Damien Gregory

Right. Good evening, everyone. Welcome to our webinar here on hip and knee replacement surgery. So, my name's Damien. I'll be hosting your session this evening, and this evening I'm joined by our consultant orthopaedic surgeons, Mr Alex Chipperfield and Mr Mark Jones. This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, do So, by using the Q and A icon, which you'll find at the bottom of your screens. Now, this can be done with or without your name. But also, please note that the session is being recorded if you do provide your name. If you'd like to book your consultation, we'll provide contact details at the end of this session. So, I'll now hand you over to our presenters, and you'll hear again from me shortly, Mr Chipperfield and Mr Jones.

Mr Alex Chipperfield

Thank you. Fantastic. Hello and good evening, everyone. It's lovely to be here, as always. I'm Alex Chipperfield. I am one of the Consultants here at Benenden Hospital. I perform hip and knee replacements here with my colleague, Mark Jones.

Mr Mark Jones

Hello. Yeah, I'm Mark Jones. I'm one of the Orthopaedic Consultants here, and I'm a knee surgeon. So, I perform the knee total knee replacements and half knee replacements here.

Mr Alex Chipperfield

So, we're going to talk to you tonight about the ins and outs of lower limb joint replacement surgery, both hips and knees. I'll start by talking about hips, and then I'll hand over to Mr Jones to talk about knee replacements. so, a little bit about us to start with. I'm, like I say, a lower-limb hip and knee surgeon. I trained in the south-east of England, and I spent years working in the NHS. of those were as a consultant in East Kent hospitals in the NHS. I left there a couple of years ago, and now I purely work in the independent sector, performing hip and knee replacement surgery. Yeah. And yeah. And yeah, So, I've been I currently work at East Kent Hospital as well as the Benenden. I've trained in the region in Kent and Surrey, Sussex, and obviously went up to Australia for a year to learn more about knee surgery, particularly sports knee surgery, before coming back to become a consultant in Canterbury, in Margate, where I subspecialised in knee surgery.

So, I'll get on with it. So, as I said, we're going to talk about the two different main joint replacements. So, hip replacement surgery and knee replacement surgery. Each one of those will follow a fairly similar pattern. We will talk about the causes of the arthritis, the signs and symptoms, treatment options, and then the surgical journey itself, what to expect, and potential pitfalls and hazards after that. We'll be quite happy to take any questions that you may have.

So, starting at the top with hip arthritis, the causes of hip arthritis. Basically, hip arthritis is a condition that causes the joints to become painful and stiff. It's a natural ageing process. It tends to be a degenerative condition for the overwhelming majority of people. So, the number one cause of hip arthritis is age; there is a slight tendency to get hip arthritis slightly more. If you're a lady rather than a man, there's a split as far as that goes. Obesity and other forms of joint injury are also, risks. So, previous sporting injuries, breaks, or damage can predispose you to hip arthritis, as can underlying conditions such as developmental abnormalities. So, problems that you might get with the hip forming as a baby or diseases of childhood, such as Perthes disease, which could cause loss of the normal shape and contour of the hip joint, leading it to wear out more earlier than you'd otherwise expect, are other systemic diseases that may have an impact on joints in general that happen to affect your hip. So, things like rheumatoid arthritis, gouty conditions, or pseudo-gout can lead to erosion of any joint, with the hips being one of them. The typical symptom that you would get with arthritis of the hip would be pain, and that's the number one symptom. Typically, that pain would be right at the front of the groin. A lot of people tend to localise there, their, when, when you ask them where their hip is, they'll indicate towards the side of their thigh or the top of their thigh. But actually, the feeling that you think is a persistent groin strain won't go away quite often. That's actually hip arthritis because the hip joint is right at the front of the groin. You would get pain that could radiate around the buttocks and down the leg towards the knee. Sometimes you would only feel pain in the lower leg or in the knee itself. In addition to pain, you can get stiffness in your hip that tends to manifest itself in difficulty getting in and out of the car and difficulty lifting your leg up and over. If you're going on a walk in the countryside and doing simple, practical things like being able to put your trousers on properly or being able to get down to cut your toenails, those kinds of things you will lose when you lose them—those first degrees of movement in the hip—as things progress, the pain will progress as well. Initially, you will get pain with activity as things become more advanced. You may well find that you're getting pain at rest or at night. And when you're in a position where your sleep is being disturbed by the pain coming from your hip, that's often quite a sign to seek help. along with pain and stiffness. The other part of moving a joint is the muscles that move; if the muscle is stiff and weak, then the muscles will start to wither away as well. If it's painful to move, then it's very difficult to try and keep the muscles around that hip joint as strong as they possibly can be. So, most people will experience pain, stiffness, and functional loss as a result of arthritis. If left untreated, treatment options vary in intensity. You don't just dive in, get out of the hammer, and sore, and do a hip replacement with a worn-out hip. There are plenty of other steps that you can take to try and live with your symptoms and make things as comfortable as possible before you're looking at the last resort of surgical intervention. So, simple painkillers will be the first place to start. Normally, over-the-counter painkillers such as paracetamol or codeine combined with an anti-inflammatory medication such as Ibuprofen or Nurofen can be quite an effective way of helping people live with mild to moderate hip arthritis. Exercise is also, very important. Keeping your joint as mobile and as strong and well supported as possible is a key factor in supporting a diseased or failing hip. Changes in lifestyle, such as losing weight, could also, take some pressure off your hip joint and allow you to get some more life out of it. Using a stick and taking the pressure off in that way can help. sometimes people find that wearing different footwear, avoiding high heels, going for a more cushioned shoe, can be more supportive, lessen the impact. And again, physiotherapy can help you maintain or limit the loss of movement that you have from an arthritic joint. Steroid injections can sometimes help, especially if there's a lot of inflammation around the hip joint itself. Those injections with a hip—the hip joint is quite deep down, you know, relative to the surface of the body. So, hip injections tend to be done with a very long needle. In order to do that comfortably and safely, it's done with an anaesthetic in the operating room and using an X-ray machine to guide the needle into the right place.

