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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 3. - Knees
RADIO 4
THURSDAY 09/12/04 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
TIMOTHY BRIGGS
PRODUCER:
ANNA BUCKLEY
NOT CHECKED AS BROADCAST
MYERS
Hello. Stiff aching knees may be the price some of us end up paying for a lifetime of running for buses, climbing stairs or mountains and getting down to clean the kitchen floor. But what happens when you're not able to cope with the pain and loss of mobility? Knee replacement surgery is available for people with severe osteoarthritis and it is successful in 9 out of 10 cases. In younger people, where it's more often a sporting injury, surgery can also help - a new and promising technique involved cartilage implants which are grown from patients' own cells.
Well if you have questions about knee surgery call us now - 08700 100 444. Or if you want advice about non-surgical alternatives - pain relief, exercise, prevention - we'd like to hear from you. You can e-mail checkup@bbc.co.uk.
And here with me to take your calls today is Tim Briggs, he's a knee surgeon from the Royal National Orthopaedic Hospital. And we've hit the jackpot with calls today, let's go straightaway to our first - Charlotte Bird, waiting to speak to us in London. Charlotte your question or indeed your comment please.
BIRD
Oh hi, hello good afternoon. Yes I've just come back from the gym having had a very successful knee replacement in August and looking forward indeed to another one at the end of February. I'm comparatively young I think to have these sort of things - I'm 54 now but I have had pretty serious arthritis in my lower limbs for well quite a long time but we started addressing it about five years ago. So I'm just really saying knee replacement is fantastic.
MYERS
Well that's music I suspect to Tim Briggs ears - that's a happy patient.
BIRD
Very happy patient.
BRIGGS
Yes I mean there's no doubt now that knee replacements are doing as well if not better than hip replacements and there are about 50,000 carried out in the UK per annum and they do indeed have a very high patient satisfaction rate and a high success rate, not just in the short term but I hope you'll be getting good function Charlotte out of your knees over the next 10-15 years.
MYERS
Well it sounds as if you're down at the gym already, you're certainly making the most of your new joint. Thanks very much for that, that's a very positive start to our programme. Jane Smith next, hello Jane.
SMITH
Hello.
MYERS
And your question please.
SMITH
Well I'm 88 now and following an accident I had a replacement knee in 1990. I'm going on well but I wondered how long it will last?
BRIGGS
Well Jane I mean even in 1990 the knee designs were really excellent and providing your knee is functioning well without any pain I think you could expect another 5, 7 or perhaps 10 years function out of your knee, allowing you to get around without pain and enjoy life.
SMITH
Oh that's good. I walk with two sticks or leaning on the trolley, I can't go very much - well on my own, I'm a bit wobbly.
BRIGGS
Okay.
SMITH
But I'm 88.
BRIGGS
I think you've done extremely well.
SMITH
Thank you.
MYERS
And long may you continue. Thank you very much for that call. We'll go now to Marjory Waugh who's in County Durham. Marjory - have you got a question for us? I'm not sure whether you're there. Let me go to an e-mail in that case because we've been talking about surgery but of course there are a lot of stages people go through before they come to see you as an orthopaedic surgeon and I guess the first thing is going to be a diagnosis. Helen's a bit worried because she - she's 53 and she's fit but her knees have started to click and she says it's an unpleasant rather than a painful feeling but is this the start of something, are things going to get worse?
BRIGGS
Well it could be the start of something and I think that if she's concerned she ought to go and see her GP who will examine the knee and make a diagnosis and what you want to exclude really is any, what we call, mechanical derangement within the knee - if anything is catching or getting stuck. You can often make that diagnosis if you examine the patient but you may even need an x-ray or even an MRI scan. Once you've made the diagnosis then clearly you can go down the track to try and resolve that problem, but it sounds like it's quite an easily remedial problem she has.
MYERS
Okay Marjory's joined us now. Marjory.
WAUGH
Well good afternoon. Yes I was wondering if you might be able to tell me about maybe some of the most recent advances in knee replacement surgery techniques. I understand there's such a thing as - called minimally invasive technique, where I believe the incision is about - is actually made on the outside of the knee rather than directly over the kneecap.
MYERS
And are you asking for personal reasons - is this something you're contemplating?
WAUGH
Yes unfortunately both of them - both of my knees will be needing done - well one is needing done now and I'm just trying to find out if there are some ways of - I mean I've been told that there was a minimally invasive technique that ...
