A study carried out by Heart Research UK found that people that received certain hip replacements in the 2000’s, could now be at risk of heart disease. This follows a deeper analysis of the heart health of those patients who received the metal-on-metal replacements, which revealed some disturbing findings.

Although concerning news for those patients affected, this has brought into focus the cardiovascular health risk for anyone undergoing hip surgery. Following this research, more advanced testing measures are being developed that will only lead to better outcomes for patients.

The Heart Research Study

Metal-on-metal implants made from a cobalt and chromium alloy were once believed to be a more durable alternative to the ceramic or polyethylene implant materials. This was a good option for the young and active. But, in fact, the lifespan was significantly shorter.

Although some loose debris is expected after any replacement, metal debris is more toxic. Over time, implant loosening caused metal ions to contaminate the blood. This caused tissue damage and inflammation around the joint, leading to pain, muscle as well as organ damage.

Research carried out at the University of Strathclyde looked at blood samples of 30 patients that had received metal-on-metal implants. It found varying levels of cobalt present in the blood, and further ultrasound analysis revealed abnormal contractile function in their hearts.

The researchers believe that cobalt interferes with calcium levels in heart cells, reducing their ability to contract. This could potentially lead to heart dysfunction in some patients.

Modern Hip Replacement Implants

Unsurprisingly, metal-on-metal bearings are no longer used for hip replacements and are exclusively used for hip resurfacing procedures these days.

Mr Punwar typically uses a combination of metals, ceramics and plastic materials for hip replacements. When using a metal head, a plastic liner will be used, or a ceramic head with a plastic liner for younger patients. All of his materials are 10* rating, and proven to have excellent long-term results on the National Joint Registry (NJR).

It is important to understand there are always risks associated with a major surgery such as a hip replacement. All aspects of the surgery, including risks and your suitability, will be discussed with you before you decide whether you want to go ahead. Mr Punwar and his team will provide a comprehensive aftercare programme and you will have regular check-ups following your surgery.

To discuss whether total hip replacement surgery is the appropriate option for you, call 0808 163 1268 or email Punwar.admin@lips.org.uk to arrange a consultation with Mr Shah Punwar.

Arthrogenic muscle inhibition (AMI) can occur after knee injuries or surgeries, resulting from neural inhibition that causes failure in quadricep activation. Its impact on quadricep strength is significant, as knee extensor peak torque may decrease by 80 to 90% within one to three days following knee joint surgery.

While this effect lessens over time, residual levels of AMI can persist for up to four years after the initial joint trauma. AMI also seems to be a constant presence in arthritic joint diseases, contributing to a considerable amount of quadricep muscle weakness.

Here, we look at how AMI can impact rehab after knee surgery, and how it can be effectively managed.

AMI could prove to be a barrier to rehab after knee surgery

AMI poses a major challenge in the rehabilitation process for those with arthritis or recovering from knee injuries and surgeries. By better understanding its root causes, improved treatment methods can be created that will benefit patients with knee joint issues. AMI can also hinder the process of strengthening the quadriceps, especially during the initial months following an injury or when there is significant joint damage.

The severity of AMI can depend on factors such as the angle of the knee joint, extent of joint damage, and the time since the injury. Its cause is linked to alterations in the output of sensory receptors within the joint, influenced by joint looseness, inflammation, damage to joint receptors, and swelling.

Spinal reflex pathways that may contribute to AMI include the group I nonreciprocal (Ib) inhibitory pathway, flexion reflex, and gamma-loop. There is also initial evidence that suggests higher-level pathways could play a significant role.

How can AMI be effectively managed?

Potential treatments to combat AMI include cryotherapy, transcutaneous electrical nerve stimulation, and neuromuscular electrical stimulation. In cases where there is strong inflammation alongside joint issues, nonsteroidal anti-inflammatory drugs and intra-articular corticosteroids (injected into the joint) may also be effective.

A recent study has shown that cryotherapy and physical therapy can help to effectively manage AMI. A comprehensive review of intervention effectiveness was carried out, following the guidelines and methodologies established by Arksey and O’Malley, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

The search terms used included a range of keywords related to knee injuries, quadriceps activation, arthrogenic muscle inhibition, and neuroplasticity. Each article’s risk of bias was assessed using the PEDro criteria, while the overall quality of evidence for each intervention was evaluated using the GRADE approach.

