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.

I will be presenting this evening on menopause HRT and other treatment options. So a quick overview of what I will be discussing this evening, we will go through some definitions, we will go through the symptoms of menopause and perimenopause and ill be looking at HRT and HRT alternatives.

Just to start with some definitions so we are all on the same page, I thought I would start with hormone because it’s a word that gets thrown a lot, women tend to feel like we are ruled by our hormones and its important to know what it is.

A hormone is essentially a chemical messenger that’s released from one part of the body and sends a message to another part of the body and an effect is created, for example FSH which is follicle stimulating hormone is released by the brain and sends a signal to the ovary to release an egg and ovulation happens. Now perimenopause/menopause/post menopause are words we hear a lot and especially at the moment we are hearing a lot of, its helpful to know exactly what all these different terms mean, so I will start with menopause. Menopause is essentially the end of a women’s reproductive life cycle, when she stops her periods, she stops ovulating and because she is no longer ovulating, her oestrogen levels drop quite significantly and its really the drop in oestrogen which causes symptoms of menopause.

For most women menopause happens at around 51 and the average duration of symptoms depending on various factors is around 7 years. Now perimenopause is the leadup to menopause, women tend to still be having periods at this time but they start to become erratic. We see a lot of hormonal fluctuations and the changes in these hormones account for symptoms. For most women perimenopause starts at around 45.

Then post menopause is the period of time where you have then gone through your perimenopause, you have gone through your menopause and you go through a phase where you are no longer symptomatic, so you are still not having periods, you are still not having oestrogen but you are no longer symptomatic because of the low oestrogen.

Then HRT or MHT the terms are used interchangeably, so HRT is hormone replacement therapy, MHT is menopause hormone therapy and really the mainstay of hormone replacement therapy is oestrogen as I said earlier it is the loss of oestrogen in menopause which causes symptoms. So by replacing the oestrogen that helps to improve the symptoms and then depending on whether or not a woman’s has a uterus a progestogen is added alongside that.

What are some of the symptoms of perimenopause and menopause, I think many of us know or associate menopause with hot flushes and night sweats, and while those are definitely the kind of classic symptoms there are over 40 different symptoms of perimenopause and menopause.

I tend to break them up into physical, mental/emotional and genitourinary symptoms I just helps to make it a bit easier to go through everything. Physical symptoms as I mentioned earlier those include your hot flushes and night sweats then around the perimenopause we see irregular period so your cycle could become shorter or longer.

Its often a time when a women experience heavier periods as well it has to do with the fact that if you are not having a cycle where you have ovulated it means that the lining of the uterus builds up over one or more cycles and so we start to see these really heavy periods and that can be very bothersome for women.

Around this time we start to see a change in sleep as well, sleep can be disturbed by night sweats or in women who are not having night sweats they could still have poor sleep. The kind of typical pattern that patients would describe to me is that they are exhausted, they get into bed and fall asleep straight away but come 2 or 3 in the morning they are wide awake, mind is racing, tossing and turning, cant go back to sleep until half an hour before the alarm goes off and they wake up feeling exhausted, so again fatigue a really common symptom, it could be due to lack of sleep, it could simply be due to the changes or loss of oestrogen as well.

Joint aches and stiffness is a really common symptom as well and various muscular skeletal complaints, dry eyes and changes in hair skin and nails we have lots of oestrogen receptors all over the body including in places where we produce fluids, our mucosa of our eyes, our mouth, vagina, bladder so we often see things like dry eyes and dry mouth around this time, along with as I said dry skin, hair and nails. Bloating and wait gain really common as well, the weight gain is very multifactorial, it could be due to the fact that you are tired and not sleeping as you well, you are achy, your sore and not exercising as much you might be reaching for different kind of comforting foods but there are hormonal aspects as well which would make women more prone to gaining weight and kind of changing body shape at this time, we see women tend to gain weight around the middle and lose the waist, that’s quite typical of changes in oestrogen.

Breast tenderness is more of a perimenopausal symptom and that’s to do with the fluctuating hormones. Now not to be overlooked by the mental and emotional symptoms these can be quite significant for a lot of women, women who have pre-existing history of anxiety or depression are prone to this getting worse around perimenopause and menopause but we also know that women can experience new onset changes around this time as well and that can range from feeling anything from low/flat or depressed to having mood swings especially before period, a lot of irritability, rage, anxiety, feeling overwhelmed, loss of confidence and brain fog this is a really common symptom and one which is very concerning for a lot of women.

