After a skiing accident last winter, Sarah Foster, a keen athlete, running coach and busy mum to a young family, needed ACL reconstruction surgery.

Sarah was determined to get back to doing what she loved doing most, running. So, after researching experienced, specialist knee surgeons in London, she felt confident that her ACL surgery would be performed by Mr Shah Punwar.

Dedicated to her knee rehabilitation plan, just ten months later Sarah completed the hilly Beachy Head Marathon. She takes us through her own experience of ACL surgery with Mr Punwar and his team.

Finding the right knee surgeon

Following a ski accident that left her with excruciating knee pain, Sarah’s main concern was that her injury would take her away from her passion of running. Furthermore, she worried that it would affect her responsibilities as a running coach, not to mention a busy mum that regularly cycled with her children on the school run.

An MRI revealed that she had completely ruptured her ACL. Sarah followed the advice of her physio, so that she could get moving again. But, amidst lockdown restrictions, she was devastated not to be able to join in with the virtual running sessions alongside her friends from Greenwich Runners.

However, Sarah was delighted when the news came that she would be able to have ACL surgery. She looked into the pros and cons of surgery, and after a recommendation she spoke to expert knee surgeon, Mr Punwar and his team to find out her options. When Mr Punwar asked Sarah what her main goals were, she replied, “I want to run a marathon again.” His response was, “Well that’s what we’ll do then!”

Sarah’s ACL knee surgery

Sarah was encouraged by the success rate of ACL surgery, and she followed her physio’s advice so that her knee was as strong as possible before the surgery. Furthermore, this would ensure a good recovery after the ACL surgery.

Sarah met Mr Punwar and his team ahead of the surgery so that she could be assessed and have the procedure fully explained to her. Sarah said, “I left feeling very reassured and very happy to proceed with the ACL reconstruction.”

On the day of surgery, Sarah remembers being greeted warmly by the reception team. And the nurses that prepared her for surgery who she said, “really put me at ease”.

“I did some strength tests with the physio, that would be compared with after the surgery. Then Mr Punwar and the anaesthetist both came and spoke to me to explain exactly what would happen – I really felt quite special!”

Sarah recalled how quickly the procedure went, “I just remember talking to the anaesthetist, and then the next thing I was waking up in recovery! I don’t remember a single thing. The best thing was the cheese sandwich after. I was so hungry as I had to fast the night before the surgery.”

Sarah was given some pain relief medication to take away, and was able to leave the hospital the same day.

Sarah’s recovery – and a marathon goal!

Sarah recalls that she was “totally pain-free” in the days immediately following surgery. She quickly came off the painkillers and was able to walk without her crutches within a few weeks.

When she returned to see Mr Punwar at the 6 month stage, he was very pleased with how her surgery had gone, and how it looked.

“It was a very tidy scar,” she said. After conducting a few tests to check the knee’s strength, he said, “I am happy to discharge you!”

Sarah had the Beachy Head marathon, taking place in October, firmly in her sights. Mr Punwar and the physio team supported her fully in her goal, and guided her through an exercise plan. In the weeks that followed, she progressed with her training, made modifications, and was continually assessed.

Although confident in completing her goal, Sarah had lost a lot of fitness in the period after she was injured. So, rather than risk another injury by running the whole way, she decided to power walk her marathon with some of her fellow Greenwich Runners. When they crossed the finish line of the race together, Sarah felt a huge sense of achievement. Furthermore, she felt “no knee pain whatsoever!”

Sarah is now making plans for other races in 2022, including the Great North Run and, of course, another marathon. Sarah’s advice to others that are considering ACL surgery –

“Go for it! Mr Punwar has been fantastic, as were the rest of his team. The surgery has enabled me to carry on running marathons, which is what I wanted to achieve.”

If Sarah has inspired you, get in touch with Mr Punwar to discuss your own knee injury and to find out whether ACL knee surgery would be suitable for you.

It has often been speculated that too much exercise could have a detrimental effect on the health of our knees. Over time, there have been many studies conducted to establish whether there is a link between exercise and knee osteoarthritis.

Until recently, nothing was conclusive when it came to the amount of exercise being connected to knee osteoarthritis. However, new research has revealed that there is no link.

