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Professor Andrew Price

Brief Outline: His undergraduate training was at Cambridge University and St. Thomas’ Hospital in London. He studied for a PhD as a postgraduate student at Oxford University and completed his Orthopaedic surgical training in Oxford, based at the Nuffield Orthopaedic Centre. He is a Fellow of Worcester College (Oxford University), where he is Director of Studies for Clinical Medicine.
Background: Andrew Price is a Consultant Orthopaedic Surgeon at the Nuffield Orthopaedic Centre NHS Trust and Professor of Musculoskeletal Science at the Nuffield Department of Orthopaedic Surgery, Oxford University.

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A doctor explains what partial knee replacement involves and shows what the implants look like.

A doctor explains what partial knee replacement involves and shows what the implants look like.

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Partial knee replacement involves taking away the damaged part of the knee and replacing that with some metal and plastic components. And the best way to demonstrate that would be to look at a model. 

So this is a model of an Oxford partial knee replacement. And we can see that the metal and plastic components are replacing this inside part of the knee where the damage is. But unlike a total knee replacement, we’re going to preserve the ligaments and this normal part of the knee on the outside, which is functioning normally and doesn’t really need to be replaced. And so the essence of partial knee replacement is replacing the parts of the knee that are damaged and preserving the parts of the knee which are functioning well.

The key parts of the procedure are the implantation of this metal component on the femur and a metal component or plate, base plate, on the tibia. And in between there’s a small plastic component called the bearing. And this is, in essence, what a partial knee replacement is.
 

A doctor talks about the advantages of partial knee replacement.

A doctor talks about the advantages of partial knee replacement.

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The first thing is they’re a highly effective operation for getting rid of the pain and stiffness that you have in your knee. And for most people it’s a really big change in their quality of life. So what we call the treatment effect is a large treatment effect. And many patients are very happy with that. 

The second advantage of partial knee replacement is, because a lot of the normal structures in your knee are preserved, that your recovery is faster. So you’re out of hospital sooner and you get going faster, and your recovery back to the level of function you want is faster. 

It’s probably also true to say that, in terms of trying to get the best function you can after joint replacement, partial knee replacement can allow you to do that. Again because of preservation of the normal structures in the knee. 

The next part of partial knee replacement which I think is attractive in terms of its advantages is a reduction in the type of complications that can occur following surgery. So we see a reduction in the amount of infection, blood clot, heart, lung and stroke problems following partial knee replacement compared to total knee replacement. And that’s an advantage for patients.
 

A doctor talks about the risks of partial knee replacement surgery.

A doctor talks about the risks of partial knee replacement surgery.

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The risks of partial knee replacement are the risks that are associated with any surgery, but also the risks which are specific to this type of operation. Any surgery has a risk of infection, blood clot and medical complications such as heart problems, lung problems and stroke. But these problems occur in less than 1 per cent of all patients having this type of operation. So they’re rare occurrences. 

There are some specific complications which are specific to partial knee replacement. And that is that the revision or failure rate can be a little bit higher than total knee replacement. 

But on the whole most patients will find that their joint replacement lasts in the long term. And 90 per cent of patients are still functioning very well at 10 years following surgery. And 80 per cent are functioning well at 20 years following surgery. 

The final, and perhaps the most important risk of partial knee replacement, and this is the same for any type of knee replacement, is that the operation doesn’t get rid of your pain in the way you would like it to. So around 5 per cent of patients will feel that they haven’t really achieved the level of recovery they would like to. They still have some residual pain and stiffness in the knee, and this may make them dissatisfied with the outcome of surgery.
 

A doctor talks about recovering from partial knee replacement surgery.

A doctor talks about recovering from partial knee replacement surgery.

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When we talk about the recovery from surgery, I think it’s a really good idea to break that up into sort of phases. So there’s the initial recovery in hospital, and patients now stay for 2, 3 days in hospital and in some cases will go home even the day after surgery with partial knee replacement. 

And in that period of time your knee is still a little sore and swollen but you’re getting up, walking, perhaps with the aid of crutches. In many cases we’ll try and get you up on the day of surgery. And you’ll find that your mobility is not drastically affected at that point. You’re able to get around. But you are sore. 

That gradually improves over the next 3 to 4 weeks. And we’ll see you again at the 6 week point in hospital, where we’ll check how you’re progressing. And we often find at that point that your mobility is much greater. You’ll often walk into the clinic very confidently. 