As the brain has so many oestrogen receptors when we are having all these fluctuating hormone levels or the oestrogen drops off the brain needs to work a bit harder and one of the things we typically see around this time around the kind of brain fog is issues with verbal memories, so women will struggle to remember the names of people even though they know exactly what it is they can’t get the word out or they might forget what people have told them and as I said this can be very concerning a lot of women will come to me and say could I have early Alzheimer’s or dementia and brain fog is not a precursor for that it is concerning and like I said not a risk factor for Alzheimer’s or dementia.

Then lastly the genitourinary symptoms as I mentioned earlier because we have so many oestrogen receptors along mucosa including the vagina, vaginal dryness is a very common symptom and this can lead to pain during intercourse as well we see a lot of bladder issues so urgency, frequency, incontinence and leaking and recurrent UTI’s as well and low libido.

The genitourinary symptoms are often symptoms women don’t want to talk about but it is important as they can be very bothersome and uncomfortable and so you know if you are having those issues they need to be addressed alongside the physical and emotional issues.

This lead onto if you are having symptoms how do we treat them and this is where HRT starts to come in and we start to have a conversation about it, as I mentioned earlier is the end of a women’s reproductive life cycle, it’s a very natural phase of a women’s life, its not a disease to be treated but because these symptoms for many women are really distressing and significantly impact all areas of her life she is looking for some sort of treatment and we know that HRT is the most effective way to treat these symptoms.

HRT has come quite a long way, it has been very good, very bad, and now somewhere in between, looking at the heyday of HRT, HRT was actually first released to market in the 1940s and that was Premarin which is the conjugated equine oestrogen, it was oestrogen which came from pregnant maze urine, that’s where the name Premarin comes from.

It was really in the 1960s where it really picked up steam, there was a book published by a man and supported by big pharma and there was a lot of messages around the benefits of HRT in keeping women kind of young, sexy and healthy it make women more pleasant and husbands were very grateful for this and there was very much the narrative that menopause was a hormone deficiency disease and should be treated with HRT and so between the 1960s and 2000s there was a massive uptake in prescriptions of HRT many women were on it and it was only around the early 2000s when a study which had been going on for a few years, the results of which were published called The Women’s Health Initiative.

The results of that study were quite alarming in that they noticed a significant increase in breast cancer, clot, heart disease, stroke things like that. There are a lot of issues with that study we know now that the patient population that the study was done on was probably not reflective of women who are actually in menopause, the type of menopause they used, and the doses were quite different, and the way that the data was interpreted and released to the public were incorrect, so there was a lot of issues with that study but with that messaging we started saying don’t take HRT, a lot of doctors stopped prescribing it, a lot of women stopped taking it and so having seen this big rise of the use of HRT in 1960s up until the early 2000s we then saw a big drop off.

If women were prescribed that they were told you can only take it for a short time, you have to stop it at 60, there was a lot of fear around HRT. Now going into 2020 and above there is a lot more conversation around menopause and HRT a lot more women are understanding if they have symptoms they should be offered something to treat those symptoms.

We have you know more data and information about HRT and know that it’s a lot safer than it was published in the early 2000s, we have different types of HRT and we have different doses, a lot more patient prescribing guidelines, so we feel very comfortable prescribing HRT now but myths still exist, women still worry that you can only take HRT if you have severe symptoms, if you have a family history of breast cancer you cant take it, HRT might cause dementia might prevent dementia, there is still a lot of conversation and a lot of uncertainties for women around HRT, and I think the role of your healthcare provider should be to reassure you around HRT and to prescribe it if you are having symptoms so that you can feel better.

As I mentioned earlier we have a lot more safety data, more treatment options, better guidelines, better access to information, I think this is really important, women now feel a lot more empowered to you know go to their doctor armed with information and symptoms and discuss HRT and menopause and so we have more patient advocacy and autonomy as well.

If you google what is HRT? It can be a bit of a mind field because there are all different types and subcategories of HRT. As I mentioned earlier HRT is hormone replacement therapy, giving you exogenous hormones, so external hormones to replace internal hormones and treat symptoms. HRT can be broken down into various different categories as I have outlined here, so the first category which ill go through is synthetic versus bioidentical.

So bioidentical is a term you might have heard of, its kind of a big term in HRT at the moment a bioidentical hormone essentially means a hormone which looks almost identical to our own natural hormones and in theory its then better tolerated from a scientific perspective and possibly lower risk.

