Damien Gregory

Right. We’ll just let a few more join. We've got quite a big attendance this evening, so we give them just a few more seconds to all arrive.

Right. Good evening, everyone, and welcome to our webinar on treatment for knee osteoarthritis. Now my name is Damien, and I'll be your host for this session. I'm joined by our presenter and Consultant Orthopaedic Surgeon, Mr Matthew Oliver. Now this presentation will be followed by a question-and-answer session. So if you'd like to ask a question during or after the presentation, please do so by using the Q&A icon, which is on the bottom of your screens. Now this can be done with or without your giving your name. But please know that 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 now I'll hand you over to Mr Matthew Oliver, and you'll hear from again shortly.

Mr Matthew Oliver

Thank you very much. Good evening, everyone welcome. I'm going to talk to you tonight. All about treatments for osteoarthritis of the knee.

So a little bit about myself, I'm a Consultant trauma and Orthopaedic Surgeon. I qualified from St. George's Hospital Medical School back in 1998 and then did my basic surgical training in Kent and Sussex, followed by my higher surgical training in the South East Thames region again in Kent and Sussex. I worked at various hospitals, some district general hospitals, and some major trauma hospitals. Once I got my final exams I went on a yearlong trip to the University of Calgary in Alberta, Canada, where I did an adult hip and knee reconstruction fellowship. This was a fantastic opportunity to work in a different healthcare system, with some very well renowned arthroplasty surgeons. I returned to the Uk in 2010, and became a Consultant at East Kent hospitals, and I started working here at Benenden in 2012. I would consider myself as a reasonably high volume. Hip and knee surgeon. I certainly do double the national average of my peers in both hip and knee replacement surgery.

So included in this session, it's going to be in five parts. The first is all about osteoarthritis of the knee to set the scene. Then spend some time talking about synovial pain because that's key. When discussing the different treatment options, we'll then follow with a discussion about knee replacements, both the standard conventional knee replacement and the robot assisted knee replacement, which has been here at Benenden for several months now, and we'll conclude with a question-and-answer session.

So what is osteoarthritis of the knee? Well, it's a medical condition of wear and tear. There's nothing we can do to stop it. It is incurable, and it will affect all of us at some point in our lifetime to various degrees. A normal knee, as you can see in the diagram here is covered with pristine cartilage, which reduces friction in the joint. When the femur and the tibia move against each other. You'll also notice between the femur and the tibia that there's some padding there known as the Menisci, or the shock absorbers. They cushion our every step and enable us to perform quite wonderful athletic pursuits in our younger years. But, unfortunately, from about the age of 40, 45 onwards these Menisci start to perish, they develop little micro tears within them, and they all join up and form larger tears, and the Menisci lose their plumpness and their shock, absorbing ability, and when that happens, more load is placed on the articular cartilage, which then starts to fragment and break away, as you can see on the other diagram next to the pristine knee. Over time, the cartilage area of loss increases, and the knee starts to mechanically deteriorate and that's when it starts to present to the patient with symptoms. So the early ones are really noticing a bit of morning stiffness, discomfort when you exert yourself. It might be something like crouching down for a while, or kneeling for a while, or just rushing around, you'll just notice a bit of an ache. You may also have the sensation of the knee, clicking and grinding, and notice that it's a little bit puffier than usual, and may have some local warmth within it as symptoms progress as the disease process progresses. Unfortunately, the amount of discomfort and the annoying issues with regard to arthritis sort of manifest, and these are pain at rest after a busy day or throb. When you're resting in the evening, it may disturb your sleep. It will wake you up when you roll over in bed. You may also notice that your knee is changing shape. You may not be able to fully extend it. You may notice it's becoming bow legged or not kneed in its shape. Along with these things you’re walking distance will also decline, as will your athletic prowess. So that's the late symptoms and signs of knee osteoarthritis.

The treatment options at the beginning are all non-surgical. As I said earlier, we can't cure the problem, but we can certainly slow down the process. We slow the process down in three ways. Really, the first is to modify our activity, which isn't ideal, but we just have to understand that the knee is no longer like it once was, and it needs to be treated a little bit more respect and care. So the more vigorous heavy impact activity won't help the arthritic knee. If we're overweight, that it is crucial to do one's best to reduce our weight, because there is no doubt that carrying extra pounds almost certainly will speed up the demise of your knee. It is categorically proven to be the case. Contrary to belief, physiotherapy is actually handy for an arthritic knee, because it keeps it supple, and all the muscles around the knee are kept in good shape, which helps you. When you're walking on uneven ground, the knee will steady itself, due to good strong muscles around it. And of course we've got painkillers starting off with the simple things like paracetamol, and progressing to the strong stuff like co-codamol, and maybe even stronger. The morphine-based tablets. Knee strapping and braces. They really have a limited role, but certainly can be utilized. The braces are a bit cumbersome and clunky, but in certain individuals they do seem to have a role to play, because you can get an unloader or an off-loader brace that jacks out the joint to stop the two surfaces from touching each other where the cartilage between them is wearing away, and that can provide a degree of pain, relief.

