Louise King

Okay, well good evening. Welcome to our webinar on hip replacement surgery, my name is Louise and I’ll be your host this evening. Our expert presenter is Associate Specialist Surgeon, Mr Kumar Reddy you can see on the screen. This presentation will be followed by a Q&A session, if you'd like to ask a question during or after the presentation, please do so by using the Q&A icon which is the bottom of this screen this can be done with or without providing your name. Please note this 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.

I’ll now hand over to Mr Kumar Reddy and you'll hear from me again shortly. Over to you.

Mr Kumar Reddy

Thanks very much Louise for the introduction. Good evening everyone, so a little bit about me and I’m Kumar Reddy and I work at Benenden and East Kent hospitals and I’m currently the Site Lead Consultant for Orthopaedic Surgeons and also a member of American Academy of Orthopaedic Surgeons and my interest always have been hip and knee arthroplasty and also I do uncompartmentalized knee replacements and in addition to this I do arthroscopies ACL reconstructions and revision surgeries including hips and knees in the NHS and one of the highest volume surgeons in the East Kent, I’m pleased to say that and I do roughly approximately around 400 joints a year which include hips, knees, revision surgeries unicompartmentals and also ACL reconstructions. That's my background.

So, I’m just going to brief my presentation today with regard to the hip arthritis and how we investigate, what are the symptoms arising from hip pain and how we are able to diagnose, what are the differential diagnosis and what types of hip replacements we do, and what are the bearing surfaces that would be best for our patients, and the supporting tools, and also recovery process, and the risks involved with regard to hip replacements.

Okay I’m proud to introduce my colleagues who are on the board and who are always helpful, and they are very experienced in this field of hip replacement surgery, which include Alex Chipperfield who is our Chair for Orthopaedics and Mr Dunnett, Mr Matthew Oliver, Omar Yanni, Raj Shrivastava and Raman Thakur. You have you got the next excellent team of surgeons with a lot of experience with regard to hip replacements.

With regard to Benenden Hospital, we do approximately 290 joints or private hip replacements in Benenden, which is next to Horder Centre, which they do about 300 a year. I mean if you look at overall figures, we do about approximately a thousand joint replacements a year, or even more this year so it's a very high-volume centre and in hospital and I’m proud to announce that our hospital has got better and has bought the Outstanding CQC rating.

So, with regard to coming to the hip arthritis, what is osteoarthrosis of the hip? It's a common disease affecting the joint in the body which is a ball and socket or joint and the joint surfaces which are covered with smooth cartilage may get damaged and it becomes rough, and the article cartridge becomes gradually thinner and eventually it turns out to be bone on bone arthritis, which can cause a lot of pain. The other factors that contribute to the joint arthritis is high BMIs with the morbid obesities and injury trauma can cause arthritis a previous dislocation or a fracture when the hip can contribute to arthritis and other conditions which include the rheumatoid arthritis, gout and also avascular necrosis which can contribute to secondary osteoarthrosis.

Next is what are the common symptoms that one can see in case of osteoarthrosis? Usually people complain of pain and stiffness with limited ability to walk and they often wake up at night because of the pain and usually when you ask the questions like do you have difficulty in cutting the toenails, putting the socks, tying the shoelaces, these are the common symptoms that the people express that doctor I have got difficulty in cutting the toenails and I can't get in and out of the car forget about getting into the bath, I only have a shower these days and all these symptoms you can come across in hip arthritis and sometimes people get confused with the trochanteric bursitis they always contribute, saying that the pain is coming from the hip and one has to you need to ask a consultant who is examining you and he they will always examine you and find out whether the pain is coming secondly to a trochanteric bursitis which is an inflammatory condition and also is the information of the tendon or the Gluteus Medius. So one should be able to distinguish whether it's coming from the trochanteric bursitis which is a localised pain around the greater trochanter of your right of your hip, either of the hips and whereas arthritic pain is usually associated with stiffness of the joint and people will have limited range of movements in the hip and usually they described as catching or cracking sensation in the hip and weakness in the muscles because of the disuse due to pain.

