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My name is Ruth Delany I’m a shoulder specialist and I’m going to be talking about some aspects of skiing injuries that have to do with shoulders. Before you even get to the mountains and get to ski there are probably some things you can do that might help in terms of being in the best possible shape for skiing and possibly even preventing injury as well. So before leaving home if you have a reasonable level of fitness that is going to help you enjoy your skiing more and hopefully keep you out of trouble in terms of injuries probably more so for the legs and for the shoulders and arms but I think overall conditioning can play a role and while you’re out there in the mountains there are some things you can think of that we often forget that may help you as well.

Some things that I’ve used and had fun with preparing for skiing can be gym stuff even just going for a run, running hills and some ski specific things there are apps like perfect turns there are ski specific machines lateral trainers, like skiers edge there’s lots of things you can do you can get really into it but I think the bottom line is if you are reasonably prepared then you’ll have a better time skiing.

When you get there remember that you’re probably going to be at a much higher altitude than we’re used to being at here in Ireland our highest mountain is probably only about a thousand meters and many of the ski resorts that we go to you’re sleeping at an altitude that’s higher than that and during the day going up to you know higher than 2,000 meters often and so hydration is relevant especially when we want to maybe go have a good time people like to have some drinks at some point and again just remembering to drink some water you may feel a whole lot better. Warming up is something that we often don’t really think about both you know tumbling out the door in the morning and just making it on time to wherever you want to get going with your day without actually doing any warm-up before you start or warming up your first run or two not going hell for leather immediately. At the other end of the day being careful of fatigue I think a lot of people are probably aware of this you know that last run syndrome where you try and push one more run or you ski down something that’s really difficult at a horrible time of day when everybody else has been on it as well and so finding an easier way home or maybe even taking a gondola down can sometimes save you and leave you in better shape for the next day. We also see injuries that don’t happen necessarily on skis or on snowboard but maybe around a resort where there’s really icy foot paths and so being kind of aware that injuries sometimes happen not necessarily during the activity, slippery foot baths and maybe slippery bar tables too so I definitely have fixed some injuries to do with après run rather than to do with skiing.

So how about if you have a shoulder injury already or a shoulder problem and you’ve got some plans to head out skiing or snowboarding can you go and what sort of things might you want to think about. So I think you know with the shoulder there can be structural injuries or inflammatory and wear and tear problems and sometimes it’s a mixture of both and so what we tend to think about is well what’s the likelihood of your skiing making it worse, most things pretty unlikely because the shoulders aren’t taking that much of a beating when you’re skiing with inflammatory problems like tendonitis, versitis things that maybe have to do a little bit with and tear it’s perfectly reasonable to have taken some anti-inflammatories or even potentially have had an injection if the appropriate specialist has recommended it and carry on with your activity. With structural problems let’s say you’ve got a full thickness rotator cuff tear something like this you know you’ve got to weigh it up you may find that it’s pretty sore and ruins your enjoyment of skiing you may find that it’s manageable, if you fall on it you may make it worse but if you fall on your shoulder you may get a new injury anyway so for a lot of things you can tend to work around them in the shoulder which may be unlike other joints. Obviously it’s a different situation if you’ve had surgery on your shoulder then it depends where you are in your rehab and what the timelines are like and you’ve got to talk to your surgeon and not take any unnecessary risks in terms of trying to push timelines just to squeeze in a trip maybe you’ve got to save it for next season.

Then if something happens what sort of things do we see in the shoulders and how do we take care of them?  The obvious one is fractures the types of fractures that we tend to see from ski injuries would be mostly collar bone and shoulder fractures being the top of the humorous bone, Proximus humorous fractures and there can be a variety of different ways to manage these. Injuries happen in recreational skiers and they can happen in World Cup racers too, so this is a video of Graham Bell a British ski racer having a clavicle fracture in a downhill race in Kitzbuhel a few years ago and you can see exactly how this happened. So that was a clavicle fracture, ski racers being ski racers I think he was back racing a few weeks after that pretty quickly but for most of us it would take a little bit longer. What do we do with these clavicle fractures then many of them don’t need surgery and sometimes we see people coming home from their ski holiday having been told they needed an operation immediately that day, they’ve been taken off the mountain still in their sweaty ski gear taken to the hospital and taken right to theatre and most of the time that’s not necessary but people are scared, they’re hurt, they’re in a foreign country maybe don’t speak the language and a doctor is telling them they must do this and so the only time that it’s probably necessary to have an urgent operation on a broken collar bone is if it’s what we call an open fracture so if the bone is out through the skin then there’s a significant risk of infection and that needs to be taken care of typically within the first 24 hours that needs an operation. Everything else you can pause take a breath unless there’s nerve or blood vessel damage which is rare so if there’s a problem with the blood flow to the hand or something like that that’s another emergency these are really rare the vast majority of clavicle fractures don’t need to be fixed right there and then. Some of them actually don’t need to be fixed at all and sometimes we see people coming home from a ski trip with plate and screws on there that probably didn’t need to be put on at all and that’s all fine as long as everything goes well but if they run into trouble get an infection or something else then it’s really a shame that they’ve been exposed to unnecessary risk so I think just kind of taking a pause and asking you know well do I really need surgery right now or can this wait, can I go home first, is there an option to manage this injury non-operatively those are all totally reasonable questions to ask. Whether or not a clavicle fracture has surgery depends on some factors that we see on the X-ray like shortening displacement comminution which means lots of different pieces, the fractur in pieces and then other things like maybe if it’s your dominant side we might be more likely to consider fixing it and it’s going to be a discussion between you and the surgeon because there’s often no exact right answer there are risks to fixing it there’s a risk if you don’t fix it that it doesn’t heal and has a non-union and ends up need be fixed later anyway so it’s about balancing all of those things but typically that’s not something you have to decide on the spot.

The other fractures that we see would be broken shoulders so Proximus humorous fracture this is a friend and colleague of mine who had a really innocuous fall skiing he was just at one of those sort of junction points in the piece and waiting for one of his kids to catch up sort of turned around awkwardly and just fell over on his shoulder and had a really nasty proximal humorous fracture and so usually we’ll get a CT scan for these. Again, he was told out there in the mountains in another country oh you need an operation right away but you know he sent a few texts, sent a few pictures and he figured that he could get himself home first and then get taken care of by somebody who’s actually going to be available to follow him up. Again you can see on the other view of his CT scan as we’re scrolling through you can see how the top of the humorous bone is pretty smashed and he had his shoulder fixed by one of the trauma guys did a really nice job put that back together there absolutely perfectly but the problem with these injuries is that once you break the shoulder it’s never the same again, so unlike a collar bone which tends to heal without too many consequences for the shoulder because the shoulder joint’s not involved, once you have a fracture of the shoulder joint be at the top of the humorous or more rarely the socket or the glenoid part that can lead to problems later on no matter how well it’s treated to begin with and the issue here was that the blood supply to that head of the humorous that nice round part of the top was damaged in the initial injury and you can tell by certain features of the initial fracture that this is possibly going to happen but there’s nothing you can do about it, so then the head collapsed over time so now those perfectly placed screws are now prominent and potentially damaging the socket of the shoulder and there’s pain and so the next thing to do is then take the hardware out and he’s left with this shoulder so probably headed for a shoulder replacement at some point and unfortunately, that can just be a consequence of certain breaks of the top of the humorous bone not all of the some of them the blood supply doesn’t get damaged some heal pretty well but you’re often left with some stiffness of that shoulder if you’ve had a break into the shoulder joint.

This is another injury that looks maybe a little bit similar this is somebody who was just standing at the bottom kind of in the lift line waiting for her friends and somebody out of control just came flying down and smashed into her. She dislocated and fractured her shoulder was fixed out there in that country and they put plate and screws on got that head of the humorous sort of back and top of the humorous but didn’t really appreciate the extent of the injury so when she turned up in Dublin for follow up and you can see on the X-ray those sorts of diamond shaped things those are skin clips so it’s really soon after surgery her shoulder is dislocated because that’s where the socket of the shoulder is and you can see the humorous is in front of it and below it and so unfortunately, her injury hadn’t really been completely treated so I took it her to theatre and put it back in but it just sort of fell out again because of the extent of the damage the surrounding tendons of the rotator cuff. She was of an age where it was appropriate that she could have this type of replacement a reverse shoulder replacement so that’s what I did for her and it worked pretty well and she got to go back skiing. So we do let people ski again after shoulder replacements what you don’t want is for someone to fall and have a factor around their replacement so maybe a conversation about changing how they ski in terms of how much they push themselves or how aggressively they ski can sometimes be appropriate depending on the person but it’s not necessarily the end of skiing.

Speaking of dislocations, the more common situation where you just have a straight dislocation, where the humorous comes out of the socket. Like you see in this picture and this is another racer who recently dislocated her shoulder during a downhill she’s one of the best speed racers in the world finished the race and sounds like her shoulders come in and out quite a lot of times before there she is in the gym just a couple of days later but people who have these loose shoulders and tend to dislocate may often find that an innocuous force when they’re recreationally skiing can cause a dislocation. So the people that we think about doing surgery for dislocations are the people that either have a first time dislocation at quite a young age especially if they want to go back to a contact sport if they normally play something like rugby, Gaelic football then they’re a high risk for dislocating again or somebody who’s had multiple dislocations, there’ll usually be structural damage to the shoulder unless somebody has very stretchy ligaments so if the labral and the cartilage bumper around the socket of the shoulder is torn that can lead to further dislocation. So we might fix that as you see on the left with a keyhole surgery, if somebody’s got a bit more damage to the bone of the socket or a dent in the back of the humorous we way have to do a bone block or what we call a latarjet procedure so sometimes shoulder dislocations end up having surgery and it just depends on the situation in terms of how many times it’s dislocated and what are the damages. Physiotherapy is often the way that we treat a first-time dislocation when somebody comes back.

This is another ski racing injury this one from last year Alexander Omakilda had a shoulder dislocation in a downhill race going obviously at a lot more speed than most recreational skiers are going to be going at but his dislocation also was complicated by nerve injury and that can happen when you dislocate the shoulder you can stretch one or more of the nerves around the shoulder. Most of the time that will get better on its own and so whether surgery is indicated or not depends more on the dislocation itself and the other factors that we just spoke about but you can see how quickly these things can happen especially with downhill racers and he crashes into the netting has a significant leg injury as well where the ski edge actually cut his leg and injured a nerve there, his shoulder dislocated he did end up having surgery for that dislocation and that was again a decision that probably had multiple factors in it. These types of ski injuries are extreme but we do see recreational skiers dislocate their shoulders in more typical recreational falls as well there’s just usually no videoing them but you can just see the force involved and the collisions with the ground and with the safety netting.

Another type of shoulder injury that we can see sometimes is rotator cuff tear and believe it or not I have seen somebody who fell off a ski lift. The rotator cuff are four muscles that are deep inside the shoulder, the tendons attaching muscles to bone, the tendons of the rotator cuff don’t have a great blood supply so over time they tend to wear and degenerate anyway. So many people will have some wear in their rotator cuff and over the age of 65 about half the population will actually have full thickness tears but not all of them will have symptoms. If you have a fall you may have an acute rotator cuff tear from an intact tendon that suddenly tears or you may have an asymptomatic tear suddenly become symptomatic because it becomes larger and more difficult to compensate for. I’ve also seen a patient who managed to tear both rotator cuffs in one afternoon of skiing, skiing moguls with his teenage daughter, fell on one shoulder pretty hard knew he had hurt it and then didn’t want  to lose face so continued to ski the bumps and next time he fell, didn’t want to fall on the shoulder he had just hurt so then fell on the other shoulder and presented to us with bilateral full thickness acute cuff tears both of which ended up needing surgery, so it can be a tough injury.

Not all rotator cuff tears need surgery typically the rule of thumb is over 70 the healing rates can be variable and a lot of people in that age group will have had the tear a long time anyway so we may try an injection and physiotherapy to get them back to the compensated state they were in before they fell. Obviously there’s not a hard and fast rule and I’ve dealt with 78 year olds, 82 year olds who are in amazing shape so it’s more to do with physiologic age than chronologic age but in acute full thickness tears in younger or very active people we usually would recommend repair and this is a keyhole surgery where we reattach the tendon to bone using anchors and heavy sutures. The tough part of that surgery is that it takes quite a lot of time to recover and rehab we’ve got to protect the repair in the beginning by putting you in a sling, we can’t allow any strengthening until about 12 weeks out from surgery so in real life day-to-day terms that means you can’t lift anything heavier than a cup of coffee for three months and that has implications not just for people’s recreation but for a lot of people’s work as well. It typically takes about 6 months to rehab from a cuff repair and people are often still improving up to a year so even though it’s a keyhole surgery there’s quite a bit involved but that’s something that can happen from any type of a fall including one on the mountain.