Non-steroidal anti-inflammatories for those who are able to take them are also quite handy, and then we've got a whole selection of different injections, and I'll talk about those more in some detail later. So synovial pain. This is an important concept to understand, because one of the treatments I'm going to discuss with you guys this evening is all about trying to switch that pain off. So in a healthy knee you have a synovial lining that provides nutrients to the joint, and just minds its own business really, and has a helpful function in maintaining the environment inside the joint. However, if you have an injury to a knee. It could be a cartilage injury, or an ACL rupture, or a fracture to the bone that needs to be treated. Then the synovium gets irritated, and that's the case in osteoarthritis as well and the synovium goes into overdrive and proliferates and produces chemicals that go into the knee that cause an inflammatory reaction, and erode the cartilage, making the knee swollen, warm, stiff, and just generally miserable and uncomfortable. There's strong evidence to show that if this process is allowed to continue, then it can actually lead to a rapid increase in cartilage loss in osteoarthritis and quite scarily in joints that aren't arthritic. So those knees that have had an injury before the onset of wear and tear.

So bringing us on to the first injection I'd like to talk about is called Arthrosamid® hydrogel, and it was introduced here at Benenden a few months ago now, and it's gaining momentum. It has been around for several years, particularly in European clinics, and it has increasing scientific evidence behind it to show that it is making a difference in the mild to moderately arthritic knee and essentially it's a compound an implant that is non-biodegradable, that's injected into your knee. It's actually 97.5% water and 2.5% of a hydrogel called polyacrylamide and it's this component that combines with the synovial, inflamed synovial tissue in your knee and downgrades the inflammatory response that I was talking about in the previous slide, and because of this ability to switch off all those horrible inflammatory mediators, it reduces the discomfort in your knee and decreases the joint stiffness, and enables you to have a more comfortable knee. It's reported to last up to four years, and there are certainly three studies that are ongoing that show promise. One of them up to about 1314 months, the other one up to about two years, and then the third study up to four years. It's not a magic bullet, though you will still have some discomfort in the knee, but hopefully a lot less. Perhaps you won't need as much analgesia, and your activities will be able to be a little bit more exciting than just

just routine daily life. So it's carried out as a day case. You have antibiotics provided to you an hour or so before the injection, and these are oral antibiotics. Local anaesthetic is, initially used in the around the injection site, and then the knee is examined using an ultrasound. We're looking to see if there's a collection of fluid in the knee known as an effusion, and that normally hangs around in an area called the suprapatellar pouch. If there is an effusion, we do our best to drain it to dryness first, and then once we know that we're in the right spot six injections are performed through the needle, one at a time. Each syringe only has one millilitre in it. You may wonder why, there are six syringes, and this is because it's quite a viscous sort of gooey material and doing it in one big syringe would require quite a lot of plunge power. I guess it’s easiest is to do it one at a time. After the injection. It's advised to have a restful 72 hours and avoid strenuous activity for up to two weeks, and we say to patients that they may have some increased discomfort in the knee for the 1st couple of weeks. There's a rehab program available as well. With this injection, therapy, and information on that can be found on the company's website and also in the brochure that's provided for you. There are minimal side effects associated with Arthrosamid®. It's actually been around for many years in various guises and different branches of human medicine. So it has a 20-year safety profile and there have been no reports of any serious side effects. Apart from what I've just mentioned, you can get some mild joint pain and swelling for a few weeks, and of course, if any injection, there's always the risk of the introduction of infection into a joint, and that's why it's done under strict aseptic technique in a minor operating theatre or an operating theatre, and the patient is given antibiotics prior to the injection to minimize this risk.

The next injection available here at Benenden is an injection of Durolane Viscosupplementation as a member, you can have one of these per membership cycle. It's carried out as a single outpatient injection of a chemical called hyaluronic acid. All of our joints have hyaluronic acid in it. In them. But as we age, unfortunately, the amount and concentration starts to dwindle, and hyaluronic acid has a really important role to play in lubricating the joint and reducing the friction between the surfaces as they rub against each other. So Durolane is essentially a synthetic hyaluronic acid boost, I say to patients, this is a bit like an injection of Castro. It really sort of reduces the pain by increasing the lubrication. It doesn't work for everyone, but it's usually quite successful in the mild to moderately arthritic knee. It can be repeated, and I've seen it on many occasions that people do return for further injections, especially at the beginning of the ski season. It seems so. The final one that we can entertain or utilize here at Benenden is the tried and tested local anaesthetic steroid injection. Again, it's carried out as an outpatient procedure, and you can have two to three of these per year.

