The Good Doctors Guide: Meet the best knee replacement surgeons and learn what exercises to do before your operation
- The Daily Mail has asked consultants who they would refer loved ones too
- Consultants who earned the most votes are the ones who made it into our guide
- Patients should bear in mind The Daily Mail’s research is not a scientific study
What are the hallmarks of a good doctor? Technical expertise and skill, of course — but someone who understands you, someone you trust, is also vital.
Indeed, research shows that a good relationship with your doctor can improve the chances of a successful outcome. But how do you find a specialist who fits the bill?
That’s where this unique series of guides, running every day this week in the Mail, can help.
We’ve identified the country’s top consultants — as judged by their peers. We’ve canvassed the views of more than 260 consultants across seven specialties from around the country, and asked them this very simple, but key, question: If your own nearest and dearest were to need treatment in your field, to whom would you refer them — and why?
The consultants who earned the most votes from their peers are the ones who made it into our guides — though patients should bear in mind that this is not a scientific study.
And, of course, there are many superb and highly skilled specialists all over the country who didn’t make it on to our list, but who spend every day transforming patients’ lives.
To help you make informed decisions about your care, we’ve also talked to experts about the latest thinking on treatment. Today, we focus on knee replacement surgery…
It can make sense to delay surgery
Knee replacement surgery is the most common type of joint replacement operation in the UK, and the number of patients having the procedure is rising.
The average age for getting a new knee is 69, but what worries some experts is that the percentage of younger people going under the knife for this major procedure is on the rise.
Almost 110,000 knee replacements were carried out on the NHS and privately in the UK (excluding Scotland) in 2016 — 30 per cent more than in 2010.
And osteoarthritis — wear and tear of the joint that causes pain and deformity — is the reason for virtually all cases.
Obesity is partly blamed for the boost in demand from younger patients; a joint overloaded with excess weight will wear out faster.
But another factor is that ‘the current generation of people aged 40-65 are less tolerant of putting up with a painful knee,’ says Richard Spencer Jones, a knee replacement surgeon at The Robert Jones and Agnes Hunt Orthopaedic Hospital in Shropshire.
He is not suggesting that we should be more robust about pain, rather that he fears the fallout from people swapping their own rickety knee for a replacement too soon, as ‘some of these people will live well into their 90s and that knee is likely to need replacing a couple more times — [these will be] increasingly challenging procedures with more risks and potential complications’. In fact, 20 per cent of knee replacement patients are not happy with the result and 5 per cent feel worse off after, says Philip Mitchell, an orthopaedic surgeon at St George’s Hospital and the Fortius Clinic, both in London.
How to see the specialist you want
It’s a little-known fact, but under the NHS Constitution, patients in England have the right to choose where to receive their NHS treatment — which means you can ask to have your treatment in any hospital or clinic anywhere in the country, as long as it has the necessary expertise.
Your GP can arrange a referral to the specialist you would like to see. You (and your doctor) can access the electronic national referral service, called the NHS e-Referral Service, which allows you to select your hospital or clinic as well as the date and time of your first appointment.
This is not a guarantee that you will see a specific consultant — and there may be a waiting list for that specialist. You must also consider practical reasons for not travelling too far; if you need hospital treatment, you may not want to be hundreds of miles away from family and friends.
Note that many of the specialists in our guides work in private practice, too, so seeing them privately may also be an option.
‘Unfortunately, if you do an MRI of the painful knee of someone in their 60s, you will definitely find some arthritis.
‘What it won’t show is the degree of pain, or if replacing that knee will make it better. Yet armed with this MRI, the patient will almost certainly find a surgeon prepared to operate.’
All orthopaedic surgeons tend to agree that the timing of a procedure is critical in achieving the best result for patients.
Operate too soon and patients with a stiff and occasionally painful knee are unlikely to be happy with the replacement.
Delay too long and you risk making patients miserable, housebound and potentially suffering more muscle-wasting and deformity — resulting in more complicated surgery and a more challenging rehabilitation.
There are concerns that the increasingly long waits too many NHS patients face for surgery may have implications for this.
At the knee unit at The Royal Devon and Exeter Hospital, surgeons will often first try using conservative measures with borderline patients before they undertake surgery.
‘Think of this as a pre-emptive strike,’ says Professor Andrew Toms, an orthopaedic surgeon at the hospital. ‘Typically, this will be a mix of exercise, physiotherapy, weight loss and painkillers with the objective of trying to reduce patients’ pain and improve knee function sufficiently to avoid or stall knee replacement surgery.