MYERS
Well that does sound rather better doesn't it, anything that's minimal has got to sound better than the full flown operation but does it work - is this something ...
WAUGH
Well that was my next question.
MYERS
Indeed, let's ask Tim.
BRIGGS
Certainly minimally invasive surgery is the current vogue, both in hip and knee surgery. I think the most important thing you can do is you go and see the surgeon you have confidence in and you allow him to choose the method in which he undertakes the surgery because the most important thing is who does the surgery, what implants they use and how they put them in. And what you want to make sure is that you're getting an operation that is done regularly and commonly and I think that minimally invasive surgery has a long way to go yet to prove its worth in knee replacement surgery.
WAUGH
Right.
MYERS
So that does suggest that you might be a little bit of a guinea pig if you go forward for minimally invasive surgery.
BRIGGS
I think at the moment, I think the jury's still out in terms of - certainly in total knee replacement - on how well in the long term patients are going to do. Can they beat the gold standard that we have at the moment of a total knee replacement done through an incision of about 18-20 centimetres with a 95% survivorship of 15 years.
MYERS
I mean should Marjory be worrying about the kind of standard operation that for example you might ...
BRIGGS
No, I mean knee replacement surgery now is very routine, patients have a very high satisfaction rate, you're in hospital between five and seven days and people get going usually 24-48 hours after the operation, which means you're out of bed walking on your knee. And even if you have it done through an incision of 20 centimetres you rehabilitate extremely well and you will be very satisfied.
MYERS
Marjory I hope that helps. We've got another caller now who's had some knee operations, may not be so satisfied however, Peter Sage in Exeter, hello Peter.
SAGE
Hello.
MYERS
What's the story?
SAGE
One of those annoying ones that I had about 10 years ago I had arthroscopies on both knees and I had the cartilages trimmed. Went down very well and unfortunately it came back again this year, had the - one of them done in June, perfect, not a problem at all, but I had another one done at the beginning of October and not gone so well. They say that in car making you get a Friday afternoon car where everything goes together right and I feel like I'm that Friday afternoon car - it just isn't quite right, it hurts, it aches, it's still not right. Been back to see the consultant who said it's one of those things that every knee operation is different, and you're getting older, so I don't really know where to go now. They've sort of said oh you have to have physiotherapy and you do this and all your tendons are all a lot looser but I'm just a bit fed up and want to know really what I can do next.
BRIGGS
Well Peter sometimes for all of us, including myself, operations don't go always according to plan. I think what I would do is I'd take the consultant's advice, I think going down the physiotherapy route to strengthen the muscles initially is the right thing to do. If that fails then what I would do is I'd go back to see the consultant who I'm sure would be happy to see you again and say that I'm not a 100% - my knee's not quite right - and I think the next step certainly at the Royal National Orthopaedic Hospital we'd probably offer you an MRI scan, just to look at the inside of the knee without a further arthroscopy, to look at the structure to make sure nothing is still getting caught or pinched or anything we can do anything about.
SAGE
Right, I haven't actually seen the consultant, I've only ever seen the registrar. When I went back today I saw a different registrar that actually carried out the operation.
BRIGGS
Well then what I would think I would do is I'd go back and ask his secretary could you please have an appointment with the consultant.
MYERS
That's very clear and very straightforward advice. But I wonder if I can just get you to backfill a little bit with this business of arthroscopy, it may not be a familiar procedure to some of our listeners. So - and obviously it's something to do with the cartilage, can you explain what happens?
BRIGGS
Basically arthroscopy is keyhole surgery - two little tiny incisions, no bigger than the width of your little fingernail, either side of your kneecap. And it's done as a day case, you walk into hospital, you walk out. The surgeon uses a telescope and a light - a bright light to look within the knee, watches everything on a TV camera and then can insert very specialised instruments to treat the lining of the joint or the torn cartilages - footballers say - or remove loose bodies or operate on the knee with the minimum amount of trauma, allowing people to go back to work within two or three days and recuperate very quickly.
MYERS
Brian Grindall joins us and he I think is interested in knee arthroscopy, either has had it - what's your question about it please Brian?