A synthetic hormone is one which is made in a laboratory it has a similar structure but not an identical structure. Synthetic doesn’t mean bad you know the oral contraceptive many of them are synthetic hormones and women have relied on oral contraceptive for many years and its you know been a great medication for a lot of women, but we do see with synthetic versus bioidenticals, bioidenticals are often better tolerated but it certainly doesn’t mean they are better, it very much depends on the woman and what her aims of treatment are. In terms of bioidentical there is a bit of a overlap in that there are also something called compounded bioidentical HRT so this means HRT which is made in private pharmaceutical kind of laboratories the doses are made up according to the patients blood results, it is not something which is endorsed by the menopause society’s they would very much recommend going with pharmaceutical grade bioidentical hormones rather than the compounded hormones.

Now oral versus transdermal, again something that has come to market fairly recently are these transdermal hormones, that means hormones oestrogen specifically which it gets absorbed through the skin as opposed to oral which is taken by the mouth. The big difference between that is oral oestrogen is metabolized through the liver whereas transdermal is not and when oestrogen is metabolized through the liver it kicks off some clotting factors in the liver as well and that can potentially increase the risk of a clot, again it doesn’t mean that oral HRT is bad, it doesn’t mean if you take it you will get a clot, it just means for patients who are at a higher risk of a clot for example if they were a smoker or if they had a family history of clots we might choose transdermal as a safer alternative.

Then oestrogen versus oestrogen plus progesterone or progestogen this depends on whether or not a woman has a uterus, so oestrogen is the hormone we need to use to treat the symptoms but oestrogen given by itself cause the lining of the uterus to grow and if this happens continuously of a period of time it increases the risk of endometrial cancer.

If we combine oestrogen plus progesterone in a woman with a uterus stops that from happening. Then lastly systemic vs local HRT, so systemic HRT is HRT given through the skin or orally, it has an effect over the whole body, local oestrogen is given for vaginal and bladder symptoms only so that would be a cream which is inserted vaginally, its very effective at treating the genitor urinary symptoms nut it will have no impact on the other physical or emotional symptoms. Local oestrogen is extremely low dose, its extremely safe and almost all women who are in menopause and have gentry urinary symptoms can take it.

Its all well and good knowing what HRT is but also important to know who could take it. HRT is indicated for the treatment of symptomatic women in perimenopause and menopause, so if you are having symptoms that are bothering you, a lot of people say to me well how many symptoms should I be having? How bad should the symptoms be? Really it depends on you, every woman is different, every woman will experience menopause differently, you might have one or two issues and that’s a big issue for you, you might have ten and they are not a big issue for you, but if you are having symptoms which are impacting you in any way those symptoms could be treated with HRT.

We also know HRT should be prescribed for women who go into early menopause or who have premature ovarian insufficiency, early menopause is defined as going into menopause before the age of 45 and premature ovarian insufficiency is before the age of 40. These patients are at a higher risk of developing osteoporosis and cardiovascular disease as of a result of the oestrogen deficiency and so in these women we offer HRT to replace the hormones they would have naturally had up until the age of natural menopause which is around 51. Surgical menopause is when a woman’s ovaries are removed this might be part of a hysterectomy or it might be done as a separate procedure for things like in women who are a high risk of getting ovarian cancer.

Again, if this happens in women who are below the age of menopause we want to replace the oestrogen that those ovaries would have been producing to prevent the risk of osteoporosis and then it actually can be considered as treatment for osteoporosis in symptomatic women, so women symptomatic of menopause under the age of 60.

The big kind of NO’s for HRT, so who cant get HRT, this is women who have had a personal history of breast cancer and some types of ovarian cancer, look this is a bit nuanced, we do have patients who have had breast cancer before and that you know, and they are having a lot of symptoms they come and see us and we have a discussion around it but its very much weighing up risks versus benefit and you know when we are looking at this category, the yes category we know that the benefits significantly outweigh the risks so we know that it is very safe for women to take. In this category the benefits are likely outweighed by significant risk for a woman with history of breast cancer there is a much higher risk of recurrence of breast cancer if she goes on HRT.

The maybe category is where we need to decide what is the benefit, what is the risk and does that benefit outweigh the risk and can we use HRT. So, these categories include women who are over 60 or more than 10 years after there last menstrual period, if they have had a previous clot if they have had a previous stroke or heart attack and if there is a significant family history of breast cancer again its not to say these women can’t get HRT, its very much a decision to be made between the patient and her doctor and looking at all the various factors.