And people may not even know you’ve had a joint replacement at that point. Your knee still is a little sore and swollen and can be puffy. But overall most people are already starting to feel the advantages of the procedure at that point. 

If there are problems, then at the 6 week point we’ll review the situation and we’ll take an appropriate course of action to try and sort that out and improve the situation. If problems emerge earlier than that, or after the 6 week point of time, then through your General Practitioner you can always have access to the services in the hospital. And we’d be really keen to see you to try and sort that out. 

In the longer term, it’s probably fair to say that the real benefit of joint replacement is enjoyed at approximately 6 months perhaps to a year following surgery. And that’s when a patient can expect their knee replacement to be functioning at its best. And that’s when they’ll enjoy the real return to function which we’re aiming for.
 

A doctor explains that the pros and cons of partial and total knee replacement surgery are discussed with patients before the operation.

A doctor explains that the pros and cons of partial and total knee replacement surgery are discussed with patients before the operation.

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Your surgeon will have a good idea of whether or not it’s possible to attempt a partial knee replacement at the time of going into theatre. And he will have discussed this with you in terms of a plan for the surgical procedure. In approximately 10 per cent of cases where you’ve planned to do partial knee replacement, there may be the case that you need to change at the time of surgery to total knee replacement. And that is a consideration. So when you go into surgery your surgeon will have talked to you about partial knee replacement and total knee replacement as a potential outcome.

In hospitals who offer partial knee replacement, a discussion about that type of surgery will occur when there are parts of the knee which are damaged but parts of the knee which are still functioning normally. So in an effort to preserve those parts of the knee which are not damaged, partial knee replacement becomes an option. And that includes not only retaining the normal ligaments in the knee but also some of the normal cartilage surfaces in the knee. And in those circumstances, partial knee replacement offers some advantage over total knee replacement. There are some disadvantages, and you need to understand both. 

Partial knee replacement on the whole will allow you to recover faster. We think it allows you better function in terms of will you be able to achieve the type of activities you want to after surgery. And that some of the risks involved in joint replacement are less when compared to total knee replacement. In particular, the important risks of infection, blood clot and medical complications such as heart problems and stroke.

This must be weighed against some of the potential disadvantages of partial knee replacement. And in the population as a whole, if you look in the UK, it’s true to say that partial knee replacements are revised or fail at a slightly higher rate than total knee replacements. However, if your surgery is performed in a centre who does a lot of partial knee replacements, and that’s certainly the case in our centre here in Oxford, then the risks of the two techniques in terms of how long an implant lasts are evened out. So I think a patient needs to have a good understanding of the pros and cons of both approaches.
 

A doctor explains what happens at the pre-operative assessment.

A doctor explains what happens at the pre-operative assessment.

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The pre-op assessment is a really important part of the process. It’s an opportunity where we get to impart a lot of information to patients about what will happen in their journey through hospital and after that in follow-up. 

Perhaps the easiest way to think of it is that we’re going to do an assessment of the patient to make sure that we’re making that process as safe for them as possible. There are some medical checks, blood tests, heart tracing and general assessment of ability of people to be able to mobilise and to be safe at home when we let them out after hospital. 

I think central to that process is the transfer of a lot of information to patients about what they can expect. And we’d also expect to answer a lot of your questions about the precise detail that may be very specific to you about having a joint replacement.
 

A doctor talks about general anaesthetic and a spinal nerve block.

A doctor talks about general anaesthetic and a spinal nerve block.

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In having a partial knee replacement, there are really two options in terms of the anaesthetic techniques that are used. And they’re both really safe. 

General anaesthetic involves a patient going to sleep throughout the procedure, waking up afterwards. And probably that’s the commonest route that people go down, certainly in our hospital. 

The second route is a spinal anaesthetic, where your legs are put to sleep so you don’t feel any pain in your legs. But the patient sleeps during the operation rather than being completely unconscious in a general anaesthetic. 

And there are advantages to both techniques. And both techniques can be used in many patients, although in some patients spinal is more applicable or general anaesthetic is more applicable. And there’s a conversation between a patient and the anaesthetist. It’s a shared decision in terms of which route you go down. But the key point is both are really safe techniques.
 

A doctor explains why injections are needed and how to do them.

A doctor explains why injections are needed and how to do them.