GRINDALL
Hello, thank you very much for your explanation of an arthroscopy. I had an arthroscopy on my left knee just over four weeks ago and prior to the surgery I asked the surgeon what kind of incidence of deep vein thrombosis would - happens after arthroscopy and he said that in his - his professional opinion he'd only ever seen the incidence of two DVTs and he felt that - he reassured me that this in fact would be - would not happen in my case. A week later I found myself down at Eastbourne General Hospital in the A&E department being diagnosed with a deep vein thrombosis. Life got very scary for a few days, whilst I was injected through the abdomen with clexane and I now find myself on 9 milligrams per day of wharfarin until next May, which has been a bit of a shock to my system. I just wonder if you could - are there national statistics regarding the incidence of DVTs on knee surgery patients?
BRIGGS
No there aren't Brian. I mean DVT following an arthroscopy, which typically takes less than about 30 minutes to complete, is extremely uncommon. But I mean you can get DVTs when you're not even having surgery, such as described now when flying across the Atlantic in an aeroplane. I think you've been unlucky, but it's been caught early, you're now on the wharfarin - wharfarin will allow the veins to recanalize but it's important if you ever go to have further surgery in the future you must tell the doctors that you've had a DVT in the past and they'll take extra precautions to prevent it happening again.
GRINDALL
Thank you very much.
MYERS
Thank you for the call. And to Yorkshire, Richard he's waiting for us, Richard Lowe.
LOWE
Hello.
MYERS
Hi there.
LOWE
My wife's a care worker and has various knee problems which have been accumulating over the past few years, largely associated with the way she has to handle the residents at the home she works at. Walking sort of backwards and sideways at the same time, guiding people who are unsighted and because of their mental handicap problems may not be able to cooperate too fully.
MYERS
So she's caring for them but at some cost to herself. So what's the actual problem?
LOWE
General pain in the knees, often going downstairs rather than up. So it's sort of an impact thing. Now she's tried various things, doesn't want to go in for surgery because we have - not personal but we know of people who have come out with MRSA etc. ...
MYERS
Oh right this is the super bug you can pick up in hospital.
LOWE
Yeah. She had a personal experience of trying to sort that problem out ...
MYERS
So if she can avoid hospital so much the better.
LOWE
Absolutely.
MYERS
... as a general rule of thumb.
LOWE
... don't really want steroids because she has had that for eczema in the past and doesn't want to accumulate them.
MYERS
Well let's get Tim to think of some alternatives.
LOWE
She has tried some things herself which may be of use to other people. Cutting out caffeine, believe it or not, has helped. I think we heard that on this programme some time ago and tried it and it works. Also the hay diet - that's where you separate proteins and carbohydrates is it?
MYERS
Okay, so I mean there are lots of tried and tested remedies and it's a question of whether this will actually really help Richard's wife or whether actually surgery ...
BRIGGS
Yeah I think Richard what I would advise your wife is that your wife appears to be suffering from a condition called anterior knee pain, which is actually not uncommon in the population. I think the way to try and manage that initially is to make sure that her muscles at the front of the knee are built up, see a physio which would certainly help that, you can take painkillers and anti-inflammatories to try and reduce the inflammation...
MYERS
Which are non-steroidal.
BRIGGS
Which are non-steriodal anti-inflammatories. You certainly don't need to take and should avoid steroids at any cost. And I think from what you're saying to us I think your wife should avoid surgery at all costs too. And most patients settle down with modifying their activities, and also strengthening up the muscles at the front of the knee and taking some anti-inflammatories.
MYERS
We've got another suggestion from John who's speaking about his mother, who's had terrible osteoarthritis for many years and she's found that fish oils do it for her. Is there any evidence that fish oils are going to help people? It's almost a sense that they're going to lubricate the joints but that's perhaps an old wives' tale.
BRIGGS
Yeah that's a very - it's a very interesting question and I get asked that by a lot of patients and the trouble is there's not a huge amount of scientific evidence to back it up. But some patients come in, they say they've taken fish oil, they've taken glucosamine, chondroitin sulphate is another very popular choice - supplement to take. And some patients swear by it, other patients say it hasn't really done them much good. But I never put patients off, I say that if it works for you then try it and take it.
MYERS
Okay and we move to Brian, I think, who's got a comment about glucosamine. Brian?
BRIAN
Yes hello.
MYERS
Yes, something you've been trying?