To sum up you know skiing is a fantastic sport is a great recreation it’s an amazing holiday, yes there can be an injury risk but I don’t think anybody should let that stop them from getting out there being active, experiencing the mountains. There are some things you can do to prepare and to try to prevent injury and maximize the enjoyment but if the worst happens then take a breath and assess the options this is not me touting for business we’re already incredibly busy it’s more I suppose from having seen some of the messes that we have to clean up sometimes when people come home just take a breath and find out your options before you get rushed into something. Either way if you have something fixed out in the mountains then you’re going to need follow up when you come home as well and we’re always happy to do that but I think the bottom line is getting out being active and enjoying skiing is far more beneficial than worrying about any of the risks of injury it’s about being outdoors having activity and of course it’s the people that you ski with as well.

Yeah I think it often is a situation where we would consider surgery for shoulder dislocation if somebody is under the age of 25  because we know that if you dislocate your shoulder for the first time under the age of 25 is a really high chance that it’s going to keep happening regardless of how much work you do with physio and how much you strengthen up the structures around the shoulder that help with stability things like the rotator cuff because usually you’ll have damaged the labarum or the cartilage bumper that helps stabilized at the socket of the shoulder. As you kind of get a bit older you are less likely to actually have recurrent dislocation whereas under the age of 25 you may have it happen again so we would have at least a conversation with you about surgery versus trying physio and only intervening after a second dislocation. So I think the bottom line is if you’re 20 years old and you’ve dislocated your shoulder it’s worth at least meeting with a shoulder surgeon and going through your options.

The title of my presentation today is ‘don’t let your knees and hips go downhill’ management of ski related injuries. So I’m going to start this presentation off with a video a little bit of a gory video so those who have any sensibilities you may wish to look away now, this is a man skiing and that snap is not his ski binding releasing but his ACL tearing and you’ll see it in slow motion now. He’s a good skier skiing in deep snow but you see he’s leaning back as he goes into the turn and that’s when his knee is in a vulnerable position, his right knee. You can hear the maniacal laugh of his friends so if you have friends like those who need enemies, but I’m sure he did get them off the mountain to a good orthopaedic surgeon.

I was privileged enough to do one of my fellowships in Vale Colorado and while there I worked with this gentleman called Dick Steadman and he used to look out for the US ski team and he had this phrase that if you were design a device to rupture an ACL you couldn’t get much better than a ski and I’ll tell you the reasons for that as we go ahead.

Well working in a ski resort is like a conveyor belt of injuries because it’s a high enough risk sport and a lot of them occur around the knee. It’s become hugely popular within society going away on an annual ski trip and oftentimes there’s alcohol included in these trips so it does make it equally hazardous.

It’s a great fun sport but risky and if you look at this little cartoon here we see that knee injuries are way more common related to skiing but shoulder injuries are more common with snowboarding so I’m sure Ms Delaney is going to speak to you about shoulder injuries and she’ll be able to show you example of those.

Why is it so risky? Well it relates to the equipment so if you’re careering down a hill on these two planks of wood with the poles in your hand there is a large element of risk associated with it. In the past they used to have boots that went up to the mid shin and were fixed to the ski, they were lashed onto the ski with leather.  Nowadays the equipment is a bit different, so initially the injuries used to occur around the tibia where you’d have fractures or ankle fractures but now they typically occur more around the knee. The reason for this is that the boots that we use are incorporate your ankle and go right up to the top of your shin so where rotation can occur is at the ski itself but when the boot doesn’t release from the binding or the ski the rotation typically occurs around the knee hence making it quite vulnerable.

The bindings are very important and these are set by the person who’s putting your skis together when you either buy them or more commonly when you rent them and the reason they ask you your level of expertise is so they can determine how easily or how more difficultly your ski boot comes out of the binding so that’s referred to as the din. So if you’re anyway suspicious or conscious of your knees ask the person to set your din at a low rating so your ski boost comes out a little bit easier.

Then it’s the ski itself so the ski’s have changed a lot since they were they were initially created and now they’re very easy, they’re actually conformed to how beginner skis as well so it makes it a lot easier to actually ski compared to what I would have started out on in the 1980s. It also has a relevance in terms of the terrain and condition, so we saw in the video at the start it was very deep snow and that makes people lean backwards so you’re more likely to lose control when you’re turning but also so in conditions like this where you very little snow and there’s exposed rock and it’s very common for the injuries to happen towards the end of the day when the snow is a bit slushy on the less difficult slopes where people are kind of relaxed but there’s lots of traffic so a lot of the injuries occur at the end of the day on blue slopes or green slopes which are regarded as being easy.

How do injuries occur? So we saw a fast video of how they occur at the start but essentially, it’s when people lose their balance and this example of images here shows when the skier is leaning backwards when their upper body is rotated into the mountain and the one of the knees get hyper flexed and then the ski acts as a lever so they say if you’ve a lever long enough you can move the world but a lever twisting on a fixed knee can tear an ACL pretty quickly and so this is how the injury occurs. Also occurs as result of stupidity so sorry about the volume here but you just can’t legislate for people like that so these people are going to injure themselves no matter where they are in the world or what pursuit they’re doing.

So what do we do when someone gets injured well on the mountain you really need to look for help and get off the mountain but before you get on the moutain the first thing we recognize in medicine is primum non nocere, first do no harm, so you really need to be conscious of where you’re putting yourself on the mountain so you don’t cause harm to yourself. It’s also key that you don’t chase after that person who’s an expert skier if you’re only a beginner and you need to be well aware of where you’re going to before you get yourself in harms way. Skiing is hazardous but it’s hazardous at the end of the mountain as well and you know it’s not so much that you as an individual need to look out for yourself but you have to look out for other lunatics on the mountain as well and typically this person was trying to get a drink pretty quickly but if you get in their way you’re in awful trouble so you do need to look out for yourself and for others around you. It tends to return to your comfort zone particularly when you’re going skiing I would advise that for the first run or two that you don’t go start doing a double black diamond or a black run if you’re inexperienced that you start off at an easy slope get your ski legs as we used to call it in our family and get confident and stay in your comfort zone when you begin, now you can go outside your comfort zone as the as the week progresses but certainly it’s advisable to start easily.

So what do we when someone has a an injury? So typically if it happens on the mountain that you’re taken off the mountain by an expert some people can ski down the mountain but the classic injury we hear about is someone who their ski binding doesn’t release they hear or feel a snap, they fall to the ground, they have difficulty skiing on and then when they get there they go down to the clinic at the bottom of the mountain or the medical centre they get an x-ray and they could put into a very overpriced brace. They’re told to either get an MRI straight away or they’re told to attend a doctor when they return home in some cases people are more avaricious and they try to encourage you to have surgery on the mountain, I would certainly advise against that because I think it’s important that you make the diagnosis first and then we decide upon what treatment is appropriate and have the appropriate resources around you.

What do we do in the clinic? First of all, we take a good history and I refer to this editorial, this is written back in the 1960s by a guy called Professor Appley and it’s still as relevant today as it was when it was written but one of the nice quotes from this editorial is “to listen is to learn we all pay lip service to a careful history but how many of us are patient enough to elicit one?” so I will say that in terms of taking a history it’s really important that you understand the mechanism of injury, whether the person has any previous knee injuries and very much you can make the diagnosis by history alone.

We then talk about clinical examination and one of the other great quotes from this editorial is “to look at one knee is absurd; man is biped and how considerate of nature to provide a normal for comparison. But nature did not provide trousers and these must be removed.” It’s really important when people are making assessments on the side of the mountain people are generally wearing ski boots they’re wearing Sala pets and it’s really difficult to do a proper examination with those paraphernalia on so when we get to the clinic we get the person to expose appropriately and you can very much see the damage and you see in this side this example here of a very swollen knee on the right side and a previous injury to the knee on the left side which is interesting. In terms of further investigation so clinical assessment we do an anatomical assessment of all the ligaments around the knee and we assess for laxity and we can typically determine how severe the injury is based on that, but we do like to get some further investigations.

A lot of the time patients will come with an x-ray which they got in the clinic the x-ray can be quite helpful and we see in this view that there’s a tiny little fragment of bone just on the outside of the knee and that’s indicative of an ACL injury and it will certainly tell you if there’s any major fracture but for the most part x-rays are more to rule out fracture than actually make a clear diagnosis.

So what else can they do? At the clinics they often can get an ultrasound that’s not that useful for us in that yes you can it’s very much the ability to understand the ultrasound is in the hands of the person doing it, but it’s not as transferable to other people who are looking at that scan. It’s not extremely useful for us, but the gold standard is for to do an MRI scan and this image here we can see the presence of bone bruising on the outside of the knee and at the back of the knee which is indicative of an ACL injury so we use MRI as a very helpful diagnostic tool. Then the next part is referral, so referral appropriately to either an orthopaedic surgeon who’s looking after these injuries but it’s important that we get the diagnosis and we’re able to then move forward with any management appropriately.

To manage these patients we do it in the cold light of day so as I alluded to anyone who’s pushing you to have intervention on a mountain unless it’s life-threatening you’re probably better off just being transferred back to your home country where things are available and we can look after you very well in that scenario. The key for us is to make early diagnosis so get the diagnosis right but often treatment is delayed and it’s delayed when the knee is ready for surgery, to go ahead with urgent surgery when the knee doesn’t move often results in poor outcomes so we try to avoid this as best as we can. We often would go down non-operative routes and I’ll give you an example in the cases below if they’re considered appropriate and sometimes we require operative intervention. One of the things I like to do is part of the assessment is to assess the person’s good side, so you look at their normal alignment and assess whether they require a brace. A lot of times people are putting braces unnecessarily, now it does give you a little bit of support when your knee is swollen but I try to remove braces as soon as possible to get the knee moving to get it ready for rehabilitation or surgery whichever is necessary. The range of motion I said is critical so you don’t operate on a on a knee that doesn’t move because it’s going to result in a knee that’s very difficult to move afterwards, so that’s really important in terms of early management. I try to get people walking as quickly as they can as well and to normalize one’s gaze is to get the muscles working appropriately and that’s very effective in terms of improving their rehabilitation afterwards.

So I’m going to give you a couple of examples of cases I’ve probably seen within the last week or so as to you know what we frequently see following ski injuries and during the ski season. The first case we see today is a novice snowboarder, so the typical letter I’ll get is thank you for seeing Ben who had a snowboarding Injury one week ago, unclear of the mechanism which is very common, he had swelling early doors, had difficulty weight bearing, he couldn’t fully extend his knee and that results from swelling, he did have some an affusion is the phrase we use for swelling in our in our parlons and he’s currently in a brace and I’ve advised him not to weight bear, so thank you for assistance in further management.

So part of the history I took further history, contact injury turning so he did strike someone and or was struck by someone, he didn’t feel or hear a pop which is important, he fell to the ground, difficulty weightbearing, had to be taken off the hill, was high speed contact, no immediate swelling but did get swollen a little bit later. Then on examination his knee was flexed so when your knee is flexed typically means there is flued within the knee, he had difficulty walking, he had an antalgic gait so like a lin, he did a swelling in his knee and he lacked an ability to fully extend his knee but there was no block there so I was able to do it passively and then he had some laxity of what we call a little bit of opening of the inside of his knee. So in in his situation these are X-rays of his knee so one of the things we see on these x-rays is that he’s a young man and his growth plates are still open so he’s a adolescent individual or pre-adolescent so he’s still a lot of growth remaining and this often bodes well for people’s recovery but it’s important that we respect that this is a growing child. There’s no obvious evidence of any fractures in these x-rays, the x-rays we do are from the front and from the side. We then get an MRI scan which is more helpful so an MRI anything that shows up as white indicates fluid and we see on the inside of his knee here that he’s sprained his medial collateral or what people will know as an MCL so he sprained his MCL. This is a view from the Inside of his knee and we see that his ACL is intact so any person who comes off the mountain with the swollen knee in my mind has an ACL injury until proven otherwise so thankfully for this young man he didn’t injure his ACL and he had an MCL injury. So in his situation that he was placed in a brace for a few weeks and was allowed full weight bear and he got his range in motion going and he’s black playing Gaelic football within three months following his injury without any long-term sequelae.