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In the immediate post-operative period, we will use some techniques to make sure that we protect you from having a blood clot. And a contemporary way of doing that is to use some injections into your tummy, which we can teach the patient how to do. 

And following a partial knee replacement these injections will go on for 2 weeks on average and involves a small injection of a few mils of fluid, drug, into your tummy. And this is a routinely performed procedure and most patients find this very acceptable and something that they’re able to master. 

But it’s very important as blood clot is a real issue for patients, although rare. And we really like to try and make sure that we’re as safe as possible in protecting patients from that.

And you will show patients how to do that?

Yes, in hospital the nursing staff, and they’re very skilled at doing this, will go through an education programme with patients in terms of their learning for how to do this. So we will make sure that patients will absolutely know how to do this before they go home.
 

A doctor talks about pain relief and how to manage it.

A doctor talks about pain relief and how to manage it.

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In hospital we’ll give you a lot of help and assistance in trying to manage your pain. And in the first day, two days in hospital, a lot of the responsibility lies with the doctors working with the patients to get that right for each individual. 

And we tend to move from painkilling drugs which are given into your bloodstream to oral tablets. And by the time you go home there’s a fairly well-established protocol with the sort of tablets you should take and how often you should take them. 

And over the first 2 weeks following surgery I would expect you to initially need quite a lot of support from the tablets. But that tails off over a 2 week period, such that most patients are probably needing only small amounts of tablet medication by certainly 2 to 4 weeks following surgery.

Should they just take it as they need it then after that point?

Yes. We’ll give you a lot of advice in hospital about how to do that. We’ll probably encourage people to take tablets very regularly for the first two or three days, and then to take them as you need them over the next week to two weeks. 

And if pain is a problem and your knee is becoming really painful and sore, then we’ll advise you to speak to your General Practitioner. And in those circumstances, which are unusual, we would like to see you again back in hospital to make sure all is well.
 

A doctor talks about the effects of surgery and medications on sleep.

A doctor talks about the effects of surgery and medications on sleep.

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I think this is fairly well established that any intervention like this where there’s surgery is a kind of general disturbance to you in your normal pattern of behaviour. And that affects sleep. It may be that your sleep was affected by your arthritis in your knee before you came into hospital. But certainly in the first few weeks after surgery, it may be because of the pain of the incision and the operation that you may find some difficulty in getting a regular night’s sleep. 

I think a lot of patients will find certainly in the first week after surgery that your sleep is affected by the operation and the medications that you take. Pain is probably the biggest factor here. And so after the operation your knee will be sore. 

It will gradually start to improve, but in the first two or three days it may be difficult to sleep through. And certainly we will support you in the use of tablet medications to try and make your knee more comfortable, to allow you to get as full a night’s sleep as possible. 

Certainly the way forward with this is that patients become increasingly comfortable and sleep is increasingly easier for them to have. And the medications on the whole allow you to do that rather than making it more difficult. Sometimes certain medications may interfere with sleep, certainly in the initial period following surgery. But actually overall the trend should be for your sleep to improve, although it will be disturbed in that first week.
 

A doctor talks about how long a partial knee replacement usually lasts and the timing of surgery in terms of age.

A doctor talks about how long a partial knee replacement usually lasts and the timing of surgery in terms of age.

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Partial knee replacement is a very effective treatment in terms of taking pain away and allowing patients their quality of life back in terms of mobility. And for the vast majority of people the knee replacement will last a long time. 

If you want some simple figures to remember... Perhaps at 10 years following surgery, 90 per cent of these operations will still be functioning really well and the patients will be happy. And at 20 years, 80 per cent of patients will still find the knee replacement functions very well. So I think they probably last to a greater degree than people might imagine.

I think the discussion with patients about the timing of joint replacement is critical in the shared decision-making process. So, regardless of age, it’s very clear for some patients who are having such a difficult time with their knee arthritis that joint replacement is appropriate. And some patients who seem very young, in their 40s, will have joint replacement. But those numbers are small. 

The average age of people having joint replacement in this country is in your mid to late 60s. And for those patients, the discussion is about the degree of symptoms that you have and the proposed benefits there are from having the joint replacement. 

In the slightly younger age group patients, if you’re in your late 50s or early 60s, the question is whether or not you would want to invest in having a knee replacement to get rid of the pain and stiffness that you have. Weighing that up against the risks, relatively few that they are, but the risks that do exist. And that’s an individual choice that you make with your surgeon in terms of how you feel about your arthritis and how you’re coping.
 

