Orthopedic Recommendation (Knee) - London

[kneeissues]

Hi all,

This seems a very knowledgeable forum and I was hoping to get some help.

A year back, knee pain triggered after a near fall. Four months of constant complains to my GP, I was finally referred to a physio except it did not work (not to mention that I had admin issues at the hospital). Went to a private physio which helped and got an MRI done in June. The MRI showed slight effusion but no damage to the ligament. The private physio helped initially but then the swelling came back and the pain has chronically gotten worse.

I have been to consultants on the NHS at University College Hospital (unfortunately, a different consultant tends to me each time I go for a follow-up). I am seeing a physio too but my problem is that I am unable to manage the pain to effectively be able to do my physio exercises (unless I constantly take painkillers). As of now, the current diagnosis stands at: hyperextension of the knee (10 degrees) + Chondromalacia patellae (which I understand to be degeneration of the cartilage). The NHS consultant believes that I do not need any surgery though I haven't had any recent examination done. Last X-rays were back in August/September.

Just for my peace of my mind, I was thinking to get a second opinion from an orthopedic. My physio recommended me these names:

1. Adil Ajuied
2. Simon Moyes

In my own research, I have across Fares Hadded (he is also running the Ortho department at UCH), Andy Williams, Richard Carrington.

I am really not sure who to go for within London. The former two are fully covered by my insurance but for the others, I will have to pay a bit out of pocket. Anyone here can help please? The more I research the more confused I get.

[Petrolsmasher]

Hi,

Although i cant help with your specific query i can tell you what my physio said for me to do which shouldent cause you any pain.

I also have pain when squatting/climbing stairs etc, he did all the tests and basically said my hamstrings are overly tight, which they are as i spend most of my time sat down, he basically said when they are tight the patella doesent track properly and ends up causing pain as the patella glides close to the bone.

I did hamstring stretches for a while (take a while to loosen them off) and my pain basically dissapeared, its come back now as ive been very lazy and sit all the time which is my own fault.

There isent much they can do surgery wise for chondromalicia patella its just a tracking issue.

Try stretching your hamstrings daily as much as possible, for a month or two first

[ocd]

Andy Williams is highly regarded and is a specialist knee surgeon. A lot of surgeons do hips and knees. I would always choose a single joint specialist if I needed surgery. Don’t go down the ‘regenerative’ route with stem cells etc. It’s cobblers.

[The_Doc]

Any of those 5 names are good choices. Don't ask me to pick one out of the group.

The more popular a surgeon is, the more he/she charges, so Mr Williams and Prof Haddad are more money. These guys are my friends and colleagues. And stem cells or Biologics are the future, so its a bit harsh to damn them so quickly. But there hasn't been much proven RCT evidence yet. That's not to say that research work won't lead to progress, and the therapies are very benign.

[ocd]

I wouldn’t blow 6k on treatment that involved sucking a bit of fat out of my belly, washing it in fairy liquid and claiming that it contained something of any therapeutic benefit. It’s funny how reluctant the enthusiasts are to subject their treatments to randomised controlled trials.....
No invasive treatment is completely benign.

[ORD]

Do your own research. Knee surgery is, in short, usually a bad idea. It performs much worse than non-surgical interventions.

[kneeissues]

Petrolsmasher said:

Hi,

Although i cant help with your specific query i can tell you what my physio said for me to do which shouldent cause you any pain.

I also have pain when squatting/climbing stairs etc, he did all the tests and basically said my hamstrings are overly tight, which they are as i spend most of my time sat down, he basically said when they are tight the patella doesent track properly and ends up causing pain as the patella glides close to the bone.

I did hamstring stretches for a while (take a while to loosen them off) and my pain basically dissapeared, its come back now as ive been very lazy and sit all the time which is my own fault.

There isent much they can do surgery wise for chondromalicia patella its just a tracking issue.

Try stretching your hamstrings daily as much as possible, for a month or two first

Thanks Petrolsmasher. That is the goal of my physio as well, to strengthen the hamstrings and quads. Like you, I spend most of my time sat down - I think my bigger concern is that the pain sometimes gets too much for exercises. Did you find the pain levels to increase while doing any exercise? I struggle with daily walking as well sometimes.

[kneeissues]

The_Doc said:

Any of those 5 names are good choices. Don't ask me to pick one out of the group.

The more popular a surgeon is, the more he/she charges, so Mr Williams and Prof Haddad are more money. These guys are my friends and colleagues. And stem cells or Biologics are the future, so its a bit harsh to damn them so quickly. But there hasn't been much proven RCT evidence yet. That's not to say that research work won't lead to progress, and the therapies are very benign.