Again, it's effective in the mild to moderately arthritic knee and again, all the risks of infection still persist. So it has to be done with strict aseptic technique. It is not suitable for everyone, and it should be avoided in those who have diabetes, as it can cause your blood sugars to go a bit haywire. The only other caveat with an injection is that if you are on the verge of needing a knee replacement, then it's probably best to avoid having it done, because most surgeons would delay knee replacement surgery for at least six months following the injection. This is because there is some evidence to show that having your knee replaced too soon after injection puts it at risk of a deep periprosthetic infection, which is a bit of a nightmare really so moving on to the surgical treatments.

Now the first one is Osteotomy, which isn't carried out here at Benenden. It's only really done in a few specialist centres, and it's usually carried out on the younger individual. When the very, very early signs of arthritis are noticed, and when there's a malalignment issue with their anatomy. The surgeon effectively fractures the bones in a controlled manner and resets the alignment of the leg to offload the area that's taking the strain. It's high morbidity associated with it with a lengthy recovery time, but if done correctly, the results are actually quite encouraging and may put off the development of osteoarthritis for many, many years. Arthroscopic techniques. So keyhole surgery to the knee. This is mainly frowned upon now, for the arthritic knee, and lots of studies have shown that it is a sham procedure. There's no point just washing the arthritic knee out and debriding it, because it will only give the patient temporary relief, and sometimes could actually, in fact, make things worse. There are a few indications, though, for arthroscopic surgery in an arthritic knee, for example, one of them is when you have a loose body of broken off bone that's floating in the knee that causes the knee to jam or lock or give way. It's a good idea to fish this out through the keyhole to relieve those mechanical symptoms, so the patient can then have better function in the knee. The other indication is an unstable, degenerative, flat tear of the menisci. Those flat tears can get stuck like a spanner in the works, and they're usually caused by an innocuous injury, such as twisting in the kitchen when you're going from one sideboard to the other and they can be really troublesome. So snipping those out can relieve quite a lot of issues for the patient and give them medium term relief. But unfortunately, as mentioned earlier, the arthritis continues in the background, and further pain will eventually happen.

Microfracture is another technique that is carried out through the keyhole. But it's sort of dwindling in popularity now, and this is when little drill holes are made in small areas of full thickness, cartilage loss in the knee in the hope that that stimulates fibrocartilage to grow, which is the second or the next best thing to articular cartilage. It's quite a headache for the patient because they have to remain, touch, toe, or non-weight, bearing on their leg for about 8 to 10 weeks, while this fibrocartilage grows over the defect, and has only really been shown to be effective about 60 to 70% of the time. So it's not routinely recommended cartilage transplantation again, really. Still only at specialist centres and still it's being trailed. Really, it's not available in the mainstream. But there's some promise for this in the future, for sure. And then we move on to knee replacement surgery which encompasses the standard technique and the robotic assisted technique and of course there are various guises of knee replacements. You can have a partial knee replacement, which is when you have just a part of your knee replaced, or a full knee replacement.

So we'll mainly be discussing tonight about full knee replacements. This is a common operation, and approximately about 100,000 performed in the Uk. Per year. The average age of the patient is about 69. Most of the patients are female and most of the patients report good health improvement. Following a knee replacement with the new modern techniques and materials being used, quite a large proportion of knee replacements can be expected to last at least 1520, 25 years everything being equal.

So what are the aims of a knee replacement? Their primary aim is to relieve pain. There's no point having it done. If, just for a bit of instability or the occasional ache. The indication for a knee replacement is pain, pain pretty much all of the time. It's a good operation for that. It will increase the patient's mobility and hopefully restore a degree of function and realign the legs. Mechanical access to the individuals. We have to be very careful with the younger patient, and really the younger patient for knee replacement is in the age band of about 50 to 65 lots of studies have shown that there's a high dissatisfaction rate following knee replacement surgery in that cohort of patient. So it can be up to 19 to 20% in some studies. So they require a lot of counselling to manage their expectations. The knee that's used at Benenden Hospital is called the Vanguard Knee. It's made by Zimmer Biomet, and it's been around many years. It has a very high ODEP rating. ODEP stands for the orthopaedic devices, evaluations, panel, and it's an independent body that assesses all of the implants that are used in the orthopaedic world, not just knees, but hips, shoulders, ankles, and so on. The NHS are very, very keen on ODEP, and you can't have, and knee or hip replacement utilized or regularly used in the NHS unless it's hit an ODEP rating of at least 10, and that means that over 95% of the implants are still going strong after 10 years use. So it's got a good clinical heritage. In our practice. We use the fully cemented knee replacement, and we can replace the patella or resurface it, or we can leave the patella alone. That is an individual assessment done by your surgeon.