So, in mild to moderate arthritis, hip injections can be quite useful to buy a bit of time. Ultimately, though, all of these measures are ways for you to live with what you've got rather than curing the problem that the joint is worn out. If all conservative measures have failed or if it becomes unacceptable for you to live like this, then you'll be looking at joint replacement surgery. What is a hip replacement? Well, essentially, a hip replacement is an operation that replaces the two worn parts of your hip joint. Your hip is a ball-and-socket joint. The ball is the top of the thigh bone. The socket is the part of the pelvis that the ball articulates with, and both of these get diseased and worn out with arthritis. And when you perform a hip replacement, you're replacing both sides of that joint. Essentially, you are removing the ball part from the femur and replacing it with an artificial ball that is held in place on a stem that goes down inside the thigh bone. The socket is replaced with a metal hemisphere, which is then lined, normally with a plastic liner, which then correlates with the ball to produce a new ball and socket joint. There are lots of different types of hip replacements. There are lots of different materials that you can use, and there are lots of different ways that you can fix a hip replacement into the body. Essentially, that's a discussion for you to have with a surgeon as to which of these particular bearing combinations and fixation methods are most suitable for you. It depends on the quality of the bone that we're implanting into. It depends on your general well-being, levels of activity, and expectations. But there are lots of different options that we can use, and we tailor them to you to give you the best, longest-lasting, sorry about this, best-suited, and best-performing implant for you. As I've said, essentially, we're replacing the ball and socket, and there's a few little cartoons there on how it's done. The operation itself, the surgery itself, normally takes somewhere between an hour and an hour and a half. It involves an anaesthetic called a spinal anaesthetic. For the majority of our cases, a spinal anaesthetic is when you have an injection into your back, which puts your legs to sleep.

Now, a lot of people worry that when they have a spinal anaesthetic, they will be completely awake from the waist up, and they'll be able to hear, see, smell, and feel everything that's going on inside the operating heater. that's not the case on top of the spinal anaesthetic. You will also, have heavy sedation, which means that you will be essentially asleep. but not fully under general anaesthesia. It's kind of a grey area between the two. Typically, you'll be in the hospital for one or two nights following the surgery. You'll be discharged at home when it is safe for you to do so. So, when we've checked that your blood tests look okay, that your X-ray looks all right, that you don't have any wound issues, and that you, the nurses, and the physiotherapists are happy that you can cope in the environment that you are being discharged to, You'll be fully weight-bearing when you go home, and most people are discharged on a pair of crutches, which they will then slowly discard over the next few weeks depending on how you're feeling from a strength and confidence point of view. A few X-rays show various different types of hip replacements. The double hip replacement is on my left. Your right is a cemented type of hip replacement, and the one on my right, your left, is uncemented. These are both brands that we use here, and like I said, they tend to be tailored to the bone stock that is being implanted in. I've touched on the recovery; if you have your hip replacement in the morning, we will have you standing on it and walking in the afternoon. If you have your operation later in the day, we'll give you the night off and then get you up and about the next day. Initially, it's going to be sore. You know, most people have an operation that involves a hammer, a sore, and a knife. You know, it will be tender, but most people are surprisingly comfortable following the operation. They tend to describe the pain as a tightness or a feeling rather than the pain that they came in with.

So, it's a very good operation for relieving pain very quickly. You'll be seen on the wards by the physiotherapists, you'll be assessed and mobilised, and you'll be guided by them as an outpatient as well to build up the strength and confidence in your hip. Like I said, most people are in the hospital one or two nights back to normality within six weeks. That's ambitious. I tell most people not to make any big plans for the first three months. because it does take time to build up the strength and confidence in your hip again. You know, building up the muscles surrounding the hip takes time. So, it's a gradual process, life after a hip replacement. It's a great operation for getting rid of your pain. Works very well, very quickly. As far as that goes most, what we aim for with a hip replacement is something called a silent hip. And I must say, the majority of people who have a hip replacement do end up with that. What I mean by that is that you're in a situation where you forget you've ever had your hip replaced. You just live your life as normal. Really. There will be some things that you may or may not be able to do, and you do have to treat your hip with a little bit of respect. You know, it is an artificial joint. It's true, and they have a finite lifespan.

One of the issues with a hip replacement is that it could wear out before you die. If you use a hip replacement as an excuse to get back to high-level, high-impact exercise, then it may well be that the things wear out before you're ready. If that's the case, you might end up needing further surgery to revise your hip replacement. So, there is a bit of a balance here. Yes, I want you to forget about your hip, but you also, need to be responsible and not go bananas with it as well. We do put precautions on you in the first six weeks just while things are knitting together and healing. We don't want everything to fall apart before it's had a chance to heal and settle in.