So the next case example is a little bit more serious so I’ve coined this legs akimbo, it was a 42y old female a recreational skier and she had an unsure mechanism injury as usual so she was skiing down the mountain trying to look after her children and she lost concentration and she slipped with her skis going one each way. She told me that the bindings didn’t release, she felt or she heard a tearing sensation within the middle of her knee and she had great difficulty skiing on, she tried to weight bear afterwards but needed to be taken off the mountain and she had immediate swelling in her knee and a really sense of gross instability that she couldn’t put any weight through this leg it felt like it was going to give way. So in terms of her clinical findings then she when I saw her in the clinic so this was probably five to seven days later she had great difficulty standing unassisted, she had gross swelling of her knee so the level of swelling typically indicates the level of injury to the knee because it means the level of bruising and she had large amount of laxity or very much a loose knee particularly on the inside and we do this test called the Lachman test which assesses for the stability of the ACL and she grows instability or increase laxity of her ACL and examination and most importantly she had a lot of bruising on the inside of her knee which would indicate damage to those structures.

I’m going to show you just an example of what we look at with an MRI so this example here we’ve seen the still image but I’m going to show you this MRI here where we look at the knee from the side, so at the front of the knee we have the kneecap, the top of the knee we have the femur and the bottom we have the tibia so I’ll go through it now more slowly. What we’re looking for here is the presence of fluid which shows up as white we then see that she’s an injury to her lateral meniscus, she’s got some bone bruising at the back of her knee and in the middle of her knee unfortunately her ACL is torn and as we go towards the inside of the knee you see this black structure the back is her PCL and the medial side of her knee or inside of her knee from the meniscus perspective looks normal but not from the ligament perspective. So over on the right side then we see there’s a lot of whiteness over the inside of her knee and we see here on the inside that she’s torn her medial collateral ligament so it’s completely torn through its substance so she had a serious injury to her medial collateral in addition to her ACL with a tear to her lateral meniscus.

I’m just going to show you a couple of examples and those for you were a bit squeamish this is looking inside this person’s knee with consent that we could show these images and what we see here is just the inside of the knee and we see that this is the meniscus on the inside but there’s lots of space here between the femur and the tibia so it means that this side of the joint is opening up so we see this is the ACL that is torn in the front here this orangey structure here so we need to reconstruct that and then we also see on the outside of the knee and this is the ACL again that she has a little bit of a tear at the back of her lateral meniscus as we saw on the scan. We clear everything out we repair the meniscus and then what we do is we put back in an ACL in her situation to reconstruct her torn ACL I’ll show you that in just one moment this is just assessing her knee and this is the ACL which we hold in with a screw there. She did very well following her surgery so she was placed in the brace this is her postoperative X-ray and we got her moving gradually with time with a brace for six weeks and she and go back to all her normal activities.

I’m going to go with a different tangent with the next case this is case three so this gentleman was affectionately known as Bandy legs not by me by the way, but by his family and he’s a 62y old male fanatical skier as he describes himself. I just imagine that this is what he looks like on the slopes. He had a obscure injury was quite innocuous that he injured his knee while getting out of his boots so you often experience this it’s probably the best part of skiing is taking your boots off at the end of the day well it wasn’t the case for him, because his bindings were stiff he had difficulty twisting getting into his boots after this and had a lot of pain over the inside of his knee. He did have swelling now this didn’t deter him he was able to ski after a few wines but presented with quite a bit of discomfort in this region. So anyone who comes to my clinic who’s over the age of 45 will get an x-ray because we want to out rule what is common and common things are common and in this situation his arthritis is common at this age. This is his left knee here and we see an x-ray which is performed initially so on the right side you’ll see that there’s nice space between the femur on the top and the tibia below on both sides of the joint but on the left side the inside of the joint is quite worn, so he has not just a meniscal tear but he has arthritis so he’s severe arthritis of the inside of his knee. In this situation the treatment for him is not to stick a camera in to take away some meniscus but ultimately he’s looking at a partial knee replacement so we counselled, we talked about what the surgery entailed and his symptoms really have been going on a lot longer than his ski accident and it’d be more chronic and he’d been suffering for quite a while so we went ahead and we did a uni compartmental or a partially knee replacement on this man here. So you see this on this view you can see the inside of the knee is resurfaced with a partial knee replacement. So the next question he asked is when can I go back skiing so in his situation I had no problem with him skiing, he’s functioning very well he no pain, no swelling after three months so he went back the following season so he took probably anywhere between 9 to 12 months to return but he was able to ski without any problems and it turns out he wasn’t wearing that outfit because he sent me a picture on the slopes. So it’s very possible to get back to the likes of skiing after a partial knee replacement or a total knee replacement, but it really depends on your level of general fitness at the time. This is a view of the knee from the side.

In terms of the final case then I’m just going to show another case of a gentleman who really wanted to get back skiing because he missed it, he said it was the best family holiday ever and the only time his kids wanted to spend time with him which was interesting but he’s probably right. He was getting progressive hip pain so once again struggling even getting his shoes and socks on but certainly couldn’t get his ski boots on without a lot of assistance. He was complaining of a lot of pain at night on his previous ski trip he really found a difficulty going up the inclines and he was waddling and wasn’t very happy on the ski trip. So we assessed him and we carried out some x-rays so he had formerly been quite a good rugby player and had a lot of injury to his hips throughout his rugby career but you see in this x-ray he’s got gross arthritis affecting not just his right hip but also his left hip. So he’s very keen to get back to skiing and asked he didn’t know what he could do after what was necessary for him which was a hip replacement but we did both of his hip replacements at the same time. I did them through an anterior approach the front of the hip which in my mind allows slightly easier recovery earlier but ultimately as the same result as the alternate which is the posterior approach but he was very keen to get back to skiing and his activities and I had no problem with him doing so once he recuperated fully. This is the final results for him so that brings us to the end of some case examples I hope you all stay safe on the slopes and should you have any issues in the cold light of day don’t hesitate to contact us so thank you very much.

Yeah well, I suppose it comes down to the length of the ski will determine the lever arm of the ski so that the torque that is you get from a smaller ski is not as large one thing I would say is the bindings can differ so that if you have shorter skis sometimes they’re fixed binding, so your boot doesn’t come out so depends on how long they are. So typically people who use the short blades are fairly advanced skiers and they go over kind of short like mogul runs and short kind of jump so they’re probably putting themselves in harm’s way a little bit more, but in general the shorter skis are probably a little bit safer but you’d have to be an experienced person to use them.

Yeah so if you look through the literature that they they’ve looked at a number of different sports and the use of braces to reduce the risk of ACL injury and its only in skiing that they’ve ever shown an advantage to using a brace when skiing. Now I will qualify that by saying the numbers were pretty small and in what we’ve looked at in further biomechanical studies is that these braces only really control the movement, the side to side movement so they protect the collateral ligaments, the inside ligament and the outside ligament but they’re not great at controlling rotation so I would say that they may be somewhat protective but they’re not going to be completely protective of sustaining a further ACL injury.

Yeah so as I mentioned at the end of my talk that you certainly can return to skiing I think Lindsey Vaughn is an elite level skier and she had a partial knee replacement and has returned to the ski circuit, so it’s certainly possible. I think that one of the things that we always tell people is you need to have you know good level of general fitness if you’re returning following joint replacement and really you need to give yourself some time to be able to get over that fitness and you need to have a knee that’s not angry or not going to be vulnerable when you ski so definitely possible. Time periods it varies between individuals typically I’d say at the very least I say around six months to ensure that you’re able to do a good level of activity before you get back. I didn’t answer one of the first part of the question that the question regarding when’s the most opportune time to have surgery if you have had an injury and you in in reality that it depends on the state of your knee so if a knee is very swollen and angry then it’s not appropriate to have surgery, we really would look for a knee that’s moving nicely that doesn’t have much swelling and there’s proper activation of the muscles around it that’s the most appropriate time and that can take up to six weeks on occasion sometimes longer to be ready other knees can be ready much quicker.

Yeah so there are a number of tests that we do and through the sports medicine department we subject most of our patient, most of my patients would go through postoperative testing so a lot of these revolve around assessing the strength of both the quadriceps and hamstring muscles. We do some jump tests to look that how your individuals behaving when they land on the leg, when they jump off the leg and we do change of direction tests now these are not specific to skiing but in general if someone has good balance and they’re allowed to take impact on the leg without any major issue then that determines that they’re reasonably ready we also use the kind of time period that typically you know it’s anywhere between kind of 9 to 12 months after you that you’re pretty much ready to go back but you should really have a  kind of sign off assessment from your surgeon or physiotherapist rehabilitation specialist before you go back.

Yeah so the best way as I mentioned is taking a proper history and just really ascertaining what the problem is now you know that doesn’t need to be with a surgeon or specialist your GP or health care professional can be able to look at that history. I think then the diagnosis comes down to clinical examination and the radiological investigations and you know they can be organized locally but we can also organize them for people if they need an appointment. It’s a very vulnerable time when someone gets injured abroad and as I said at the start we’re very happy to help out and very well able to take over that problem so just contact us and we’ll take all the hassle and make it easy for people when they’re in that vulnerable state.

Tendonitis can be tricky it’s a situation we typically involve or most of the time it’s non-operative management so involve you know rehabilitation and some particular stretching. So occasionally if it’s refractory or if it’s not settling with non-operative manager there are surgical procedures that can be done but we try to hold off on them until an individual has tried everything else. There can be injection therapies as well so it can be tricky enough tendonitis is not our favourite condition to manage because it’s tricky it can be hard to settle down.

I’m going to be giving a talk with regard to knee replacements but from a slightly different angle and the talk is entitled “Getting away” with a Uni? Hopefully as we go on I’ll be able to explain a lot more. Some of the slides actually have quite a bit of information in them and I only will be touching over some of the detail but it’s just so that there is more information there for people who actually want it and I’ll try and as to say keep things as simple as I possibly can.

So the first question is obviously what is a uni or a unicondylar knee or it’s often referred to as a partial knee replacement as well. The knee joint I always say to people is one big joint all right essentially the capsule of the knee goes right the way from the top to the bottom of the joint and but within the joint itself there are three separate areas which sounds very non-technical but that essentially rub off each other. The first is where the kneecap or patella rubs off the front of the femur and the second and third then are where you can see the diagram in front where the femur divides into two knuckles one on the inside, one on the outside and they essentially rub off the meniscus or cartilage on the inside and the outside respectively and a piece of the tibia. So, essentially there are three areas within that joint that make contact with each other and a knee replacement as we know it essentially replaces all three of those but we know that there are lots and lots of people who get wear within one of those areas and either of the three areas can be replaced. The most common by far is the one on the inside knuckle which is would be a medial unicondylar knee replacement and these account for about 90% of the partial knees that I would do the outside to a lesser extent. Then lastly simply for me would be the patellofemoral or the one at the front and if you just look then this is a sort of a classic X-ray and the two views are slightly different one is just with the knee a little bit more bent but you can see that on the inside knuckle there’s a bit of narrowing and with the knee bent a little bit more the two ends of the bone essentially make contact with each other and that would be what we call isolated medial compartment arthritis within that knee you can kind of see where and I would often compare this to the tread on a car tire or something like that there whereby the wheels aren’t balanced and essentially the tire is pretty bald on one side and fine on the outside. That’s unfortunately where the analogy kind of ends because what we do then is we just take off the tire and replace it with a new tire whereas if you could imagine if it was possible to rethread part of the tire that’s essentially what the idea of what a partial knee would be.

This is then just a x-ray then, it’s actually the opposite side of the knee so it’s not the same patient’s knee at all, just to complicate things the x-ray to the left is the view from the front the middle one is the view from the side and you can see essentially what you do with a partial knee is that you replace a bit of the end of the femur and a bit of the end of the tibia all right and as I say  for me the majority of these are on the inside knuckle as is shown here. The x-ray on the right is a front view of a total knee replacement for comparison and you can see there where you essentially replace the whole end of the tibia and the whole end of  the femur and what you have to do in order to do that there is you got to take out the anterior cruciate and you may or may not take out the posterior cruciate as well depending on basically the configuration of the knee itself. Every total knee replacement relies on the ligaments on the inside and the outside and whereas a partial knee replacement relies on having everything there, so you maintain your cruciate ligaments as well and this is one of the big benefits when it comes to the knee in that it tends to feel and move and behave much more like the native knee and hence they a big part of the reason that that I’m such a fan of it. It is by far the most natural feeling knee that I can give back to someone where possible.