Cartilage Damage

In the UK roughly 1 in 10 adults have diagnosed osteoarthritis. This condition commonly occurs in weight-bearing joints of the hips and knees. Known as the ‘wear and tear’ arthritis, osteoarthritis is a painful long-term condition that is directly linked to cartilage damage. It causes the protective layer of cartilage in the joint to break down, decreasing its ability to be a shock absorber.

The exact cause for the development of osteoarthritis is not fully understood however the condition involves genetic, biological and biomechanical components.

The symptoms of knee damage include joint pain, swelling or stiffness, clicking of the joint and locking or catching joints.

Exercising and Knee Osteoarthritis

Research has revealed that specific recreational exercises such as running, cycling and swimming all have little direct connection to knee arthritis. However, more strenuous activities involving repetitive movements can lead to joint overuse or injury, and would put you at greater risk of osteoarthritis.

The study also confirms that time invested in leisure exercise is not connected with knee osteoarthritis. Nevertheless, further research continues into all of the components of physical activity such as the type, intensity, frequency and duration.

Misconceptions on Exercise

Exercise is an important part of protecting against osteoarthritis. This is because strong muscles help to support the joints. Additionally, people who exercise regularly tend to manage a healthier weight, which can also help protect the joints from osteoarthritis.

Furthermore, exercise can actually increase the level of anti-inflammatory chemicals inside the joints and these can protect against cartilage loss and joint damage.

Treating Knee Osteoarthritis

If you have severe knee pain, and you are concerned about osteoarthritis, there are treatments available. These include physical therapies, medications and self-management techniques. Knee joint replacement surgery might be your last resort, but it can be very effective in reducing your knee pain. What’s more, they can last for twenty years or more.

If you would like to find out more information about knee osteoarthritis and the options available to you, get in touch to arrange a consultation with Mr Punwar.

 

As we now move into the winter we are preparing for the shorter, colder days ahead. Temperatures in the UK are predicted to plummet to an average of around 4 degrees Celsius along with expected frosts. Winter is well known for causing significant challenges for those who are suffering from ongoing joint pain, and it’s not just one aspect that is responsible for this.

There are several contributing factors that can make dealing with joint pain through the colder months quite problematic.

Under Pressure

One of the primary factors that lead to winter knee pain is the changes in the air pressure. Prior to the cold weather arriving, the barometric pressure falls which causes the fluid and gas within the joint to expand which can lead to an uncomfortable feeling of painful pressure around your nerves.

Cold and Humidity

The cold temperature paired with higher humidity influence the cellular structure of both bone and cartilage. These changes can lead to feelings of expansion and contraction which can induce pain.

The nerves within your joints increase in sensitivity during the colder months and the lower temperatures can cause this sensitivity to increase.

As the temperature drops from the changing seasons, it can cause the fluid within the joints, called synovial fluid, to thicken. As a result, this thickened fluid impedes flow around the joint which can cause them to become stiffer.

Inactivity and Staying Indoors

During the winter months, it is common for activity levels to decrease. As the days become shorter and colder, people tend to spend more time indoors. This reduction in mobility is harmful to joints as they remain inactive which may lead to increased stiffness pain.

Staying indoors can also reduce the levels of Vitamin D your body absorbs from the sunshine. Some studies have shown a link between Vitamin D deficiency and joint pain, so it is important to ensure you have a nutritious diet or take supplements to boost your Vitamin D.

Treatment Options for Joint Pain

There are many things that can help to reduce the occurrence of joint pain in the winter which include wearing warm clothes, keeping fit and active, staying hydrated and immersing yourself in a warm bath.

Floatation therapy can also help alleviate the symptoms of joint pain as floating in warm water helps to remove the effect of gravity on the body and reduces the strain and stress on joints.

If joint pain is becoming unbearable and interfering with life, then you can talk to Mr Punwar about the different surgery options. If there is widespread cartilage damage that is causing you a lot of pain and discomfort, you might consider a joint replacement. To find out more, get in touch to arrange a consultation with Mr Punwar.

Cartilage damage is a common type of injury that often involves the knee joints, although it can also occur in other major joints around the body including the hips, ankles and also elbows. Here we look at the causes of damage and symptoms that lead to choosing knee cartilage repair surgery.

The Role of Knee Cartilage

Cartilage is a tough but flexible structure that forms the main type of connective tissue throughout the body. It forms a firm tissue that covers the surface of joints which gives them protection from impact, as well as allows the bones to slide comfortably over one another during active movement.