So, there are restrictions on what you can and can't do and how far you can bend that kind of thing. But that's only a temporary measure and will be lifted after six weeks. The this is an X ray that you never want to see. That's an X ray of a dislocated hip replacement. And that is one of the potential problems that you could develop following hip replacement surgery. Fortunately, it's rare. It tends to happen. If it's going to happen, it will be early on before the soft tissues are fully healed around the hip, which is why it's important to follow your precautions in the early stages. Other than dislocation, you can develop blood clots in the leg, get an infection, or get bleeding or bruising. You can get injuries in and around the joint itself, leading to broken bones. Sometimes you can change the length of people's legs. And sometimes you end up in a situation where a hip replacement either fails or is unsatisfactory enough that you end up needing further surgery to redo all of these risks. We do everything in our power to avoid them happening in the first place. If you are one of the unfortunate people where something bad does happen, we do everything in our power to make it right again. But the sad fact is that sometimes an operation turns out not as well as anyone expects. That's just a fact; there's never a 100% guarantee with this kind of operation. Having said that, though, it's a fantastic operation. The risks are small but real, the benefits are huge, and on the whole, you know, it is something that, you know, absolutely would be worth considering. I've noticed just before I move on to knee replacements, there's a question that's come up. Does osteoporosis in the opposite hip or thrombosis preclude looking at hip replacement? The short answer to that is no. If you do have osteoporosis or slight weakening of the bones, that could be an indication for using a cemented implant rather than an uncemented one to help augment the strength of the bone and minimise the risk of problems as far as that goes, as far as thrombosis goes. Hip replacement is at risk of causing a blood clot as it has had a previous blood clot. So, it does mean that your risk of blood clots following hip replacement surgery might be a little bit higher. We give you medicine to minimize that risk following surgery and you would certainly be put on that, as a, as a matter of routine following a hip replacement. But it does mean that you might be at a slightly higher risk of developing a blood clot. One last one has just come in before I move on. I've been told I have a couple of cysts on my hip in addition to severe arthritis. Is this a problem? The answer to that is no. cysts are part and parcel of developing arthritis in your hip. One of the five radiological features of arthritis is what's called sub subchondral cyst formation. So, pretty much everyone who has the typical appearance of arthritis on x-ray will have cysts, it's part and parcel of the worn out joint and not something that tends to cause any trouble. That is all I've got as far as hip replacements go at this stage and hopefully, I've answered a couple of those questions that have come through.

I'll now pass you over to mark to talk about knee replacements and then we'll, we'll come back and answer any more questions from that.

Mr Mark Jones

Thank you very much for that talk, Alex. So, we're going to move on to knee replacements, which is largely covered a lot from what Alex has said that the process of arthritis is very similar in both hip and knee. It's a degenerative disease that is caused by the wear and tear of a knee joint. Symptoms: early symptoms tend to be a bit of stiffness within the knee, and patients tend to talk about pain in certain areas of the knee or generalised pain, which then affects their activity levels that they can do because of the arthritis and because of other degeneration within the knee. You can get a symptom—what we call mechanical symptoms. And these are clicking, grinding, or crunching within the knee, which can be fairly off-putting and can be painful as well. And because of the inflammation that the arthritis causes, this can cause swelling within the knee joints. And this can then lead to a restricted range of motion. And, with further pain, patients then further develop the arthritis, and the pain develops. So, they get wrist pain. So, when you're sitting down at the end of a long day, you can have pain in your knee, which is unbearable, and then you go to bed, and you have pain that either stops you from sleeping or wakes you from sleeping. And this can be a very late-stage sign, which we take fairly seriously in terms of what we're going to do with the management plan because, because of the arthritis, you wear out your cartilage and your meniscus within the knee. And it's, and as a result, you can develop deformities where your knee can either bow or become knock kneed, and this further increases pain, and further deformity can happen as a result. And all of this leads to reduced muscle pain. And therefore, you're going to reduce the distance you walk and the activities you do. And as a result, your quality of life really decreases. So, there are stages of arthritis, and when we look at x-rays, we'll talk to you about whether you've got mild arthritis or moderate-severe arthritis, and really, on x-rays, we're looking at what the joint space looks like in between the two bits of bone. We're looking for little deformities and new bone formation on the sides of the bone that are formed as a result of the arthritis. And basically, when you have severe arthritis, we're talking about you having bone-on-bone arthritis, which is going to lead to severe pain. There are many treatments for knee arthritis, and it all depends again on the severity of the symptoms and the X-ray changes that you see. First of all, we all, again, as Alex said, don't all jump in with sores and hammers straight away to treat your knee arthritis. There are non-management options. The first thing is activity modification. We don't want you to stop all activities completely, but you do need to start. Take a rest. You need to start building up the strength around the knee, start increasing your range of motion, and increase your activities slowly. So, you can introduce certain weight-bearing activities later on down the line. Running high-impact sports will cause more pain and swelling, which will then further deteriorate the knee, but do So, in the right setting. We can sometimes get patients back to higher levels of activity. Along with this, decreasing the load through the knee really helps. So, weight loss—any weight loss through the knee—is a benefit. And this, the reason being that you don't just put your own body weight through the knee as you weight bear through it; you actually put up to times your body weight through your knee joint, which can then lead to significant pain. Physiotherapy will help you with giving, guiding you in terms of exercises to do to keep the leg strong, and increasing your range of motion. And sometimes, this can help with your pain and get you back to the activities that you want to do. Alex has talked about the simple analgesia that you can give to patients. So, co-codamol, naproxen, and ibuprofen are really good painkillers that you can take even over the counter to help with pain. And nice guidelines have suggested that cocoon and naproxen are adequate painkillers for arthritis for a lot of non-operative management. And then we talk about strapping the knee. This can give it a sense of security around the knee; it can warm up the knee, which can help with pain. And we also, have special braces that can correct the alignment of the knee to correct that deformity that's been caused by the arthritis So, that you stop putting less weight through the damaged areas. One of the last things with non-surgical management are injections. These can be in the form of steroid injections, where we inject corticosteroids into the knee joint, which take down the inflammation. And usually, the effects start at around eight hours and can last up to six months. Usually, Durolane is a type of hyaluronic acid injection that is a viscosity supplement and basically gives lubrication to the knee joint to help with your pain. And I'm going to talk in a minute about Afro Zume, which is a new injection that has been recently released in the UK. It is the implantation of a material that allows for good pain relief. Surgical options for the treatment of arthritis are not just a knee replacement; we can talk about correcting the alignment that's been formed by the deformity of the arthritis. And this is called an osteotomy. And this is where you can either break the bone in the t in the shin bone, in the thigh bone, or in both to correct the alignment and then put less pressure through the damaged area of the knee. There are certain arthroscopic techniques that can be helpful. In arthritis, microfractures are used for certain isolated areas of the disease. Cartilage transplantation or other methods can be used to try and stimulate the healing of that cartilage. And lastly, we move on to the joint replacement techniques, which we'll talk about now.