BRIAN
Well my wife's been trying it yes. I once heard a consultant - people were commenting on I think the constituent part of cartilage or something in this cosamine or in the chondroitin and he said - well you might as well take tablets made up of hair to cure baldness. I wonder whether there's been any further studies with regard to glucosamine with chondroitin.
MYERS
One of those terrible words isn't it - I've heard it pronounced glucosamine - glucosamine. Okay but it is - there's plenty available, people buy it off the shelf as it were and some people do seem to get some benefit.
BRIGGS
Yes and glucosamine and chondroitin sulphate are part of the make up of articular cartilage. But I don't think there's been any scientific studies that have proven by taking these particular compounds that actually you regenerate the normal lining of the joint. Once the normal lining of the joint starts to degenerate we're in trouble and we're into holding operations trying to prevent further degeneration.
MYERS
Are there any other ways then you would say to patients to try and prevent further wear and tear if their joints are vulnerable with or without taking supplements and dietary changes, is there any other sort of really useful bit of advice?
BRIGGS
Yes I think the most important thing is to make sure you lose weight - so you're putting less force through your joints ...
MYERS
That's obvious isn't it.
BRIGGS
I think keep your joints mobile, you mustn't let them stiffen. And alter the sort of activities you're doing, so instead of running on the road go to the gym, use a rowing machine or bicycle in a gym or swim, avoid the high impact loading which will actually reduce the stresses across the knees and your knees will last longer.
MYERS
Well on the exercise Jo Flanagan's e-mailed asking if she should continue with her pilates class. She's obviously got some pain and discomfit in her knees, that's a particular form of exercise, is to do with the core muscles, would that affect you - would that help you?
BRIGGS
No I think exercise is good but I think modify the exercise within the limits of the discomfit of your knee pain. And pilates I don't have a problem with that but what you want to avoid is repetitive high impact loading, so you don't want to go down the gym and do an aerobics class on a regular basis, that means you put a lot of jarring through the joint.
MYERS
So I think I've got the answer to Killian Doherty's question, he's e-mailed from Stockholm saying that he's had an injury, was recommended exercise, done them fairly assiduously for two months, knee feels much better. He's now stopped the exercises wondering whether he should maintain them or if he doesn't will the problem return.
BRIGGS
Yes I think that a lot of people find that when they go to see the physiotherapist they do really well because someone's there making them do exercise and then they stop seeing the physio and then the pain comes back and that's because they often stop exercising because no one's telling them to do so many repetitions, the most important thing is if you see a physio, exercise does your joints a lot of good, keep it up at home, do it regularly and they'll keep your pain at bay.
MYERS
Martin Kingsby joins us from Chiswick with I think another exercise related question. Your question please for Tim Briggs.
KINGSBY
Well I had an operation on my knee two and a half years ago and six weeks later my kneecap twisted, so they operated again, opened my knee up and straightened the kneecap. Then I got an infection inside the knee. The surgeon opened the knee, took out the knee then filled it up with cement and antibiotics, sewed it up again. And put my leg in plaster for 18 weeks. He then opened up the knee after 18 weeks, took it all out and put a new knee in, which seemed to be alright but the trouble is I've now got cellulitis and I can hardly walk and the pain is terrible, it also swells up every night, what should I do?
BRIGGS
It sounds as though what you had - you got an infected knee replacement and taking the knee - it's called a two stage revision - taking the knee out, putting a cement into the gap which is impregnated with antibiotics, tries to kill all the bugs within the cavity and then you go put another knee back in its place. It sounds as though you're still in trouble, i.e. that you've got the cellulitis and pain. I think what you ought to do is go back and see your consultant, where I'm sure he'll take some x-rays, he'll do some blood tests to make sure there isn't any infection in the joint and he'll take things from there. It may even be that you have to consider taking the knee replacement out, if it's infected, and maybe stiffen the knee to get you out of your pain and keep you mobile.
KINGSBY
Yeah the trouble is I went back last Monday to see the consultant and he wouldn't see me, he gave me the registrar, he said he was too busy to see me.
MYERS
Oh that's the second time we've heard that complaint today.
BRIGGS
It is and I think what you must do, I mean you sound as though you're a very deserving case, you're in a lot of trouble, and I think if you phoned the consultant's secretary and say I must see the consultant I'm sure she'll sort that out for you.