‘If after going through this, patients don’t feel they have improved, then I will operate,’ says Professor Toms.
Knee replacement falls into two main categories: partial knee replacement, where just one compartment of the arthritic knee is replaced; and total knee replacement, the choice for patients with widespread arthritis, where two or three compartments are replaced. The advantage of partial replacement is that it is a smaller operation which preserves the ligaments, so the chances are it will feel more like a normal knee; with total knee replacement one or both of the main (cruciate) ligaments are sacrificed. But one of the drawbacks is that surgeons who do few of them get worse results than with a total knee replacement (see box overleaf).
After surgery, patients have to brace themselves for hard work to regain full function in their new knee. But patients still struggling with pain six months or so later should have no qualms about returning to their consultant to be investigated, says Andrew Porteous, a knee surgeon at Southmead Hospital in Bristol.
‘This could be caused by infection or because the knee was done badly — some surgeons try to fob patients off because they are worried a number of re-dos will flag a problem with the data they have to submit to the National Joint Registry [which publishes outcomes for every orthopaedic surgeon and hospital unit]. So they will do X-rays and say, “These don’t look too bad, off you go.”
‘In instances like that, the patient should go back to their GP and ask for a referral to a regional centre.’
So how do you avoid the pitfalls and pinpoint the very best knee replacement surgeon? The best are high-volume surgeons, who do a large number of operations, and are expert in both partial and total replacements, so you get the full range of options. Patients can check their prospective surgeon’s profile on the National Joint Registry website to see how their surgeon’s caseload measures up against the average (see right).
To identify the country’s very best knee replacement surgeons, we canvassed the views of almost 40 leading consultants from around the country. Here, we reveal their choices, with a selection of personal comments about why they chose them.
Knee Replacement surgeons rated by their peers
PROFESSOR ANDREW TOMS
Royal Devon & Exeter Hospital
WHAT THEY SAY ABOUT HIM: ‘A leader in knee replacement. When he was drafted into the Royal Devon, it was renowned for hip replacement. He has now put the hospital on the map for knees in the same way,’ says one of his peers. ‘He is honest and thorough and discusses the risks and benefits of surgery with his patients.’
‘Andrew has made it his life’s work to eradicate every painful knee in the country,’ adds another. ‘He takes on very complex and challenging cases and sorts them out.’
PRIVATE: Nuffield Health Exeter Hospital.
Southmead Hospital in Bristol
WHAT THEY SAY ABOUT HIM: ‘He is measured, hard-working, considerate and highly skilled in all aspects of knee replacement,’ one of his peers reveals.
‘He tailors his surgery to the needs of his patients and is a firm advocate of partial knee replacement where appropriate — his view is that a lot more knee replacement patients could benefit from partial knees.’
PRIVATE: Spire Bristol Hospital, Nuffield Health Bristol Hospital.
Nottingham City Hospital
WHAT THEY SAY ABOUT HIM: ‘Quietly spoken, gentle and with a beautiful pair of hands — in other words he is technically gifted. When you see him operate, he makes everything look so easy. He does a lot of revision [when the implant has failed and has to be replaced] and complex work,’ says one surgeon.
‘He did my dad’s knees and is undoubtedly the most experienced and able knee surgeon in the country,’ says another.
PRIVATE: BMI The Park Hospital in Nottingham.
RICHARD SPENCER JONES
The Robert Jones and Agnes Hunt Orthopaedic Hospital in Oswestry
WHAT THEY SAY ABOUT HIM: ‘Highly knowledgeable, he is excellent technically and renowned for his revision surgery. At this top level everyone is dexterous, but he manages to stay cool even with the most challenging cases,’ says one. ‘He gets very good results and is the sort of person you’d want to operate on you,’ reveals another of his peers.
PRIVATE: The Robert Jones & Agnes Hunt Orthopaedic Hospital (private care), Nuffield Health Shrewsbury Hospital.
Musgrave Park Hospital in Belfast
WHAT THEY SAY ABOUT HIM: ‘A quietly spoken, gentle man who has the most phenomenal work capacity and who does no private work. He was brought in to clear the waiting lists in orthopaedics in Northern Ireland and has made it his life’s work, but unfortunately this has faltered in recent years due to further demand and no additional funding to pay for it,’ comments one.
‘A dedicated and very good surgeon.’
PRIVATE: Mr Beverland does not work privately.