Oh, we will in a minute. Sorry, we'll talk about Arthrosamid is a relatively new injection in the UK, but it's been around for quite a while. Denmark has been using it for quite a while in patients over there, and it was originally found in horses, where actually horses who had this injection seem to get back from injury. It's called an implant because the injection you're giving stays within the knee permanently, and it combines with your own tissue to basically allow for a thicker barrier of protection within the knee. Currently, it's being brought, we're about to bring it, use it in the Benenden, and it would be a day-case procedure where you come in for a day-case procedure where we give an injection under ultrasound guidance into the knee. It requires six small injections into the knee using one needle and six rings. And the idea is that it should last for up to three years. And that's what the research from Denmark has shown, and it has been better than using steroids and hyaluronic acid injections.

So, let's get back to knee replacement. So, this is the final outcome of knee arthritis. In terms of surgical management, it's a very common operation and is performed in the UK every year. The average age of a patient having a knee replacement is around 65. And again, it's more common in females, in a similar ratio to what hip replacements were. There are significantly improved health outcomes from a knee replacement. and most patients do well with a knee replacement, and they can last for, you know, hopefully years. But again, the research from the past is not really there to, for example, give you accurate numbers. Knee replacements come in many sizes. You can have half knee replacements, and this is where you have an isolated area of arthritis in your knee. A half-knee replacement can correct that arthritis. This can be either for the inside of your knee, the outside of your knee, or just underneath your kneecap. Knees are called partial knee replacements. The benefits of partial knee replacements are that the recovery is slightly quicker. Probably the early patient-reported outcomes are better. The one downside is that because we don't replace the rest of your knee, you can develop arthritis throughout the rest of your knee and require an earlier revision. The other option is a total knee replacement, and this is where we replace all the surfaces of the knee. And this can be done in different ways. We can use standard instrumentation, which we've been doing for many years and has very good outcomes. And we can also, now in Benenden offer you robotic-assisted surgery, which uses computer navigation to aid in a slightly more personalised knee replacement. With the aim of trying to give you earlier, better outcomes and early patient-reported outcome measures. Signature implants are custom-made implants where you have CT scans of your leg and your lower limbs to try and produce a knee replacement that is customised for you. But I think with computer navigation and robotic-assisted technology, this is less used now. Total knee replacements are for those more complex knee replacements that have ligament laxity or require revision surgery. And again, this is a bigger surgery, but it still has very good outcomes in terms of its reported outcomes if it's needed.

So, the surgical journey will start with your GP referral. You'll be referred to one of the surgeons here at the Benenden and we'll see you, assess you, and look at whether you're suitable for having a knee replacement. We'll want to optimize you as much as possible. So, you have the best outcomes after your total knee replacement. And this will co will be rehabilitation with physiotherapy, strengthen the knee, increasing your range of motion, you'll be assessed by the pre assessment team who will make sure they optimize all your medical conditions So, that the operation is as safe as possible. And one of the biggest things here is making sure that your diet, if you have diabetes, that this is controlled is this ha does have higher chances of infection and poor wound healing and poor outcomes, post operation. Another thing we do in this pre optimization is try and have weight loss because again, the weight loss weight has been shown to have poor outcomes in long term out in, in knee replacements, in terms of high risk of infection, high risk of blood clots after the operation. And So, the more we can do preoperatively, the better your outcomes will be. On the day of surgery, you'll be admitted to our ward, where you'll be seen by the nurses and admitted, and you'll be seen by the surgeon and the anaesthetist. Most as with a hip replacement, most knee replacements are done under a spinal anaesthetic and potentially a block where the nerves around the knee are y are numbed So, that you can have loss of sensation. But you, after the operation, you can still move your knee So, you can get up and about without pain. And a long same as the hip replacement. You'll be given some kind of sedation. So, you don't remember it and you can't hear the sounds or smell, smell, what's going on in theatre, which is a lot of people are worried about as was mentioned with the hip replacement. And then afterwards, you'll be taken to the ward where you'll be, and if you're done early in the morning, you'll be mobilising by the afternoon with the physios, whereas if you're done in the afternoon, you'll probably wait till the next morning before you're mobilised and moved out of bed, and then you'll be seen by the physios twice a day before you're discharged, which is usually on the first or second day after the operation. This really kind of looks at the rapid recovery protocol, but basically just mentions everything I've just said about how we're going to optimise you as much as possible preoperatively. So, we can get you out of hospital as soon as possible afterwards and get you back to your own home.