The main benefits of HRT is symptom relief, that’s the primary reason to use it and it’s the best thing you will do to improve you symptoms, and the symptoms are really what we went through earlier so in terms of your mood symptoms, vasomotor symptoms, the genitourinary symptoms, those will improve with HRT, musculosketal and sexual functions, we know we have good evidence, if you take HRT and you are in menopause those symptoms will be improved.

As I mentioned earlier it should also be considered first line for prevention and treatment of osteoporosis that would be in our kind of younger patients who go into early menopause or have been diagnosed with osteoporosis. They talk about a critical window for HRT and this is really about when should we be using HRT to ensure that there’s benefit from a kind of cardiovascular perspective because we do have good evidence HRT reduces the risk of cardiovascular disease but it must be started within that critical window which seems to be within 10 years of the last menstrual period or before the age of 60.

On my slide earlier about the kind of changes in HRT and the views to it, there was something about dementia, there appears to be a reduction in dementia risk when we use HRT but we need more evidence and it is certainly no reason to be prescribing HRT we shouldn’t be using it you know giving it to asymptomatic women to reduce the risk of dementia because we don’t have good enough evidence to say that and then as I mentioned earlier benefits for early menopause and premature ovarian sufficiency.

Now what are the potential side effects and risks? Its these risks which have been overstated over the years and that’s what many women are afraid of. The side effects are you know the most common ones would be breast tenderness, irregular bleeding, some fluid retention, certainly not weight gain but fluid retention, headaches and GIT symptoms, these are often temporary and can often be alleviated by changing the type of HRT that we use.

Now the big kind of risks around HRT be the increased risk of breast cancer and then potentially endometrial cancer, clot and stroke, the endometrial risks comes into play if we are not using progesterone alongside oestrogen or enough progesterone alongside oestrogen but if you are on a regimen and if you have a uterus and you are on oestrogen plus progesterone that risk is very insignificant and the clot and stroke risk again depends on the type of HRT that we use, if we are using transdermal its very low.

The breast cancer risk overall is very low as well this is a graphic from the British menopause society and it shows that 23 per 1000 cases of breast cancer diagnosed in the UK an additional 4 cases occurred in women who were on HRT, so yes there is a risk but its significant and certainly not as dramatic as what was stated in the past. However, for some women this risk might be unacceptable and she may decide so doesn’t want to take HRT.

In that case for women either can’t take HRT, that are in that no category of the slide I showed earlier or they don’t want to take HRT, they might still have symptoms though that they want to treat and that are bothersome and that’s when we need to look at non-hormonal therapy.

Sometimes I say this to patients and they so oh but you know I don’t want to go on supplements, I want medication, and I want to make it clear that there are medical treatments available that are not hormonal but can still very effectively treat your symptoms. So, the first class of medication would be anti-depressant medications these are your SSRI/SNRI we are certainly not using these medications for women who are depressed in their menopause we are using it because it treats the symptoms of menopause like hot flushes and night sweats. Its very effective at treating symptoms, it can obviously help with positive mood benefit, it may help with sleep and we typically use much lower doses in menopause or menopausal symptoms compared to the doses which are used in clinical depression. Clonidine and oxybutynin are medications which help with hot flushes and night sweats, they don’t have any other benefits and they tend to have side effects that are quite unpleasant including dry mouth and headaches so a lot of patients will stop taking them as they find it quite difficult medication to take.

Gabapentin is an interesting medication, its an anti-epileptic its also used for chronic pain, it can also be used as a mood stabilizer and again has good benefit for alleviating hot flushes and night sweats, it can have a sedative effect so good for sleep and may help with mood as well. Then veoza is a brand new medication which has just been released, it’s a really exciting development because it is the first medication which has been designed specifically to treat hot flushes and night sweats, so these other medications have other indications and they also have the benefit of treating hot flushes and night sweats, whereas veoza is designed to work in the brain to stop hot flushes and night sweats from originating and it’s a great option for women who are not able to take HRT.

Under medical therapies I have put psychotherapy and CBT as well, CBT is cognitive behavioural therapy we have really good evidence for this in terms of helping with hot flushes and night sweats and help with mood and sleep as well. CBT is a specific form of psychotherapy, kind of helping with reframing thoughts about events and a lot of women find it very useful either by itself or in addition to these other medications.

Looking at the non-medical alternatives these are things that probably all women should be doing anyway to support their health during this time but for women who didn’t want to take HRT or they felt that their symptoms were mild and they wanted to manage it from a lifestyle perspective these are things that we should be looking at.