Usually, cartilage damage happens as a result of an impact injury, often sustained in sports, or through continual wear and tear over time.

Osteoarthritis Risk Factors

Osteoarthritis is a long-term condition that is directly linked to cartilage damage. This happens when the protective cartilage surrounding the joint breaks down, leading to swelling and mobility issues. The exact cause for this is unknown but risk factors include previous joint injury, conditions such as rheumatoid arthritis, family history, age and obesity.

Symptoms of Knee Cartilage Damage

Unfortunately diagnosing cartilage damage can be a challenge as it cannot be found through a physical examination alone. The symptoms of cartilage damage can include;

  • Joint pain
  • Swelling or stiffness of the joint
  • Clicking of the joint
  • Locking or catching joint

Magnetic Resonance Imaging (MRI) scans are commonly used to detect damage within the cartilage as the scan is able to produce detailed images to determine if there is any damage present.

Knee Arthroscopy Options

An arthroscopy is a form of keyhole surgery that is used to treat and diagnose joint issues. A small medical telescope is inserted into the knee joint in order for the internal structure to be accessed. The small incisions required means that the surgery is less painful and has faster healing times. Additionally, an arthroscopy promotes a lower risk of any infections occurring.

The following types of knee surgery are on offer with Shah Punwar:

Meniscal Surgery

Meniscal tears often occur due to twisting injuries which can lead to swelling, pain, clicking and issues with stability. Often, these types of injuries are unlikely to heal on their own requiring the meniscus to be either trimmed or removed entirely.

Cartilage Surgery

If the cartilage lining the joint is damaged then it can be probed and any loose flaps can be carefully smoothed. If the damage is full-thickness then a cartilage restoration procedure known as a microfracture may be considered. This is where small holes are made in the surface of the joint which aims to stimulate a healing response.

If you would like to find out more about knee cartilage repair options that would be suitable for you, get in touch to arrange an appointment with Mr Punwar.

A hip replacement is a common type of surgery where a damaged hip joint is replaced with an artificial one. This can totally transform quality of life and offers relief from a very painful joint as well as improved mobility. Adults of any age can be considered for this surgery however it is most common for individuals between the ages of 60 and 80.

Mr Shah Punwar uses both cemented and uncemented stem systems usually with an uncemented metal socket. He only uses hip components with a 10A* rating which are proven to have excellent long-term results on the National Joint Registry (NJR). Mr Punwar will be happy to discuss the choice of implant and the NJR during consultations.

What To Expect Post Operatively

After hip replacement surgery, you will be cared for by Mr Punwar’s healthcare team who will monitor you and ensure that you are well hydrated and managing any pain. You can expect to be in hospital for at least a few days and Mr Punwar will check on you to ensure that you are regaining mobility and have a satisfactory post-operative X-ray.

Nausea, loss of appetite, and constipation are all common following surgery but will usually return to normal function after a few days. Medication can be prescribed to aid recovery from these.

It is very common to experience ankle swelling and some bruising around the operation site and this usually takes several months to resolve.

During the first four-6 weeks following surgery, some general hip precautions may be advised in order to protect the hip whilst the muscles are healing eg: sleeping on your back and avoiding leg crossing, however following this period your normal sleeping position and activities can be resumed.

It is generally recommended that you refrain from driving until 4-6 weeks post-surgery as you will need to ensure that you are able to perform an emergency stop and put your foot down on the brake and clutch safely.

Rehabilitation After Hip Replacement Surgery

Following hip replacement surgery, you should be able to put all of your weight through your new hip, however, you will be guided with a rehabilitation programme provided by a highly skilled physiotherapist. Initially, you may need the assistance of walking aids however you will quickly progress to becoming independent.

You will be advised to take analgesic medicine to help reduce any pain or discomfort and allow you to maximise the required physiotherapy in order to aid a rapid return to normal mobility. You will have regular check-ups with Mr Punwar to make sure that you are recovering well.

Complications After Hip Replacement Surgery

In order to prevent the risk of developing any blood clots post-surgery, you are likely to be prescribed anticoagulation medication in either injection or tablet formulations. You will also be provided with anti-embolism stockings to wear which are also designed to help reduce the risk of blood clots.

There is less than 1% chance that the ball joint can dislocate from the socket. But the highest chance of this happening is within the first 6 weeks as the tissues around the hip are not fully healed. This is why some general hip precautions are usually advised.