MYERS
Martin thank you for that and I'm sorry about the difficulties you're having but there's some clear advice there from one consultant, which is to go and see your consultant and make sure you get to see him or her. But of course this does really give us the bookend doesn't it - we heard at the very beginning of the programme with Charlotte that she's fantastic, she's just been down to the gym after her operation, she's fine and now we hear from Martin things have gone very badly wrong, he's in a lot of difficulty. Hard for people then who may be facing this operation, where do you really give the reassurance?
BRIGGS
Well I think that most knee replacements are very successful, there'll always be some that fail for various complications such as infection and as one person said about DVT - deep vein thrombosis. But on the whole the majority of patients get a good result. I think all I can say to patients is you go to your consultant, you ask how many knee replacements have you done, what's your success rate, what's the success rate in the hospital, what's the infection rate in the hospital, so you reduce the risk of any adverse event occurring either during or after surgery.
MYERS
And a good result means that you will be free of pain, you will be mobile again, you'll be able to get on with your life.
BRIGGS
Yeah, I mean most of the patients that I treat ride bicycles, go hill walking, some of them ski - I tell them not to but they don't take any notice, they go skiing. And they lead a very active life, some of them play gentle tennis, what I wouldn't want them doing is running, to try and make sure the knee joint lasts the test of time. But yes it can give a very good quality pain free life.
MYERS
Our next caller's in Suffolk, Mike - hello your question please.
MIKE
Hi, good afternoon. I had an ACL replacement on my right knee and the ligament is intact but it seems like it's stretched, so the whole knee is very, very loose. And I had - when they - the ligament that they used to replaced it was part of the hamstring ligament and so I had a problem with my foot - controlling the foot afterwards. I was just wondering now as far as doing another surgery what are the options as far as taking something else to use instead of part of - more of the hamstring and also for the cartilage is there any research into stem cell implantation as far as renewing cartilage?
BRIGGS
Right that's two questions. I'll answer the first one first. Certainly if the hamstring - anterior cruciate ligament reconstruction has failed you can use the middle third of your patella ligament and that's called the Jones procedure, which is really the gold standard and something I use a lot. And you can interchange and therefore you could easily change from the hamstring, which appears to be loose, and use a middle third patella ligament. And most patients would do well following that, it would certainly tighten up your knee. As regards cartilage transplantation, it's something that we've been pioneering at the Royal National Orthopaedic Hospital now for about six years. We actually don't use stem cells, we use the patient's own chondrocytes, which are the cells that make up your articular cartilage. And we take a little biopsy of about 20,000 cells, we then grow them in the laboratory to about 20 million over about four weeks and then we go back and re-implant them. And we've been carrying out this sort of multi-centre study over the last six years and we can guarantee a success rate in the order of about 75% improving function and reducing pain.
MIKE
That's fantastic. Does it actually put a nice neat smooth layer across the surface?
BRIGGS
It certainly appears to be at the moment, six years down the line. So we're very encouraged and the other great centre in the world really that's been doing this is in Sweden and they have data now going out to 12 years and again if you're good at two years they say you're good at 10 years. So it's very encouraging.
MYERS
And if I can just throw in a quick final e-mail from Rob who says he's heard about a revolutionary treatment - a disc of plastic inserted between the knee bones to act as a cartilage alternative. Anything in that?
BRIGGS
No I think that they've tried - and certainly in the States - they're using a metal disc and I know in New York one surgeon was putting them in and the other side of town one surgeon was taking them out. Expensive and I don't think proven and I think if you're going to resurface your cartilage you need to - you want some cells - your own cells - grown in the laboratory and at the moment reinserted four or five weeks later.
MYERS
Thank you very much. I'm afraid we've got a lot of calls that we haven't been able to get to today and e-mails but thank you very much for everyone who made contact. And thank you, in particular, to my guest Tim Briggs. There's more information from our free and confidential help line and from our website which is at the usual bbc.co.uk/radio4 and you can hear the programme again online. I'll be back at the same time next week but before I go today I just want to briefly tell you about a special end of the year edition of Check Up. We will be taking your questions on the common conditions that people go to the doctor with - the top three by the way are respiratory problems - that's coughs and colds and don't I know about that today - muscle ache and the third is skin rashes. So if these or indeed any other common complaint affects you or your family and you have questions about them you can call us right now. The number 08700 100 444, phone us right away, the lines will be open for just half an hour. Till next week goodbye.
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