The review found moderate-quality evidence supporting the effectiveness of cryotherapy and physical exercises in boosting quadriceps activation after ACL injuries and reconstruction. As a result, these treatment methods are recommended for managing AMI.

Mr Shah Punwar has occasionally seen AMI in patients after knee surgery. Book an appointment today if you suspect you have AMI following a recent surgery, or to discuss the risk involved if you are due to undergo a knee procedure.

Long-distance runners are often cautioned about the potential wear and tear on their joints. However, a recent study has revealed that running distance, frequency, and speed are not linked to a higher risk of osteoarthritis.

In this blog, we explore the findings of this latest research and look at the factors that do increase the risk of knee arthritis.

What did the latest study find?

The latest research was presented at the American Academy of Orthopaedic Surgeons (AAOS) 2023 Annual Meeting.

In the study, investigators collected data from 3,804 runners who took part in either the 2019 or 2021 Chicago Marathon. The participants provided information on their running history, weekly average mileage, and typical running speed. Also, any known osteoarthritis risk factors such as BMI, family arthritis history, and prior hip and knee injuries that affected their ability to run.

On average, the runners were around 44 years old and covered 27.9 miles per week. Most respondents (37.3%) had completed two to five marathons, approximately 21% had finished six to 10 marathons, and 17% were participating in their first marathon.

With an average of 15 years of running experience, 1,892 participants reported previous hip or knee injuries, and 413 had undergone knee or hip surgery. In total, 36.4% mentioned experiencing hip or knee pain in the past year, while 7.3% had been diagnosed with arthritis.

The general belief has been that running might elevate the risk of osteoarthritis due to the increased stress on joints compared to walking or standing. However, the study’s findings revealed no connection between osteoarthritis risk and factors such as weekly mileage, duration of running experience, the number of marathons completed, or running speed.

What factors increase the risk of knee arthritis?

While the study didn’t find any correlation between long-distance running and increased arthritis risk, it did reveal some risk factors. Runners with a history of knee or hip surgery, or past hip or knee injuries, had the highest likelihood of developing arthritis.

Other factors that contribute to the development of osteoarthritis include increasing age, which is the strongest risk factor. Also, being female, as hip osteoarthritis is nearly twice as common in women compared to men. Obesity also plays a role by increasing the load on weight-bearing joints, making knee arthritis over three times more likely and speeding up disease progression.

Both high bone density and low bone density can impact the risk of osteoarthritis. The former increases the likelihood of developing the condition, and the latter raises the chances of rapid progression.

Protecting the knees in long distance runners

Even though marathon running and arthritis are not inextricably linked, safeguarding your knees during long-distance runs remains crucial. Key practices to adopt include proper warm-up routines, selecting appropriate running shoes, and progressively increasing the distance.

If you encounter knee discomfort after running, don’t hesitate to schedule a consultation with Mr. Shah Punwar.

Having travelled the World in the military, and working as a chef at top class events including the London Summer Olympics 2012, Brian knows all about excellent service. After his total knee replacement surgery with Mr Shah Punwar, he likened the procedure to ‘a five star plus hotel experience’.

Having led a very active life, including playing football and working long shifts on his feet, Brian developed arthritis in both knees. Brian was taking medication for the pain and received regular injections from his physio. But his pain was getting more severe, so he was referred to Mr Shah Punwar for total knee replacement surgery.

He takes us through his knee surgery experience with Mr Punwar and his team.

Discharged in 19 hours!

On the day of surgery 5th January, Brian remembers signing in and going straight up to the ward at The Blackheath Hospital. There he was greeted warmly by the surgical team that all introduced themselves.

“Everyone was so friendly. They were just gorgeous people!” He said.

“When I went down for the surgery, the anaesthetist explained everything that was going to happen. The whole thing was so pleasant!”

Not squeamish, Brian was happy to watch them perform the operation on his right knee under a spinal anaesthetic. “I was peeking over the screen to see what they were doing,” he chuckled. The surgeon fitted the implant, then closed the wound with staples and a special surgical dressing.