Treatment options of hip arthritis are mainly conservative and like lifestyle changes, pain relieving medications like paracetamol non-steroid inflammatory, opioids and in case of early to moderate arthritis than a steroid injection can be helpful, this will also determine the diagnosis and also therapeutic value because if following the steroid injection one has significantly for symptoms it definitely indicates that it is arising from the hip. If it is not, it would not make any difference usually it is very valuable when you got both hip and spine arthritis to distinguish between these two and a walking stick would be beneficial and special footwear also can be beneficial along with physiotherapy. If all the conservative methods of treatment failed significantly improve your symptoms then surgery comes into place which would be a hip replacement surgery and previously people used to do joint fusions it is not advocated anymore because of the cumbersomeness to the patients so joint replacements have given good results over the years and people tend to do joint replacements these days, and with regard to hip replacement surgery you can see 48 percent of the hip procedures are done within the independent hospitals in the UK in 2021 and approximately 84,000 primary hip replacements are being done in UK in 2021 and hip replacement surgery is the second best operation in the world behind cataract surgeries and 96 percent of the patients are happy that they had this surgery performed. It is mainly getting rid of the pain, improving your quality of life, and getting back to your normal day-to-day activities. Out of 84,000, 60 female average ages and five percent of secondary to trauma that has contributed to the arthritis later on and 90 of them are lost arthrosis.

And what is the hip replacement? Hip replacement is a surgical procedure as you all know it is a ball and socket joint and the joint is made up of two parts which is the hip socket which we call it an acetabulum as you can see here that is the socket and you got the thigh bone where you can see the femur here so and where we ream the canal of the middle area canal and then we put in the hip replacement that's what it is and you get a ball on the top of it which we put in a ceramic head or a metal head as in this place.

You can see a metal head, so this is what is the two damaged parts of the socket and the pole or removed and they're replaced with an artificial socket along with the plastic liner and also in the femoral stem that goes into the thigh bone with a modular head either metal or ceramic. My preferred choice is a ceramic bearing on a polyethylene socket, which it eliminates squeaking, if you put ceramic on ceramic with some of the patients can squeak and cause a loud noise, whereas the long-term survivorship of this ceramic heads is much longer when compared to the metal heads. The main reason for one to offer a hip replacement surgery is mainly to get rid of your pain and to improve your quality of life and you need to have symptoms, significant symptoms arising from this and also radiologically the x-rays MRI scans have to confirm and they're consistent with moderate to significant arthritis in the hip if the radiographs or MRI scans do not show any evidence of that is we should be looking into other causes what is contributing to the pain.

Do I need a hip replacement surgery? The reason I have stated earlier what are the reasons for one to have a hip replacement and severe pain that is limiting your everyday activity, you find it hard to walk in a distance without any significant pain and if you're taking lots of painkillers every day and again there are quite a lot of side effects which can upset your stomach and kidneys in the long term if you're taking non-sterile anti-inflammations. You have moderate severe hip pain when resting either during the day or night and there is an increased stiffness and inability to blend and straighten your hip.

With regard to the types of hip replacements that we have got 10 A* ODEP rating for implants at Benenden Hospital and we've got two types of implants one is Zimmer Biomet, which is a Tupelo and G7 which I’ll show you in a minute so this is the Biomet socket where we put in a hydroxyapatite which is a like coating and this is a type 1 that goes into the socket and this one bonds against the bone like a glue because of the hydroxyapatite coating you don't have to put any cement and again in the thigh bone as you can see and we ream the canal into the thigh bone and then you put in a femoral stem again it is proximally coated with the porous coating or a hydroxyapatite coating and this one goes into the thigh bone and on top of it you've got the neck and you can attach the head into the femoral head goes on the top of it and it articulates with the socket and the hip as you can see this is the hip joint, ball and socket joint, so and one can either cement the hip you can have cemented implants and uncemented implants my practice has always been an uncemented total replacement which have been doing for the last 20 years and when the bone quality is quite poor then we tend to cement the stem rather than the socket which we do a hybrid hip replacement uncemented socket and a cemented stamp. In addition to this we also have products like hip replacement again this one is you can see the whole femoral stem is coated with hydroxyapatite which is again a type 1 collagen which encourages it to bond against the thigh bone and also integration take takes place so that you don't have to use any cement. Again on top of the female you can put a metal head or a ceramic head which is there and this got the long-time better survivorship than the metal heads that you can see here, so these are the two differences that you can see and all these implants have been time tested for the last 30 years and majority of them nearly 95 percent of them the survivorship is a minimum of 20 years or more.

