Mr Kirti Moholkar: Knee replacement therapy for patients with venous disease

I'm Kirti Mahalkar. I'm one of the orthopaedic surgeons. I work at the Royal Orthopaedic Hospital in Birmingham and privately I work at the Droitwich Knee Clinic in Brombsgrove. I've been appointed as a knee and shoulder consultant since about 2004 and I've got a special interest in knee replacement surgery as well as arthroscopic and arthroscopy of the shoulder joint as well. Particularly with knee replacement surgery, I think it is a challenge and maybe in my opinion about maybe 20% of patients who do have venous disease, who do have lymphedema disease, it becomes a true challenge to treat them because to reduce their swelling down before doing the knee replacement surgery is my and in my opinion is very very required so that we look after them pre-operatively quite well but to get that knee swelling or the leg swelling to completely reduce for them to be appropriate for surgery is a huge challenge and I know there are leg clubs in Worcester but my NHS practice is based in Birmingham and I'm really sad that there is none in in Birmingham and if there was a possibility of setting one up you know you'd be doing a great job. So currently what we do is we do have tissue viability nurses at our hospital they do a good job but I think what you have in your leg clubs is is that volume of experience and expertise which is which is highly desirable that if we could steal one off for us it'll be it'll be splendid. I think in non-edematous legs or in normal patient shall I say, I don't think it's a huge problem because through proper care as well as prophylactic antibiotics and we only do about maybe two doses or three, my personal infection rate is fairly fairly low and is acceptable. Well, let me rephrase it, I don't think any infection is acceptable but we do reduce it down to the bare minimum. Of course, in legs that are edematous, the infection rate can be quite large but I'm pedantic to the nth degree and I will not operate if I don't think that I'm going to make the patient better. To expand on it I would try and and not leave one stone unturned to optimize the patient and that optimization process can take anything between two months to maybe a year. I do have a chat with my patients and and do tell them that look I think what I'm trying to do is to optimize you for surgery. So even if there was delay, pardon me, because I think in the presence of cellulitic leg or swollen legs, undertaking such a big knee replacement type procedure is fraught with complications. Of course, there is a chance that they might not get it, but who would like to cross the motorway if it is full of traffic? This prophylaxis is better than cure. I use Betadine Alcoholic. We usually prep it twice so when the patient has an anaesthetic, they get prepped in the anaesthetic room, then they are draped, they come into the main operating theatre, I prep it again with Betadine Alcoholic and we do use what is called IMS, which is virtual spirit, just around the skin incision side. Why that? Because A, it cleanses the skin and it takes away the the slimy fatty film if you like that the skin has because we do use what is called as a iodine base adhesive on the skin before we cut the skin to make sure that the bugs in the dermis don't kind of leach out. So yeah we gain quite pedantic at it and you know my infection rate is fairly low but I would like it even lower than that. With knee replacement surgery again I'm pedantic enough. I open my skin and I will close it. You know good old days used to be when the bosses used to say you know you you know you open I'll do the job and you close. In my hand just does not work. I do know who needs more care. I do know who's going to be a straightforward straightforward patient to close but to answer your question straight yes appropriate layers. Patients who are at high risk will definitely need a different type of approach. If the layer of fat underneath the skin is quite large, I do treat it with caution because that is a layer which is not full of blood supply. So while closing, special care is required so that I don't cause further more necrosis. So my intention is to not leave any potential dead space and at the same time get very good tissue approximation so that the skin heals fine and so do the tissues underneath the skin. If the patient was going to get infected, that dye is cast before you close the skin. That's my personal anecdotal opinion because dressings don't stop infections from occurring. They may reduce the chances but I think majority of the time it is what you do before, how the patient is and what you do at the time of surgery. Infection in a knee replacement is a disaster. for patients, disaster for me, disaster for the hospital. The worst sufferer is the patient. So surgeons, if they were to spot a cut on the skin or an ulcer or a wound, are very pedantic in saying, look, this is elective surgery. Legs are not falling off. We can manage to do your knee replacement a couple of weeks later, a couple of months later. Let's heal the ulcer. The intention behind it, and I think there is a scientific basis as well is that if that ulcer has a couple of bugs on it or thousands of bugs on it and if you were to do knee replacement, after knee replacement surgery, normally tissues heal with inflammatory response. The blood is going to gush into the knee, some of the blood that the ulcer has received can get into the knee as well through the lymphatics. Now if that was to happen, you need a specific amount of coliforming units or bacterial units to reach the prosthesis and if you have that type of scenario, you've virtually got an infected knee. I think as far as my responsibility to the patient is concerned, if I know that that ulcer or the cut is or has a potential chance of harbouring bacteria, then it is my job to advise my patient that look let's get that lesion healed up before undertaking knee replacement surgery. So I think, unless I'm convinced with data and science, I think getting that particular wound healed is my priority and what I do do is, of course that's not my area of expertise so I would refer them to the appropriate clinicians and if and only if the ulcers or wounds are healed would I undertake knee replacement surgery. you