Now the first thing I like to say about partials is to break the myth that some people often say ‘oh they’re very difficult to do’ and that’s something that’s just simply not true like everything else it’s a technique that just needs to be learned and performed well but they can be extremely repeatable and this actually is one person that had replaced both sides on at the same time and essentially the cuts of bone that have taken off were exactly the same, the implants that I put in were exactly the same on both sides, and actually the time was exactly the same on both sides as you can see from the machine and it just goes to show that you can actually execute the plan really well with a partial knee and as a surgeon it’s great to have something that is extremely repeatable that you can do pretty much the exact same thing time and time again and that’s one of the best ways where we give best outcomes for our patients.

Again there’s a lot of detail in this slide I don’t expect you to know it but it just to explain a little bit in that partial knee replacements a number of years ago were sort of very much limited in that there was like under 5% of knee Replacements that were performed were partial knees and the these criteria that that were described a number of years ago placed very sort of strict conditions on what you could and couldn’t do a partial knee on and since that the Oxford Group which would be a major users of partial needs have come, they’ve revised all these criteria and essentially up to about 50% of knees in all commerce now are potentially suitable for a partial knee rather than the old sort of from the old criteria it was about 10% that would be suitable. Now in saying that well it’s up to half of knees are potentially suitable for partial knees, the uptake of them remains relatively low and I think that’s for a number of reasons I think there’s a lot of fear, there’s a lot of sort of ignorance out there about how they can perform and again as I say I just want to go through and sort of bust some of these myths if that’s possible. So the one myth that other surgeons will often say to me is that I just don’t see them as and I don’t see patients that are suitable for partial these and this is essentially just not true in that it’s like everything you see what you want to see and if you’re a fan of using a particular operation you’ll see lots of people with it, if you’re not you simply won’t but there are lots and lots of patients out there who are suitable for partial knees.

Now then if we move on and look at some of the indications, so the classic indication essentially for a partial knee would be bone on bone wear in that affected compartment and that’s something that we tend to stick with although there are indications whereby people who present with a pretty nasty tear in their cartilage and have a bit of wear often the problem with them is that they’ll often get worse if you go ahead with keyhole surgery and certainly there are lots and lots of patients out there who we know that have unfortunately actually almost fallen off a cliff in terms of their symptoms get worse after keyhole surgery again there are very sort of definite indications for arthroscopy or keyhole surgery but we have to sort of remember that sort of middle-aged patients with these what we call degenerative tears in the cartilage, often it’s very much more sensible to take things a lot slower and we’ll often just try an injection or a couple of injections to try and let things settle down. One of the big problems with what we do I suppose is that everything doesn’t always obey the rules and quite often we’ll see patients with nasty tears in the cartilage quite a bit of where and the knee can completely settle down and they can remain symptom free for potentially years and years. Others with even simpler tears just don’t sometimes get better and settle down and as I say these are the ones who potentially I would consider going in a little bit earlier with a with a partial knee but obviously this would be after sort of several consultations and potentially a trial of a couple of injections before jumping in with something even like a partial knee.

Busting a couple more of the sort of the myths with regards to the maximum weight with regards to partial knee and the short answer is there isn’t one, now there’s potentially maximum issues with regards to going ahead with an anaesthetic or going ahead with a spinal but in terms of the pure load on the knee for a partial knee itself there isn’t actually one and this initial criteria was a weight of 82 kilos and this is complete nonsense this just doesn’t exist now and indeed it can be a really successful operation and patients essentially of all sizes. There’s the postoperative there, were both knees at a separate sitting actually.

Then if we go we then look at sort of, this believe it or not this picture on the right is a postoperative picture and this is actually it’s six weeks following a partial knee replacement and you can see that the bend is pretty much a complete knee band and this is something that you would very rarely see with a total knee replacement. Certainly, it would be extremely usual at 6 weeks and anecdotally we used to always sort of settle for sort of 90 degrees after a few weeks but now we look to sort of 105/110 degrees bend in someone after with a total knee replacement at six weeks but certainly not the like of this bend which is pretty much 150 degrees. The questions then that you need to sort of ask yourself in terms of a getting a knee and is that as you can see there would you prefer a knee that feels better functions better but may not last you as long, we’ll talk about the outcomes in years to come down the line.  Would you prefer a knee that has a quicker recovery or one that potentially lasts a bit longer, would you prefer a knee with less risks but that has a higher failure rate and I often say that is a total new replacement a procedure for a patient or the surgeon and sometimes the answer I think honestly is that it’s more of a procedure for the surgeon and that what I mean by that is that with a partial knee you have to be prepared to sort of deal with other issues down the line in years to come and these shouldn’t necessarily be looked at as failures at all but that the bottom line as I say is, would you prefer a knee that feels better, moves better and allows you back to more activities.

Now and this is the problem in that what we do with regards to a consultation it’s unfortunately an awful lot to try and sort of get your head around when it comes to sort of having you know your history taken, your examination completed, looking at any Imaging and then having a discussion on what or where we go from there and it can take a bit of time and it is kind of hard to get your head around for all of us never mind someone who’s just hearing about it for the first time. The problem with that I see is for informed consent is that well we can’t assume what we think patients want to know and some patients love a lot of detail with regards to what they’re going to get done other people just want it fixed, but we cannot assume that we know what is best for the patient and those days are essentially gone whereby it is now a question of going well which would you potentially prefer. If we sort of look at again there are lots of numbers on this graph but basically these figures are odds ratios for different risks and problems comparing a partial knee with a full knee and essentially a partial knee if you look at all the risks on the right, a partial knee replacement comes with a lot less risk. So, you can see most of those figures or half that there are 5 or less that sort of number, in fact death at 30 days which is thankfully extremely unlikely is less than a quarter that of a full knee and all the risks I sort summarize them by saying on average the risks are a half to a third that of a full knee. Now the downside then is that you’re potentially 1.4 times more likely to have a further operation within the next number of years, so you have to be able to sort of decide whether you want less risk or do you want a knee that’s going to last longer and longer. The other thing then the last factor to bring into that there is well how does the knee feel and perform and this OKS is the Oxford knee score and essentially the higher score the better patients do and you can see that the risks of having a much better score or more satisfied knee is significantly higher with a partial knee than with a full knee. What we know from lots and lots of literature is that on average following a full knee replacement about 90% of people are happy, which leaves about 10% of people who aren’t happy in some shape or form and that’s unfortunately quite a significant number. The big issue with that obviously is that well once a knee is replaced there is in general no going back there are potentially other things that can be done but you certainly can’t go back and swap it back for the knee that you had prior to surgery that’s for sure.

Then if we look at a score called a forgotten knee score and you can see here that so basically the higher the score the better and the forgotten the score is as it does as it says on the tin, it’s a questionnaire that assesses how people feel their knee is forgotten for various activities so It’ll ask you things like you know getting in over a car, going downstairs or with general day-to-day activities, how much awareness you have of that knee so obviously a higher score the better and you can see there the partial scores for the scores for a partial knee replacement are significantly better than that of a full or total knee replacement. The next myth I would like to bust, is that someone saying well I don’t have all my total knees do well and unfortunately this is just not the case a total knee is unfortunately is not an operation for everyone and it comes with potential problems.

So the other alternative procedure when it comes to fixing isolated arthritis within the knee is a procedure called high tibial osteotomy and essentially if you look at the diagram on the right side it involves cutting the tibia bone opening it up on one side and a wedge shape and then fixing that with some plates and screws and the idea is that you offload the warn side and basically take the load away from the worn side and increase it on the non-worn side and younger patients, indeed patients of multiple ages of this is procedure that can work well. This is often essentially it’s an operation that preserves your joint which it technically does but one thing that it doesn’t necessarily do is result in a more normal feeling joint than that of a partial  knee replacement and that’s been demonstrated in several studies.

Again if you just if you look at potentially the risks of partial knee replacements compared to the osteotomy group as well again there’s plenty of evidence to say that the risks are actually lower in the partial knee group not higher as one would sort of  potentially think and there’s more information there for patients who wish and again the myth just there is the joint preservation has potentially less complications than something which seems more invasive as an a partial knee.

Again then if we look at how partial knees behave in terms of return to Sport and this is something that is becoming more and more important for us and certainly something I would hear of more day to day in that I see lots and lots of patients some in their 30s, some in their 40s with well-established arthritis, on one side of their knee and but also lots of patients in their 50s, 60s, 70s, who are very fit and active and want to remain that way. Obviously it’s a much bigger a challenge for us as surgeons to be able to get patients back toing all the activities that they want to do and  just purely with regards to osteotomy one would sort of intuitively think that you’re more likely to get back to sports when you have your old your old joint and in fact that’s not necessarily the case at all and a partial knee replacement is every bit as likely to get people back to sports. It is very important I suppose that to a certain extent I put the brakes on there a little bit in that if people are running marathons, if people are involved in really high end activities they have to know that any form of either osteotomy, replacement be that a partial or a full may not reliably get them back to the level that they wish to, it isn’t necessarily the case but it certainly can’t be guaranteed and ultimately I suppose any form of replacement or even an osteotomy is an end of the sort of the road procedure and it’s much more to get you back doing your normal day-to-day activities rather than high-end sporting activities as such.

Now if we look then at return to sports for a partial you can see there that there’s plenty of data here that that lots of people can get back to you can see the activities hiking cycling, swimming and even winter sports are quite possible to get back. Now a lot of these activities I often say to people that it’s much more of a philosophical question rather than a sort of a physical one in terms of can you get back well a lot of time you can get back to them the question is do you want to sort of that run that risk of something happening and again if someone wants to go back skiing I have certainly no problem with them with even with a the total knee or partial they potentially can but they have to realize that there is always a small chance that they could have a fall and run into difficulties but that can happen either with or without any replacement for sure any and year to year we see lots of the results of these.

Another myth that it’s often out there is that it’s harder to actually convert as either an osteotomy or a partial knee replacement down the line to a full knee replacement that’s in patients who say several years down the line, say their arthritis has progressed and an actual fact I would generally look at a partial knee replacement as something that keeps your options open. If you’ve taken pretty conservative cuts and I mean by not taking off an awful lot of bone then years down the line patients can generally get away with a standard knee replacement rather than anything complicated. Now if they have had a full knee replacement early on then potentially taking that out and converting it to a full knee or a further full knee is essentially a full revision procedure and that is considerably more difficult. Again I frequency see patients who’ve had osteotomies in the past and it’s not an easy total knee replacement down the line so in many ways a partial knee is something that keeps options for the future open and not close them.

If we look at sort of the results of a partial knee this data again there’s loads and loads of numbers there but there’re just the various different types of partial knee and essentially the physic ZUK which is the partial knee replacement I use, if you look at the 15-year results and this is the UK joint registry data which is for a partial now is out to 15 years. You can see that at 15 years there’s been about an 8% failure rate with these which is 92% survivorship at 15 years and this compares to about a failure rate of about 6% for a full knee so it really only falls very marginally behind a total knee in terms of the potential outcome and this is with obviously with getting to keep two thirds of your own joint. So as I say they people often think oh it’s not going to last and actually fact it tends to last very well and this graph on the left side is an interesting one and this is from the New Zealand registry and essentially what they looked at, they looked at Oxford knee scores which I mentioned before so the lower the score the worse patients are doing and the number on the side is the chance of getting a revision procedure and essentially what they showed, so the two bars at the bottom are the partial and full knee and essentially what they showed in New Zealand was something really quite interesting in that if you had an unhappy partial knee you were much more likely to get another operation rather than an unhappy full knee. Basically to translate that phrase is that well you’d over if you came back and your partial knee wasn’t doing well a surgeon would an average take it out and put in a full knee if you came back with an unhappy full knee you were essentially told well listen there’s not much we can do you’ve had your knee replaced and that’s it and so that really potentially even skew the data as well and that it doesn’t mean that full knee replacements out there are all happy it means that the ones that aren’t happy are all too often told that there’s nothing else that can be done for them. So that’s something that you have to sort of bear in mind when it comes to looking at the sort of survivorship on these things as well and that registry data only essentially looks at how many have been revised they don’t really there are parts of them that’ll look at the scores in terms of how patient satisfaction but the main emphasis is on survivorship of the implant themselves and so the last minute I’d like to say there is the results are simply not true they can behave really well.