As with any operation, there are always risks, and we talk about and break down the risks as they occur. So, they can occur during surgery with blood loss, and every operation has some bleeding. But we manage this during the operation, and occasionally blood loss does require a blood transfusion. During the operation, there can be damage to the bone. and this can lead to a fracture, which might need to be managed at the time of surgery, or if it's not seen or managed, then we may need to manage it afterwards and try to give you a good outcome from that. Nerve injuries can occur as well as injuries to structures within the knee, such as the ligaments and tendons that surround the knee joint itself. After the operation, you may have problems with the wound. The wound can have wound breakdown, and there can be early infection within the wound or within the deep aspect of the knee. And you can develop blood clots, and these blood clots can go from your legs up to your lungs. And this is why we send you home with blood-thinning medication to reduce this chance after the operation. It's a really painful operation. And as a result, it does get a bit stiff, and it does swell up, So, it's important to get this knee going to try and prevent long-term stiffness. And we do all of this by trying to send you home with painkillers that adequately control your pain So, that you can continue moving your knee. The late-late risks do include late infections, and this can be anywhere from, you know, three months down the line to even years down the line. You can get an infection into the knee. And again, we would manage this by managing the infection and washing the knee out. And it may then, at that point, require further surgery in terms of revision surgery over time as the hip can wear out. The more you do, the more load you put through this knee, and the more activities you do, the quicker it will wear out. So, as it wears out, the knee replacement can become loose and wobbly, and that then might need further surgery. And again, any time around a knee replacement, you can have a fracture if you have a fall when you're skiing or walking, and it fractures around the implant. You might need a revision of that implant that's in.

So, we're going to talk a little bit about the ROSA robot now. So, this is a new introduction to the Benenden that's been in for the last few months, and it's a robotic-assisted knee replacement. It doesn't mean that the robots are doing it for us; the robots are there to assist us in giving you a more personalised knee replacement that hopefully will improve your surgical outcomes. We have a couple of trackers in the theatre to monitor where your knee is and to give us the balance of your knee and how much of the cuts we need to take off, and we interact with this robot to make sure we can give you the best knee possible from the robot. And then I think we've got a little video, So, I'm just going to play this, and it's just about a minute and a half. Rosa Knee is a robotic surgical assistant for total knee replacement. Your surgeon is specially trained to use the robot, which does not operate on its own. Your surgeon is in the operating room the entire time, making decisions throughout your surgery. Your surgeon creates a plan for your surgery based on your unique anatomy. The robot helps to ensure the plan is executed as intended. Rose and Knee uses a camera and optical trackers to know where your leg is in space. If your leg moves, the robot can tell and adjust accordingly. Rosa Knee provides your surgeon with data about your knee. This helps to personalise your surgery based on your unique anatomy. Ok. So, I mean, if you have any problems, these are the knee and hip surgeons who will actually help you. And So, we are just, I think, going to move on now.

Mr Alex Chipperfield

If we have any questions, should we start at the top? So, now, Mark, you have to talk about ROSA, which is exciting. You also, got to talk about Arthrosamid, which is new. So, you have to answer the difficult questions to make up for that. So, shall we start with this top one and see what you think?

So, I had total knee replacement surgery in June last year. It's now apparently unstable because the ligaments weren't strong enough. I've been told I need revision surgery. I'm reluctant to have this because of the risk. So, I've opted to use a brace that has been fitted by a physiotherapist. What is likely to happen if I don't have the surgery at present? I am managing quite well and have no pain; ligament, balancing, or knee replacement is difficult. If, if the, if the knee replacement is loose and as a result, you then have unstable ligaments, it can lead to instability in your knee giving way. And lots of patients complain when they come downstairs; they don't trust their knee, or if they're doing activities where they're twisting, turning their knee can give way, which can be quite dangerous non-operative ways of managing. Managing this are braces, and braces can give you the stability that you need to control the ligaments mainly on the outside of your knee to stop your knee giving way.

I think if you're managing quite well and have no pain, I certainly wouldn't be in a rush to do revision surgery because revision surgery a year down the line is big surgery, and you may never be thankful for that surgery either. I think if your pain is well controlled and you're managing with the brace and you don't mind wearing the brace, I personally would continue that way if I were you.

Mr Mark Jones

I absolutely agree with that. It is a huge operation to go through, and you only do it if you can't cope with the way you are with the bra.