Again I tend to do for younger patients less than 50 years with this short stem hip replacement, mainly to conserve the bone and also it makes anybody's life easier after a period of 20 years to revise this because they're only proximately quoted, it is much more easier to remove rather than a full stem that is going right into the thigh bone with the hydroxyapatite, so it's only the proximal coating so it only burns in the proximal surface and that's why I do in younger patients because at some point they would require some surgery so I’m trying to be quite considerate to my colleagues who are going to do revision surgeries in the long term. Again, with regard to gait analysis justin call from imperial has done several studies and his time and again proved that short stems have got better functional outcomes when compared to standard type replacements.

What is involved during a hip replacement? An operation approximately, the common questions I come across is how long does the operation take, normally about 45 minutes to an hour is the surgical time and again it includes your anaesthesia and the recovery period which may take up to two so for you to get back to the work two to two and a half hours in total. Majority of patients get a spinal aesthetic with some nerve blocks and also if they don't want to hear any noises people can be sedated and the next question people ask is how long we're going to stay in the hospital, majority of the time with our expert physiotherapists input and with our specialist nurses looking after the post-op care and the rehabilitation is much quicker nowadays majority of the patient's day about a day or two and most of them go home within two days they have their post-op x-rays which will be checked and they'll be discharged home and again they'll be seen in the clinic after six weeks and if you got any problems between them and usually they're linked to the wards who will bring into the respect to consultants attentions who have done the surgeries and they'll be on phone to you the very next day or so to talk to you about your concerns.

So, what is involved in during surgery? You just remove the damaged parts as you can see on the slide that it's a ball and socket joint we take the cut from the neck you take this ball off from the hip joint and also the socket will be reamed to appropriate  fit size and we put in appropriate size of the socket, we got all the sizes available in theatre so we put the appropriate size and then we add the cement or and do an uncemented femoral stem depending on the a surgeon who is used to cement it or uncemented hips.

So, I’m just showing you an example with regard to the hip replacements that we put in here, one is hybrid hip replacements where you can see on either side bilateral hip with all the cement mantle across the femurs, also uncemented socket with a ball being attached. Again, you can see on the other side an uncemented totally uncemented hip replacement with an uncemented cot established shell along with the poly liner and also a femoral stem that is going inside the thigh bone.

With regard to recovery from my hip replacement surgery as I said to you earlier about the hospital stay is about a couple of days at the most usually patients are allowed to walk as quickly as possible after surgery with the help of physiotherapist, the physiotherapists we've got an excellent team who will be looking after the post-op patients, giving you the advice with regard to do's and don'ts and initially discomfort in the leg and swelling of the feet and you'll get involved with the exercises given by the physiotherapist in order to strengthen the hip and also they'll be advising you with regard to the do's and don'ts after surgery.

I always tell the patients to use the crutches until they regain the confidence, usually it is like learning to walk again after a hip replacement surgery once you develop confidence which most of the patients do develop confidence and majority of the patients within four weeks they get rid of the crutches and they walk independently and some may require a bit more longer to rehabilitate.

With regard to recovery from a hip replacement to going home you only let you leave the hospital once every one of us are happy that it is safe for you to do, so usually they provide you a frame and majority of the patients do get a couple of crutches so that you can fully weight bear and walk on it, you'll be also shown how to safely go up and down the stairs and after about a week most people can walk independently with the sticks.

At two weeks people I advise people to take some painkillers not to his state and you can see some bruising around the hip where the surgery has been performed and with within six weeks you'll be seen our patients clinic and when I see you in the clinic I will download them to go back to driving and also to lie on either side of the hip with the pillow in between the knees and to go back to swimming.

With regard to life after hip replacement measure to the patients do say that 90 percent of the pain that they had has gone away and this would allow the patients to carry out their normal activities of daily living may not return to active sports but most of the patients do return to active sports like playing golf and some of them have gone back to tennis and the main reason I would have asked them to avoid impact activities is because these are artificial joints they're subjected to wear and tear and the last thing we want is wearing out of the poly and the poly debris can contribute to loosening of the hip, so that's what I tend to explain to most patients to avoid high impact activities and again precautions to avoid dislocation of the hip, don't bend further than 90 degrees, don't cross your operated leg, don't turn your leg inwards which can contribute to dislocation.