So just a few take home points as I say there’s lots and lots of data to go through there your own time if you want to look at the some of the slides and but for me when it comes to a partial knee I would often look at the physiological age for the patient as opposed to their actual chronological age, in that if someone is a really good 75 year old there is absolutely no reason why they shouldn’t have a partial knee replacement and likewise someone is an excellent sort of an active 40-year-old for me they can potentially still have a partial knee replacement rather than the alternatives which we spoke about. I think it is extremely important that we maximize injection therapy before going down the route of any significant operation really. I mentioned to sort of beware of the keyhole surgery and this is something that is still done it still has a role but it is important to know that keyhole surgery and lots of these knees that have a bit of wear in them simply won’t fix them and I often say to those is with every case that we look at and see we should be there asking ourselves can we get away with a unicondylar or a partial knee replacement and as I said earlier in about 50% of cases the answer is I think we can. In terms of where we sort of fix them if you’re knee is a bit bowed we aim to slightly under correct you as in not leave you completely straight and this means that we don’t increase the load on the on the outside half of the knee then as well and thus it should be very rare that any arthritis within the knee will actually progress.

This sort of last lady is just one interesting little case to pop up and it was a 45y old who’ previously fractured her tibial plateau and if you look at the first x-ray you can see the sort of the pretty big hole and in the tibial plateau on the outside so this is on the opposite side to the vast majority and the problem there is that well and again it’s even more dramatic on the MRI scan but the problem there is that that’s quite a big hole to fill and a full or total knee replacement in someone who’s 45 years of age is anything but ideal, but with this degree of essentially the defect, your options are quite limited. So what I what I did there was to go ahead and put in a partial knee on the outside and you can see that essentially like it built the joint right up again it straightened out her leg which was pointing essentially the wrong direction beforehand and yet was quite a small procedure compared to full knee replacement and thankfully she’s done very well since. So as I say are lots and lots of different options for partial needs and all I say to people is that well that they keep an open mind in terms of looking at those options and what’s the right and best option for them but for me in approximately up to 50% of cases a partial knee is an option so I hope this hasn’t confused everyone more than giving them some more information but it’s just to give an overview of what exactly a partial knee is from my point of view and a lot the advantages of it that sometimes aren’t considered.

Yeah funny that’s an interesting way of putting it and perception on things so the reality is that day case hip and knee surgery has been done for quite a few years now right across the world. Equally with total knee replacements and partial knee replacements as much as hip replacements now the big question is if I had my knee replaced would I like to go home the same day and the answer is absolutely not, and I would say that actually to counter that argument I would say that hip replacements hasn’t really progressed at all it’s not. So the most significant progression we’ve had in hip or knee surgery has probably been the use of tranexamic acid which is to stop increased bleeding it is reduced bleeding a lot so something such a simple medication that’s been around for a hundred years has humbled us all. Back to the whole idea of the day case now you even with hips like I mean if I had my hip replaced I’d like to go home after one maybe two days that’s the sort of time where I think is the sweet spot. Where your pain is controlled, you’re confident and you’re independently mobile, now it’s quite possible to go home the same day because quite often you’re loaded up on all the local anaesthetic that’s in the area but to say and I don’t mean to knock this as the idea it is a little bit gimmicky and that you’re kind of like sent out whilst you’re still quite good and then the rest is up to yourself and obviously some very young healthy people can absolutely fly it but I mean you’ll see anyone after a joint replacement, you’ll see their confidence grow day one, day two and even day up to day three so I would basically say listen to people my advice would be listen take it, take the love when you can get it right you know right it’s a big bad world out there and often you know there’s no harm whatsoever in a bit of TLC you know for that first couple of days.

I would say well a little bit of both right in that you get it done when you’ve a lot to gain by getting it done. So we know we’ve been through that a knee of any option variety isn’t an easy option right it’s the recovery is hard and it’s often several months all right but I mean if it’s causing you day-to-day disability, day-to-day pain its holding you back from doing your activities you like to do then it’s very reasonable to go ahead and get it done. Likewise what I sometimes don’t like to see is someone really quite old just getting sort of put off with another little injection to tide them over for another few months and then potentially the best window opportunity is running out but at 74 you’re off nowhere near there at all you know so there is time and again most people by the time it comes to they’re like going yeah I’m ready, I’m ready for it you know.

So absolutely I mean Durolane is one brand of hyaluronic acid injections which we we’ll frequently use, so sort of they’re usually next in line from steroid injections as the sort of stepwise increase in injections that we have. The next sort of would be like PRP or platelet rich plasma injections as well and then up from that which you’ll hear some people mention is things like stem cells but back to the hyaluronic acid yeah I mean it’s simple to try it’s a very low risk profile and absolutely if you’ve had a break that is going to you know ultimately end up with something more significant it’s well worth a try and you simply know if it works for three or four weeks it’s going to be a waste of time. If it works for several months then it’s well worthwhile trying and a lady back today just for brought the injection stuff with her she got 18 months of complete relief with injections all right now that’s you know that’s towards the other end of the spectrum doing very well but it still happens quite routinely so it’s very simple do and worth a try.

Even believe or not January last year would still only be just beyond a year and a half you know but at sort of nine 10 months that’s not unusual at all so we have data to show that knees continue to improve for up to two years after surgery which is really quite remarkable and quite often not quite I could say the a time you’ll see the odd grumbly knee at sort of six, nine, 12 months even, that actually goes on to do pretty well so I would never say always or never in this game all right but it still isn’t necessarily run its course as of yet. Replaced knees are sometimes just not even in terms of swelling sometimes the tissue around them is just a little sort of thicker and feels a little bit stiffer and I often think that the females are more likely to sort of perceive a sort of like or describe a tighter band around the knee they just they just seem to more perceptive in that regard do I have definite evidence on that no I just see it from time to time so I would say It’s not unusual particularly at this stage and there’s still considerable hope.

Yeah so things like walking and hiking I would consider normal day-to-day use all right and implants like hips and knees are very much designed to take that load. What they’re not necessarily designed to take just as well are a lot of like twisting type of sports so I would say the walking hiking all absolutely fine on it. Now interesting that they put their age for the two as well in that if you look at say UK registry data which is sort of probably the most similar to Ireland in terms of the spectrum of things that they’re done and if you look at the survivorship say for a knee replacement 10 years 96% of overall knees are going strong at 10 years right at 15 years that might drop down to I think it’s about 91% and somewhere around 85% at 20 years. Now if you break things down into age that you actually had the first procedure and they tend to do it in under 55s, under 55s that 96% straight off the bat is down to 90% at 10 years. So the in essence in younger people the results tend to be worse, but all of this is still an odds game and you’ll see plenty of people who had their first knee in at 45 and the thing is still going strong at 30 year. So very difficult to put an answer to that there at some stage one of them will probably cause trouble right and need something doing with again.

So walking with a straight leg will probably not load the Patellofemoral joint in the same manner so assuming it’s just in on the patella it’s unlikely to be as sore for that reason just you’ve really no load going through there with a straight leg whereas as you bend it the load progressively increases. Quite often what you’ll find is if you think of it I suppose full on arthritis in any area of the knee is a bit like a tar road where the road is completely worn what people often have is like a little pothole on the road where there’s a little area that’s worn and what could be happening there is that that little pothole just manages to engage with another little pot hole at a certain angle so people will sometimes describe it say when they’re driving a car or something that just that angle let say 30° or something is enough to really lift them out of it as such in terms of not in terms of acceleration but in terms of the pain and so it could be something like that as well is potentially causing it.

So the options are well I mean depending on the scans if she had cartilage removed from one side there is a fair chance that these are knees that would be suitable for partial knees right which is the first thing that would jump to mind from a from a surgical point of view. Further keyhole surgery and those knees is not going to be the answer, injection therapy which we’ve talked about is an option in terms of trying to tide things over at 57 not something like an osteotomy I wouldn’t really consider and potentially depending on how worn they are then full knee replacements, if partials aren’t suitable that’s really the gamble but that’s the problem in that we kind of have an all or nothing approach and that the injections are sort of the least we can do and then it’s a huge step up in terms of partials and full knee replacements.

My name is Paul Magill I’m a consultant orthopaedic surgeon working in UPMC Sports Surgery Clinic in Santry.  I specialize in hip replacements and knee replacements and this evening I’ll be discussing ‘Hip Arthritis’.

Pauline was a previous patient of mine and I went on a journey with Pauline through her hip arthritis Journey. So, Pauline came to see me early in her diagnosis and we went through a certain period of managing her problem without surgery and then it came a point where she could no longer manage, so Pauline decided to go ahead and have hip replacement she was petrified but thankfully the procedure went well and she made a great recovery and for her this whole journey was so momentous that she decided to celebrate it by renting out her local Social Club inviting all of her friends for her new hip party. It just illustrates nicely that hip arthritis is a journey and I suppose that’s the theme of this talk. I’m going to bring you through the different steps of that journey and I hope by doing so I will answer the most commonly asked questions that I get in the clinic.

So, starting with what is hip arthritis and how do I know I have hip arthritis is there anything that I can do to stop it or reverse it or if I ignore it am I doing more harm. We can talk about injections and we can talk about the optimum time to get a hip replacement, we can then talk about with the different types and the different nuances of hip replacements and then finally, recovery what does recovery entail? Can I play sports and why am I not recovering at the same speed as the person down the road?

To begin with what is hip arthritis? Hip arthritis simply means that the shock absorber in your hip is worn away. This is an x-ray of a patient who has hip arthritis on one side and a healthy hip on the other side, as we are looking at the screen on our right-hand side is their healthy hip, so the hip is a ball and socket joint so that’s the ball formed by the femoral head and that’s the socket which is formed by the acetabulum which is part of the pelvic bone and you can see that there’s a gap between that ball and socket, that gap is a positive finding, that gap is filled with cartilage which is your shock absorber. In comparison as we look at the screen on our left the patient’s right hip there’s the ball there’s the socket and you can see in this case there’s no gap between the ball and the socket so this patient’s hip cartilage is completely eroded away on their right-hand side, so they have bone touching bone so that is arthritis there are lots of causes for arthritis. It could be a childhood injury, it could be a previous infection, it could be a road traffic accident, it could be a disease such as rheumatoid or psoriasis or gout, but more often than not we label it as osteoarthritis and osteoarthritis simply means we don’t really know what’s caused it and more than likely it’s a genetic predisposition. In any case when it reaches this stage when it reaches bone touching bone, there’s no surgery that I can do to reopen that space, there’s no injection that I can put in there to reopen that space and unfortunately there’s no supplement that you as the patient can take to reopen that space. When the cartilage is gone it’s gone and the bone on bone contact will remain until we do hip replacement.

How do you know if you have hip arthritis? So, the two most common symptoms are pain and stiffness but these can be very variable so if you have any concerns at all the best thing you can do is see an orthopaedic surgeon and the diagnosis of hip arthritis is usually very quick and easy with an x-ray and an examination. The most common description of pain is groin pain but it can be thigh, it can be lower back, it could be knee. The most common description of stiffness is a difficulty putting on your socks but again it can be very variable so if you have any concerns please come and see one of us.

The first port of call once you have a diagnosis of hip arthritis is to manage it as best you can without surgery. Now I know a lot of you logging on tonight are probably in the middle of that journey already and many patients come to see me already halfway along that journey where they have been managing their arthritis for many years without any intervention the key to managing arthritis is to remain active. I appreciate this is difficult how can you remain active if you have a sore hip but the key is to identify activities that you can tolerate or that your hip can tolerate and do plenty of those and to identify the activities that you cannot tolerate or your hip gets really angry after and to avoid those activities. For example, if you’re a runner it might be time to cut back on the running and take up more cycling, if you’re a farmer and you got a really busy life maybe try and cut down your work and get some help on the farm and somebody else to take up the slack a little bit, simple things like that can get a few more years out of your hip. In conjunction with that is weight loss again easier said than done I appreciate that but if you are able to manage weight loss it will reduce a significant amount of burden from your hip. Thirdly and lastly are painkillers, so painkillers are not the answer there’s certainly part of the toolbox but they’re best used intermittently and it’s best if you can stick to the more simple type of painkillers, it’s best if you can avoid if it all possible morphine-based painkillers because after a while they don’t work but painkillers are certainly a useful party of the tool box, especially if they mean you can remain active. If you need to take a painkiller to remain active to get it right for that big long walk by all means take it it’s better to take the painkiller and remain active.

Two very common questions I get at this stage are can I stop it or reverse the process? unfortunately not, there are a lot of supplements out there like glucosamine, hyaluronic acid, turmeric all of these things are good and they do no harm and some people find that they’re great so by all means you should try them but unfortunately there is no evidence if you look at the data objectively there’s no evidence that they will make any difference to your arthritis in the long term. Probably most importantly if I ignore am I doing more harm? The answer to that is categorically no, I can reassure anybody who has hip arthritis the best thing you can do is remain active, it does not benefit from rest. Activity is really important because it maintains the muscle bulk around your hip and if your muscle bulk around your hip is strong it will act in some way as an external shock absorber but also if you eventually do go towards hip replacement the stronger your muscles are going into the operation the more predictable your positive outcome will be post operatively so you are not doing more harm. Find whatever way you can to remain active.