It is also important to monitor your surgical wound as this will need to be kept clean and dry with the dressing changed regularly in order to reduce the chances of any external infection occurring.

Get In Touch

If you would like to find out more information about hip replacement surgery, please get in touch to arrange a consultation with Mr Punwar.

As we are now learning to adapt to life alongside COVID, athletes across the globe are eager to return to the arena. However, questions are being raised by professionals as to whether the prolonged break in training regimes could be damaging. And this will result in an increase in the occurrence of immobilising injuries – particularly anterior cruciate ligament (ACL) injuries.

A primary concern raised by professionals is that the break-in practice could lead to a higher rate of injury and re-injury. This would be a result of delayed and potentially compressed workload and gameplay as events resume.

Anterior Cruciate Ligament Injury

An ACL injury is a tear or sprain of the anterior cruciate ligament. This is a strong band of tissue that helps to connect your thigh bone (femur) to your shinbone (tibia). Most ACL injuries occur during sports after a sudden stop or change in direction along with jumping and landing. These injuries are very common in sports such as football, basketball, rugby and netball.

After surgery, it is unlikely that an athlete would return to play for at least nine months – which is a significant chunk of an athlete’s career. Additionally, re-tear rates are as likely as 20%. Although strengthening muscles around the knee, as well as balance exercises, can go a long way to reduce the risk of this happening.

Prolonged Breaks In Athletic Performance

The break forced by COVID is likely to have resulted in the deconditioning of important physical qualities associated with performance. Additionally, there are expected reductions in competitive match fitness and sport-specific skills.

The physical and psychological impact of competitive environments can also add an extra level of pressure. Especially for athletes who have not been in these situations for a prolonged period of time.

Currently, there are increased risks of playing sport in a world adapting to COVID, such as meeting social distancing requirements.  But there are also concerns that this extra pressure could be detrimental to athletes’ ongoing mental health.

Returning To Play after ACL surgery

Surgery to repair an ACL tear can help you to return to your previous athletic form. Furthermore, when training or a rehabilitation programme has been compromised, a graded return to full training is recommended.

For more advice on ACL injuries or if you have any other questions about returning to sport after surgery, get in touch with Mr Punwar today to arrange a consultation or book online.

Researchers from Lund University in Sweden have discovered that out of all cruciate ligament injuries, 69% can be explained by genetics.

This discovery may have important implications when predicting those individuals who are at higher risk of developing this type of knee injury. It will also enable more individualised injury prevention plans.

Anterior Cruciate Ligament (ACL)

The anterior cruciate ligament (ACL) injury is one of the most commonly occurring knee injuries. It is especially common among those who undertake sports on both amateur and professional levels.

The anterior cruciate ligament is a ligament in the knee which joins the femur (upper leg bone) with the tibia (lower leg bone) and its primary purpose is to keep the knee stable. It is commonly injured through motions such as sudden stops, changes in direction, and after jumping and landing with impact.

Genetic Origin

The main risk factors in sports, that result in an ACL rupture include playing on surfaces with high friction. Also, sports like basketball and football where there are sudden stops or pivoting. However new research is suggesting that it is also associated with risk factors that have a genetic origin. This includes bone geometry of the knee, malalignment and generalised joint laxity. This type of injury has also been linked to hypermobility.

An anterior cruciate ligament rupture can lead to reduced quality of life and is associated with up to 10 fold increased risk for developing osteoarthritis of the knee.

Osteoarthritis Genes Discovered

Almost 9 million people in the UK suffer from osteoarthritis. This degenerative joint disease affects the joints, that become damaged, painful and often very restricted. There is no current treatment for osteoarthritis and it is often managed through pain relief and often eventual surgery.

New research investigating the genetics behind osteoarthritis has revealed nine novel genes for osteoarthritis. The research will help to identify genetic risk factors for the disease. This might be a stepping stone into the understanding of osteoarthritis and the development of treatments.

By revealing how these genes contribute to osteoarthritis, this research could open the door for new treatments to help millions of people.

Get In Touch

If you have concerns about your knees and have a family history of knee joint problems, Mr Punwar can carry out a thorough examination, as well as MRI scans if necessary.