Again, with regard to, you've seen Andy Murray had a hip arthroplasty and his back playing tennis and he played nearly five rounds in the second round and it's a shame that we could not see him go through the quarter finals, but he played a great tennis. And again, you can see Arnold Schwarzenegger again who had a hip replacement at the age of 55, he's still enjoying life and he got rid of the pain.

With regard to the complications that one may come across following a hip replacement arthroplasty, one is infection and I’m proud to tell you that infection rates in Benenden are much lower when compared to any other hospital and also with regard to development of deep vein thrombosis in the legs, sometimes these products can dislodge and they can migrate into the lung and cause a pulmonary embolus in the lung and usually when you develop the patient requires admission and anticoagulant therapy and the other one is dislocation of the hip and people who do can experience posterior dislocation where the ball can come out of the socket and cause a dislocation and either in the front or back depending on the approach and sometimes you can have leg length discrepancy though we try to do our best to check the leg lengths during surgery, sometimes it is impossible to correct the leg lengths because you also got to rely on stability of the hip and sometimes it's possible to lengthen the hip but you won't make much of a significant difference up to two centimetres and then on it can be quite painful and the other thing is they can be slight damage to the nerve or the vessels again it's a very rare entity with regard to developing a foot drop after a hip replacement surgery when there is slight damage to the nerve which is the mainly the sciatic nerve it can end up in having a foot drop. Again it's a very rare entity and during surgery one can come across a fraction the femur the bones are fragile, there is a risk of fraction of the femur and once when we come across and when we get into that situation usually the fractures are stabilized with the cables and if necessary a plate and make sure that it is stable enough to close you down with the surgery and after a period of time late complications one can see loosening of the implant which nowadays it is known before 15 to 20 years and if you come across a loosening then you need to investigate further whether it is secondary to low grade infection or whether it is secondary to poly wear and depending on that we do conduct multi-disciplinary meetings nowadays discussed with the number of Consultants who are experienced in this field and we make a plan of how to proceed and how to investigate further and deal with this situation, which would be a revision surgery.

Again, you just want to let all of you know about the National Joint Registry and which is there for all of us it's not only for you it is also for every one of us too. It's mainly it is voluntary if you volunteer to be on the register, it is mainly for the total hits total knees total shoulders and we now have recently introduced for ACL reconstructions as well. The registry will help to find out which are the best performing implants and the most effective types of surgery and this also gives for the surgeon how many hips, knee replacements is done and how many complications he had and anybody who is out there would be flagged up straight to the medical director if there is increased in number of complications for any surgeon and recording your details enables the National Joint Registry to link people to the implants received during surgery and if any problem with the specific implant is identified in the future the NJR will be able to help identify the patients who received it and your details enable you to participate in a feedback survey and all personal data is treated as a confidential at all times. It is, it will also be reported to the respective companies if their implants are not performing well in the joint registry and the NJR chair will write to them if there are any outliers either with the implants or with the surgeons. You can review these sites in the public domain, and you can see the surgeon profiles which are available in the public domain, and this will enable you to choose the surgeon who has good data in the national joint registry.

In summary, this is a hip replacement is highly regarded surgery the main reason for anyone to offer a hip replacement is to get rid of the pain and to improve the quality of life and as I said earlier in 90 to 95 percent of the patients are happy that the pain has gone away after hip replacement. It's not just for older people living it’s for patients who are suffering from arthritic pain or people who have developed a sudden onset of avascular necrosis following trauma can be treated with hip replacement surgery nowadays and you can have your life back.

Thank you everyone for listening to me and having some patience and I’ll hand over to Louise.

Louise King

Thank you for that interesting presentation and we'll just go through some questions now, we have quite a few that come through already and yes let's go for it.

So, the first one is I ask is there a maximum BMI for undergoing a hip replacement at Benenden?

Mr Kumar Reddy

It's an it's a good question I mean I’m always very sympathetic for patients who are high BMI because it's extremely difficult for them to exercise because of the pain and it's difficult for them to lose weight so in Benenden our cutoff is 41 BMI whereas in NHS I do up to 46 to 48 is my cutoff, so we do encourage people to lose some weight to take other measures like seeing the gastroenterologist surgeons with you to lose weight and come back for surgery, the evidence is that people need to lose a little bit of weight and if they can prove that they can lose at least a stone in weight it would immensely help that the determined to lose weight which would help post-operatively as well.

Louise King

Great, thank you. Next question, would a hip replacement also deal with a history of the trochanteric pain syndrome that might have caused a lot of pain in the past but went away to concealing the deterioration of the hip joint?