After the surgery, when Brian was back in the recovery room he enjoyed being given pots of tea. He recovered that night on the ward, already using a walking frame to move around and visit the toilet, refusing any manual support offered by the nurses.

Keen to get home to get home to his girls (two beautiful black cats) he was determined to pass his early morning checks with the physio. He proved that he could walk with crutches and get up stairs – making it up a whole floor! He was given some pain relief medication to take away, and was able to leave the hospital just 19 hours after his surgery began.

Brian’s recovery – preparing for his other knee replacement

“My neighbours, everybody, couldn’t believe I was walking so quickly,” said Brian. He was already visiting the local shops, and using uneven steps down to his garden to play with his two cats.

Now building up strength with more walking, he said that he feels no pain in his operated knee. The only evidence of the surgery is a very neat, straight line. Mr Punwar has been monitoring his progress in readiness for his second surgery, expected before the Summer. Then, he is planning to go back to living in Tanzania in Africa with ‘his two girls’.

His final word on knee surgery with Mr Punwar,

“I highly recommend it. I’m just so pleased! I couldn’t give Mr Punwar and his team high enough praise.”

Knee replacement surgery can be a life-changing treatment for those suffering from severe knee pain and limited mobility. This common procedure is carried out on thousands of patients each year, helping them to regain a better quality of life.

Prior to undergoing a knee replacement, it helps to know what to expect. In this blog, you’ll discover the answers to the most asked questions about the surgery. This includes what to expect before, during, and after the procedure.

Before knee replacement surgery

Prior to having knee surgery, you should try to keep yourself as fit and healthy as possible. This means maintaining a healthy weight and exercising regularly. Avoid shaving or waxing the area where the incision will be made, and if you smoke, make sure you quit a few weeks before the surgery.

These recommendations will help to reduce the risk of complications, as well as aid in the recovery process. Mr Punwar will be able to give you specific pre-op care advice you can follow to prepare for the procedure. His expert team are always on hand to answer your questions.

During the procedure

During a total knee replacement procedure, also known as knee arthroplasty, the damaged or worn out knee joint will be replaced with an artificial implant made of metal and plastic components.

The surgery is typically performed under general anaesthetic and will take around 90 minutes to complete. Your surgeon will make an incision on the front of the knee, before removing the damaged cartilage and bone.

The ends of the thigh and shin bone are then prepared to fit the new artificial joint. Mr Punwar only uses modern implants that have an excellent track record.

The implant is positioned and secured in place before the incision is closed with stitches or clips. Then, a surgical dressing is applied to keep the wound clean and to minimise infection. You will be given antibiotics before your surgery and several doses following the procedure to give you the best coverage.

Recovery after knee replacement surgery

The recovery process after a knee replacement surgery can vary depending on the individual and the specific type of surgery performed. In general, it typically takes up to six weeks to fully recover and to return to normal activities.

Immediately following the surgery, you will need to stay and be monitored in the hospital for a few days to manage pain and begin physical therapy. Pain and swelling can be eased with medication, ice, and elevation. After a couple of weeks you will be booked in for a wound check to ensure the skin incision has healed properly.

After being discharged from the hospital, patients typically attend physical therapy sessions 2-3 times a week for a total of 4-6 weeks. You will also be given exercises to do at home. It may take a few weeks, but you may be able to start putting weight onto the knee in as little as a few days.

It is also important to note that knee replacement surgery does not necessarily restore the knee to its normal function. This means you may have some limitations when carrying out certain activities. Mr Shah Punwar will give you plenty of after-care advice. He will let you know what kind of activities you should avoid and what kind of activities you can do.

If you have more questions about what to expect from total knee replacement surgery, book a consultation with Mr Shah Punwar now. He has carried out hundreds of knee replacement surgeries and can answer any questions you have.

Hip replacement surgery is an operation to replace an arthritic, damaged hip joint. When there is significant cartilage loss in the hip joint causing pain, stiffness and mobility issues, a full replacement of the joint may be required. By the time hip replacement is necessary patients are often waking in pain at night and unable to put their shoes and socks on. Getting out of the bath or low chairs and car seats can be a struggle.