PROFESSOR LEE JEYS
The Royal Orthopaedic Hospital in Birmingham
WHAT THEY SAY ABOUT HIM: ‘He does lots of complex revision knee replacements [where the implant fails and has to be replaced] where he deals with infection, bone loss and rebuilding bones and ligaments,’ according to one of his peers.
‘A lovely chap with a great pair of hands who also does primary [first-time] knee replacement, but he has carved out a niche for himself with challenging revisions.’
PRIVATE: BMI The Priory and Edgbaston Hospitals.
Royal National Orthopaedic Hospital in Stanmore in London
WHAT THEY SAY ABOUT HIM: ‘Loads of experience and he does everything from primaries, in other words the first knee replacement, to revisions, when implants fail and have to be re-done,’ says a fellow surgeon.
‘He’s very straightforward and if he feels knee replacement will not work for you, he will say so and spare you lots of unnecessary investigations,’ says another.
PRIVATE: Royal National Orthopaedic Hospital (private), The Wellington Hospital, both in London, Spire Bushey Hospital in Watford.
PROFESSOR ANDREW PRICE
Nuffield Orthopaedic Centre in Oxford
WHAT THEY SAY ABOUT HIM: ‘Part of the next generation, he is very good technically and at teaching,’ says one. ‘He has a fantastic reputation which is well-deserved and his patients are fond of him.’
PRIVATE: Nuffield Health The Manor Hospital in Oxford.
Also highly thought of:
Nuffield Orthopaedic Centre in Oxford
WHAT THEY SAY ABOUT HIM: ‘Excellent dedicated knee surgeon who is a specialist in partial knee replacements.’
PRIVATE: Nuffield Health The Manor Hospital in Oxford.
Basingstoke and North Hampshire Hospital
WHAT THEY SAY ABOUT HIM: One of his peers describes him as ‘an excellent surgeon, recognised as an expert in early interventions such as osteotomy.’ This is where either the top of the shinbone or the bottom of the thighbone are cut and shaped to realign the knee and ease pain. ‘He believes you can sometimes hold off replacing the knee for a while with this.’
PRIVATE: BMI The Hampshire Clinic.
Chelsea and Westminster Hospital in London
WHAT THEY SAY ABOUT HIM: ‘Very empathetic, level-headed and what we in medicine refer to as a good pair of hands. He would not operate unless he felt it absolutely necessary,’ according to one of his peers.
PRIVATE: Bupa Cromwell Hospital, The Lister Hospital, Fortius Clinic, all in London.
DAVID HOULIHAN- BURNE
Hillingdon Hospital in West London
WHAT THEY SAY ABOUT HIM: ‘Gifted technically and down to earth, he gets on well with his patients and is a great communicator.’
PRIVATE: Bupa Cromwell Hospital, Fortius Clinic, both in London, BMI The Chiltern Hospital in Buckinghamshire, BMI Bishops Wood Hospital in Middlesex.
Royal Derby Hospital
WHAT THEY SAY ABOUT HIM: ‘Old-fashioned in the best sense, sensible and meticulous. He’s not interested in fads. He does things because they work and have been shown to work over a long period of time,’ reveals one surgeon. ‘He is a thinker, who pays great attention to detail. He does knees awesomely once, so they last a jolly long time.’
PRIVATE: Nuffield Health Derby Hospital.
Tunbridge Wells Hospital in Kent
WHAT THEY SAY ABOUT HIM: ‘A lovely man and excellent technically, very good with patients, he is very thorough and pays great attention to detail,’ says one.
PRIVATE: Nuffield Health Tunbridge Wells Hospital, The Horder Centre in Crowborough.
University Hospital Coventry
WHAT THEY SAY ABOUT HIM: ‘He was my choice for both my father’s knees,’ one of his peers reveals. ‘A senior surgeon who pays great attention to detail and is very self-driven and organised.’
PRIVATE: Nuffield Health Warwickshire Hospital, Fortius Clinic in London, Spire Little Aston Hospital in Birmingham.
PHILIP CHAPMAN- SHEATH
Southampton General Hospital
WHAT THEY SAY ABOUT HIM: ‘Technically a really excellent surgeon who does both partial and total knee replacements and primary [first] knee replacement and lots of revision surgery [where the implant fails and has to be replaced]. Also a very nice guy.’
PRIVATE: Spire Southampton Hospital, Nuffield Health Wessex Hospital.
The questions to ask your surgeon before you sign up
How often do you operate?