So what's the recovery like? It is a painful operation, and you mustn't underestimate that. But with modern anaesthetic techniques using the enhanced recovery protocol it is getting better and better all the time. Certainly the first six to eight weeks is tough going, though, so you'll have a couple of days in hospital usually, and you'll have a private room of your own en-suite. The knee will be bandaged overnight, and then the following day that heavy bandage is unwrapped to show you a protective dressing on your knee, and that dressing should ideally be left alone for at least seven days. You'll be provided with plenty of pain relief. Once the spinal anaesthetic has worn off, and ice therapy is good at removing the swelling from the knee.

the physio team will visit you daily and help you get up on your feet. The knee replacement is designed to weight. Bear on fully from the offset, and you'll be encouraged to do that you'll be encouraged to start bending it. The nursing staff are on hand as well to make sure that you remain well hydrated, and your needs are all met. We'll only let you go home once you're safe. You need to show the physios that you've ticked all their boxes, and one of the tests is to go up and down the stairs, you'll be provided all the kit you need to go home with frames or crutches if required and in our experience. Most people are able to walk around their own environs with sticks after a week or two, so you're reasonably active quite early on albeit in some discomfort, so breaking it down into time frames.

First two weeks you'll be regularly taking your painkillers. You'll notice that your leg will be swollen and significantly bruised. It will go all the colours of the rainbow, and it will hurt. Despite this, you have to work hard on your exercises. It is literally no pain, no gain. If you let scar tissue take hold and win that race against you getting movement, then it's very difficult to undo that. So the take home message is to just get up and running of those exercises as quickly as you can. By six weeks you'll be back to driving hopefully, and you'll have a follow up appointment with your surgeon, where your progress will be checked. You'll be able to see your X-rays and we will be able to indicate to you whether you need to up the ante with the physio, or just encourage you to keep doing the same. It will take up to a year to fully recover from a knee replacement, and the crucial period really is the first six months, and it is important that you keep on with those exercises as you gradually return to normal activities.

There are risks during the surgery. You can bleed, but it's incredibly rare that a patient needs a blood transfusion. After a knee replacement. We can fracture the bone nerves can get injured and is quite common to have a bit of numbness over the scar site, but that usually gets better. Very rarely you can get a foot drop, but again, that normally recovers very rarely, an important vessel can get injured which may require repair. We have to be extremely careful during the surgery. We don't damage any of the ligaments we wish to retain nor damage the patella tendon, but there is a degree of risk involved during the recovery. You can have some problems with the wound. So it's important that you're in good physical shape before the operation. If you're a smoker, you've got to really cut back on that, because smoking affects wound healing, you've got to ensure that you keep it clean and dry and covered. So you don't get any infections.

but you can get a wound infection on the scar itself, or deep infection, a wound infection we can normally get sorted with antibiotics, but a deep infection which happens about 1% of the time or less is a tricky situation to deal with. We'll give you blood thinning medication to reduce the risk of a deep vein, thrombosis, and pulmonary embolism. But they still occur. You'll have a bit of a limp, and, of course, stiffness and swelling. Unless you get cracking with the exercises.

The late complications that can happen are infection, and the late infection normally happens due to a blood-borne infection. You may have a waterworks infection, or a chest infection that gets into the bloodstream and lodges in your knee. There's nothing that you can do about that. It's just one of those things, and unfortunately it's very rare over time. The implant will gradually wear out. You may find that it becomes a bit wobbly and less stable with time.

You can also have a trip or a fall and injure one of the ligaments that stabilize the knee. That puts it at risk as well and of course there's always the risk of having a fall and fracturing the bone around the knee replacement which will need remedial work.

So moving on to the ROSA now, or the robotic surgical assistant knee. This has been available at Benenden now, since I think it arrived around December 2023, and it started to be used mainly a few months later. We all had to go on various courses to get the accreditation to use it. I went to Cologne for a couple of days with the Zimmer Biomet team and was very fortunate to be able to perform the ROSA knee replacement with some world experts on cadavers, and that was a very worthwhile experience. So in essence, it's an adjunct to help the surgeon provide a more tailor-made knee replacement for the patient and to minimize or reduce surgical error which can happen with conventional techniques. The other thing I'd like to say from this slide is that those who sign up for the Rose and me also get signed up to the my mobility app.

which is an app you can have on your apple watch or iPad or iPhone, and it's absolutely golden. It's like having a physiotherapy physiotherapist with you 24 HA day. That may sound a little bit scary, but it actually encourages you to work hard on your exercises to get the best out of your knee, and you follow it for a whole year at various times throughout the Postdoc period. You'll also be asked to fill out functional outcome scores which are fantastic resources for audit and research purposes, and help us to see whether the ROSA robot is actually making a difference or not and the other key about the app is that your surgeon can remotely log into it to see how you were getting on as well and I've certainly found this very useful and so I really encourage you to embrace that technology.