I must say a lot of women struggle to implement these changes when they are not feeling great, sleep hygiene is very important but when your sleep is being constantly disrupted because of night sweats its quite difficult to make those changes but sleep hygiene is really around things that we all know should be doing, don’t be on your phone late at night, going to be at the same time, don’t drink coffee too late in the day, just optimizing things to make sure you have a better sleep quality.

Weight management and diet, it is important to maintain a healthy BMI, during this time a women’s risk of cardiovascular disease increases when she goes into menopause and so we want to try and reduce that by managing lifestyle factors. The best kind of diet is probably a Mediterranean type diet that’s a lot of brightly coloured fruits and vegetables, lean protein, healthy wholegrain carbohydrates, good fats and a reduction in really processed and refined carbohydrates and sugars.

Then stress management is something much easier said than done, they talk about doing things like yoga, meditation, breathing exercises, all things to help reduce stress in the moment, like I said easier said than done. Supplements are a big one if you are going into any health food store and you ask for something to help with menopause there are almost hundreds of options available, a lot of them at best wont work or at worst could have some harmful side effects, so I would be cautious of the wide range of supplements that are available. I always recommend my patients to take vitamin D especially during the winter, we just don’t get enough sunshine unfortunately and omega 3’s are quite helpful as well if you are not getting kind of two portions of fatty fish a week, otherwise you don’t need to be buying hundreds of expensive supplements. Acupuncture, a lot of women will anecdotally report that it helps their symptoms, it is unlikely to do harm, so you know if this is something that makes you feel better there is no issue with using it although the actual data in terms of efficacy is quite sparse.

Cold exposure, this is you know when I moved to Ireland, I’m from South Africa, I was quite amazed at how many people were swimming in the freezing cold see and I have noticed a lot of women as well, interesting they have recently released a study in the UK which showed that women who regularly sea swam had a reduction in menopausal symptoms or perceived reduction so there is definitely something to it, I think it’s a big social thing as well which is really important as well from a lifestyle perspective but again as long as you are dressing warmly afterwards, you have got your tea and your dry robe its probably unlikely to do harm and could be a nice thing to add.

In summary menopause is not a disease it is a natural phase of life but if this phase is accompanied by bothersome symptoms they should be treated. HRT is the most effective treatment and while HRT has been thought of as very good and then very bad it is kind of somewhere in the middle now and we know that it’s a safe effective option to be used although it’s certainly shouldn’t be used solely for the prevention of disease. There are good alternatives for women who can’t or choose not to take HRT.

Cholesterol levels can definitely increase postmenopausal but statins are still the preferred way to treat them, HRT is not indicated to treat high cholesterol.

In theory you can be on HRT for the rest of your life, previously there was this cut off you could be on it for five years or up to the age of 60, and that’s changed, women can be on it for as long as they are getting benefit from the HRT and there are no side effects or major health issues that arise. If you come off HRT your not going to go into menopause again, really the principle of HRT is to treat the symptoms during menopause but once you go into post menopause and those symptoms significantly reduce at that point we could take you off HRT and those symptoms shouldn’t come back because you are now in post menopause.

Patient dependant really around symptoms, so if you are getting symptoms in your mid 40s and they are bothersome consider it, if you are only starting to get symptoms in your early 50s consider it, but its really around rather than age go by symptoms and how bothersome they are.

Your fertility declines as you through perimenopause because your egg numbers reduce, ovulation becomes sporadic, pregnancy is not impossible in perimenopause, its about a 1% chance of falling pregnant and then menopause can’t fall pregnant for they say that you should consider using contraception up until one year post your last period. So, contraception is still advised and the best options would be condoms, the progesterone only pill which can be used up until the age 55, the marina coil or vasectomy if your partner is open to that.

So that’s really important as I mentioned with in the symptoms there are a lot of genitor urinary symptoms that occur during perimenopause and menopause, and a lot of changes in the vagina, the vulva, the bladder, the pelvic floor and women might start to experience bladder issues but also bowl issues as well including things like faecal incontinence so any bladder issues that are bothersome around that time a pelvic floor therapist can be incredibly helpful and help you to know which muscles to engage and which muscles to relax and how to manage those symptoms, rather than just relying on medication.

When talking about Menopause we can talk about Perimenopause which is ages 45-55. We can find post-menopausal which is the time after menopause so really fitness and exercise in menopause we are talking about a large part of a woman’s life. If the average age of a woman is 84 then menopause will be about 1/3 of your life. If we are talking about perimenopausal age 45 that would be considered as mid-life and this is an opportunity at this stage in our life when you look at the choices you make in terms of activity and how that will help your ability to do things and move on into the future.

