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Knee ligament reconstruction

 Poster: A snowHead
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Advice needed on torn knee ligaments. My daughter has had a bad snowboarding accident in Courchevel, all four ligaments broken. She is now back in the UK and we are trying to find the best surgeon for the job. We are in Battle East Sussex but will travel to get her the best treatment. We are not wealthy so will be NHS. The people we've spoken to so far have told us what a nasty injury it is but haven't said anything that's filled us with confidence. Any advice would be gratefully received. Thanks, Paul Sedgwick.
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The resident expert here is Jonathan Bell (an orthopaedic surgeon specialising in knee ligaments) - hopefully he’ll be along soon...
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@Paul Sedgwick, I didn’t think you could chose your consultant on NHS? You can request chose and book but that only allows you to chose the hospital location from a list your GP sets up, it doesn’t let you select the consultant.

As to private. Jonathan Bell ( he posts on here) at Wimbledon clinic has a very good reputation.

The consultant did my original ACL recon was very good Mr O’leary He was at Royal Berkshire (Reading) when he did mine.
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Thanks Nicky. Have just painfully realised that after talking to my GP this evening. If you're not private you have little choice, its local or nothing as NHS referral to a different area takes months, time we don't really have.
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@Paul Sedgwick, requesting they set up choose and book will at least allow you to pick the hospital with the earliest appointment. By requesting that last time I did my knee in it meant I was seen 2 weeks later rather than 3 months later, and as I was non-weight bearing with a locked knee that was needed. I was being referred directly to a consultant who could book me straight for surgery as I paid to see a consultant and I had paid for an MRI to get a letter stating what was wrong and what needed to be done... letter stated I needed urgent surgery. When the consultant I was referred to saw me, the MRI and report he started muttering and told me I should never have been sent home from A&E and he got me booked in the following week apologising that it couldn’t be sooner (he had to argue with his secretary about me taking that slot, as I don’t think it was earmarked for an NHS patient Happy)
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@Paul Sedgwick, ouch. Poor girl. Hope she gets to see a decent surgeon.
Please accept my sympathies on her behalf.
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@Paul Sedgwick, gosh, that sounds - well, not at all nice. Very unusual to do all 4 in 1 knee all together. My sympathies.
I would have thought that with these injuries she should command the interest of some pretty competent people.
Google will/should give you some idea of the NHS consultants who are available to you (as others said, via C&B). You could also try the Knee Guru site.
Just to be clear, if we can help you more because if it, has she "torn" (i.e. partially ripped) all 4 (and all in the same knee) or "broken" as in 'ruptured' completely all 4, or a mixture - or don't you yet know? Has she had x rays, MRIs etc? Are there any other injuries associated? Have you been told that she must have surgery, and when, or is that your assumption?
I presume that she is under the care of the GP and a physio, and a local acute NHS knee clinic?
The good news, potentially, is that 3 out of the 4 ligaments, if not too badly damaged, can heal themselves - though it won't be so easy when their friends aren't there to help them.
Wishing you all the best; it might be a bit of a haul but I'm sure she'll make it back in time.
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Thank you Nicky Frosty and Grizzler. That's all incredibly helpful info. She has had an MRI scan. I don't honestly know if the ligaments are damaged or torn right through. There are no other injuries, it's just the right knee. She can't bend it or put any weight on it. I was hoping that the consultants at our local hospital would say helpful and encouraging things, they've just said it's serious and possibly life changing. All very worrying. Ellen is 21 and fit, she wants to snowboard again next season. I will digest what you guys have told me and hopefully get somewhere. Thanks again.
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If Johnathan Bell turns up I'd like to ask his advice on my wife's Tibial Plateau Fracture, its not displaced .. but she is worried about what she is going to be left with,
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Hi Jonathan Bell. The MRI has confirmed that my daughter has completely torn the medial and lateral collateral ligaments and the anterior and posterior crucial ligaments.
We are starting to panic slightly as to the best way forward .
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@Paul Sedgwick, you need an appointment ASAP with the best knee surgeon to yu. Perhaps an initial private consultation with that person will at least get you on their list.

I would have thought this was an urgent case as without ligaments the knee will be incredibly unstable and prone to further meniscus damage.
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@Frosty the Snowman, I think the OP's daughter has already seen his local hospital's consultants and they have recognised the seriousness and implications of this. My instinct, like yours, is the same: but I am not an expert knee doctor, and I would seriously hope that she has managed to get an examination by one of those, even at the local level (some of whom are very good at what they do, or so one would hope). I don't know what she has been advised as yet, and it may (will, I hope) be good advice for her case. I would presume that she is braced up and resting. Perhaps they intend to see how well, if at all, the ligaments which can heal do heal. Perhaps they are waiting for swelling to go down and then will reassess and plan accordingly. We don't know. I hope that she has a follow-up appointment booked.