Understandably, you may have a lot of questions when you are told you need surgery. Here, we reveal the answers to some of the most common questions patients have about the procedure.

Before hip replacement surgery

Prior to undergoing hip replacement surgery there are things you should do to help limit the risks, and ensure the procedure runs smoothly. While the risks of hip surgery are minimal, it helps to ensure you are as fit and healthy as possible before the surgery.

Partaking in gentle exercise such as walking or swimming, will help to strengthen the hip muscles and aid in your recovery. If you smoke, you should also aim to quit a few weeks before the surgery. Nicotine has been proven to complicate healing, and it significantly increases the risks involved.

You will be given antibiotics to take before the surgery, and once again afterwards to reduce the chance of infection.

It is important that the skin around the hip and leg is in good condition at the time of surgery.

Other medical conditions, such as diabetes, should also be under control and there will be a pre assessment process to check general fitness for surgery. This will include routine blood tests.

Mr Punwar will advise you on the best ways to prepare for the surgery and his expert team are always on hand to answer any questions you may have.

During the procedure

Hip replacement surgery takes between 1 to 2 hours to complete. A consultant anaesthetist will see you prior to surgery and discuss the options available.

You will generally be given a spinal anaesthetic, ensuring you don’t feel anything during and shortly after the procedure.

A 10-15 cm curved incision will be made at the side of the hip, before Mr Punwar dislocates and removes the femoral head. An uncemented metal socket will be attached to the pelvis, before a metal stem with a ceramic or metal head is implanted in the femur. The femoral stem may be cemented or uncemented depending on bone quality and shape. Mr Punwar will plan the surgery beforehand and make sure you are aware of the intended procedure.

Any blood loss will be minimised and the procedure will be carried out in an ultra-clean air operating theatre to minimise infection.

The wound will then be closed up with clips or sutures and protected with a surgical dressing to minimise the risk of infection.

Recovery from hip replacement surgery

The few days after undergoing hip surgery, Mr Punwar and the physiotherapy team will keep a close eye on you to ensure you are regaining mobility. A postoperative x-ray will be taken, and you may experience some bruising and swelling around the site of the operation. There may be some lower leg swelling. You will be given compression stockings to reduce swelling and guard against deep vein thrombosis. You will also be given daily injections of a low dose blood thinner to prevent thrombosis for 4 weeks. This is recommended by the National Institute for Clinical Excellence (NICE).

Pain relief will be prescribed as necessary to help your recovery. At 2 weeks a wound check will be performed to make sure the skin incision has healed well.

For a period of six weeks, you may need to take precautions to protect the hip such as sleeping on your back, sitting in very low chairs and avoiding crossing your legs. You will be provided with specific aftercare instructions you should follow, after the procedure by Mr Punwar and the physiotherapy team.

Ideally, you should avoid driving for 4-6 weeks after the surgery. In most cases, patients recover and can resume daily activities within six weeks. A review will be arranged 6 weeks after surgery. This ensures you are recovering as expected. Further follow-up will be arranged as required.

To discuss whether a hip replacement surgery is a suitable option for you, contact Mr Punwar today. You can call on 0808 1631268, or email punwar.admin@lips.org.uk.

Knee pain affects millions of people every day, leading to a lower quality of life and issues with mobility. Treatments for knee pain largely depend upon the root cause of the problem. For those suffering with pain due to bone marrow lesions, one option that is proven to work is subchondroplasty.

So, what is subchondroplasty for the treatment of knee pain? Learn everything you need to know below…

What is subchondroplasty?

Subchondroplasty is a minimally invasive procedure that aims to fill in subchondral bone defects. It is a fluoroscopically assisted procedure that uses AccuFill®Bone substitute material (BSM) to fill in the gaps.

The procedure tends to be carried out alongside an arthroscopy. This helps to both visualise and treat the problems discovered in the joint. The Accufill BSM hardens and creates new bone as the body heals.

Those who undergo a subchondroplasty report a reduction in pain and an improvement in quality of life. Having the procedure also doesn’t impact your ability to have further surgery if it is needed.

What types of knee pain will subchondroplasty help?

