One of the most common questions Mr Shah Punwar is asked by patients facing ACL reconstruction is a simple one: which graft is best? It is a fair question, and the honest answer is that there is no single right choice for everyone. The best graft depends on the individual patient, their sport, their age, and the specific demands they will place on the knee once they return to it.

The main ACL graft options

ACL reconstruction involves replacing the torn ligament with a graft, most commonly taken from the patient’s own hamstring tendon. This remains a well established and reliable choice, and is the graft Mr Punwar uses most frequently. However, two other autograft options, the patellar tendon and the quadriceps tendon, are increasingly discussed in the research, and each has its own profile of strengths.

Mr Punwar’s technique

When using a hamstring graft, Mr Punwar uses the UltraSTAR surgical technique, taking a single, quadrupled semitendinosus tendon rather than the more traditional approach of harvesting two separate hamstring tendons. Preparing the graft this way creates a thicker, single-tendon construct that more closely resembles the size and structure of the native ACL, and research has shown this configuration can improve graft strength and reduce the risk of re-rupture, while also avoiding the need to take a second hamstring tendon, reducing donor site morbidity.

How grafts perform in tests

A 2026 systematic review and meta-analysis of randomised controlled trials compared quadriceps tendon grafts against the more traditional hamstring and patellar tendon options. It found that all three produced broadly comparable results in terms of graft failure rates and knee stability, with some evidence suggesting quadriceps tendon grafts may carry a lower risk of donor site problems such as ongoing discomfort at the point the graft was taken from. You can read the full review here: Knee Surgery, Sports Traumatology, Arthroscopy, 2026.

A separate 2026 study looked specifically at how graft choice performed in different risk groups. It found that in higher risk patients, defined as younger patients with a steeper natural slope to the top of the shin bone who play pivoting sports, such as football or basketball, patellar tendon grafts were associated with a lower rate of re-rupture than hamstring grafts. In lower risk patients, the two performed similarly. The full study is available here: Archives of Orthopaedic and Trauma Surgery, 2026.

Why this matters for treatment planning

What this research reinforces is something Mr Punwar already builds into every consultation: graft choice is always carefully selected. For most patients, a hamstring graft remains an excellent and well proven option. But for those with particular risk factors, such as younger athletes returning to high demand pivoting sports, the evidence increasingly supports a more tailored conversation about whether an alternative graft might reduce the risk of a further injury.

This is also why a thorough pre-operative assessment matters so much. Understanding a patient’s age, activity level, joint flexibility, biomechanics, and the specific demands of their sport allows a graft to be chosen that fits the individual.

If you have suffered an ACL injury and are weighing up your options, or want to understand which graft might be most suitable for your circumstances, book a consultation with Mr Shah Punwar by calling 020 8194 8541.

A total knee replacement is designed to provide long-lasting pain relief and improve mobility, and for many people it does exactly that. Modern knee replacements can last for 15 to 20 years or longer, allowing patients to enjoy a more active lifestyle with less pain. However, like any joint replacement, they do not last forever.

In some cases, further surgery may be needed to correct a problem or replace the original implant. This is known as a revision total knee replacement.

Although revision surgery is less common than a first knee replacement, it is a more complex procedure that benefits from careful planning and specialist expertise. Here, we’ll explore why a revision knee replacement may be required, what the procedure entails, and why a specialist approach is essential.

Why might a revision knee replacement be needed?

There are several reasons why a knee replacement may need to be revised. One of the most common is wear and loosening of the implant over time. As the artificial joint ages, the bond between the implant and the bone can gradually weaken, leading to pain, swelling, or instability.

Although uncommon, an infection around a knee replacement can affect both the implant and the surrounding bone, often requiring specialist treatment and, in some cases, revision surgery.

Some patients may also experience stiffness, ongoing pain, instability, or repeated dislocation of parts of the replacement. Occasionally, the original implant may fail earlier than expected due to changes in the surrounding bone or other mechanical issues.

Whatever the cause, the goal of revision surgery is to restore stability, reduce pain, and help patients return to everyday activities with greater confidence.

