolutely I echo Kumar’s thoughts on that. People with metal allergies; it tends to be that if you're going to have a problem, it will be with a knee not with a hip. I would recommend that before you embark on surgery that you have formal allergy testing performed, so that you know exactly which materials you're allergic to.

Louise King

Okay, thank you. Right we have a couple of questions in the chat from Richard King. He says, do I need to lose weight or gain muscle strength prior to a total hip replacement? That's question one do you want to answer as they go?

Mr Alex Chipperfield

Okay, it sounds like you're trying to set a trap for me because it's very difficult for people to lose weight and gain muscle function when it's very hard for them to move. Do you need to lose weight? It depends on what your weight is. There is a clear correlation between risk of surgery and Body Mass Index, which is your weight in relation to your height. And there's a very clear point, when your BMI goes over 40, that puts you at a significant risk of developing complications in the perioperative period.

There are different rules regarding BMI; what's acceptable and what isn't acceptable, depending on the hospitals that you choose to attend. Most private hospitals will have an upper limit on what BMI they're prepared to accept, and it would be around 40 at Benenden. Do you need to lose weight? So, like I say, depending on what your weight is.

Muscle function. It is vital that you try to maintain whatever muscle strength and whatever joint movement you have. If your joint is failing, then the best way for you to help deal with it is for the soft tissues around that joint to be as strong and as supportive and as flexible as possible. So regular exercise that helps you keep that joint moving not only will it support your failing joint but yes, of course, it will help your recovery that you get from your operation.

Louise King

I think before we go on to his other questions, that relates to another question we have. They've been told by their NHS GP that they won't give them a knee replacement because of their weight, and they struggle to exercise because of the painful knee. What do you suggest they do and, of course (that you've already answered) what BMI do you need to qualify for a knee replacement surgery?

Mr Alex Chipperfield

Like I said, each local authority is different. The NHS hospitals or hospitals that have access to high dependency and intensive care facilities tend to be a little less selective or a little more forgiving when it comes to Body Mass Index but generally most people I come across they tend to struggle getting that initial referral - getting through from the GP to us. A story that you hear very often is that my GP refused to refer me because I'm too big. I perform hip and knee replacements - and Kumar is the same - on people of all shapes and sizes and each decision is made on a case-by-case basis. And if, as long as you are fully aware of the relative risk involved, then I don't believe that such a blunt tool as a defined number should determine whether or not you have this surgery. So there may be some selective private institutions that will not accept you but there are other ways around that situation.

Mr Kumar Reddy

In relation to that if I may say, they are in a Catch-22 situation because their mobility is poor and it is extremely difficult for anybody to lose weight, because if they do exercise they get a lot more pain and they are in a Catch 22 situation. I feel extremely sorry for such patients and both Mr Chipperfield and myself, we tend to do those patients, making sure that there are ITU facilities and they have a clear and realistic assessment prior to surgery to enhance safe return of them to their homes after surgery.

Louise King

Okay thank you. I think we just about heard that there's a bit of vibrating going on the moment but thank you.

If we go back to Richard's second question, so he says his left hip has been a big problem for about 10 years. Recently his right hip (so it was his left hip) his right hip has started to give pain. He also has problems with a prolapsed disc. Are these problems likely to progress more quickly if I were to delay getting the first hip done (which is the left). He has limited ability to walk and to exercise.

Mr Alex Chipperfield

It's very difficult. I mean, you've got problems in three areas all closely linked, you know - and they all go hand in hand. People who have arthritis of one hip will almost certainly develop it in the other side because they do come in pairs. And then the lower back is the next joint up, so people who have trouble in one big joint will often have trouble in the other joints as well. So, hip and spine tend to go hand in hand. As to hip and knee, will delaying having one hip done have an effect on the disease progression in the other hip? Probably not. If it's going to happen, it's going to happen really and I suggest that you if you've got two joints that are bothering you, that are affecting you, then I would choose the one that's giving you the most trouble. If the right hip has only just started to hurt but is more now more of a problem than the left, I would start with the right.

Louise King

Thank you, okay Mr Reddy, we have a question that is around the knee. And they have pain at the back of the knee due to a sport injury. They've had six physio sessions; the pain is still there, and they can't walk for long. Do they need a knee replacement even if the pain is not at the front of the knee?

Mr Alex Chipperfield

Right, we need to make a clinical assessment to examine the patient and see where the pain is actually arising from - and also, we need to investigate the patient thoroughly with an MRI scan to see where the source of the pain is. And it needs to be a clinical and radiological diagnosis. That diagnosis is extremely crucial before we embark on any replacement surgery. So that's what we need to assess before we make a start.

Louise King

Thank you, that makes sense. Thank you very much. Okay we have a question from John. He says he has bad arthritis in his joints and hand and cannot hold a crutch. Sorry John is not John, John is a woman aged 81! Sorry, I think there's a couple together. So, a lady aged 81, Mrs Hubbard. Is she too old for a full knee replacement and she also has bad arthritis in her joints and her hands so can't hold a crutch?