Mr Kumar Reddy

The two different entity entities whereas trochanteric bursitis or what we call it a Gluteus Medius tendinopathy is the inflammation of the tendon with the associated bursitis which means muscle sac with the greater trochant filled with fluid, this is a soft tissue condition and inflammatory condition and this need to be diagnosed and usually with MRI scans the sensitive or an ultrasound scan usually these are self-limiting conditions which can take up to two three years to reach a plateau but if your symptoms are mainly trochanteric bursitis my suggestion is not to have a hip replacement unless it is been proven beyond doubt by x-rays and MRI scans that you have got significant arthritis. Otherwise despite you having a hip replacement surgery your symptoms may not be relieved because your pain condition and source is different which is actually bursitis.

Louise King

Okay, this person is quite young for hip replacement and they're in their late 50s, would you recommend them trying to wait until the pain is unbearable or should they go for treatment?

Mr Kumar Reddy

I always tell the patients if it is something they can manage by taking some painkillers and some physiotherapy sessions which may help in the interim I always ask them to do so and also it is worth trying a cortisone injection especially hanging patients to buy some time if all these affect their quality of life and pain significantly and if they've already been taking painkillers and had all these type of treatments then I would not hesitate in doing a hip replacement surgery. The youngest patient I’ve done was 26 years old and yeah I’m still following them up and had a great result and a good pain relief when he's back playing tennis and he developed this arthritis when he did London marathon and following that he had a loss of blood supply to the hip joint and the hip has crumble when we did a hip replacement so if your symptoms are significant that you've already tried this conservative methods of treatment and it is reasonable to proceed with hip surgery provided you got significant bone on bone arthritis confirmed on the x-rays.

Louise King

Okay, this person previously had a knee replacement and asks is it safe to have a hip replacement on the same leg?

Mr Kumar Reddy

Of course, if you go beyond doubt that your hip is currently getting affected certainly would certainly benefit from hip replacement surgery and there is no harm when you already had a knee replacement that if we come do a hip replacement surgery it is quite possible to do it.

Louise King

Are there are the options provided by Benenden such as metal ceramic etc the same as the options provided on the NHS?

Mr Kumar Reddy

Of course, yes. We've got both ceramic and metal options here so most of us we use ceramic bearing because of the long-term survivorship of these implants and the implants that we use in Benenden have been time tested and they've got excellent 10 or more than 10 a star ODEP rating for these implants.

Louise King

Thank you. How long a car journey is possible when leaving hospital after a hip replacement?

Mr Kumar Reddy

I would always ask them to break the journey if it is more than an hour so they need to break it up for an hour just to have a walkabout and then rest and have a cup of coffee or so and then get back to their journey so some of the patients we see they come from Essex from Scotland from all over the place in UK so we just need to make sure that they break these journeys every hour or so until they reach home.

Louise King

Right, thank you. Does your team perform hip surgery using both posterior and anterior approaches?

Mr Kumar Reddy

Majority for guys we do posterior approach with regard to anterior approach you need a couple of assistance or at least a special cable to perform through anterior approach. We do either by lateral approach or a modified approach which my colleagues Mr Shrivastava and Mr Oliver or and Mr Dunnett are familiar with and Mr Chipperfield and Mr Raman Thakur and myself, we do tend to do posterior approach.

Louise King

This person says, would I be comfortable to stand and walk for long periods after they are fully recovered? They used to enjoy long family days out but can't do that anymore due to hip pain.

Mr Kumar Reddy

Yes, is it after hip replacement?

Louise King

Yes, so after they've had this.

Mr Kumar Reddy

Yeah usually it takes about six weeks for you to get back to normal activities so I would say probably approximately three months for you to do prolonged walks and also to get back to your routine if you want to stand for a long time or go for long walks and that is the time when you can do but I would always advise to not to fly for at least a period of three months because the increased risk of thrombosis and you'll be given tablets of anticoagulants for at least 35 days following hip replacement arthroplasty.

Louise King

Sensible. Do you perform minimally invasive surgery at Benenden?