What happens during revision surgery?

Revision knee replacement is usually more complex than a primary knee replacement because the surgeon must first remove the existing implant before preparing the bone for the new one.

Depending on the condition of the bone and surrounding tissues, specialised implants may be needed to provide additional support and stability. Sometimes bone grafts are also required if there has been bone loss around the original replacement.

As every revision is different, no two operations are exactly the same. Some procedures involve replacing only part of the original implant, while others require the entire knee replacement to be exchanged.

Recovery is often similar to a primary knee replacement, although rehabilitation can take a little longer depending on the complexity of the surgery. Physiotherapy remains a key part of the process, helping patients regain strength, movement, and confidence in the joint.

Why specialist experience makes a difference

Revision knee replacement is one of the most technically demanding procedures in knee surgery. It requires careful surgical planning, experience in managing complex cases, and access to a wide range of specialist implants.

A 2025 systematic review and meta-analysis, led by researchers from the NHS England Getting It Right First Time Programme, examined outcomes following revision knee replacement. They used data from the National Joint Registry. The review found that higher surgical volumes were associated with improved patient outcomes, supporting the value of specialist experience in this type of surgery. The same lead author published a second study in 2025 which specifically showed that surgeons who perform higher numbers of revision knee replacements had lower rates of early failure following surgery.

As more patients undergo knee replacement surgery, the number of revision procedures is naturally expected to increase over time. This makes access to surgeons who regularly manage these complex cases increasingly important.

What to expect after revision surgery

Although revision knee replacement is a bigger operation than a primary knee replacement, the aim remains to relieve pain, improve function, and help patients get back to living life more comfortably.

Most patients notice gradual improvements over the months following surgery as swelling settles and strength returns. Following your rehabilitation programme, attending regular follow-up appointments, and giving the knee time to recover all play an important role. Many patients go on to enjoy significant improvements in both comfort and mobility.

If you’re experiencing increasing pain, instability, or problems with a previous knee replacement, an assessment by a specialist can identify the cause and determine whether revision surgery is appropriate. Book a consultation with Mr Shah Punwar today by calling 020 8194 8541.

When high-profile athletes get injured, it often brings complex conditions into the spotlight. In a recent interview with ESPN, Olympic skier Lindsey Vonn revealed her plans to return to competitive skiing, after a serious crash earlier in her career left her with a tibial plateau fracture.

Tibial plateau fractures are one of the more serious knee injuries, requiring complex treatment and management. Here we’ll explain what these fractures are, how they are treated, and what to expect from recovery.

What is a tibial plateau fracture?

The tibial plateau is the top part of your shinbone, where it meets the thigh bone to form the knee joint. It plays a major role in supporting your weight and allowing smooth movement of the knee.

A fracture in this area is more than just a simple break. As it involves the surface of the joint, it can also affect cartilage, ligaments, and overall knee stability. That is why these injuries are taken seriously and often need specialist care.

They usually happen during high-impact events such as skiing accidents, contact sports, or road traffic collisions. In younger people, it is often linked to sport or trauma. In older adults on the other hand, weaker bone means even a short fall can sometimes cause this type of fracture.

Common symptoms include pain, swelling, and difficulty putting weight on the leg. In more severe cases, the knee may feel unstable or look visibly swollen quite quickly after the injury.

Treatment options

Treatment depends on how severe the fracture is. Small, stable fractures can sometimes be managed without surgery, using a brace and a period of protected weight-bearing. However, many cases do require surgery to restore the joint surface properly.

The most common operation involves realigning the bone and fixing it in place with plates and screws. This is known as open reduction and internal fixation. In some cases, surgeons may use a less invasive, arthroscopic-assisted approach, which allows them to look inside the joint and treat any associated damage at the same time.

A recent study in the European Journal of Medical Research, compared these two approaches and found that both can work well. The choice depends on the specific fracture and patient need, with treatment tailored to the individual.

Recovery after tibial plateau fracture

Recovery from a tibial plateau fracture does take time, but modern approaches are helping patients get back on their feet sooner.