Mr Shah Punwar is highly experienced in treating ACL tears, as well as treating those with osteoarthritis. He can help advise on how to manage your condition and give you a personalised treatment plan. Get in touch and book a consultation today.

Knee replacement surgery is an operation to replace the damaged parts of your knee and is also known as knee arthroplasty. If there is widespread cartilage damage within the knee accompanied by pain and limited movement, a knee replacement may be the best option.

Before Knee Replacement Surgery

Before the surgery takes place, you will be able to speak to Mr Punwar in a consultation. He will make sure that you understand and are comfortable with the treatment and he will be able to advise on what to do beforehand to help ensure that it is a success. You should let him know if you are taking any medication, as this needs to be considered before you undergo any invasive surgery.

It’s also important to keep yourself fit and healthy especially in the build-up to your operation. This includes maintaining a healthy weight, exercising regularly and also making sure that you stop smoking several weeks before the operation.

In terms of skin preparation, it is a good idea not to shave or wax the area where the incision is likely to be and try to have a bath or a shower either the day before or on the day of surgery to prepare your skin and reduce the chances of infection.

During the Procedure

Once you are safely anaesthetised, an incision will be made on the front of your knee. Any damaged joint surfaces are removed and then replaced with an artificial knee joint. Mr Punwar only uses modern implants that have a good track record, and he will try to minimise tissue damage.

The skin is then closed using either stitches or clips and secured with a surgical dressing to keep the wound clean and minimise the risk of infection. To aid this you will also be given antibiotics before your surgery and several doses following the procedure to give you the best coverage.

Recovery

After the surgery, you will be cared for by Mr Punwar’s healthcare team who will monitor you and ensure that you are hydrated and managing any pain.

Mr Punwar will keep a close eye on you whilst you recover in the hospital for a few days after the procedure, ensuring that the results meet your expectations. It can take up to 2 weeks for your wound to heal and you will be given plenty of after-care advice.

You will have regular check-ups with Mr Punwar to make sure that you are recovering well. Most individuals recover and return to their normal activities within 6 weeks.

If you would like to find out more information about knee replacement surgery, please get in touch to arrange a consultation with Mr Punwar.

The most common form of arthritis of the hip joint is osteoarthritis (OA). This is characterised by pain and stiffness in the hip, usually worsening over time.

There is, however, another form of arthritis that can affect the hip joint. It is called rheumatoid arthritis (RA) – a chronic, inflammatory, progressive autoimmune disease.

Here, we take a look at the differences between these two forms of arthritis, what causes them and how they can be treated.

Osteoarthritis causes

OA of the hip is often known as a ‘wear and tear’ condition. This means that it can really affect anyone, as it is caused by overuse of the hip joint. This can occur in sport, or as a result of occupations which involve repetitive squatting. A break of the hip joint can also lead to OA years later. Problems with the hip in childhood and subtle anatomical mismatches between the ball and socket joint can also lead to OA in later years.

It usually presents in older people, however there is an increasing prevalence of osteoarthritis in younger people. It commonly starts in the 50s and affects women more than men.

Mainly affecting those who have led extremely active lives, or who are seriously overweight, it leads to pain mainly felt in the groin and difficulty bending down to put shoes & socks on or to get out of a low chair.

Rheumatoid arthritis causes

Rheumatoid arthritis is an autoimmune condition. This is when the body’s immune system has decided to turn on itself and start attacking healthy cells. It is still unknown exactly why this happens, but it is believed to have a genetic link. This sets up an inflammatory reaction in the joint with synovitis (inflammation of the joint lining) and erosions into the bone. The bone often becomes softer than in OA and this can lead to deepening of the hip socket and thinning of its floor.

Rheumatoid arthritis is more common in people with a family history of the condition. And similarly to OA, it also tends to affect more women than men.

Symptoms – osteoarthritis versus rheumatoid arthritis

The main difference in the symptoms of osteo versus rheumatoid arthritis, is that the problem may affect just one hip joint, rather than both. In both conditions pain is felt in the groin area or buttocks and sometimes on the inside of the knee or thigh.

Sufferers of both conditions may also experience a grinding sensation when trying to use the affected hip. Furthermore, they may find that the joint seems to ‘lock’ into place.