‘Patients shouldn’t be afraid of asking their surgeon about the number of knee replacements they carry out,’ says Professor Phil Turner, a knee surgeon at the NHS Stepping Hill Hospital in Stockport and vice-president of the British Orthopaedic Association. ‘The key is accuracy putting the implant in and, in general, the more operations a surgeon does, the better they will be at it. If a surgeon is doing fewer than 20 a year, that’s not a good sign and patients should think about going elsewhere. Most specialist knee replacement surgeons will be doing a least 150 a year.’
How many knee ops do you have to re-do?
Ask your surgeon about his or her revision rate (where a failed implant needs replacing). You can also check The National Joint Registry, which has information on over two million joint replacement operations in England, Wales and Northern Ireland since 2002. This includes more than 2,000 individual surgeons’ results and how they compare with the national average. It also provides data on the number of knee replacements, revisions and mortality rates by hospital. If yours has a higher-than-expected revision rate, ask why. Rather than a red flag, it could mean they’re specialists in salvaging knees when surgery has gone wrong (and such surgeons are very well-placed to avoid such mistakes themselves). See njrsurgeon hospitalprofile.org.uk and njrcentre.org.uk
Should I try anything else before I go under the knife?
An artificial knee will never be as good as your own — most patients rate them about three-quarters as good, according to the charity Arthritis Research UK. Plus, surgery carries a risk of infection, bleeding and the implant failing, so if you don’t need it, you don’t want it. There are options to try before surgery, ask your surgeon if you are suitable. ‘If you wait too long, the knee gets stiffer and more deformed,’ says Professor Turner, ‘and results of surgery are worse if knees are really bad to start with.’ Steroid injections can ease inflammation and pain, while physiotherapy strengthens the thigh muscles that support the joint. Orthotics (insoles to correct knee alignment and gait) or an ‘off-loading’ knee brace (which applies pressure to the unaffected side of the knee) may have ‘some benefit’, he adds. But in most cases, these only delay surgery by six months to a year.
Are there other surgery options for me?
Arthroscopy — keyhole surgery to clear debris in the knee — used to be common for osteoarthritis, but is now rapidly in decline as NICE has said it doesn’t help. A recent review of 25 studies in The BMJ concluded that the procedure offers no ‘important benefits’, as it neither reduces pain nor improves function and mobility, and carries risks of pain, swelling and difficulty putting weight on the leg. But osteotomy — where bone is added or removed from a damaged joint to shift the weight away from the damaged area — can ‘buy’ most patients ten or 15 years before having a knee replacement. Professor Adrian Wilson, a knee specialist at The Wellington Hospital in London, says osteotomy is the ‘operation of choice’ for people who want to stay active. ‘Wherever possible we advise joint preservation procedures such as osteotomy,’ he says.
Could you get away with just HALF a knee op?
During a knee replacement operation, the worn ends of the thigh and shin bones and any remaining cartilage are removed and replaced with titanium or cobalt-chrome components.
Almost all knee replacement operations — which take around an hour — are carried out through a 10 in incision down the front of the knee. Just 5 per cent of procedures are keyhole (through a 5 in incision).
Here, we guide you through the different types of implants on offer.
If arthritis affects only one side of the knee, it may be possible to have a partial knee replacement, where only the damaged bone is scraped out and replaced.
Most partial replacements are mobile-bearing implants, which means the plastic insert replacing the cartilage is not fixed to the metal part of the implant attached to the shin. Mobile-bearing is said to wear better in partial knee replacements, but needs support from existing tissue, so isn’t suitable if you have ligament problems.
Because the operation is less invasive than total replacement, as less bone is removed, recovery is quicker and the knee functions better afterwards.
‘It is not uncommon to be off your crutches at two weeks and walking normally by four to six, compared with a total knee replacement where you are off crutches by six to eight weeks,’ says Professor Adrian Wilson, a knee specialist at Winchester University and The Wellington Hospital in London.
A recent study in BMJ Open suggested that half of patients needing a knee replacement could be suitable for a partial replacement. The Oxford University study found that when partial replacements are carried out by surgeons who do lots of them, the outcomes are better than total knee replacements — and it’s cheaper for the NHS.
If arthritis affects only one side of the knee, it may be possible to have a partial knee replacement, where only the damaged bone is scraped out and replaced (stock image)
However, if the surgeon only does a small number of partial operations, the outcomes are worse than a total replacement.