Mr Alex Chipperfield

Yeah. The next one we have is if needed. What are the pros and cons of having both hits done at once?

I answered this question today. Actually, I saw a patient. We, we, we spoke about that. Essentially, I do lots of joint replacements. I do about a year, and probably one of those every year, I will end up doing a bilateral case. Essentially, it's a massive operation to go through, and it has to be the particular set of circumstances. Everything has to align, and both joints need to be equally worn. You need to be in a situation where, if you just have one done, you can't mobilise because the other one is still hindering. You have to be physiologically strong enough and young enough to have it done. And you also, need to be in the right environment to have it done. What I said to my patient earlier today was that, as a general rule, I would have one hip replacement done at a time, leaving a decent amount of space to recover between them if there was no other option. But having both done at the same time, my advice would be that you have that done in a hospital that has at least a high dependency unit, if not an intensive care unit. And that would rule out having that done in most private hospitals in the south-east of England, in particular. You know, like I said, I do lots of these. It's rare that I do a bilateral case simply because it is a massive thing to go through, and most people just aren't quite strong enough to go through that.

Mark, how often do you do a bilateral knee?

Mr Mark Jones

Never in this country. I did when I was in Australia on my fellowship; we would do one a week, but they all went to ICU for a couple of days, and yet the first six weeks were very horrible. It's awful; it's like they did not enjoy it. I mean, it does mean that by three months they tend to be getting back to jobs. So, for self-employed patients who just want one operation, I think, you know, you've got to be really fit and healthy; you've got to be able to withstand that massive surgical trauma. And also, in Australia, we were doing both knees at the same time. So, the operation was slightly quicker, whereas here it would be one operation on one knee, then a move to the other. So, your operation is double the length of time, So, your risks are doubled. So, the answer is probably best avoided.

Mr Alex Chipperfield

I had a left hip replacement three years ago through avascular necrosis. My right has started; is it the same?

It could be; if it feels the same, then it may well be the same. It's very difficult to tell without seeing you assessed; you would need some investigations. An X-ray is quite a good way of showing a vascular necrosis, or a VN, when it's at a very advanced level. Sometimes, in the early stages of a VN, you can't pick up on an X-ray. but you can see very clearly on different tests, such as an MRI scan. So, if you're concerned that your hip is feeling the same, my first advice would be to come along and see someone like me, and we would look at basic investigations and go from there.

Mr Mark Jones

You mentioned being on blood-thinning medication to prevent thrombosis. Is this a permanent medication after the op?

So, no, unless you're already on it. If you're already on blood-thinning medication before the operation, then yes, you'll go on it after the operation, and you'll just continue it. If you're not on it before the operation, then you go on it for knee replacements for two weeks and for hip replacements for days, four weeks, and days. Sorry, I don't do it. But you stay on for that period of time, and they can either be in two forms: injections with Clexane or tablets with river rock span. And that's what we use here in, in, in the Bey. And that'll be your discussion with your surgeon about which one you tend to go to.

Mr Alex Chipperfield

We've now got two questions that are kind of asking the same thing. So, we've got one saying both my hips need replacing. Left is first, how long am I likely to wait between operations to get the other one done, and the next one down is I need both a hip and knee replacement. I've been told I need a hip replacement first. How long do I need to wait for the knee replacement? Essentially?

You know, we're talking about two big operations, one after the other, whether that is one hit, then the other hip or one hit, then knee or one knee, then the other knee. My answer to those questions tends to be the same. I tell people to give yourself a good six months. You need that time to fully recover from the first operation and then to build up the strengths and reserves in your system to go through it all again. Some people will operate a little bit sooner. I personally think anything less than three months is not the right time between three and six months if you're really desperate, but if you can hold on for that six-month period, you'll find that the recovery from the second side is a lot more straightforward, and I completely agree. I usually, if someone needs two operations, see them at the six-week stage, and then they usually hate me still at that stage and maybe don't want the second knee done. But if they do, then I tend to say I'll put you on the list, but I would rather do you if, I mean, at least three months after the operation, ideally six months. And it depends again if they're self-employed or, you know, if they need to build up some money. Sometimes they need to wait a bit longer. But if they've got reasons, I'll do it in three months. But ideally, after six months, I think the outcomes are slightly better.

So, can you have a knee replacement if you've had an ACL?

Mr Mark Jones

Yeah, absolutely. During a knee replacement, we actually remove your AC L in all of them, apart from the half knee replacements. So, you don't need a competent AC L to have an A to have a knee replacement. The only thing about having an ACL reconstruction is usually where the tunnels have been drilled and what implants have been used to fix that ACL in place. There are a few implants that take out quite a lot of bone, and that can weaken the bone. So, doing a knee replacement can then have a high risk of fracture. So, some knee replacements might need to be done in two stages, where we remove the metalwork first, let the bone heal as if it's a normal fracture, and then come back maybe six months later to do the total knee replacement. So, you have the best outcome without a reduced risk of fracture. But most of the ACLS that are put in place can be done in a single setting, just removing metalwork if it's in the way. You might not even need to remove the metalwork if it's not going to get in the way of your knee replacement.

Mr Alex Chipperfield

We got a question here from a lady saying that she's had groin pain for a year, and the X-ray shows that you've got arthritis, you're starting a course of physiotherapy, and you've been doing exercises for six months. Your question is, How long do you think I will need a hip replacement? I do not yet have nighttime pain.