Thanks Doc, glad to hear that they are all good choices. Choosing a consultant is a tough choice! Unfortunately, Andy Williams is booked out until May and similar for Prof Haddad. Boils down to whoever is earliest first (think Adil Ajuid's not available until March either)

[The_Doc]

ORD said:

Do your own research. Knee surgery is, in short, usually a bad idea. It performs much worse than non-surgical interventions.

Unsubstantiated untruths. Would you like to see my data?

A bad knee surgeon performs worse.

Ignore this low value comment

Edited by The_Doc on Wednesday 13th February 13:00

[ORD]

The_Doc said:

Unsubstantiated untruths. Would you like to see my data?

A bad knee surgeon performs worse.

Ignore this low value comment

Edited by The_Doc on Wednesday 13th February 13:00

Yep. Show me the long term data for thousands of patients showing surgery giving good results for general knee pathology relative to other treatments.

[The_Doc]

ORD said:

The_Doc said:

Unsubstantiated untruths. Would you like to see my data?

A bad knee surgeon performs worse.

Ignore this low value comment

Yep. Show me the long term data for thousands of patients showing surgery giving good results for general knee pathology relative to other treatments.

National Joint Registry 15th report Year 2018 Aprox 950,000 Total Knee replacements with 96% still going strong at 14 years
http://www.njrreports.org.uk/Portals/0/PDFdownload...

Surgical Outcomes at 8, 5, 12 and 15 years after partial meniscectomy
https://www.ncbi.nlm.nih.gov/pubmed/17989415

Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis.
https://www.ncbi.nlm.nih.gov/pubmed/19251676

Long-term outcome of grade III and IV chondral injuries of the knee treated with Steadman microfracture technique.
https://www.ncbi.nlm.nih.gov/pubmed/28228789

Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients
https://www.ncbi.nlm.nih.gov/pubmed/28205075

Twelve-Year Outcomes of an Oxinium Total Knee Replacement Compared with the Same Cobalt-Chromium Design: An Analysis of 17,577 Prostheses from the Australian Orthopaedic Association National Joint Replacement Registry
https://www.ncbi.nlm.nih.gov/pubmed/28196029

The Effect on Long-Term Survivorship of Surgeon Preference for Posterior-Stabilized or Minimally Stabilized Total Knee Replacement: An Analysis of 63,416 Prostheses from the Australian Orthopaedic Association National Joint Replacement Registry
https://www.ncbi.nlm.nih.gov/pubmed/28678126

Cartilage repair surgery for full-thickness defects of the knee in Germany: indications and epidemiological data from the German Cartilage Registry (KnorpelRegister DGOU)
https://www.ncbi.nlm.nih.gov/pubmed/27062375

About 1.3 million patients in those studies.

Question: If knee surgery is such a waste of time, why do I do it, why does NIHCE give it a thumbs up and what are you going to do when you are 65 with KL grade 4 knee changes and an Oxford score of 25?

[ORD]

Deliberately missed the point. Those are studies showing that various surgical procedures generally work OK. They are not studies demonstrating that surgery is the best option for relatively minor knee pathology.

Is the OP 65? If so, that’s a different matter. By the time I am 65, I would expect vastly more effective and less invasive treatments.

[The_Doc]

ORD said:

Do your own research. Knee surgery is, in short, usually a bad idea. It performs much worse than non-surgical interventions.

I'm out.

[craig1912]

Fares Hadded- used and trusted by a few premier league football clubs, Royal Ballet etc. My son had an op by him and was very impressed.

[SVS]

The_Doc said:

And stem cells or Biologics are the future ...

How far into the future do you think this is?

[millen]

I wouldn't diss stem cell regeneration for minor cartilage deterioration - up to 5pence size hole and not full depth. I guy I cycle with has had both knees done (one year apart) and is very pleased. They were done by Gorav Datta in Winchester under an NHS clinical trial which is now closed but I think he's continuing privately. (He wouldn't do me as I was too far gone!) Downside is the gruesome recovery - I believe the joint has to be immobilized under a brace for up to 3 months, with flexion gradually reintroduced. He likened it to sewing a new lawn - the grass seeds are extremely vulnerable until they take root and gain strength.

For myself, I was very impressed with Charles Willis-Owen in Bournemouth. He's an extremely strong cyclist and aims to maximise functionality. His cv (on his website blog page) is good. I ended up with a partial replacement (medial grade 4 OA), accepting that it will probably have to be converted to a total replacement after 10-15 years, but hopefully that will see me through to end of life.

For London and environs, I did seek a number of recommendations before seeing CWO. SWELOC in Epsom has some recommended guys though the one I saw on the NHS (Adhikari) didn't inspire confidence. Another recommendation from a surgeon friend of a friend was a guy who operates from Parkside Hospital in Wimbledon and apparently looked after the Queen Mum's joints. Happy to look up his name in old emails if you're interested but I recall he was nearing retirement age (other things being equal, I'd prefer someone mid-career) and very much top-end pricing.