Researcher Professor David Murray said: ‘This is an important finding. If surgeons use partial knees in a quarter or more of knee replacements, this will improve results, save money and more patients will benefit.’
Currently, partial replacements are only used for 20 per cent of patients — more commonly younger, slimmer, active ones — as for most patients the wear and tear in the knee is too advanced and the ligaments are not strong enough.
Although movement can be better afterwards than with a total knee replacement, figures from the National Joint Registry suggest a partial replacement is also more likely to fail.
Around 10 per cent will need a second operation after ten years compared with less than 5 per cent with full replacement.
This is the most common type of knee replacement surgery, used in 75 per cent of cases. It involves replacing joint surfaces at the end of the thighbone and top of the shinbone and inserting a plastic spacer in between; this acts like cartilage, helping the joint move freely.
There are several versions of this operation and 60 different prostheses can be used.
Cemented OR uncemented? Most artificial knees are cemented into the ends of the thigh and shin bones for greater stability. If cement is not used, the surface of the implant facing the bone is coated to encourage bone to grow on to it, forming a natural bond.
Uncemented knees are more expensive, but the surgery is quicker, and some say it fits to the bone better. But there is little difference in results.
FIXED VS MOBILE: Normally, the plastic spacer in an implant is fixed to the metal plate on the end of the shin (a fixed-bearing joint) but, with a mobile-bearing joint, the spacer can rotate within a certain range on the plate, so it can ‘find its own position of comfort’, says Howard Ware, a knee surgeon at Chase Farm Hospital in London. It’s thought this reduces wear and tear, but there’s no evidence yet it’s better than fixed bearing for total replacement.
LigamentS: Keep or sacrifice? Ligaments are bands of fibrous tissue that connect bones to each other. They are essential for keeping the joint stable.
Some knee implants retain the posterior cruciate ligament (PCL) which runs from the back of the shin to the bottom of the thigh; others involve removing it (as the implant is differently shaped) to give the knee the equivalent stability.
If the PCL is retained, it should make the knee feel more ‘normal’, but is only suitable for those with ligaments strong enough. Yet research shows keeping or removing the PCL makes little difference to the functioning of the knee.
Kneecap: resurface it or not?
A total knee replacement may also involve replacing the under-surface of your kneecap with a smooth plastic dome.
Surgeons are split 50:50 on whether this should be done.
Those in favour say it’s an opportunity to treat arthritis in the kneecap as well as the joint itself and reduce pain afterwards, so there’s a lower risk of further surgery. Those against argue that treating the arthritis in the main part of the knee is enough to treat the pain, and resurfacing the kneecap can cause problems of its own.
‘Persistent pain after a knee replacement can occur, and when it does it can be a significant problem,’ says Mark Wilkinson, a professor of orthopaedics at Sheffield University who operates at Claremont Hospital in Sheffield.
This is thought to be caused by the way the nervous system works in some patients. ‘Anything to reduce that risk makes sense, so I always resurface the kneecap,’ he says.
Deluxe models may not be worth it
FEMALE IMPLANTS: Some artificial knee joints have been designed to more closely match the size and shape of an average woman’s knee. But there’s no research to show ‘gender specific’ implants last any longer or provide better function — most ‘off-the-shelf’ artificial joints come in a range of sizes anyway.
TAILOR-MADE IMPLANTS: Scans and computer software are now being used to tailor the surgery, implant and even surgical tools to the individual patient’s anatomy. But it’s significantly more expensive — several thousands of pounds rather than £800 to £1,000 for an off-the-shelf knee.
‘These techniques are available on the NHS as well as privately but are rarely used (less than 1 per cent of knee replacements) in the NHS because they’re more expensive, time-consuming and haven’t been shown to provide significantly better results’, says Howard Ware, a knee surgeon both in Chase Farm Hospital and The Wellington Hospital.
‘A tailor-made replacement would only be available on the NHS if the knee is severely deformed.’
The future, he says, is still conventional implants using standard instruments.
‘For most people this is going to give you the best results in the hands of an experienced surgeon.’
ROBOTIC SURGERY: Patients are given similar or the same prostheses as with traditional surgery, but a robotic arm improves the accuracy of it, according to a 2016 study in the Journal of Bone and Joint Registry.
Raghbir Khakha, a knee surgeon at Guy’s and St Thomas’ Hospital and The Wellington Hospital, says robotic surgery is not the ‘Holy Grail’, but can help improve the fit.
‘However an experienced surgeon should be able to do that anyway.’
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