I would also suggest an initial private consultation with a specialist who also does NHS lists, and it isn't too expensive, considering: but they charge ridiculous sums if X Rays or MRIs are also required (though the OP says there is an MRI already, which is a blessing).
The problem which the OP doubtless has, and is asking, is which surgeon does she go and see? This is where getting a list of available ones via the GP and then Googling them is necessary. I don't know how else you do that. Sometimes local physios know, if you can find ones who deal with a lot of knee surgery, particularly via local private hospitals which the surgeons operate at. That's also a more direct route to investigate: the private hospitals directly.

@Paul Sedgwick, I hope that some of the above is helpful, and I really do hope that your daughter is getting suitable care via the local hospital. I understand the panic (having done only my MCL and ACL, but on both legs) and uncertainty. Go and talk it through with your or your daughter's GP if you have concerns. Google is great, and very informative, but also take with a pinch of salt as always.
The good news is that your daughter is young and fit: muscle strength is so important in knee injuries, although at the moment and the next few months may be not there. Investing in strengthening and stretching work is vital, and will be her life for the next season or two at least; I think realistically that she is not going to be boarding next season, except perhaps trying a few gentle bits at indoor domes or wherever, but there is no reason why not in a couple of years' time, hoping that they have managed surgically to reattach everything and that it has all gone well. It's a nasty injury and it can be life changing in terms of carrying a bit of weakness and pain from here on, a few niggles acquired and carried, but that's not to say that a reasonable to complete recovery cannot be made also, and I would hope that there is a good chance of that. She probably will need to buy a good brace though.
Physiotherapy is going to be vital, and I would recommend tracking down a specialist if one is available, as well as taking advantage of hospital and GP-based services - but it's not in my view essential to spend huge amounts on it (private ones, I mean) if your daughter can do the exercises and work herself. Depends on what's needed and when, obviously. Have you consulted one yet? Might be worth at least a word, though it's possibly too soon to do much, given the injuries.
Bear in mind also that there is not always an urgent action to be done (caveat, not a doctor, but I presume that her consultants so far will have assessed that need). Sometimes time is needed for the initial trauma to settle, for the swelling and inflammation and all the physiological things going on to settle down, and then they can assess what stability and problems she has and what they can best do about it and when. Sometimes they will then surgically reattach or mend several or all ligaments at once, sometimes they will do them in stages. Different surgeons have different opinions I suspect. The important thing for her to do in the meantime is to deal with the practicalities of the injury and to accept where she is, unpleasant and annoying as it is and could well be for a few years onwards. And to rest and take care of her injuries and not irritate things further.
I know that it's not easy, but try not to worry or panic too much. Bodies, especially younger ones, heal. Even older aching ones sometimes surprise you (I have not had surgery on either knee and am back skiing and baording, although having acquired a few aches and pains a bit prematurely - others on Snowheads are also coping without surgery, and those who have had surgery also are doing well. If you want to read some tales, there are many threads on here - and some people have done some pretty nasty injuries too, fractures as well as ligaments.)
Annoying that there's still boarding to be done, but at least there's a summer coming to start resting and getting things sorted.
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The Horder centre in Crowborough East Sussex has a good reputation and takes NHS referrals. It may be worth seeing if she can access them through the NHS
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Thanks Grizzler. That is massively helpful and comprehensive, just read it out to my wife and daughter who have gained comfort from it. We have a friend who is an excellent physio, she came around this morning for an informal chat and to discuss reply simple things that Ellen can do now. Also the correct way to ice the area. We are now doing research into consultants various including local ones. It's quite a rare injury apparently and not that many people seem to have had patients with all four ligaments gone. She is braced and resting and has had an x ray and MRI.
We are trying not to panic, the odd glass of whisky in the evening is helping!
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@Paul Sedgwick, so sorry to read this. Jonathan Bell works from here: https://www.wimbledonclinics.co.uk/about-us and you will see that they offer a free telephone consultation. If you mention the magic word 'snowHeads' I guess he might speak to you himself.
FWIW I would trust his advice even though the nearest I've got to him (so far!) was when his wife (who also works there and is a brilliant physio and diagnostician) showed him an x-ray of my knee she wanted a second opinion on last year. In case you don't know, they are both keen skiers.
The very best of luck with whatever happens next.
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Paul Sedgwick wrote:
Thanks Grizzler. That is massively helpful and comprehensive, just read it out to my wife and daughter who have gained comfort from it. We have a friend who is an excellent physio, she came around this morning for an informal chat and to discuss reply simple things that Ellen can do now. Also the correct way to ice the area. We are now doing research into consultants various including local ones. It's quite a rare injury apparently and not that many people seem to have had patients with all four ligaments gone. She is braced and resting and has had an x ray and MRI.
We are trying not to panic, the odd glass of whisky in the evening is helping!