Good luck!

[ocd]

millen said:

I wouldn't diss stem cell regeneration for minor cartilage deterioration - up to 5pence size hole and not full depth. I guy I cycle with has had both knees done (one year apart) and is very pleased. They were done by Gorav Datta in Winchester under an NHS clinical trial which is now closed but I think he's continuing privately. (He wouldn't do me as I was too far gone!) Downside is the gruesome recovery - I believe the joint has to be immobilized under a brace for up to 3 months, with flexion gradually reintroduced. He likened it to sewing a new lawn - the grass seeds are extremely vulnerable until they take root and gain strength.

For myself, I was very impressed with Charles Willis-Owen in Bournemouth. He's an extremely strong cyclist and aims to maximise functionality. His cv (on his website blog page) is good. I ended up with a partial replacement (medial grade 4 OA), accepting that it will probably have to be converted to a total replacement after 10-15 years, but hopefully that will see me through to end of life.

For London and environs, I did seek a number of recommendations before seeing CWO. SWELOC in Epsom has some recommended guys though the one I saw on the NHS (Adhikari) didn't inspire confidence. Another recommendation from a surgeon friend of a friend was a guy who operates from Parkside Hospital in Wimbledon and apparently looked after the Queen Mum's joints. Happy to look up his name in old emails if you're interested but I recall he was nearing retirement age (other things being equal, I'd prefer someone mid-career) and very much top-end pricing.

Good luck!

Stem cell treatments are unregulated and there's no evidence to show that they regenerate cartilage. If there were, everyone would be using them. Who's to say that your chum's recovery wasn't the result of enforced rest in a brace for 3 months, followed by careful physio? The plural of anecdote isn't research. If I see someone with a knee problem, the surgeons to whom I send them don't offer stem cell treatment. Careful research done as part of unbiased multi-centre randomized trials is the way to show that a particular treatment is better than an alternative, or no treatment.We aren't there by a long way.

[topgunkos]

ocd said:

Stem cell treatments are unregulated and there's no evidence to show that they regenerate cartilage. If there were, everyone would be using them. Who's to say that your chum's recovery wasn't the result of enforced rest in a brace for 3 months, followed by careful physio? The plural of anecdote isn't research. If I see someone with a knee problem, the surgeons to whom I send them don't offer stem cell treatment. Careful research done as part of unbiased multi-centre randomized trials is the way to show that a particular treatment is better than an alternative, or no treatment.We aren't there by a long way.

As someone in the Ortho Device industry I have to disagree with you. You have no idea on the amount of money and time both companies and surgeons are investing in Stem Cell research.
I will admit that Level 1 studies are still lacking, but there are literally dozens if not more of these ongoing in their follow up phase. Knowing the surgeons involved in some of these, the early results are very positive and the general consensus is that this in fact the future. People such as yourself had the same approach to THR and TKR when they were first introduced 30-40 years ago.
However I understand your skepticism due to the lack of research and will admit that what constitutes Stem cell therapy is debatable and his become a marketing buzzword for less scrupulous individual.

[ocd]

topgunkos said:

As someone in the Ortho Device industry I have to disagree with you. You have no idea on the amount of money and time both companies and surgeons are investing in Stem Cell research.
I will admit that Level 1 studies are still lacking, but there are literally dozens if not more of these ongoing in their follow up phase. Knowing the surgeons involved in some of these, the early results are very positive and the general consensus is that this in fact the future. People such as yourself had the same approach to THR and TKR when they were first introduced 30-40 years ago.
However I understand your skepticism due to the lack of research and will admit that what constitutes Stem cell therapy is debatable and his become a marketing buzzword for less scrupulous individual.

I am sure there is plenty of money being spent on this. Therein lies the conflict of interest. The industry wants quick returns and is unwilling to finance the high quality research that is needed. By the way THR has been in use since 1962. The devices industry has a long and chequered history when it comes to the introduction of new technology soit's just as well there are sceptics around to try and prevent harm.

[SVS]

ocd said:

Stem cell treatments are unregulated and there's no evidence to show that they regenerate cartilage.

The evidence is currently being researched. Hence why stem cell treatments are in trials, not routine NHS use. In due course, I’d expect NICE to evaluate whether they’re clinically- and cost-effective.

As they’re still in research, these treatments are regulated by the EU Clinical Trials Regulation. (With Brexit, of course, the future of UK clinical trials regulation is being determined.)

ocd said:

The industry wants quick returns and is unwilling to finance the high quality research that is needed.

The industry knows it needs to finance research of sufficient quality to meet the demands of the regulators and NICE.

In addition, Government funded research in the NHS and universities also takes place.