Mr Mark Jones

That's a very difficult question to answer. What it boils down to is that you will tell us when it's time to have a joint replacement. There's no test that I can do that says if you need it done, it is when you cannot live with what you've got, what you've got, or what you've got anymore. For the most part, that tends to be when someone is, when their pain is dominating their life. So, when their decisions are being made by the worn-out joint rather than by them, when their world is shrinking, when they're struggling to. I mean, sleep is a big one. If your sleep is disturbed, that's a problem. If your pills aren't working anymore, if you can no longer live the life that you want to, if your world is shrinking because of your joints, then it's time to have that done. I'm afraid I cannot tell you when that may be because everyone is different, and everyone differs from joint to joint as well. So, it's an impossible question. I'm sorry.

Mr Alex Chipperfield

Next one, another hip. I broke my hip years ago, and it was fixed with a plate and screws. You then had them removed in March. You discovered that you've got a VN in that hip, poor thing. You've had pain and limited mobility in that hip. Since the surgery, you're now thinking about a hip replacement, but it's complicated by the fact that you've got cerebral palsy. You also, have APID. What's that? Oh, I don't think. I don't know what APID is. I'm sorry; I was only diagnosed in recent years with lung problems. What advice would you give me on where to start?

My first piece of advice is that you need to see someone. You need to come to a clinic where we can look at you and assess you. Talk about what your various options are. It sounds like you're heading for a hip replacement. Whether or not you would be suited for a hip replacement depends on how much muscle control you have around your hip.

Mr Mark Jones

So, how do you know how severe your knee is and what kind of type you have? Has it led to any particular kind of deformity or problem around your hip as well?

That is a question that can't be answered from that paragraph. But, you know, there's nothing in that question that makes me think it would be impossible to do a hip replacement or that it would be impossible to allow you to live a better life than you've got at the moment. So, there will be things that can be done to help. but we'd need to talk to discover exactly what the best treatment path would be for you. So, we've got a couple of injective questions about injections.

Mr Alex Chipperfield

So, first of all, does the Arthrosamid injection impact the ability to get a total knee or partial knee replacement later? And also, I understand that steroid and hydrocortisone do not mean a knee replacement cannot be done for two or three months. So, in terms of the Arthrosamid injection, no, the idea is that it is an implantable injection, but there's been no studies to show that you can't have a knee replacement again. I would probably do the same as I do with a steroid, hydrocortisone, or duralene injection; I certainly wouldn't do a knee replacement within three months of giving it. And ideally, if you can wait six months, it's better in terms of the infection risk, but if it won't, it's a good stepping stone to try and see if it will help, and if it doesn't help, it doesn't then preclude you from having a knee replacement later on as long as you have that gap between the injection and then having the knee replacement.

Mr Mark Jones

Yeah, I would agree with that. There is some evidence of an increased infection risk with steroid injections. Arthrosamid. The idea of Arthrosamid is that it will delay or negate the need for a knee replacement in the short to medium term. But when you get to the stage where you do need a knee replacement, there's no evidence that it has any effect on you.

The other point is, if you've got psoriasis or eczema around the knee, would that stop you from having a knee replacement?

In my book, the answer to that is no, as long as there's no acute infection with your psoriasis or acute flare-up. But no, actually, the wounds tend to heal fairly well. You're covered with antibiotics like everyone else. There would be no reason why I wouldn't do it. We got one here regarding blood loss during surgery; do use the patient's blood if they wish for that. So, the need for transfusions following elective joint replacement surgery is very small. But you know, there is a potential for blood loss during the operation. Typically, if you need to replenish someone's blood, you do that with donated blood, which you would have cross-matched and typed for you in preparation before the operation. If there are reasons why you can't have someone else's blood, say, you're a Jehovah's witness and you're precluded from receiving blood products from other people, Then there is potential to use what's called a self-save machine, which would suck away the blood that you lose during the surgery and then give that back to you after the operation. In the routine elective setting, the amount of blood that you use means that the amount of blood that you would lose during an operation is not enough to trigger the cell salvage system to actually work properly. So, if it tends to be a waste of time and money to use a cell salvage machine for more prolonged procedures or revision procedures, then it's routinely used. But in a typical elective setting, for a standard primary joint replacement in a person with no particular risk factors, It's not routinely used because it doesn't give you enough blood to give it back.

Mr Alex Chipperfield

I have moderate PAD in both legs, which is peripheral arterial disease. I think my knee is bone-on-bone. I'm told that the P ad complicates my knee replacement surgery in terms of maintaining the blood supply to the lower leg. Can you comment?

Mr Mark Jones

So, yes, peripheral arterial disease does have an effect on knee replacements, particularly wound healing. Obviously, depending on how high that level of peripheral arterial disease goes, it will affect the blood supply to the skin around the knee. So, you do have a higher risk of blood or wound issues in peripheral arterial disease. The only change I make to patients who have peripheral arterial disease is that I don't use a tourniquet in patients with peripheral arterial disease. So, I don't cause any more occlusion of their vessels, but I still do knee replacements in patients with arterial disease. As long as we've had that conversation about it has a slightly higher risk of infection and poor blood supply afterwards. But I think you are the same as Alex. This is interesting because we haven't compared notes beforehand and our answers have been pretty similar throughout and consistent, which is nice. The only thing where we vary slightly is I, yeah, I, I do need replacements on people with peripheral artery disease and you know, for the majority of the time, I, they, they're, they're treated exactly the same as any other patient and I do use tourniquet for them as well. Unless it depends on the level, if we're talking about critical disease, then some would argue that you need to get that sorted before you would have a knee replacement anyway. So, the kind of disease that is affected by having a tourniquet up for half an hour is So, brittle that I would suggest that that would be the priority rather than the knee replacement itself.