Don't worry too much - reconstructing knee ligaments is bread n butter to leg orthopods so I'm pretty sure it will all work out in the end. Push and project manage the NHS as much as you can for an early op date but don't panic if its not for a month or so as initial swelling has to go down. Then she needs to be prepared to put in the rehab as directed - not overdo it early but certainly but the work in when it is allowed.
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@Dave of the Marmottes, Yes and not sure - I have never come across a single incident, total ligament rupture.
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Frosty the Snowman wrote:
@Dave of the Marmottes, Yes and not sure - I have never come across a single incident, total ligament rupture.


Woman at our sailing club had a complete knee blow out in a windsurfing fall - only thing holding her knee in place was her wetsuit. She had it very successfully rebuilt by Andrew Langdown at Portsmouth Hospital Trust and skis, runs, sails and windsurfs quite happily. I have a couple of colleagues who have been treated by him and they are very pleased with the result.

I saw Naill Flynn (also of Ports HT) for my ACL rupture - i cheated, paid privately for the initial consultation and then got bumped up his NHS list. I was very impressed, he skis himself and is also missing ligaments and meniscus so understood the issues.

As others have said, Paul Sedgwick, your daughter has youth on her side and whilst it probably all seems devastating right now she will repair.
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@Paul Sedgwick, I second others’ suggestion that, budget permitting, it might be worth doing an initial private appointment with a consultant who does both private and NHS, and then going on their NHS list. If you can get hold of the MRI CD and take it with you, you’re only looking at the cost of the consultation. All I can offer up is the consultant who did mine, Rahul Patel (UCH for NHS and London Bridge Hospital and Wellington Hospital for private). He’s a knee specialist and does a lot of sportspeople. He’ll also have a few good physio recommendations - and honestly physio in this injury is incredibly important. It’s the physio that steers you through what can often feel like a very long and winding rehabilitation. Others will have other recommendations, so you’ll at least have a list of names to start your research with. I was lucky enough to have private insurance through work, but initially I had no idea where to start in choosing a consultant. If it helps, I had ACL recon with hamstring, and meniscus repair. My small MCL tear and LCL sprain healed pre op.
Very very best of luck to your daughter. As others say, youth is on her side, which is a pretty big plus!
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@Paul Sedgwick, check her travel insurance...she might have cover for some physio. I had £500
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Thanks Borntorun, that's very helpful, especially in regard to Rahul Patel who was on our long list of consultants of interest.
All the best,Paul.
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@Paul Sedgwick, best of luck! As per above, she’s young and fit so should be able to make full recovery. Don’t rush. Make sure you get a surgeon who’s a specialist in knee reconstruction surgery and a good motivated sports Physio.
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Only ACL and meniscus, but 9 months after with a good surgeon and Physio skiing same as before, and I’m much older... Might take her a bit longer but she’ll get there!

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BobinCH wrote:
@Paul Sedgwick, Don’t rush. Make sure you get a surgeon who’s a specialist in knee reconstruction surgery and a good motivated sports Physio.


Very much agree. It’s actually a pretty specialist surgery and recovery. For physio I’m seeing James Vickers at CHHP and Four Sides London. He works with both Jonathan Bell and Rahul Patel. He’s excellent (and a skier).
Again though that’s courtesy of my luck with the work insurance. If you’re going NHS and if budget permits, might be worth an initial assessment with a private physio and or a couple of top up sessions during the rehab. That depends also on who/what you get physio-wise on the NHS. You might be lucky and get someone specialist, fingers crossed.
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@BorntoRun, James Vickers is indeed excellent
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@Paul Sedgwick,

Its very unusual to injury all four ligaments. Even if reported as showing injury one or more are at a lesser grade.

It is crucial that the knee is examined by a specialist and that they don't just treat the MRI, which can result in over treatment.

It may be possible to avoid reconstruction on some of the ligaments.