Rheumatoid arthritis often affects both hips. But people who have rheumatoid arthritis often first experience symptoms in the smaller joints, such as in the hands or feet. Then it spreads to larger joints like the hips. Other specific symptoms of RA include:

  • Pain and stiffness that may feel worse in the morning or after periods of resting or sitting
  • Pain that may lessen with movement and increase with vigorous physical activity

Treatment – osteo versus rheumatoid arthritis

Because rheumatoid arthritis is a chronic, progressive condition, symptoms are often managed using medication to prevent ‘rheumatoid flares’. This can help to alleviate some of the pain and swelling and in recent years, with the introduction of novel drugs, has led to a large reduction in severe rheumatoid cases.

Osteoarthritis can also be treated with medication, but other ways of managing symptoms are also recommended. People often find relief by making lifestyle changes and minimising the activities that aggravate the condition. This might mean switching your sport of choice to something lower impact.

Surgery

With both osteo and rheumatoid arthritis, surgery is something of a last resort. If your symptoms cannot be relieved with medication or lifestyle adjustments, then hip replacement surgery may be the answer.

Generally, total hip replacement surgery presents the best option for arthritis sufferers. This removes the whole hip joint and replaces it with a new surface. Mr Punwar uses both cemented and uncemented stems with excellent long-term results together with an uncemented metal socket. Cemented sockets are sometimes used with very weak bones, particularly in rheumatoid sufferers. Hip replacement relieves the pain of arthritis and restores movement to the hip joint.

Hip replacement surgery can have a dramatic impact on the quality of life. But you should always be aware of the risks, and be able to make an informed decision about the best time to undergo surgery. For more information, please call us on 020 8194 8541 to arrange a consultation with Mr Punwar.

There has been a dramatic increase in recent years of female athletes suffering from knee injuries. In Australia, the AFLW (Australian rules Football League for Women) saw 12 ACL injuries last season.

It is tempting to assume that this rise in knee injuries is mostly due to the increased media coverage that women’s sport is seeing. And that certainly goes some way to explain why we’re hearing about them.

But new research has shown that AFLW players are nine times more likely to suffer a knee injury than men. So this suggests that there is a biological cause.

Anatomical differences

One major reason put forward by medical experts for this gender imbalance when it comes to knee injuries, is the anatomical difference between men and women.

And the anatomical differences that cause the problem are not in the knees themselves, but in the pelvis and hips.

The female pelvis is designed for childbirth. This means the cavity is shallower and wider than in the male pelvis, and it tilts forward. This forward tilt impacts on the angle of the hip joint, which in turn can cause the femur (thigh bone) to be angled inwards.

As a result, unless the muscles in the core, hips and thighs are extremely strong, there is a tendency for the knees to be angled slightly inwards, which increases the risk of anterior knee injuries.

Hormonal differences

The other reason cited – although in fact it does tie in with the first – is hormonal. When boys go through puberty, they experience a rush of the hormone testosterone. This allows them to build muscle quickly.

The skeletal structure also changes during puberty, both for boys and girls. The skeleton becomes taller and denser, and an influx of testosterone allows boys’ bodies to cope with that. This means that the muscular structure is able to support the skeleton.

Women do have a small amount of testosterone in their system, but not enough to have a significant impact on their muscles. So while their skeleton increases in density and height, they don’t have the same muscular structure to support it.

How can women avoid ACL injuries

The key to avoiding knee injuries is to increase the strength of the hip and thigh muscles. Any weakness in these muscles will correspond to problems in the knee. This includes anterior knee pain or patellofemoral syndrome as well as ACL tears.

In Australia, as a result of this recent research, the AFLW has instigated a ‘prep to play’ regime. This focuses on the implementation of specific strengthening exercises for the hip and thigh muscles.

Another way to help protect your knees from injury is to practise ‘balance training’ – this essentially means trying to balance on one leg on progressively less stable surfaces. This helps to build up the muscles around the hip, knee and ankle.

Mr Shah Punwar is highly experienced in treating ACL tears and has an excellent track record. He submits all his ACL cases to the National Ligament Register, allowing long term follow-up and monitoring of outcomes.

Surgery to repair an ACL tear can help you to return to your previous athletic form, but expect a structured rehabilitation programme to prevent re-injury. Also, if you are returning to contact sports, expect to be on the bench for at least nine months post-surgery.

If you have concerns about ACL injuries and would like to consult with Mr Punwar, please call us on 020 8194 8541 or email Punwar.admin@lips.org.uk .

 

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