First of all, defining what is exercise and what is activity? They can be easily interchanged but physical activity is any activity you do in daily life and that could be gardening, housework, or playing with children, whereas exercise is a planned physical activity that keeps you fit or makes you fitter.

Exercise has always been a part of life right through to older ages. The Grandparent Hypothesis looks into how societies that flourish rely on the older members of society to be active and healthy and have the ability to help out in physical activity in order to keep the community going. We are genetically programmed to be able to keep fit and strong right into later life.

Exercise has been strongly proven through epidemiological studies to reduce the risk of getting seven of the most common cancers including breast, colon and endometrial cancer and this is in the realm of about a 20% reduction when comparing people who are physically active to people who aren’t.

There is a pretty big change in terms of a womens cardiovascular risk and that’s the risk of heart disease and that’s comparing before menopause and after. Oestrogen has quite a protective effect on the heart and so in the absence of oestrogen then for a number of reasons the risk of getting cardiovascular disease goes up by a factor of 2.6 between pre-menopause and post-menopause. On the left are the main contributors to this such as worsening insulin resistance, higher blood pressure, higher cholesterol, reduced sleep quality, and mood changes can also have an effect.

Exercise can improve every single one of the risk factors. Exercise can also help improve your mental health with strong evidence from studies that follow women through menopause such as the Swan study in the United States, following a group of women for 20 years through menopause with clear evidence showing women who were physically active reporting better mental health and better quality of life, while reducing symptoms of depression anxiety and stress.

Something quite topical at the moment is whether exercise can improve symptoms of the perimenopause transition? The classic symptom being hot flushes but there are many other symptoms associated with perimenopause which is a period that can negatively impact a woman’s health and well-being.

There have been studies done on how exercise can potentially help some of these symptoms. One of the interesting studies looks into the relationship between musculoskeletal pain and menopause. Musculoskeletal pain has been proven to be one of the most common menopausal symptoms causing pains and aches in muscles or joints causing about 1.6 times the amount of aches and pains to premenopausal which is a big increase. There has also been good evidence from these studies that people who are active and take regular exercise reported less headaches, less joint pain, and less heart palpitations. This evidence that symptoms such as difficulty sleeping, mood changes, low energy, heart palpitations, headaches or migraines, and joint/muscle aches can be positively affected by exercise. The jury is still out on whether exercise has a significant effect on hot flushes. There is a theory that as we know that exercise increases your parasympathetic tone is upregulated so this may help with hot flushes although we don’t have strong evidence for this.  There is good evidence from studies that keeping physically active will also help maintain a healthy body composition, maintain your muscle mass, and reduce the amount of central adiposity or visceral fat which is the weight you carry around your middle. This increases after menopause so maintaining good activity and exercise can help offset this and has health benefits as carrying weight around the middle has effects on cardiovascular health, and insulin resistance.

The main musculoskeletal effect that we see in menopause such as the decline of oestrogen. Oestrogen is not just a reproductive hormone it has effects on lots of body symptoms and has a really strong effect on our muscular system and on our bones, this can have a big knock-on effect on a woman’s health. Oestrogen helps to maintain muscle mass, it helps with muscle’s response to exercise and also helps with making new muscle fibres. There is an increased risk of sarcopenia in menopause but really that comes about when you combine inactivity with a lack of oestrogen. Osteoporosis then is when you get a decrease in bone density which causes an increased risk of fractures which later in life can have a devastating effect on a person’s independence. This drawing in the top right is what is meant by sarcopenia, where you have muscle in the dark red over the years if you have a lack of oestrogen and a lack of exercise have the combined effect and cause the muscle to get smaller and the fat mass to get bigger. In the absence of oestrogen and bone breakdown starts to exceed bone formation so our bones get thinner and a lack of mechanical stress can breakdown bone. This is why exercise is so important to maintain bone health.

When talking about sarcopenia and the loss of muscle it is something you definitely want to avoid and it is because muscles are so much more to our bodies than a piece that just moves us. Muscles can send messages to other parts of the body and it is an endocrine organ. Substances released from muscles are called myokines which can have effects on the brain, the gut, the kidney, the pancreas and bones. When you have muscle and maintain muscle it sends all these positive messages out to the body which decreases inflammation, decreases immunity and this is where the decrease 9in cancer risk comes from. It helps you metabolise your food better, makes you happier, makes your bones stronger so muscles really are such an important organ in your body rather than just being something that moves us

Is menopause a one-way ticket to sarcopenia and osteoporosis? The answer is no and the reason is that it is possible to maintain your muscle mass and function to keep your bones strong with the magic pill and that magic pill is exercise.