Subchondroplasty can treat subchondral bone defects which may occur due to osteoarthritis for example. Over time, conditions such as osteoarthritis can wear down the cartilage and bone. Not only is this extremely painful, but it can also lead to a loss of mobility.

A previous study has shown that subchondroplasty can also be highly effective at treating bone marrow lesions. The study also showed that the procedure could reduce pain and prevent the need for a total arthroplasty at the follow up stage.

Whenever the pain is caused by the bones, and not the tissue of the joint, subchondroplasty can help. As it is an outpatient procedure, patients can usually leave on the same day. It is provided via an injection into the bone, making it a minimally invasive procedure.

Seeking a diagnosis for knee pain

If you are experiencing any type of knee pain, it’s important to get to the root cause of it. If left untreated, knee pain can worsen, and you may start to lose function in the joint. This can limit your quality of life, preventing you from moving around and putting you at greater risk of other health problems.

To find out what might be causing your knee pain, contact Mr Shah Punwar today. Mr Punwar is a specialist in knee pain and he can determine the cause of your discomfort and the right treatment for you.

Soon, Mr Shah Punwar will be offering subchondroplasty treatment (Zimmer Biomet method), but he can discuss all of your treatment options that would give you the best results. It may be that a knee replacement is the best way to treat your knee pain permanently.

New research funded by the National Institute for Health and Care Research has found that fewer knee replacement procedures are being carried out in England due to strict guidelines. Many surgeons are refusing to carry out the procedure until patients lose weight.

Those who do not lose weight are being refused a knee replacement in some cases, leaving them in pain and suffering with mobility issues.

So, why are patients advised to lose weight before knee surgery? And can patients get help with weight loss to progress with their knee surgery?

Achieving a healthy BMI before knee surgery

Most health professionals use the Body Mass Index (BMI) formula to work out whether your weight is within a healthy range. BMI is your weight divided by your height squared (multiplied by itself). Having a raised BMI increases the risk of having a complication from any surgery. Risks of surgery with a raised BMI include medical problems including DVT, wound infection, heart problems, respiratory problems, nerve injury and even death. The usual requirement is a BMI of 40 or less.

Patients over 40 BMI are given a target before they can proceed with their surgery. They can engage with weight loss services either through their GP or other sources. Occasionally, patients can be referred for bariatric surgery.

Losing 20lbs can help your recovery

A study carried out in 2019, revealed that patients who lose 20lbs are likely to have shorter stays in hospital, and be discharged home rather than to a rehab facility. Interestingly, these results occurred even if the patient was still classed as morbidly obese.

Recovering at home can improve your surgery results, as there is less likelihood of post-surgical infection. Additionally, there are advantages of home comforts such as a better night’s sleep in your own bed. However, weight loss can be extremely challenging, particularly for those who are morbidly obese.

The dangers of losing weight too quickly

While losing weight does reduce the risk of surgery, patients face new risks if they lose it too quickly. Some of the main issues that can arise from losing weight too quickly include:

  • You may lack important nutrients
  • Headaches and muscle pain
  • A reduced metabolism
  • A loss of muscle mass

When patients are told that they need to lose weight in order to have a procedure, it can cause them problems trying to lose weight too quickly. Unfortunately, they don’t often realise the dangers of doing so, and in some cases, it could delay the knee replacement even further.

Seek advice to prepare for knee surgery

According to research, losing just 20 pounds is a good goal before knee surgery. However, if you have a BMI over 40, your surgeon can refer you to weight loss services. This will help you to lose the weight required to progress with treatment. This greatly reduces the risks, even if you are classed as morbidly obese.

If you are in need of knee surgery, book a consultation with Mr Shah Punwar today. If you are concerned about your weight, he will be able to advise you on how to prepare for knee surgery, so that you benefit from the best results after the procedure.

Hip arthritis can be a very painful condition that makes life difficult for many people. Normally, following symptoms of prolonged pain or tenderness in the hip joint, it is formally diagnosed after a clinical assessment by a GP and an X-ray.

However, sometimes the pain of hip arthritis can be misleading. This is because the distribution of pain can be more widespread. It can even be felt in the knee, and mistaken for other conditions.