So a little bit more about the ROSA. It offers several benefits over the standard non-robotic knee. It is supposed to reduce the likelihood of injury to the soft tissue surrounding your knee joint during surgery because of its increased accuracy. Certainly less dissection is required

and less bony work is required. We don't have to do as many drill holes like you do of a conventional knee. So I think there is some reduced pain so you may not need as much pain medication after your operation. Potentially, there's the opportunity for a shorter stay in hospital and a quicker recovery. So you can get back to your routine the long-term aim, of course, is that we hope that it provides better function than a standard knee replacement and we know this. We can track this by looking at the patient recorded outcome measures and the functional outcome scores. I alluded to earlier with the MyMobility app.

So how does it all work? So basically, everything is pretty much the same other than

two pins that are fitted into your tibia and two pins into your femur, and on those pins some sensors are attached, or tracker probes, and those tracker probes communicate with the robot which has a camera and theatre, and it means that when your knee is moved around in space that it can track it because we've registered some important landmarks to ensure that it knows where it is in a three dimensional space. So at the beginning of the operation we do what's called an initial knee state evaluation where we see how much you can extend your knee what the deformity is, how much you can flex your knee, and then we strain and test the different ligaments in the knee to see whether the correction can be, the deformity can be corrected, or whether it's a fixed deformity. All that information is then fed into the robot and on the computer screen you can see in the picture. There a preoperative plan is produced.

We then pause for a bit and have a look at the plan and see where various tweaks need to be made to make sure that the knee replacement is customized to you and is balanced in both flexion and extension. So it has a feeling of security with every step that you take.

Once we're happy with the preoperative plan that gets saved, and we move to the next step, and the next step is when the ROSA arm comes into view and it comes down and it's fixed onto the femur with some pins, and then on the arm is the cutting jig, and it's that that's fixed onto the femur. It has to be placed in the precise position that the computer or the robot wants it to be placed. If it's not, then we can't proceed. Once it's pinned. The surgeon then cuts the bone in the conventional manner. The pins are then removed, and the robot arm is swung out of the way and then we validate the cut that we've made with the computer and it's so accurate. It's usually within half a degree or a millimetre, and sometimes it's spot on. Once it's been validated, the computer or the robot lets us move on to the next step, and we follow that pattern, validating every cut as we go until we've done all of the bony cuts that a knee replacement needs.

Once that's happened, we fit the trial knee replacement into place, and then do another knee State evaluation, checking how the knee, the trial knee replacement functions against our preoperative plan and most of the time nearly all the time. In fact, it. It matches the plan, and the deformity is corrected, and the knee feels stable, and it has a good range of motion. Once we're happy with that. Essentially, the robot has served its purpose, and we then remove the trial implants and cement in place the knee replacement that we've planned all along for you, and if you wish, right at the end, the final real knee replacement is then evaluated to check that nothing has changed, and it shouldn't have. Once that's happened, the pins are removed, and the knee is closed up with sutures and clips and dressings in the conventional fashion, so the surgeon still does the operation, but is assisted in its accuracy by using the robot to ensure that the bony cuts are precise, and that the surgical plan is carried out precisely to match the preoperative plan. So we use this data to make more informed decisions, and we can tailor make the surgery to your individual needs.

I just talked about that. Does the robotic arm perform the surgery? No, it doesn't. We still perform the surgery, but the cutting guide is positioned precisely by the robotic arm.

Is the ROSA knee system right for me. Everybody's knee is different, but I don't think there should from memory I don't think there are any contraindications to say it shouldn't be good for anyone. It's certainly very useful for those who've had previous trauma to their knee, or to their femur or their tibia, where the bone is healed in an incorrect fashion, because that makes conventional knee replacements very difficult. So the ROSA has a role of the deformed femur and tibia patients, but any arthritic knee is suitable for the ROSA. It's even being used in some centres for revision surgery as well. Obviously, it's important to have a discussion with your surgeon about whether you wish to proceed a bit or not, and to check suitability. There's a short video here about how it works. I think I have to click on it with the mouse to make it play.

So that's the initial piece, by the way.

So that concludes the talk, there are a few decision support tools on to be viewed here that will help you make help you with your decision, making well worth having a look at those.

So we'll move on to the question and answer.

Damien Gregory

Yeah, lovely. Thank you, Mr Oliver. Very interesting. So actually, some of these came through initially while you were talking about injections, and Helena is asking how steroid injections actually relieve the discomfort caused by osteophytes getting trapped in the joint space?

Mr Matthew Oliver

So the steroid injection really works by reducing inflammation in the due to synovial lining being inflamed. If you've got a bit of bone that's trapped in the joint space, I don't think the steroid injection will be particularly effective if it's certainly, if it's a loose body that would ideally need to be removed there aren't usually any osteophytes actually on the weight bearing surface. They're normally on the periphery of the knee on the outer edge of the tibial plateau or on the femoral condyles. They're not actually on the weight bearing surface.