Mr Alex Chipperfield

So, what are the benefits of ROSA over other methods for knee replacement? And are any special scans x-rays required?

Mr Mark Jones

So, with the ROSA, we just need X rays and it's the intraoperative findings that we, we get from the ROSA to make the knee replacement personalized for you. The intended benefits and I can only say the intended because the research isn't really there long enough at the moment to show that robotics or assisted surgery is beneficial long term in terms of year, year revision rates. But the idea is that if we personalise your knee replacement, we have a group of patients who have knee replacement who are unhappy, and we're hoping to make that unhappy population happier. So, make that percentage of unhappy patients smaller. And the idea is that if we give you a knee that is personalised for you and is balanced properly in the cup, then the outcome should be better. And there are a few studies coming out looking at year-early patient-reported outcomes, which show that patients who have robotics-assisted surgery are having slightly better early outcomes. But IC, I couldn't say long-term whether it's going to reduce your chances of having revision surgery in the long term or anything else like that. The only thing again with robotic surgery is that it does have a slightly increased risk of complications just because it's a slightly longer operation and we have to use two pins in the shin and two pins in the femur. So, you have a slightly higher risk of infection and a slightly higher risk of fracture. But again, these are fairly small. Have you got anything else to add to that? No, not really. It kind of covers it. I mean, it's early days, but as far as robotic surgery goes, the advantages are more potential than real. The gains we're talking about are marginal, not massive. but it certainly feels like an improvement over conventional knee replacement. I was quite sceptical before I started using the robot that I had absolutely converted to. I think it does add benefit to surgery; whether that is measurable in years and decades is difficult to tell, and we won't know that answer for years and decades, but it certainly feels like an improvement in the way that we perform the surgery.

Mr Alex Chipperfield

I have to skip down to this one because it mentions my name. This is it. Thank you very much. This is a lady I saw in the clinic today who says, Thank you very much for our meeting today. If we have a consultation with you, do you do that patient's operation?

The answer to that is yes and no. what I mean there are, there are different ways that you can have surgery here at Benenden You can have some operations are covered by your Benenden membership. Such as keyhole surgery on the knee. Bigger operations like knee replacement are not covered by Benenden membership, but you, they, they are still performed here at Benenden and those big operations, those joint replacements can either be performed privately. So, that means you either fund yourself or you have an insurance company that funds for you, or you can be, they can be performed via the NHS route. which means that you get referred to a private hospital as an NHS patient. If I see you here as a Benenden member and you decide that you would like to have your knee replaced here as an NHS patient, it becomes slightly con what has, has to happen is you have to go back to your GP to be referred back as an NHS patient. And there is a chance that you might not be referred back to see me when you come back as an NHS patient, you might end up with Mark. If you're lucky, you know, or any of the other guys who's, who's were, were up on the system earlier. So, but once you've seen that person and they put you on the waiting list, you will have surgery by that person unless there's a problem. So, unless they, you know, they have a flat tyre on the way or get COVID or something like that, once you are put on the list, you, you, you will have that person performing your surgery.

If you come and see us as a Benenden member or as a self-funding or insured patient, then we put you directly on the list at that point and yes, your care will be continued under the person that you see. So, you would, So, you have the choice with self-funding and insured. There's a little bit less of a choice with NHS work. But once you come through as an NHS patient, that person you see, number one, is perfectly qualified to do it. But number two will be the person who performs the operation. If you've previously had treatment by any of us here as a private patient and you come back as an NHS patient, they do their best to align you So, that you come back and see the same person. I think that's best for continuity of care. It's not always possible, but everyone here does their best to do that. The great thing about being in a place like Benenden is that it's small enough that there are still human beings at the end of the phone. And a lot of people are able to help, rearrange, and accommodate you to the best of their ability with a simple phone call. So, the answer is yes and no.

Damien Gregory

Thanks for that Mr Chipperfield. Sorry, I'm going to know that I'm actually off mute. I thank you for that presentation also. Thank you for asking and answering and reading out those questions while I was on mute.

So, actually, I'm sorry if we didn't answer all of your questions. If you have provided your name, we will answer yours via email. So, if we could just move on to the last slide for me, Thank you, Grand.

So, as a thank you for joining this session, we are actually offering 50% off the value of a consultation. You'll get a call back from your dedicated private patient advisor. You'll have an email tomorrow with a recording of treatment, information, loyalty reward points, and an update on news and future events. So, we'd be grateful if you could complete the survey at the end of this session to help us shape future events. And if you'd like to discuss or book your consultation, our private patient team can take your call up to eight o'clock tonight or between eight and six Monday to Friday.

Our next webinar is on cataract surgery, which you can sign up for via our website. So, on behalf of our presenters and our expert team at Benenden Hospital, I'd like to say thank you for joining us, and we hope to hear from you soon. And thank you, Mr Chipperfield and Mr Jones. Much appreciated.