There will come a point however where there will be a decision whether or not to operate. So, because we’re using the theme of a journey in this talk let’s bring it back to roads so I would ask you which of these three roads would you consider repairing or resurfacing? I certainly don’t think anybody would argue that the road on the right-hand side of our screen is in disrepair and needs fix to repaired but what about the road on our left it’s a little bit cracked but it’s certainly workable, I guess we could resurface that if it’s a very busy road but if it wasn’t a very busy road we could leave it alone. What about the one in the middle well it’s progressed to potholes not a very good road but it’s still workable if it wasn’t a busy road.

Well the same applies to hips I think the hip on the right you can argue there’s no hope for that hip and of course that patient would definitely benefit from hip replacement. Whereas the one on the left it’s just about bone touching bone and it’s only in one side so you may get a few more years out of this hip yet, whereas in the one in the middle it’s kind of somewhere between the two the patient has both hips affected you can see there’s bone touching bone on both hips but it’s certainly not as bad as the one on the right. The problem is though the patients are not roads clearly there’s more nuance to managing patients than there is to managing roads so I have patients who coming to me with X-ray’s like the one on the right but they don’t want a hip replacement they’re able to manage their symptoms just fine likewise I have patients who come to me with the X-ray on the left and their pain is out of control. So, the decision to operate is not simply based on x-ray, and it’s simply not made by me but it’s a decision that we come to together and it’s largely based on your symptoms. It’s important to highlight obviously that hip replacement is a big operation and of course like every big operation it carries risks. It is a great operation, it’s successful in over 90% of people but if you’re one of the unlucky one’s statistics don’t matter so of course there are risks like nerve injury, dislocation, infection and it’s important that patients know this and this is an excerpt from my clinical letters so if you do have a hip replacement under my care this will be included in the letter which I post to you in preparation for your surgery. So, it’s important when you’re making the decision that you realize this is not just something you should be taking lightly hip replacement is a major undertaking.

If we do decide on surgery unfortunately there are no other options than total hip replacement. Keyhole surgery has no role if there’s already established arthritis likewise stem cell therapy has no role if there’s already established arthritis so the only show in town is total hip replacement. Thankfully that’s a great operation so much so that in 2007 the Lancet which is one of the most prestigious medical journals, it published a paper and the title of the paper was the operation of the century total hip replacement so it is a fantastic operation it and cataract surgery are comparable in terms of results, pretty much every other operation has a much poorer result than those two.

Hip replacement was invented by John Charley, served as an orthopaedic surgeon from Manchester in England and this was in the early 60s and in a lot of ways things have changed since the 1960s but in a lot of ways things haven’t changed the basic concept and the ingredients of a hip replacement are still pretty much the same today, our materials have improved we’re much more streamlining the way we do things but a lot of things are very much the same. One of the biggest changes I suppose is in the patients that we treat in the early 60s John Charley would have treated only patients who were in dire need. This is a video of a lady he treated, the same patient the left and the right and you can see this poor lady was struggling to walk her hips were so bad that they were contracted in a fixed crossed position she struggled to get from a to b. Clearly then you can see walking very well six months later but this lady would have spent weeks possibly up to six weeks lying in bed possibly with the broomstick between her legs to keep her hips apart while they healed so it would have been a very laborious and long recovery whereas now we’re performing hip replacements on people like this. Whilst this is amazing and whilst it’s a validation of Charley’s concepts it’s also a problem because we shouldn’t ignore the fact that the primary reason to do hip replacement is take away pain.  Patient expectations nowadays need to be managed much more carefully than they used to be back in the day of Charley.

So, clear expectations for the patient are key, so both of these expectations on screen now are not correct so some patients have an expectation if I don’t have surgery I’m going to end up in a wheelchair well I would suggest that’s not correct very few people end up in a wheelchair. I can’t remember the last person I’ve met who’s ended up in a wheelchair because of hip arthritis most people are able to maintain some level of mobility no matter how bad their hip is on the other end of the spectrum it’s an incorrect expectation to think that you’re going to be a brilliant runner you’re going to be running like Usain Bolt after your hip replacement of course you’re not so both of these expectations are incorrect and it’s important that that’s clear and that sign posted prior to hip replacement.

The best thing that I can signpost for any patient going into hip replacement placement is if you have a hip replacement there is an over 90% chance possibly even as high as 95% chance that you will no longer have pain in your hip, everything else is secondary. Can I play sports after my hip replacement? Maybe, maybe not even if you can do things like skiing, playing tennis, running marathons of course we, all know people who have done this after hip replacements, the bigger question is should they be doing those things and I would argue they shouldn’t. If you’re doing these things you’re placing yourself either in a risky position where you could be doing damage to your hip or you’re going to were out the artificial hip sooner than you should be. Having a hip replacement comes with some sense of responsibility so if we did hip replacements and only Andy Murray’s in the world our results would not be as positive.

After you’ve made the decision to go for hip replacement the other factors surrounding hip replacement should be discussed with your surgeon and that’s because the answers to those questions are specific to you the patient and specific to the surgeon. So, there’s a lot of things we can discuss there’s an implant shape, there’s a type of fixation, do we use cement or not, there’s materials that we use in the hip replacement, there’s a surgical approach we can put the hip in from the front or we can put it in from the back so the front is called bikini incision, the back is called a posterior approach and there’s reasons why each surgeon chooses that approach and there’s patient factors and surgeon factors for that. There’s articulating surfaces so that’s probably the most important thing to consider so most hips these days we use a ceramic ball and a plastic liner, there’s the concept of the hip replacement is a total hip replacement or resurfacing hip replacement. Some surgeons like myself applicate for day case surgery I think there’s a lot of positives for that for the right person. Robotics are advocated by some surgeons and some surgeons advocate for doing both hips at the same time if both hips are bad enough but it’s difficult to say as globalized talk, the answers to all of these questions this is something you need to discuss with your surgeon after you’ve made a decision for surgery. These shouldn’t affect whether or not you’re going for surgery but they can be teased out with your particular surgeon.

Recovery is said to take about six weeks and part of that is true so this is a graph of data from my own patients so if you have had a hip replacement under my care, I log you onto an app and I invite you to submit your surgical scores both preoperatively and postoperatively. So, you can see surgical scores pre-operatively are poor and that the scores make a significant improvement and that improvement is most marked within the first six weeks but you can see that the improvement continues right up to six months, one year and beyond so recovery really does take one year by all means the first six weeks are the most important and that’s when you have the most contact with me and the physiotherapist in terms of information but recovery will continue for up to a year, so it really is a journey.

Lastly you shouldn’t compare yourself to others so we are all different we all recover at different speeds so don’t worry if you’re not off your crutches at six weeks, don’t worry if the old man up the street is recovering much quicker than you, paradoxically younger people often do recover slower than older people and that’s because probably they have higher muscle mass so it takes longer to heal and secondly expectations are different. So, it’s dangerous to compare yourself to others but of course if you think you have a problem contact your surgeon.

So just to reiterate hip arthritis is a journey, like any journey it has its highs and lows it has its challenges. Hip replacement is not the pinnacle, hip replacement is part of that journey and recovery can take up to a year afterwards.

Yeah good questions I’ll do with the second one first actually do cholesterol medications cause joint pains they can, they definitely can it’s not common everybody in the street is on a cholesterol medication but not everybody has joint pain but there are definitely incidences where if you’re not able to figure out the reason for the pain, if the x-rays don’t look too bad and the patient still has pain sometimes I will stop the cholesterol medications or ask the GP to stop the medications if it’s okay to do so and that in some cases can help the pain. If the x-rays show arthritis however it’s more than often the arthritis cause in the pain. The other question so injections are good in the right person at the right time. Plasma I believe is no better than steroid which is no better than hyaluronic acid which is no better than stem cells there are a lot of things you can have injected, if you look at the medical literature the evidence would suggest that they all work in the same way and that is they all have an anti-inflammatory effect. I think they all really pretty much do the same thing and again if you look at the literature they all seem to have the same level of effect. So yeah, I I’m happy that some patients get plasma injections but it has to be for the right patient at the right time they’re very rarely a cure for the problem but they can temporize things and give you a little bit longer out of your native hip prior to proceeding to surgery.

Yes, so that procedure the anterior approach has been in the news recently I’m aware of that. Anterior approach is not a new approach it’s been used for a very long-time and it really is surgeon preference, it’s really what the surgeon has been trained in so I have experience of doing the anterior approach during my training but I decided against it I personally use a posterior approach. Like everything there are positives and negatives to anything there’s no perfect solution so I felt that in my hands the posterior approach gives better results, it doesn’t result in any quicker recovery so personally I’ve done a lot of people day case procedures with the posterior approach and they recover just as correctly as somebody who does the anterior approach, both are good approaches, both have their positives, both have the negatives but it would be untrue to think that one results in a quicker recovery.

Yeah think you’re right there is a lot of people having hip and knee replacements these days. I don’t know if Ireland has a higher rate than any anywhere else. I don’t think so, I have trained abroad and certainly they’re equally busy in New Zealand and Australia where I have worked as well so I don’t think Ireland has a higher rate than anywhere else we do have a higher rate of hemochromatosis so that maybe something that we don’t fully appreciate but I don’t think so. Why does this happen why are so many people having hip replacements near I think its expectations, back in the olden days if your granny or granddad had arthritis they sat in the corner of the room beside the fire and they didn’t expect much. These days we as a society expect much more from ourselves and I think we intervene earlier and we’re more aggressive we know that hip replacements and knee replacements work, so we’re probably more aggressive in suggesting them for patients.

Yeah, I guess I can’t say for sure without seeing the imaging but what you have described there are you’re ticking a lot of boxes for why you should have a hip replacement. If you’ve no quality of life, if you can’t do the basics in life hip replacement is an excellent option for taking away pain as I said in my talk there’s an over 95% chance that hip replacement will take away your pain, so as long as your x-rays or your scans fit with your clinical picture. Certainly, from your clinical picture it sounds like you would benefit from a hip replacement even though you’re young if you’re in that much distress yeah you should speak to your surgeon about hip replacement for sure.

So similar to the anterior approach, robotic surgery is increasingly in the news and it’s a similar answer to the anterior approach it’s got positives and negatives robotic surgery can be extremely accurate you can cut one degree or 1 millimetre but that does not always translate into a better clinical outcome. Robotic probably has a role but I would encourage you to consider your surgeon more than the robot the best results we see over and over again are surgeons who do a lot of hip replacements or knee replacements it’s the volume which gets good results. If a surgeon is using a robot and only doing one or two cases I can guarantee you those results are not going to be as good as somebody who’s doing a lot and I think that’s probably the most important factor in choosing your surgeon and choosing your hospital.

Yeah 28 is very young, is it too young no I have operated on people in their 20s before. I never like doing it, no surgeon ever enjoys doing a hip replacement in somebody so young but again like the previous question if your life is so miserable, if you’re struggling to cope, then of course we can consider it as a last resort. Again, it’s hard for me to say for sure without seeing the imaging but the purpose of hip replacement is to take away pain and restore some quality of life and that’s applicable to any age, we do hip replacements in teenagers if there’s absolutely no resort left. It’s a big step but if it’s restoring some quality of life it can be considered.

Groin pain is typically hip related so by all means it doesn’t necessarily mean there’s hip arthritis, there can be lots of things in around the hip joint which giving you pain but by all means yes please get it checked out come and see us we can get you examined and scanned.

Firstly I’d encourage you not  to give up hiking I want you to keep as active as you can if you’re getting foot pain and there is some arthritis there I think one of the things you can do is look for biomechanical assessment and look at the way your foot moves, and look at certain strength markers in and around your ankle and foot and even higher up in your calves and your knees because often if there is excessive loading on your foot it’s because other areas are weak likely your calves, likely you’re higher up in your quadriceps and even in your hip and your pelvis so I wouldn’t give up yet on the hiking and I’d look at maybe getting a biomechanical assessment and see what way you move and certainly we can do that in the in the Sports Surgery Clinic we’ve got guys there that are very good at assessing that. The injections are good and they give you some time and space so you can build up your strength without causing too much pain but there might just be something to do with the way you’re loading through those joints in your foot because there are plenty of them.