Mr Kumar Reddy

Shall I answer them? Age is not a criterion and both Mr Chipperfield and myself we've done - even at Benenden - more than 90-year-olds, because it's the pain and their quality of life. If they’ve survived up to 90 or 80 and above, I mean they have to be strong enough and to survive that long. So, their health is always better than most the other people. So, in fact 90-year-old has put others to shame because he walked out the very next day after surgery after having a hip replacement surgery. So, I don't think age we need to discriminate. It is mainly their pain and the quality of life.

Mr Alex Chipperfield

Absolutely! And as far as the crutches go, there are many different walking aids that are designed to help. Obviously worn-out knees do tend to go hand in hand with other problems elsewhere, whether it be a painful shoulder or a painful hand too. So there are walking aids that don't put pressure through your hands or wrists you can rest your forearm on or up in the armpit so that wouldn't that wouldn't be a problem either.

Louise King

Great, thank you. Okay. Neil asks what is the method used for hip replacement at our hospital? Is it PA, DLA, DAA etc.?

Mr Alex Chipperfield

Okay, so by method there - and those acronyms - you're talking about the surgical approach to the hip replacement. So, you're talking about whether or not you perform a hip replacement through an incision at the front at the side or to the back of the hip joint. Ultimately there are a mixture of hip surgeons here at Benenden and we tend to be split sort of pretty much 50/50 as to which approach people use. The two main approaches that people use in the UK are the lateral approach or the posterior approach (DAA). It stands for direct anterior approach which is a relatively new way of performing a hip replacement.

The idea behind the direct anterior approach is that there's some evidence that your recovery in the first few days or a couple of weeks is slightly quicker due to the different muscles that are involved in in the surgery. When I was in Australia, I was one of the people who are working on the direct anterior approach that is now more commonly used and we certainly found that within the first 24-48 hours we'd notice a difference with the patients. The problems though; it comes at a price. The direct anterior approach tends to give a more visible and slightly, uglier scar but the big problem that we found was that there was a higher incidence of complications during and after surgery through a direct anterior approach. So, things like broken bones and malposition of the implants were higher with a DAA.

If I were having my hip replaced, I would not have a direct anterior approach. I would have a posterior approach which, coincidentally, tends to be the approach that I use for a hip replacement. That gives you - in my mind - the best combination of safe and expansile exposure in order to correctly implant and orientate the replacement in combination with the least amount of damage to the muscles and the best chance of being able to walk without a limp. I hope that answers your question.

Louise King

I think it did, it sounds like it did! And we just have time for one more question. I'm so sorry but I know we have so many more in the chat, in the question-and-answer session, but we will actually answer those offline afterwards. Our last question is for you, Mr Reddy. An anonymous person says they have a valgus deformity in their right knee. Can anything be done about it they've seen a physiotherapist and had exercises given to them, but they're not sure if it's doing anything?

Mr Kumar Reddy

If it's not doing anything, and if they've tried braces as well - where you can correct the valgus deformity into a neutral alignment with some braces - if that has not given them any sufficient pain relief and, if it is the pain that is the cause of concern, then they need to be seen sooner than later. Because the more you leave it, the deformity gets progressed, and it becomes a challenge for the surgeon to correct the deformity. Our aim is to get rid of the pain and also to correct the deformity to a neutral alignment where the leg can be looked at as a straight knee after surgery. That's what we need to do. We need to get them properly investigated with the radiographs and then we can plan the surgery accordingly. It's not a problem, it's a valgus knee or a varius knee. It can be done and we need to clinically assess them and get them properly investigated.

Louise King

Great, thank you. Okay well, thank you very much - both of you - for your time today. It's been really interesting, and we've had some very varied questions, so hopefully that's been helpful to all the listeners. As I mentioned beforehand, we will get back to your questions via email at a later date - so don't worry about that - and thank you Richard, I'm pleased you think it's fantastic. I’ll pass that on to you.

Now after this, a survey will pop up and we’d really appreciate it if you could complete the survey. It really helps shape our future events and give feedback to our wonderful presenters. Our next webinar is on the 17th of March. It focuses on varicose veins and it's with Vascular Surgeons Mr Eddie Chaloner and Mr Aaron Sweeney. So, if you are interested in that, or if you know anyone, please do pass that on. And - as mentioned on screen - we do have our Private Patient number line open until 8 pm this evening, so for another hour. Chelsea and Karen are available to take your calls if you wanted to book a consultation with any of our Orthopaedic Surgeons but in particular Mr Reddy or Mr Chipperfield. So overall, thank you very much for attending and thank you very much both of you for presenting and thanks for the team in the background supporting this webinar. So have a lovely evening and we'll see you all soon. Thank you, bye.