In the past, patients were often advised to avoid putting weight on the leg for a long period. However, a 2025 systematic review found that early, carefully guided weight-bearing after surgery, can be safe and may even help speed up recovery. This is encouraging, as it means patients can start rebuilding strength and movement earlier in the process.

Physiotherapy is a big part of recovery. Early on, the focus is on reducing swelling and gently improving movement. As healing progresses, strengthening exercises and balance work are introduced to support the knee and restore confidence.

Getting back to sport

One of the most common questions patients ask is when they can return to normal activities or sport. The answer varies, but most people can gradually return to daily activities over a few months, with higher-impact sport taking longer.

As seen with athletes like Lindsey Vonn, returning to a high level of activity after a serious knee injury is possible, but it requires time, patience, and the right support. Getting the alignment right early on and following a structured rehabilitation plan is crucial.

If you have experienced a significant knee injury or are struggling to recover, schedule an appointment with Mr Shah Punwar today. With the right treatment and rehabilitation plan, even complex injuries like tibial plateau fractures can be managed successfully, helping you get back to moving with confidence.

Knee pain is common across all age groups, but research consistently shows that women are at a higher risk of developing certain knee problems, particularly osteoarthritis. While lifestyle and activity levels do play a role, there are important anatomical, hormonal and biomechanical factors that also contribute.

Understanding why women are more vulnerable allows for earlier intervention, smarter prevention strategies and better long-term outcomes.

Knee osteoarthritis in women

Osteoarthritis is the most common form of arthritis. According to research, women are more likely than men to develop knee osteoarthritis, particularly after the age of 50, and they often experience more severe symptoms.

Several factors contribute to this. Women typically have wider pelvises, which affects the angle between the hip and knee, sometimes referred to as the Q angle. A larger Q angle can increase stress across the knee joint, particularly at the patellofemoral joint. Over time, this altered load distribution may contribute to cartilage wear.

Hormonal influences also play a role. Oestrogen is thought to have a protective effect on cartilage. As hormone levels decline around menopause, the protective effect may diminish, potentially accelerating joint degeneration.

Imaging studies show that cartilage loss appears to progress more rapidly in women. A comparative study found that women experienced a greater rate of cartilage loss at the knee compared with men over time. This faster degeneration may partly explain why women report higher rates of symptomatic knee arthritis.

ACL tears and the long-term consequences

Women are also more likely to sustain anterior cruciate ligament injuries, particularly in sports involving pivoting and jumping such as football, netball and skiing. Differences in neuromuscular control, landing mechanics and ligament laxity are thought to contribute to this increased risk.

The long-term implications are significant. A study of female football players found that more than half developed radiographic knee osteoarthritis within 12 years of an ACL injury.

An ACL tear doesn’t simply affect stability in the short term. It can alter joint biomechanics and increase the likelihood of secondary meniscal or cartilage damage. Even with reconstruction, the knee may remain at increased risk of developing osteoarthritis later in life. Early diagnosis, appropriate management and structured rehabilitation are therefore crucial to protecting the long-term health of the joints.

Patellofemoral pain and alignment issues

Another condition more commonly seen in women is patellofemoral pain syndrome, often referred to as anterior knee pain. This typically presents as discomfort around or behind the kneecap, particularly when climbing stairs, squatting or sitting for prolonged periods.

Biomechanics again play a central role. The combination of pelvic width, muscle strength patterns and dynamic knee alignment, can increase lateral forces on the patella. Weakness in the hip stabilisers and quadriceps may allow the kneecap to track slightly off-centre, leading to irritation of the joint surface.

While patellofemoral pain doesn’t always lead directly to osteoarthritis, persistent maltracking and abnormal loading can contribute to cartilage wear over time. Early physiotherapy focusing on strength, movement control, and load management, can reduce symptoms and improve long-term outcomes.

Protecting knee health in women

Although women face a higher risk of certain knee conditions, many of these issues are modifiable. Strength training that targets the quadriceps, hamstrings and gluteal muscles improves joint stability and reduces abnormal forces across the knee. Neuromuscular training programmes have been shown to reduce ACL injury rates in female athletes by improving landing mechanics and control.