Exercise, a combination of aerobic and resistance exercise in other words getting out of breath and lifting heavy things will keep your muscle mass and muscle function. In terms of osteoporosis, menopause is not a one-way ticket to osteoporosis. If you are maintaining and currently doing impact activity or taking up impact activity now then that loading effect on the bone will maintain bone density and perhaps even improve it. The impact is basically jumping, landing and things like running and in fact it actually does not take a lot to get a good stimulus of the bone and 50 jumps a day would be enough to maintain your bone and that is something that all of us can do right up to the elderly ages with the right advice and modifying what sort of impact they do.

In terms of what exercise to do, there are plenty of science-backed recommendations on what’s the best mix to do. Interestingly, I came across this in the paper and in certain states in Germany it has been mandated that people who own dogs must walk them twice a day for at least half an hour so an hour exercise for dogs because if not then it would be considered as cruel.

There are bodies such as the World Health Organisation (WHO) who come up with recommendations that are all pretty similar and this is for adults in general not specifically women in peri-menopause or menopause because the same advice would be true for a man or any healthy adult and there is importance on the bone loading part of this for menopausal women. The advice is 3-5 days a week of moderate to vigorous aerobic exercise at 30-60 minutes each time. To make sure that some of those are bone-loading or impact-type work and then a really strong recommendation is to do two days a week of resistance training. It is also worth doing some flexibility and balance work.

So first of all you have some moderate aerobic exercise which is exercise which feels somewhat hard the best way to think about is as exercise where you can talk but you can’t sing a song so something like brisk walking where you are a little out of breath, swimming, jogging, cycling or also team sports or racket sports can all be considered moderate aerobic exercisers.

What is bone loading/ impact? Not all moderate aerobic exercises can be considered bone loading, walking doesn’t have enough impact to consider it bone loading neither does swimming or cycling. You need something in which you are jumping or hitting the ground a little harder for example tennis would be an excellent bone-loading activity It is multi-directional, your running forward and back all those things give novel stresses, so changing messages to the bones and that’s what really stimulates them to get strong. Dance is a really good form impact exercise, the picture on the left is Zumba which has been shown to be really good in terms of bone loading because of the jumping and sideways movements. Team sports are great, the picture there is Gaelic football but really any sport where you are changing directions, and the other benefit for this is that they can be really fun and social. As mentioned just simply jumping, jumping off a box hitting the ground that’s the impact. Needs to be a little thought around the safety of that for an older person or a person with osteoporosis but they can all be modified. Getting impact loading in two/three times a week so not just walking, cycling or swimming.

Strength or resistance training is basically where your making your muscles work hard and get tired, so again there is lots of different ways to do this, certainly gyms, gym classes, anything with lifting weights is good. Things like Pilates are also a form of resistance exercise, your body weight Is a from of resistance. Things that work your big muscle groups like your glutes and your quads like squats or lunges are really excellent.  Lots of different ways to achieve two days of strength work, it could be through something like a class or going to the gym or it could be in your own living room with some weights and there is some pretty good YouTube workouts if you are looking for inspiration. Obviously going to see a professional to develop a program for you would be optimal, some good online things and some good apps as well. Big benefits by doing resistance training twice a week in terms of strength function and maintaining that muscle mass, which is so important for your overall health.

The best exercise is one which you enjoy and you keep doing so if you can find something you can enjoy that’s always going to be the best.

Menopause and Tendons are really quite complex, we are kind of a bit unsure on how the decline in oestrogen effects tendons, well we know it reduces collagen formation, increases the stiffness but again if you keep your tendons strong through exercise that’s the best way of keeping them strong and avoiding injury.

Quick word on MHT (menopausal and hormonal therapy. In terms of taking HRT or MHT that’s going to replace the oestrogen that you would otherwise be losing through menopause. It’s been shown pretty clearly to help maintain muscle mass and function and it also has a positive effect on bone. This coupled with exercise is going to give the best results in terms of maintaining muscle and bone mass.