Here, we will look at why patients often experience knee pain when they have hip arthritis, and the best ways to manage it.

Why does hip arthritis cause knee pain?

The reason you may seek a diagnosis for hip arthritis is experiencing pain in and around the hip joint that lasts more than a few days. But, pain relating to hip arthritis can be felt in one or more parts of the body including in the groin, the front of the hip, lower back and even in the knee.

The main symptoms of hip arthritis include:

  • Pain and tenderness in the hip joint
  • Joint stiffness after sitting or lying down for a long period of time
  • Difficulty in performing daily activities
  • A feeling of bone rubbing against bone

When you have hip arthritis, inflammation of the tissues and nerves can occur. This causes pain initially in the hip, but can refer to the knee. This usually follows the distribution of the saphenous nerve, which branches from the femoral nerve. However, the obturator nerve which passes from the hip to the inside of the knee can also cause referred pain.

Get your knee pain checked

If you have knee pain without any symptoms of hip arthritis such as stiffness, then it is very unlikely that you have hip arthritis. But, you could have knee arthritis – another very painful condition that affects the knee joint, caused by inflammation that develops over time due to cartilage damage. It can also lead to other problems including swelling and muscle weakness in the legs, when left untreated and can cause mobility issues, usually later in life.

When you have knee pain, it is best to get a confirmed diagnosis of the cause so that you can look at the best treatment options. You can request X-Ray imaging from your GP, that should confirm a diagnosis of arthritis. Imaging can also help you understand the nature and extent of damage, and your doctor can check your joint movement and function.

Treating your knee or hip arthritis

When you have a diagnosis of arthritis, the next best step is to organise a consultation with experienced knee and hip surgeon, Mr Punwar. You can discuss treatment options, including lifestyle changes, medications, physiotherapy and whether joint replacement surgery would be the best option for you.

If you are experiencing knee pain, hip pain, or a combination of symptoms, consult Mr Shah Punwar today.


A new study has revealed that walking can help to prevent knee pain for those suffering with osteoarthritis. The research, carried out by the Baylor College of Medicine, highlights the long-term benefits of walking regularly for patients over 50. Additionally, it also suggests walking could be an effective way to slow down damage within the joint.

So, how can walking help to prevent knee pain caused by osteoarthritis, and what other treatment options do patients have? Find out everything you need to know below.

What did the study reveal?

The study, published within the Arthritis & Rheumatology journal, used the results of a multiyear observational study known as the Osteoarthritis Initiative. Participants aged 50 and over, self-reported the frequency and amount of time they spent walking. Those who reported that they exercised more than 10 times were categorised as ‘walkers’, while those who didn’t were categorised as ‘non-walkers’.

It was discovered that the walker group had a 40% reduced chance of developing new frequent knee pain. Additionally, the results showed that walking regularly can help to slow down degeneration of the joint.

How can walking help to prevent knee pain?

Walking is best known for its cardiovascular benefits. However, as the new study shows it can also be useful in pain reduction of the joints. So how does it help to prevent knee pain?
There are several reasons walking could help to reduce pain in the joints. These include:

  • It can help to rebuild the joint
  • Weight management
  • Strengthened muscles

In osteoarthritis, the cartilage of the knee can become damaged and worn. When you walk, it helps to rebuild the cartilage, reducing the pain experienced over time. This can also aid in mobility, further reducing the risk of further degeneration.

Walking also helps to keep your weight under control. Being overweight puts a lot of pressure onto the joint, leading to additional pain. By managing your weight, it will help to ease the pressure on the joint, effectively minimising the pain felt.

Finally, walking regularly helps to build up and strengthen the muscles. This in turn helps to take the pressure off the joint, reducing pain felt in the knee.

Treating knee osteoarthritis

While this new study highlights the benefits of walking to ease knee pain, it is worth noting that knee osteoarthritis won’t just go away by itself. You may delay suffering pain and mobility issues, but the condition may worsen as time goes on.

In order to treat knee osteoarthritis, patients should seek advice from a specialist. It could be that knee replacement surgery is required to reduce pain and improve mobility.

Book a consultation with Mr Shah Punwar now to determine whether a knee replacement could be the best way to treat your knee pain permanently.


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