A doctor explains what happens at follow-up and who to contact if there are knee problems after that.

A doctor explains what happens at follow-up and who to contact if there are knee problems after that.

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Well, the follow-up appointment is a really important moment. When you’re discharged from hospital we might not see you until the 6 week point where you attend for follow-up. And that’s an opportunity for the majority of patients to have some feedback from our perspective about how the operation has gone, to assess the wound and check that you’re progressing in the right direction. 

It’s also a point where patients, if they are having problems, can raise that with a health care professional. And in the small number of instances where there are real problems, we can address them. And we can bring you back into hospital to make sure that you’re back on track. 

I think patients are really reassured by that follow-up appointment because it’s an opportunity for you also to ask questions that may have arisen in your rehabilitation, reinforcing the amount of activity you can do, what you can expect going forward from that 6 week point. So I think it’s a really useful meeting, the follow-up appointment.

Is it usually the physiotherapist who they’ll see at the follow-up appointment?

There are two real streams. A lot of our patients are routinely followed up by our physiotherapist practitioners, who are highly experienced in seeing patients after joint replacement. And I think patients enjoy that contact with them. 

A smaller number of patients are seen by the doctors involved in looking after the patients. And there may be reasons why you are brought back to a physiotherapy clinic or to see a doctor, which are specific to each individual. But overall everybody is seen at 6 weeks, and it’s a great check to make sure everybody is moving in the right direction.

Some people were wondering if they’d be having x-rays at the follow-up appointment. So what usually happens when they get there?

The follow-up appointment usually doesn’t involve an x-ray. X-rays are taken whilst you are in hospital, before you leave hospital. And then at the 6 week point you’ll have a meeting, an interview with a physiotherapist or a doctor, where we will check the wound, make sure the knee is moving well. And that improvement in movement is a key marker for us of how the patient is progressing. 

We’ll check that, we’ll ask you a lot of questions about how you’re doing. And we might take a score to see, so we can try to measure your progress.
 

A doctor talks about the importance of exercise during recovery. It’s difficult to damage the knee unless someone has a very bad fall.

A doctor talks about the importance of exercise during recovery. It’s difficult to damage the knee unless someone has a very bad fall.

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What’s really important after joint replacement is regaining a good range of movement. And a physiotherapy [exercise] programme is critically important in doing this.

Anything which allows you to try to get your leg moving in a full arc of movement is to be encouraged. And this strengthens the muscles around your knee and in the end improves the functional recovery that you get. 

In a small number of cases, patients struggle with their range of movement. And what we’d like to do is to intervene early in that situation. And that’s one of the important checks at 6 weeks is to make sure your movement is coming back. And that’s a key part for us.

Sometimes when people were doing their exercises in the early stages of recovery, they wondered if they could damage the knee. Is there any way that they could damage it or is that highly unlikely?

If you follow the guidelines for recovery following joint replacement and specifically partial knee replacement, there are very low risks of damaging a knee replacement. 

The thing that we’d wish to avoid are falls. And falls can lead to damage or sometimes fracture around a knee replacement. But that’s very, very unusual. And most people recover very steadily and avoid those sorts of issues if they stay within the realms of the recovery programme we lay out.

If someone did accidentally fall, who should they see first?

Well, I think once you’ve had a fall, if you’re able to get up and everything seems fine, then I think you can monitor that yourself. 

If you have a fall and you feel new pain or there’s swelling in the knee and it’s clear that something more serious has happened, then I think initially the person to contact is your GP. And your GP tends to assess that situation and will refer you through the appropriate channels.
 

A doctor talks about kneeling after knee replacement surgery.

A doctor talks about kneeling after knee replacement surgery.

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Up to 50 per cent, will find that kneeling is uncomfortable following joint replacement. But whether it’s uncomfortable or not, patients will not be doing themselves any harm by kneeling. So it isn’t true to say that you can’t kneel following joint replacement. But it’s very much up to each individual patient to see how they feel. But if you can do that and it’s not painful, and particularly if your work demands it, then we would encourage you to kneel.

So in the case of someone kneeling on the ground, maybe with a knee pad, they should…

Yes. There are ways to support patients who have to kneel. And knee pads and other appliances that you can use to protect you in that are really helpful.
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