So, this really common condition that we in the Sports Surgery Clinic and it can be quite debilitating so it’s pain at the source of your heel and it’s to do a lot with again too much loading through your foot and your ankle. So your Plantar fascia is like a tight band and if that has too much force going through that then that can flare up and cause pain. Typically again we look at someone and see what level of pain they’re in, if they’re in really bad pain we might offload them in a short walker boot and to try and offload the force going through the Planter fascia and then we can consider other adjuncts like shockwave therapy which actually causes a little bit of inflammation at the source of that heel to cause then your own body then to act in an anti-inflammatory way. Then others other things we can do, we can inject the Plantar fascia, again these are in kind of extreme cases. In most people it settles down on its own but you need some guidance in terms of building up the strength especially in your Achilles and in your calf and it’s about how you can do that and it takes time, it takes about three to four months to kind of recover from that.

Once you roll or sprain your ankle once you’re risk of doing it again in the in the next 12 months is significantly higher, about two-thirds of people will do it again so it’s about giving your ankle some stability, so that’s the purpose of ligaments they hold your bones together in around your ankle. If one of those ligaments’ sprains it does scar up a little bit but it never fully recovers to the way it was, so what you need to do then is build a strength around your muscles so depending on what side the ankle was sprained if most common people it’s the outside then you need to build the muscles on the outside. That can be done through exercises under guidance of physio and building up through strength. If it’s too painful you can come and see one of us and we can consider things like injections but most of the time people don’t need that and that they are able to build up the strength, but strength building takes time for you to feel different and stronger and stable in your ankle you’re talking about 14 to 16 weeks of work, even though you might feel good at kind of week six, week eight it’s going to take that extra bit of time to build up the strength in your ankle and that will prevent recurrence especially in hill walking where you’ve got that uneven terrain and that unlevel terrain.

It depends how bad the injury was and not trying to be difficult about that, it does honestly depend so if you’ve got I’m presuming that there’s no complete tear and there isn’t any surgery, if there’s a partial tear or inflammation of the Achilles the main thing is to try and one, calm the pain down and sometimes people again if they’re in extreme pain they need a boot for that, other people are able to start doing rotational exercises and building up the movement through their ankle but typically with kind of strength and conditioning and building the strength through your calf muscles this can take up to three months to kind of typically recover and for you to feel stronger in yourself and confident in yourself to go and  do things like hill walking. Again, the uneven terrain, the unlevel terrain underneath you will put excessive strain on that on that Achilles tendon especially going uphill.

That sounds like early days still after an arthroscopy about six weeks, the main thing is that has the swelling come down to the level of before the arthroscopy and have you got your full range of movement through your knee. Then after that once you’ve got your range of movement then it’s about building your strength, your quadricep muscles will unfortunately will quite quickly waste away if you haven’t been using them but the great thing is they will come back quite quickly as well. I think you need to after you get your range back, to build on your strength and once you feel confident walking you know day to day on the level terrain and then you can start doing inclines in a safe environment before you would go out on a mountain or a hill and then once you feel comfortable and you don’t get reactive swelling to that then you can start short hill walks and hikes. Everyone’s a little bit different but again going back to strength and conditioning to feel stronger in your knee you’re looking at three to four months to feel that difference so it may be that time, some people are a little bit sooner but on average it would be that kind of timeline.

So when you go downhill I think I mentioned in my talk there’s far more force going through your knee, about three to four times than you would if you’re on the flat so you need ultimately stronger muscles to take that load and ultimately that’s working on your quadriceps because they take the vast majority of that and your quadriceps quad is four, so you got four muscles there that come into the tendon, into the top of the knee so really to prevent that kind of flare up and that pain I think you need to build up on your quadriceps not to the point that you’re pain free on the flat but to the point that you’re pain free going downhill and I think you may have built on your quadriceps already but it’s just about building more on that and that will prevent further loading on your knee. Then there’s other areas higher up in around the hip muscles especially the outside hip muscles that are classically weak that I see day in day out and these are areas that can help the knee, help the offload of the force going through the knee.

If its what we call Doms or delayed onset muscle soreness a lot of that is due to muscle fatigue and a lot of that is due to I suppose the endurance and what you’ve asked your muscle to do and again that can be worked on through gradually building up a strength and conditioning program and often the more mountain climbing and the more hill walking you do the less time this happens. If it’s night cramp only that’s probably a different condition and that might be unrelated to actual hill walking and you might need to talk to your doctor about that things certain medications can cause that and certain and certain other conditions non-musculoskeletal can cause that, but if it’s if it’s solely after kind of excessive exercise a lot of that is to do with muscle fatigue and the build-up of lactic acid. There’s been lots of research done on what people can do and from a nutrition perspective to stop the build-up of lactic acid, but ultimately lactic acid builds up because of your aerobic and anaerobic thresholds, so if you can build up your cardiovascular fitness and your muscle strength then the chance of getting that significant soreness and restlessness becomes less and less.

So, balance is really important for anyone over the age of 60, the chief medical officer recommends that you do balance exercises at least twice a week. I think I had an infographic on one of my slides that balance exercises things like yoga, Taiichi, things like that can certainly help, but simply just at home standing on one foot and just holding yourself in that position and being safe while you do it can actually just start the activation and that gives you feedback into your brain as where the position of your foot and your leg. There are other techniques you can do some people then go on even ground if you’re if we’re talking about hill walking on even ground then you can start balancing on uneven grounds. There are things like wobble boards that you can use or even if you stand on like a pillow or any of those balls in the gym that give you that balance then that will certainly help you improve your balance and ultimately prevent falls which is the big thing as we get a bit older.

For the bike I suppose it depends on the resistance that you have when on the bike so if you just have low resistance and you’re going bike riding that probably won’t do much for your knee, that will do a lot for your cardiovascular fitness. If you’re doing you know high resistance or going uphill yeah that’ll start activating your quadriceps quite a bit, but ultimately, I think the bike is there for cardiovascular fitness and then the specific strength based exercises would be used for building up the strength in the muscles.

I suppose if you’re on blood thinners the biggest risk is falling because the chances of you bleeding are significantly higher not just falling on things like your hip or your muscles but you don’t want to fall on your head as well so going back to balance exercises is really important if you’re starting blood thinners from the AF perspective, from the I suppose cardiovascular fitness you just want to check that you’re stable and most people it takes a number of weeks, if not a couple of months, just to get that stability so what you don’t want is to be up and mountain and suddenly get a fast atrial fibrillation because you’ve been a little bit unstable so it might be worth having a chat with your cardiologist just about saying look if I’m going away on a hike and I’m going to be gone for a few hours when do you think I can start doing that from a stability perspective of my atrial fibrillation and most of them won’t mind you doing it but it’s just about the first few weeks to months just to check that you’re stable and you don’t get recurrent episodes, but the big thing with blood thinners is just making sure that you’re safe and that you’re stable and that you don’t fall while up a mountain and that you let people know that you’re on them in case you do.

Good evening it’s a great pleasure to speak with you again, I’m going to speak on the topic of arthritis of the hip and knee and the title of my presentation is ‘don’t let arthritis keep you down, a hiker’s guy to hip and knee arthritis’, so my name is Brian Devitt so I’m going to start with a picture of a patient of mine, this is a lady I did a knee replacement on and we’re hiking here in Vietnam. There’s a couple of features first of all she’s smiling, so she’s pretty happy she’s also using a walking pole and she’s got the appropriate walking equipment including walking boots and her backpack and she’s willing to take the assistance of our guide, she is walking up quite a steep terrain. We see a lot of patients of ours who are interested in hill walking and hiking and it’s a fantastic pursuit it’s one I enjoy myself also but unfortunately they are afflicted by our arthritis which affects the knee and also the hip and our goal is to get them back on the mountain and allow them to continue their pursuits hopefully without surgery but occasionally we need to intervene.

While we were in Vietnam we learned about Confucius and he has a fantastic quote which I think really sums up this this talk and the treatment of arthritis in general “it doesn’t matter how slow you go as long as you do not stop” so that’s the key factor to keep our joints moving.

We all come in different shapes and sizes some of us have straight legs, some of us have bow legs, and some of us have valgus or Knock knees and it also is the same with the hips in terms of the shape of our hip joints and some of those people are more predisposed to getting arthritis particularly people with knock knees tend to get more arthritis in the front of the knee and they can particularly have issues walking downhills.

Long before we go into the surgical we speak to patients in our clinic and we find out what exactly is their issue. Our main goal with any type of arthritis is to try to keep people going as long as they can, but when people start getting a lot of pain within their knees particularly affecting them at night and affecting their sleep that really has an impact in their quality of life, so therefore there those type of patients are more likely to present for surgical opinion if they’ve exhausted all non-operative measures. For the most part GPS and physiotherapists are well able to manage mild arthritis symptoms and I’ll talk to you about the effective treatment in due course.

I wanted to start with just a few x-ray examples of those type of patients we see, so this is an x-ray of someone with bow knees, bow legs and severe arthritis of the inside part of the knee, you’ll see this on both sides, remember this x-ray I’ll show you a bit later how we manage this case. We also get other patients who have maybe knock knees and but if you look at the joint space here on the outside between the femur and the tibia, there’s plenty of space on the outside of the joint and also plenty of space on the inside and this is symmetrical so this person doesn’t have a problem with the inside or outside of the knee, but if you look at the knee from the side you see that they have lots of problems in the front of the knee, where the space between the kneecap and the front of the knee is quite diminished so this person is pain on the front of the knee or anterior knee pain as we call it. We do this other view where you see quite clearly that there is very little space between the kneecap and the front of the femur, so this person would have awful issues going down hills or going downstairs.

We then look at some people and they have asymmetrical arthritis, so this individual he has a loss of joint space on the inside of his left knee with his right knee is fine and the outside of the left knee is also fine so how do you manage these cases and we’ll see an example later on.  We look at the front of his knee and there’s plenty of space between the kneecap and the femur.

We also look at people with hip arthritis and I deal with many of these patients and we see quite clearly on the right hip that the hip is superiorly migrated so it’s moved up compared to the left hip which is a ball and socket joint but you see the ball here is has lost its position and you see the there’s lots of little cysts, these grey areas within the fermal head which is as a result of severe arthritis, so this individual is a keen mountain walker but couldn’t walk because his he had a marked limp on the right side and you can see why. Then we have individuals who have arthritis of both hips and really noticed that their stiffness is a big issue so really struggling to put his walking boots on or struggling to really just get up a hill because he can’t lift his or flex his knee because his hip is so stiff to get up those steep inclines.

I’m going to go back to school now for a bit of physics and you’ll see why Isaac Newton was so right and he wasn’t an orthopaedic surgeon but he knew a lot about gravity and the effect of gravity and we also know that when people have a lot of weight on or hiking that if the load going through their knees particularly going downhill tends to be a lot more. So, if we talk about the weight that goes through our knees or hips when we walk, so we’re just walking twice body weight goes through our knees on average. When we’re walking downhill that increases to four times so we often feel a little bit exhausted going uphill because of the physical demand but going downhill is what really hurts our knees, but if you’re running downhill or running on any surface it’s eight times your body weight so one of the first treatments of arthritis in individuals is to reduce your body weight and that reduces the load going through the knees and the hips so it’s a key factor to remember. Let’s just take a calculation of an example so 100-kilogram male so you imagine a little bit overweight, it’s 400 kg walking downhill that individual is putting through each knee. When we’ve talk about a 10 kg weight loss so it’s 10% body weight that’s 40 kg less per knee per step going downhill so it’s significant with the impact that this has on the treatment of people with arthritis.

Well let’s talk about specifically how do we avoid injuries while hiking. Well I think the key factor is knowing your limits so we’re not going to start off climbing Everest in terms of our pursuit, we’re going to do probably a more of a flat walk to initially and then increasing to an incline.

We also recognize we need to improve strength around the ankle and our general core and strength and our stability within our abdominal muscles, so I often recommend palates as a fantastic exercise particularly with former palates for holistic body approach to maintaining strength.

One of the simple factors using walking poles, so we’re able to dissipate the load going through our knees by helping our knees out with our arms and it adds to good balance so walking poles are fantastic addition when we when we hike to help our knees out. It’s also important to wear the appropriate footwear so we aren’t going to go walking with these type of sandals as you’ll slip or something for with a bit of ankle support is appropriate and it’s also appropriate that the rest of your clothing is correct, that if you’re if you’re walking on icy environments you need some type of crampon or something on the your feet so you can actually get some grip and just be cautious going out if it’s very slippery because you will injure yourself and sustain a fracture and also exacerbate arthritis on occasion.