Maintaining a healthy body weight also reduces stress on the knee joint, lowering the risk of osteoarthritis progression. For those who have sustained previous ligament injuries, regular follow-up and proactive rehabilitation remain important to monitor joint health.

If knee pain persists, early specialist assessment can help identify underlying biomechanical or structural factors. With tailored treatment and preventative strategies, many women can maintain active, pain-free lifestyles while reducing the long-term risk of joint degeneration.

If you are experiencing knee issues and want to get to the root of the problem, book an appointment with Mr Shah Punwar today.

With the Winter Olympics bringing skiing back into the spotlight and ski holidays approaching, many people are looking forward to time on the slopes.

While skiing is an excellent way to stay active, it places significant demands on the knees. Twisting forces, sudden stops, uneven terrain and fatigue all increase the risk of injury, particularly for those who are not adequately prepared. Understanding how knee injuries occur and how to reduce the risk can help you enjoy your holiday while protecting your joint health.

Why knee injuries are common in skiing

The knee is particularly vulnerable during skiing because the foot is fixed into the ski. Falls or sudden changes in direction can place excessive strain on ligaments, cartilage and surrounding structures. One of the most common ski-related knee injuries is an anterior cruciate ligament (ACL) tear, often occurring during a twisting fall or awkward landing.

Other injuries include meniscal tears, ligament sprains and overuse-related pain that develops over several days of skiing. Fatigue is a major contributing factor, as tired muscles provide less support and control around the knee joint.

Preparing your body before you travel

One of the most effective ways to reduce the risk of knee injury is to prepare your body well in advance of your trip – preferably six to eight weeks before travel. Strength and conditioning exercises that focus on the quadriceps, hamstrings, gluteal muscles and core can improve joint stability and control. Balance and proprioception training are also important, as skiing requires constant adjustments on uneven surfaces.

Equipment, warm-up and recovery on the slopes

Correctly fitted equipment plays a crucial role in protecting the knees. Boots that are too loose or too rigid can affect control and increase stress on the joint. Bindings should be professionally adjusted to your weight, ability and skiing style so that they release appropriately during a fall.

Warming up before skiing helps prepare the muscles and joints for activity. Gentle dynamic movements can improve circulation and joint mobility before heading onto the slopes. Equally important is cooling down at the end of the day, followed by adequate recovery. Stretching, hydration and rest allow tissues to recover and reduce the cumulative strain that can lead to injury later in the week.

Listening to your body is essential. Continuing to ski through pain or fatigue significantly increases the risk of injury.

When knee pain or injury occurs

If knee pain develops during or after skiing, it should not be ignored, particularly if there is swelling, instability or a feeling that the knee may give way. ACL injuries are common in skiing and can sometimes be mistaken for a simple strain in the early stages.

Mr Shah Punwar regularly treats patients who sustain knee injuries while skiing. One such example is his patient Sarah, who went on to complete a marathon following knee surgery after appropriate diagnosis, treatment and rehabilitation. Her story highlights the importance of early assessment and a structured recovery plan. You can read more here: https://shahpunwarortho.com/news/sarah-completes-a-marathon-after-knee-surgery/

Mr Punwar remains up to date with the latest advances in knee injury management and surgical techniques. He recently attended the Imperial Sports Knee Meeting, where modern ACL reconstruction and the management of complex multi-ligament knee injuries were discussed alongside international experts.

If you experience knee pain or instability after returning to the UK, early assessment is important. Mr Punwar can arrange appropriate investigations, including imaging, to reach an accurate diagnosis. Where possible, treatment will focus on non-surgical options such as physiotherapy and rehabilitation. However, if the knee is unstable or significantly injured, surgery can be carefully planned to support long-term joint health and a safe return to activity.

Skiing should be enjoyable, not limited by preventable injury. Preparation, awareness and timely assessment are key to protecting your knees both on and off the slopes.