If there are any elite athletes or anyone who competes as opposed to just keeping fit, there are a few studies which show that the MHT or HRT can help with performance more so the adaptation to training, it’s not like it makes you run faster on the day you take it, its more in terms of being able to maintain muscle mass. There is also a bit of evidence around recovery from exercise sessions so probably something worth thinking about for elite athletes but that’s not necessarily promoting it to so people can keep winning races but there is some science there.

In terms of training and the effect on muscles and bones it’s pretty clear that it is a positive influence, it’s a little less clear in terms of oestrogen supplementation or oestrogen replacement on tendons. So the best advice that through good strength training that you maintain your tendons in good condition.

The final thing is some conditions which commonly occur in postmenopausal and perimenopausal women, the first being Knee osteoarthritis which is really common in the general population but it is twice as common for women as it Is for men. The advice for managing Knee Osteoarthritis is really clear from all the major medical bodies that deal with it, both the medical rheumatological surgical and this little graph here is good from the Osteoarthritis research Society International and that’s that everybody who has Knee arthritis should receive education about activity, exercise and weight management, because this is what makes the biggest impact on the osteoarthritis so maintaining a healthy weight as best a possible, keeping good strength in the muscles around the knee and keeping the knee moving. Exercise is good for Knee Osteoarthritis, in the old days people might have thought that rest was the answer but that’s been shown to actually make things deteriorate because of some of the metabolic effects, the negative metabolic effects that being inactive have, so again exercise therapy is really the mainstay of managing osteoarthritis. Some people may benefit from medications or injections and very few need surgery but in our clinic we manage the vast majority of people with exercise and it works well.

Another common and really annoying and painful issue is a pain at the side of the hip, it’s mainly the gluteus Medius and Minimus tendons which come down the side of the hip and attach onto the Bony part of the outside of the hip called the greater trochanter, that’s the bit that kind of sticks out when you lie down and so it can often be quite uncomfortable to lie on, it can be really debilitating, stopping people from running or walking even so that’s something we would see a good bit of, again the management of that there has been some really good interest into it, and specific exercise and strength along with some simple advice on some postures to avoid can be quite effective for this. That doesn’t mean it’s a quick fix it takes a while but it’s been shown that exercise and education beats injections for improving gluteal tendinopathy. Sometimes we would use injections or shock wave therapy but good strength work is the way to both prevent and treat Gluteal Tendinopathy.

A few of my patients have mentioned to me whether HRT might help their Gluteal Tendinopathy and there has only been one study on it so not a lot of evidence, but that did show a combination menopausal hormonal therapy in the form of oestrogen combined with an exercise program was better than an exercise program alone. Only one study but potentially promising.

Finally, exercise can bring its own problems in terms of picking up injuries so simple advice to try and minimise that risk. So Festina Lente is latin for make haste slowly, that’s the single best piece of advice, whatever your doing, if your starting from a low base just build up slowly, if you’re already doing a lot don’t add a lot suddenly just build up slowly and let your body adapt to it. Before you do impact work like running make sure that your muscles are strong, and make sure that you get good recovery. It takes a little longer to recover once you go past the age of 40 that goes for men and women, so a day off in between hard sessions, make sure you eat well, and get some expert advice if you are embarking on a training program.

Bursitis doesn’t burn itself out in the same way that frozen shoulder does over a long time maybe 2 years. Eventually, frozen shoulder burns out but bursitis doesn’t particularly do that in the same way so something has to change to relieve that bursitis whether that is better movement patterns in the shoulder or treating the inflammation that goes with the bursitis. The other thing to say is that with night time pain that is often an inflammatory issue and the other thing to think about there is that although it may be bursitis on the MRI it is not necessarily the bursitis causing the pain it could be something else. Although there may be fluid in the bursa on the MRI that still may not be the thing causing the pain. The rotator cuff tendons may be causing the pain or the Acromioclavicular joint (AC). You may even have pain coming from the neck and I know you said the person in question has had a steroid injection if that has not worked then maybe they should look into getting it checked again to see if it would be re-diagnosed as it may be something else. Sometimes, if it does look like bursitis a second injection would help even if it is under ultrasound as it can target a small area.

If it is gluteal tendinopathy which is pain on the outside of the hip then there is a high likelihood that it is gluteal tendinopathy. The tendons are the bit that is sore but the muscles that are attached to the tendons are on the side of the hip and they can feel it and be really tight and sore and this can work it’s way up to the buttock area and it feels as though you should stretch it but it actually does not help it. It might be detrimental by pulling the tendon across the outside of the hip. Gluteal tendinopathy is something where stretching should be avoided.