Damien Gregory

Okay, thank you and actually, I think Kathleen was referring to Arthrosamid®. So I'm missing the pronunciation now. So she was actually asking. This was when you were talking about the four-year effectiveness and so I guess she's asking why it actually seems to stop around that time, but also why you inject into one spot or whether you do or not?

Mr Matthew Oliver

Okay. So they're interesting questions. I can't tell you categorically, why does it stop working? I guess, over time. Its effectiveness just declines. It's supposed to be non-biodegradable. So there forever. But I guess other areas of the synovium start to become inflamed, and the Arthrosamid® has already been taken up elsewhere in the knee, and not on that particular spot.

What happens to the substance when it stops working? It continues to be bound to your synovium and just stays there and why do we only inject in one place the knee? There's no real need to inject anywhere else as long as we're in the knee joint because once you get up from the couch and move around, they Arthrosamid® washes around the knee joint and goes to the various areas of the knee, but you can certainly inject in other places. It doesn't have to be solely in one place, but there's no need to inject in multiple different sites.

Damien Gregory

Okay, grand. Thank you. I'm not sure what Graham's situation is, but perhaps maybe he's suffering from an arthritic knee, and he's asking what the best exercises are for a painful arthritic knee?

Mr Matthew Oliver

It would be light load bearing exercises such as walking on flat, even ground, cycling aqua aerobics, a bit of swimming, and also I would recommend some strengthening exercises, such as leg raises hamstring curls, and so on. What you need to avoid is a heavy impact exercise and a lot of pivoting and changing direction and walking on uneven ground where you jar your knee because that won't help at all.

Damien Gregory

Okay, thank you. So we've got a question here. I'm 63 and have been referred to have a total knee replacement by an NHS Consultant. You mentioned that this is not the age you recommend?

Mr Matthew Oliver

Yeah, that's a good question. It's tailored to the individual. So the youngest patient I've operated on for a knee. Replacement is 28, and the oldest is, I think, 98.

Yeah, it's 98. Age is just a number, really. If the patient has got an extremely arthritic knee, and they're really suffering then, and you're 63. Then that is the right thing to do. It isn't the right thing to do. If you're 63, and your knee X-ray doesn't show bone on bone arthritis, and you haven't exhausted all conservative methods. First you just have to be counselled appropriately and carefully by your surgeon. So your expectations are met. It's not a silver bullet. There will be some restrictions to the activities that you may wish to do. But if all goes to work to plan, and you work hard on your exercises, you can return to most activities, and that even includes recreational racket sports in a doubles capacity, and some people have even managed to get back to the ski slopes. But that obviously has added risk. So there you go.

Damien Gregory

Yeah, absolutely. Thank you. So David's asking, How do you determine if Arthrosamid® is the correct solution for the patient? But also after an injection has been given, how soon can he fly?

Mr Matthew Oliver

So to answer part one. I think Arthrosamid® is a good treatment choice for the mild to moderately arthritic knee and has limited indications in a very arthritic knee. But I think it still has a role to play. I will determine whether it's suitable for a patient after examining them, taking a history, and looking at the X-rays and if the knee has some local warmth and an effusion which indicates that the synovial lining is inflamed, that's another indicator to me that the injection may be of benefit with regard to the four-hour flight. No hard and fast rules about that, but I would certainly probably wait a couple of weeks before you take a long-haul flight, because I think it'd be quite uncomfortable to sit in a chair for a prolonged period in the 1st couple of weeks.

Damien Gregory

Okay. Fantastic. Gordon's asking. Some reports suggest Arthrosamid® injections are less successful for over seventies. This ties in nicely with the patient you were mentioned earlier. Do you have a view on this?

Mr Matthew Oliver

Yeah, I've seen those reports. It's in the company data and on their website, actually, they say that the success rate or the pickup rate of success is, I think, it drops to about 60 to 63% in the over seventies for memory. But that's still good odds, 63%and I'll share with you. I saw a lady today who I provided this injection for 4 weeks ago, and the rep said don't bring her back too soon, it will take about 8 to 12 weeks to work. But I saw her early because she's going on a long haul flight and a long holiday, so she wouldn't be available for follow up and after 10 days she noticed that her knee was much more comfortable, and she stopped taking painkillers, and has even managed to play a bit of golf which she hadn't been able to do for ages, and she is 74 years of age. So that was very encouraging.

Damien Gregory

Good! No, that's a nice story that. Robert's asking is MRI the usual. I guess, diagnostics prior to a knee replacement?

Mr Matthew Oliver

Not usually, a plain X-ray is fine. That will tell the surgeon all that one needs to know. However, an MRI is useful for a patient, specific knee replacement which sort of precluded the ROSA robot technology, and it used to be quite popular a few years back. It's called the signature knee again by Zimmer Biomet, using the vanguard knee replacement and the MRI helped plan for special molds or yeah molds to be produced that are fitted on the knee to produce the bony cuts. But ROSA has superseded that. Now you can get an image-based ROSA

operation done, and that's taken from special X-rays, and I think Ct. Scans. But the image lists ROSA. Knee replacement is just as good, and that's what we utilize here at Benenden.