Mr Kumar Reddy

Yes, we do perform a minimally invasive surgery. We've got instruments here to perform minimally invasive, the main the understanding of minimal invasive surgery is that your incision has to be less than 10 centimetres, that's what is a minimal invasive surgery definition is about. So, we can do minimally invasive surgery, some consultants do not cut the tendons. Myself and a couple of my colleagues who do posterior approach we do perform surgeries which is called a spare approach and also piriformis sparing we don't cut the piriformis from its tendon we just go inferior to the piriformis tendon and inside the capsule and go into the joint which in measure to the patients the recovery is much quicker.

Louise King

Is a ceramic replacement likely to crack or shatter as opposed to a metal one?

Mr Kumar Reddy

Good question, it used to crack in the past but over the years the ceramics have significantly improved it's extremely difficult for the ceramic to crack or break, unless there is a malalignment in the hip also and which would pack and now the ceramic ceramics have significantly improved the quality of the ceramic so it is very difficult for the ceramic heads to break.

Louise King

Okay, just a few more questions now. We're asked do you need an MRI to prove osteoarthritis or just x-rays?

Mr Kumar Reddy

Majority of the cases we tend to rely on x-rays, if the x-rays do not show any evidence of arthritis then if your pain is still in the groin then we tend to get an MRI scan to see whether there is significant matter oedema or whether it is related to femoral stabler impingement sometimes there can be impingement in the hip which can be diagnosed with an MRI scan and along with contrast would especially help in diagnosing liberal tests that's why you normally ask if the x-rays do not show any evidence of arthritis then I’ll be thinking of differential diagnosis and asking for an MRI scan with contrast.

Louise King

Is there any way to prevent hip arthritis getting worse before considering surgery?

Mr Kumar Reddy

Yes, definitely you can help. I mean one is losing weight not to put on any weight and also a healthy diet and if there is a strong family history at some point you're born to get it and also a high impact sports, again it's good for your heart and running and all these things are good for your heart bad for the joints in the long time people may suffer from arthritis so again just doing in moderation would significantly help until again some anti-inflammatory the national diet federation have time and again have advised that nightshade vegetables are bad for the joints as they tend to cause inflammation and also supplements like glucose and sulphate would help and turmeric and they also suggest that pineapple fruit is the best for reducing the inflammation.

Louise King

Okay, thank you. You mentioned only going outside after six weeks so is it recommended to stay indoors for the first six weeks?

Mr Kumar Reddy

No, you can walk in moderation. It's basically developing your confidence and walking so as long as you've got confidence in walking I first I would suggest is indoors to walk without the help of any walking aid once you're able to manage indoors then you can go for short walks up to six weeks then after six weeks, unless there is some restriction, nothing stops you from going.

Louise King

Wonderful and our last question is from John, and he asked can you cycle after surgery or does the angle of the hip exclude that activity also is jogging another impacts exercise discouraged?

Mr Kumar Reddy

No, I would encourage people to go for cycling after three months they can get back to cycling and also gentle jogging if they wish to. Again, one has to remember that this will impact and as long as it is gentle it will not create a tremendous stress on the joint one has to remember these are artificial joints which are again subjected to wear and tear.

Louise King

Lovely, thank you. We do actually have one more which we'll just go through and then any others will just message you afterwards with any answers, but Susan asked what painkillers would you recommend for hip pain? If on the long term, can you get addicted?

Mr Kumar Reddy

Yes, opioids can be addictive and the best the person will be your GP who knows your history so I would suggest to ask GP for some simple painkillers but again anti-inflammatories have got a detrimental effects on your stomach and also on your kidneys so I would suggest to take them with caution and also speak to a GP who would be the best man to guide you with the painkiller painkilling medications.

Louise King

Wonderful, thank you. Okay I think we managed to answer everyone's questions this evening so that's really good, yes, I think that's really good. So, if you would like to discuss a book your consultation, Chelsea from our private patient’s team could take your call this evening until 8 30. And she and the rest of her colleagues are available 8am to 6pm Monday to Friday using the number on your screen. We're offering a discount for joining the session for the next seven days with the terms displayed. After we finish this webinar, you'll receive a short survey and we're really grateful if you can spare a few minutes to let us have your feedback as it helps influence our future events. Our next webinars include varicose vein treatment, gynaecology and knee replacement surgery and you can visit our website to sign up to these.

So, on behalf of Mr Kumar Reddy and our expert team at Benenden Hospital, I’d like to say thank you for joining us today and we hope to hear from you very soon. So, thank you very much and goodbye.

Mr Kumar Reddy

Thank you.