It’s also really important to hydrate adequately because then you have better physical function you’ll be more equipped for the pursuits that you’re going to engage in.

So, let’s just look at the treatment that works with arthritis there’s a variety of treatments which people have been promoting over the years and this is a very famous quote from Macbeth “Eye of newt and toe of frog, wool of bat, tongue of dog, adder’s fork and blind worm’s sting, lizard’s leg and howlet’s wing, for a charm of powerful trouble, like a hell-broth boil and bubble”. I bring this up because it’s amazing how many people come up to me and have all these outlandish types of treatments and none of these work for arthritis by the way but it’s important just to stick to the tried and trusted in my mind.

If we look at just a Google search of arthritis you’ll find a whole array of different treatments and oftentimes it’s the sponsored ones are the more wacky ones with laser therapy, people suggesting stem cells, with no back up in terms of evidence. I really think it’s important that we stick to the tried and trusted.

Let’s look at the non-operative approach or conservative management some people call it, so keeping up your activity is really important, so by staying still as Confucius told us you’re really going to struggle so you don’t want to stop, keep active, you want to do exercise that is not going to affect you or going to you know give you those sleepless nights because of pain. As I mentioned and I showed you the equations that weight loss is really important probably one of the best methods of reducing the pain with arthritis, acupuncture you know hasn’t been found to be hugely effective but you know it doesn’t do any major harm but I wouldn’t spend a lot of money on it if it’s not going to do good. Massage can help out that sometimes if your muscles are bit crampy particularly around an arthritic knee that can be helpful, using braces provides a little bit of support but hasn’t been shown to reduce the progression of arthritis. Insoles likewise they make you kind of feel that you’re a little more secure in your footwear but haven’t been found to reduce arthritis. Glucosamine has not been found to be effective but it’s a cheap, easy medication to take and in my mind if people want to take it I don’t discourage them if they have the placebo effect at least, that’s good enough for me.

We look at the pharmacological treatment and we see anti-inflammatories and they’re very effective because anti-inflammatories reduce the fluid within the knee when you have fluid within your knee you’re more likely to have inhibition of the muscles particularly the quadriceps, the muscles at the front of the knee and they’re very active them were walking downhill so if you can activate those muscles, because when you fluid they don’t activate if you get rid of the fluid and can activate those muscles you tend to be much less symptomatic. Steroid injections can occasionally be helpful but they don’t alter the natural history of the condition they just give you a bit of pain relief and similarly with hyaluronic acid which is a chondroprotective jelly that can be helpful but only really in the early stages of arthritis, and it’s typically to give you enough pain relief that you can get on with your strengthening exercises. Platelet Rich Plasma once again the jury’s out in terms of its effectiveness but it has been shown to be effective in certain studies.

In terms of surgical treatment in the past people used to get an arthroscopic wash out when they had arthritis and we no longer do that because it hasn’t been found to be effective, occasionally if there’s a displaced meniscal tear with good joint space we can do an arthroscopy to remove a displaced tear but it tends to be not the gold standard treatment nowadays. We can change the shape of the leg if there’s too much load going through one side of the joint and this is typically reserved for younger patients, and this is a salvage procedure to offset or postpone a joint replacement later on but can be very successful in certain cases. Joint replacement therapy is extremely successful when needed and we try to push this down the road as long as we can but when we do it patients tend to do very well following joint replacement.

So let’s just revise or go back to some of the images we saw so this is the first case of bilateral so both knees affected with arthritis so in this individual they have arthritis particularly of the inside but also severe arthritis at the front of the knee and also arthritis towards the outside of the knee so in this case this individual got a bilateral knee replacement, so we actually did them both at the same time because she had um severe arthritis which affected both legs. Nowadays we’re more likely to do both sides, if both sides are affected obviously if only one side is affected we just do that side but it really stands to reason if you get reduce your rehabilitation, the risks aren’t significantly increased by doing both at the same time, but if one leg can’t achieve full extension or full straightening  and you’re doing a joint replacement on the other leg it really is hard to rehabilitate, so that’s why we do both together. If they’re both affected we tend to treat both at the same time.

So this the example of the patient who had the valgus knee with the arthritis under the kneecap, so in this case as we saw previously the joint space on the inside and outside of the knee was well preserved so we just did an isolated joint replacement of the kneecap joint and this was very effective for her. Her issue was walking downstairs and walking downhill and because she’d really no arthritis in the other side of the joint we did an isolated Patel thermal joint resurfacing. This is a very effective treatment for her and she did very well and got back on the hills.

This is the other example of the isolated unicompartmental knee arthritis so just the one side of the knee here on the left side the inside of the left knee and this gentleman we did a partial knee replacement of just the inside of the knee, and once again he got back to all his pursuits without any major issue. In this case his knee felt, really just back to normal because we hadn’t taken away any of the ligaments and we just resurfaced the side of the joint, so you see it quite clearly here and we’re just resurfacing that side of the joint and putting a metal resurfacing and then the plastic in between the two sides of the joint. So, one with the tibia with a tray and plastic which you can’t see in the X-ray lies in between the two joints.

In terms of your knee replacement what I always say is for knees in particular earn your knee replacement, the key factors are weight loss, modify your activity if possible if you need to use walking aids it’s really effective, maintain your strength and physical activity, and use anti-inflammatory medication. From my perspective there’s a limited role for arthroscopy and only seek to have a need replacement when you’re ready and your surgeon will speak to you about this and try to exhaust all non-operative measures before you go down the route of surgery. These are typically the indications, night pain and significant quality of life issues if it’s really affecting your ability to do things you want to do it’s really important.

The next question I ask is how active can I be with an knee replacement and nowadays we let people do whatever they want to do really in terms of getting back to their own activity you recognize that people aren’t probably going to run a marathon at that point, when they get arthritis they tend to be slightly on in years so it’s not in their interest to run marathon but a lot of people can get back on the mountain hiking, skiing, and really do whatever you want to do we’re not very particular in terms of limiting you but most people will be certainly limiting their own exercise tolerance but we definitely encourage to get back to most activities.

I want to share with you a quote I got from a patient of mine who’s a farmer and he misread the postoperative reviews instead of coming back at 6 weeks he came back at 6 months and I asked him did he have any pain and he said occasionally I get pain, I said when do you get pain and he said after sharing 50 sheep so he was a very active man with his knee replacement but he told me something very insightful and I share with a lot of my patients. He said “I quickly realized that it was a case of my knee getting used to me and not me getting used to my knee” and it was really interesting just to turn it that he wanted to get on with his pursuits and his knee just had to come along with him, he wasn’t going to sit down and mollycoddle his knee so it’s a very nice quote I think from his perspective and I think it sums up what we expect for patients after knee replacement.

Finally I just want to show you the other examples we started at the beginning of the talk and this is the example of severe hip arthritis and I do the hip through what we call an anterior approach so we divide between the muscles at the front of the hip, and this allows people to get back to the activities very quickly and this is an example of how we template the hip so we use the x-rays and we measure the appropriate size. The advantage of doing it this approach is I can x-ray during the surgery so I can try to mimic what I’ve templated and also ensure that we get the prosthesis in a good position.

This is the final product so this is a nice hip replacement so you see the hip is nicely balanced now and this individual is back to all his normal activities within 3 months of surgery. The advantage from my perspective with the anterior approach is that we don’t have as many precautions, so some people are you know restricted on how they lie in bed, we’re happy for people to get up and walk the same day of surgery and get back to their normal activities as quickly as they can.

Finally, the other example of an individual who has arthritis particularly infecting the right hip but also arthritis of the left hip where there’s extra bone forming here, so this is the man who really struggled to walk up hills because his hips were so stiff and couldn’t put on his walking boots. Well just like when you’ve arthritis of both knees we did a bilateral hip replacement in this individual so the combined procedures take less than 2 hours and he was up and walking same day of surgery, so he was back to all his normal activities as well. Certainly nowadays can manage most arthritic problems with ease but the key factor is when we choose surgery and the key decision maker in that is the patient. My objective is to get you back on the hills get you enjoying the outdoors for as long as possible.

Yeah that’s a very interesting question, I think in many respects people there’s a genetic predisposition to developing arthritis so we can’t really fight genetics but we can fight our environment and what we put into our bodies. I think you know really keeping fit as we age is so important, it’s important for our physical well-being, but also our mental well-being and I think moving as much as we can within reason is really important as we age but keeping your body weight down puts less load through your joints, so definitely keeping a really physical and active activity level is hugely important.

Yeah so a lot of the stuff which I kind of mentioned in my talk, kind of covers this point and really we want to look at the tried and trusted methods and one of the things that we’re very big on in UPMC SSC is using evidence-based practice, so you know supplements have not been shown to really reduce the rates of arthritis but they don’t do any major harm so if you feel it gets some effect and individuals can benefit differently I would have no problem recommending them. The key factors is keeping the muscles strong around the body and you know doing exercises to strengthen the quadriceps is particularly good for going downstairs, you can have minimally invasive procedures like injections can be helpful in the short term, but as I mentioned once the pain gets so severe that it affects your quality of life and particularly your sleep you’re looking at you know more invasive methods like joint replacement which are very successful.

I think you just need to be sensible regarding what to do afterwards and we recommend in the early phase that really the key focus is regaining range of motion and normalizing one’s gaze I think that’s really important so we walk before we run and I think you know doing the likes of hiking is a little bit more robust and it requires more energy and it puts the knees through a greater degree of load so we have to be prepared for that I think building up the strength in our lower legs is really important before we embark on a hike. I think then it’s also just listening to your body, I think in the early postoperative period there’s still a lot of swelling and I have a little phrase that with respect to the wound that, once the wound goes white there’s no pain at night, that once you see your wound whitening it means the inflammation has gone and you stop having discomfort in the evenings. That’s really a good phase where you get back into the more rigorous activities like hiking.

It’s hard to say I think the modern hip replacements really are fantastically manufactured and they can last for a really long time. I was at a conference recently and one of the presenters was asked that same question and they had a good answer which says that there’s a failure rate of 1% per year, that the hip replacement is in, so if you think about 20 years you have a hip replacement there’s an 80% chance that that hip is going to be functioning very well and that’s failure for all causes um so I think that kind of rule of thumb probably applies.

As I said that kind of fits into my phrase, no pain at night if the wound yeah so I think that you’d expect the pain to dissipate by probably 12 weeks so three months postop. A little bit of discomfort is no harm and I probably emphasized that she’s doing some good work as it sounds from her range of motion. So, really she can start integrating maybe some gentle inclines in her walks and definitely take some walking poles and really start getting back into it but start with small little you know hikes not too long don’t get stranded up a mountain and in pain and if there is a little bit of discomfort after hike there’s no harm at that stage taking some over the counter anti-inflammatories if it is a little bit painful. Although we’re very much of the opinion you need to use your knee and as I mentioned that quote don’t let your knee define your life you just go on with your life your knee will follow.

Yeah so, I think labral tears in in the hip an awful lot of times they’re precursor to developing arthritis I think you know if they’re very painful and you know there’s a lot of swelling in the hip, taking anti-inflammatories is very important. An injection can be helpful if there’s fluid in the hip and a lot of these label tears will settle down with time so it’s kind of avoiding any kind of deep flexion can be an issue, so if the individual is height and very steep inclines that might exacerbate the pain. So, building up the strength and just treating the inflammation is the key factor in managing label tears.

They can it relates to the posture, one has when they walk I think it’s really important if you can’t extend your knees you tend to walk with the more flex posture of your knees and if you try to walk with your knees flexed you’ll find your hips flex over and then it puts a bit more strain to your lower back. We often find people particularly with hips actually less so with knees, but do present with lower back pain and oftentimes when you resolve the contracture or stiffness within the hip, by a hip replacement the lower back improves, it doesn’t completely settle in all cases because you can have arthritis there too but it typically improves and likewise with the knees if you get the knees straight.

Yeah well I have no problem with people taking Difene provided there’s no contraindications in terms of other medications they’re taking but you know occasional Difene is not that harmful and if it’s taken as per the recommended methods, after food and if there’s any gastritis you can take some proton pump inhibitors to help the stomach but really occasional Difene is helpful if you have inflammation and in fact it’s very useful to reduce the inflammation in the joint and allow the muscles work so I’d say it can really treat a lot of problems very nicely. If you’re taking it on a daily basis that’s something that you need to look at and discuss that with your GP because it probably means that your joint is worse than you maybe think it is.