Damien Gregory

Fantastic. Now we've got, Tim asking, does bone on bone evidence mean that the replacement is probably more appropriate than continuing with any injections?

Mr Matthew Oliver

Probably on balance, because I think the injections are going to be less effective, but it all depends on where you are in your in your life and what's going on. I guess you know you may be too busy to have a knee replacement because of personal circumstances and work circumstances. So therefore, an injection will be okay to tide you over, but, as I say, I think they'll become less effective. Some patients are medically infirm to have major surgery like a knee replacement, so injections are very useful in that. In that category of patients.

Damien Gregory

No, fantastic. We got an anonymous question here, but they are a runner. I am actually having a vanguard knee replacement next month but wasn't aware of the ROSA option. I'm 54. Would there be any benefit of having a ROSA option firstly? And then she goes on to ask whether she could potentially continue to run post knee replacement?

Mr Matthew Oliver

So yeah, so if you wish to have the ROSA option, then it's not too late to express that wish, especially if you're having surgery of us here. If you wanted the latest technology, then that is the way to go, and being only 54, you would want to make sure that the knee replacement is the best that you possibly could be. There's nothing wrong with a conventional knee replacement. Don't get me wrong, especially in experienced hands. But if you wanted cutting edge the latest technology, then certainly the ROSA option should be discussed. So you are fully aware of it

with regard to running, not many people get back to running after a knee replacement.

Maybe some light jogging on soft parkland, but not running. I've had patients who have been able to get back to reasonably competitive levels of squash, tennis. I've had a few patients that have gone skiing horse riding but not many that I can recall that have been running.

Damien Gregory

Okay, thank you. So we've got Lynn asking. I'm guessing this might be related to Arthrosamid® because of the timeline she's talking about. But can you have more than one injection after three or four years?

Mr Matthew Oliver

I believe that is the case. Yeah, it can be repeated. That's correct.

Damien Gregory

Yeah, brilliant, brilliant. We got an anonymous one here. What is the advantage of Durolane over steroid injections?

Mr Matthew Oliver

They're two totally different things. Really. Durolane works by increasing lubrication in the knee doesn't really have any direct pain. Killing ability. It's like it reduces friction between the worn-out surfaces. Steroid has an anti-inflammatory effect in the knee. I guess the only advantage that comes to mind is that with a steroid if you have too many of them. It is actually counterproductive because it can have a corrosive effect on the articular cartilage and steroid also reduces the local immunity of the area so slightly increases the risk of infection.

Damien Gregory

Okay, thank you. Pamela is asking where there is a significant leg length difference, will this cause problems within potential knee replacement?

Mr Matthew Oliver

Yeah, that's an interesting question again, potentially so that would have to be assessed carefully to see whether anything can be done to address that, and if it can't, because you certainly can't lengthen your leg or shorten your leg, particularly with knee replacement surgery. But if you couldn't rectify the problem. Then various shoe wear and foot raises, and things like that to go in the shoe would have to be used to ensure that there isn't too much discrepancy. Otherwise, you just rock on the leg, I guess and yeah. That has to be assessed on an individual matter.

Damien Gregory

No, absolutely. I bet. I bet now we've got Anthony asking. Now Anthony suffers from therefore is immune, compromised. He's taken oral chemo in a recent consultation with an NHS surgeon, he was told there's a 25% risk of infection, and that if the infection occurred he might need an amputation, was the Consultant conflating risk with consequence.

Mr Matthew Oliver

Certainly, it would be very high risk to have a knee or hip replacement, or any operation that requires the permanent insertion of a metal implant into you because the metal implant has no blood supply, and if an infection were to take hold, it grows what's called a biofilm over the implant which antibiotics can't penetrate. The antibiotics need a blood supply to work, so the only way of eradicating the biofilm is to physically debride it and scrub it and even that isn't particularly effective. So I can understand why the NHS orthopaedic surgeon was very cautious. 25% risk of infection seems a little high, but certainly the risk of infection would be greater than the 1% national average. I can't give you a figure, but I would prefer my patients to be off all immunotherapy and all steroids ideally and all chemotherapy before having the operation.

Damien Gregory

Okay, thank you. We've got a question here. This person has an elderly relative in their eighties, with very severe arthritis. They've been assessed not medically fit for a knee replacement due to arterial fibrillation. Would Arthrosamid® be an option?

Mr Matthew Oliver

Certainly don't think it would do any harm. It may help. As we alluded to earlier. The older the patient, and the more severe the arthritis, the less effective it may be. But even if it were to diminish the pain, 10, 15, 20%, that would still be a benefit to the patient absolutely and it's minimally invasive. There's no immunocompromising material in it. Yeah, so shouldn't. Yeah. It's worth a go.

Damien Gregory

Yeah, absolutely. Absolutely. We've got Adrian asking that his 65-year-old wife had a traumatic injury to her knee 6 years ago, and was left with Valgus, deformity, and pain. The Consultant advised previously that her niche should be replaced when osteoarthritis sets in. But they're unaware if the pain is down to the previous injury or his osteoarthritis. how can they tell?

Mr Matthew Oliver

That's another good question, it would need to be properly evaluated with a good history examination and a set of weight bearing X-rays. It's probably a combination of both. The previous injury has now led to what's known as secondary osteoarthritis. Yeah, that's how we would tell.

Damien Gregory

Okay, thank you. We've got quite a lengthy one here from Jill. So Jill's been told that she has limited space in order to inject into her knee. As her arthritis is very advanced. She has a damaged tendon that is causing her problems now, along with her arthritis to the tendon injury.

She was coping well, I also use lipoedema, which lymphedema, which means, I have very heavy legs. That's due to all of this. I've been told, infection is a real issue.

Mr Matthew Oliver

So there's a few problems going on here, isn't there? So lymphedema or lipoedema makes knee replacement surgery a little bit more challenging because the leg is very swollen to start with, and they only swell more after the operation, and the patient needs to be counselled about this, because it usually makes the exercises very challenging, and therefore the knee becomes stiff.

which is not ideal, because that's poor function, and you've just gone through all that, and you've got a stiff knee with regard to the injections. That's the beauty of using an ultrasound. If the probe is sensitive enough, we should be able to scan through the lymphedema to ensure that the injection goes into the correct place into the joint, and therefore provide the injection

correctly positioned, and therefore hopefully it will work.

Damien Gregory

Yeah, no, absolutely. Thank you. So Marilyn's asked that she's had an arthroscopy and various steroid injections. Already she's had her follow up appointment, but still too soon for a replacement. Apparently she's had. I've had pain elsewhere. Also she's had five other injections at another clinic in a knee, but no idea what they were called. She still has pain to the left of her knee, which she believed might be a sciatic issue and are there any things that you can do maybe?.

Mr Matthew Oliver

Well, if you think it's sciatica which is a trapped nerve in the back, then the best way of having that ruled out is to ask for an MRI of your lumbar spine that will tell us whether you've got trapped. Nerves also weight bearing X-rays of the knee will be able to tell us what stage in the arthritic process that you're you know you're at, and then we could manage it from there. If you've had all these injections, and then the pain is still there that does concern me somewhat. Either the injections are not hitting the spot and are going into the fat or the soft tissue, not the joint. Or you've got a trapped nerve like you say the sciatica. So yeah, further workup required.

Damien Gregory

Yeah, absolutely exactly. Exactly. Give us a call. I tell you what, we're going to answer these last two because we are running out of time, and we definitely don't want to make sure we're not snowed in. This is the lady from Prior, and she's actually asked, would I need to discuss the ROSA option prior to our operation, or can she decide on the day?

Mr Matthew Oliver

I would certainly recommend that you discuss it pre-op, you know. Come in and have another appointment with one of us, because it's a big deal, not only for you financially, but also it's a different setup and you just need to be fully informed.

Damien Gregory

No, absolutely and this one actually interested me, so I'll be finished with this one if you have one very painful knee and the other not so painful. Is it better to have Arthrosamid® in both knees together.

Mr Matthew Oliver

I haven't done two knees at the same time, but it can be injected. You can have bilateral injections. So that's a good question. Actually, I would probably wait to see if the if you responded to one injection 1st before having the second one done, not only because it's financially quite pricey. But also you just want to see if it actually works for you or not. Yeah, absolutely. I just have one done at a time personally.

Damien Gregory

Okay, no, that makes perfect sense makes perfect sense. Right, so thank you for that much appreciated. If we didn't get to answer any of your questions. If you did provide your name, we will be able to get back to you via email. So we need to close that there, we just move on to the next slide. Okay, so thank you. Thank you ever so much again. As a thank you for joining this session. We will be offering 50% off the value of your knee pain consultation and that will be available for seven days. Call back from our dedicated private patient team advisor, an email with a recording treatment, information and loyalty reward points and update on news and future events. 

We would be really grateful if you could complete the survey at the end of the session. As this helps us shape future events. If you'd like to discuss or book your consultation, our private patient team can take your call up until 8pm. Tonight, or between 8 and 6 Monday to Friday. Using the number on the screen. 

We have more events and webinars coming up in hip surgery, urology, and varicose veins which you can sign up to via our website. So on behalf of Mr Matthew Oliver and the expert team here at Benenden Hospital, I'd like to say thank you for joining us, and we hope you have a lovely evening. Thank you.

Mr Matthew Oliver

Thank you very much.