I'd be happy to see her and tell you what i think needs doing if you want but i'm afraid i don't do NHS any longer.

Jonathan Bell
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Hi Jonathan. That is helpful and encouraging. Ells is under the care of an orthopaedic surgeon called Andrew Armitage at Eastbourne general. He seems to be pretty good and has done many ligament reconstruction surgeries. He has recommend not operating until the end of May as the damaged sections can 'gum up' given time, presumably start to repair themselves? There will a further MRI before any surgery. She is walking around without crutches a lot of the time in a hinged brace.
Mostly, she is really annoyed at missing two months of her season and can't wait to go back. Thank you for your comments, all best, Paul Sedgwick
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Hi Paul, No sure if this is a liitle late for current discussion...but I had a ruptured ACL last year, and went to see Paul Gibb at the Horder through the NHS. Paul Gibb was recommended as THE knee man for Sussex. He has done an excellent job and I would thoroughly recommend. Happy to talk you you through the process for getting that referral through the NHS to get a consultation and subsequent surgery if that would help. Best wishes Simon
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Good luck to your daughter. Spend some money for private physio. The NHS budget will give her enough physio to get her home and doing daily tasks. This does not cover regaining muscle speed, response etc for specific sports. The "sportier" the physio, the more they will understand what your daughter will want to achieve in the future.
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Thanks all for your helpful comments and advice. Snowheads has been an amazing source of help! All very best, Paul Sedgwick.
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If you want to find the best knee surgeon find out who does the footballers knees.

I lucked out big time when I separated 3 of the 4 big ones and finished up with a guy called Fraser [ I think ] it is 30 + years ago who did Gascoigne's knee in the queens Medical Center Nottingham. He did not do mine but had trained the surgeon who did the work and looked in on the procedure.

Do impress upon your daughter that she must do the physio. It will be hell at times and sweaty scary. I had sessions twice a week for a bit and was amazed by the half hearted and less approach of some. One young pretty girl just lay there and whined that there should be a machine for this, what was she paying here NI contributions for.

So if she slacks off on the physio beg bully bribe get some peer pressure but make her do it. It is absolutely critical to build up the muscles around the knee. Small children and cats can be impressed by my knee bulges and antics.

I am 71 now and will off to Salt Lake City next weekend for some Easter skiing. Still on my natural knee.
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TQA wrote:
If you want to find the best knee surgeon find out who does the footballers knees.

I lucked out big time when I separated 3 of the 4 big ones and finished up with a guy called Fraser [ I think ] it is 30 + years ago who did Gascoigne's knee in the queens Medical Center Nottingham. He did not do mine but had trained the surgeon who did the work and looked in on the procedure.



I was working for John Browett when he did Gazza's ACL 30 years ago. He was at Barts and Princess Grace in London.
He's retired.
Undoubtedly there are some very good people who work on footballers but the best don't usually
need to advertise that fact - they are already known to be good.
Be cautious of those who need to champion the fact they work with this or that athlete/sport.
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Another vote for Paul Gibb (Horder centre) Although my ACL was repaired at the Nuffield Tunbridge Wells. He sorted me out when theNHS refused to.
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Further advice needed on Ellen's knee. Three months on and no surgery yet. She can't bend her leg past about 30 degrees, consultant says it's scar tissue and needs forced manipulation under anasthaesia. Is this the only way? She's only 21 and this sounds quite drastic!
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Can you get a second opinion?
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No personal experience of MUAs, but I’d also try to get a second opinion.
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@Paul Sedgwick, hi - I tore my ACL (only) Feb 2018 and saw a surgeon covered by BUPA at The London Clinic. However, I know my surgeon also works for the NHS at the Homerton sport's clinic. He does about 4-5 ACL reconstructions every week (on top of other knee surgeries), and is a specialist knee surgeon who works exclusively on the knee. A referral through the NHS nay take a while, but I was informed that it could be faster to go through the homerton sports clinic channel.

https://www.deepusethi.com/
http://www.homerton.nhs.uk/gps-referrers/consultant-directory/s/sethi,-mr-deepu/
https://www.iwantgreatcare.org/doctors/mr-tapan-sethi

edit: in reference to comment above regarding footballers...I was referred to Mr Sethi by my MSK consultant who also works for west ham fc.
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@Paul Sedgwick, Oh dear. But if you're not happy with this advice (from Consultant), then certainly seek a 2nd opinion.
It took me a long time to get decent flexion (kneel type bend) and I had to do a lot of forced exercises to push through it; one day, it just seemed to improve. 3 months isn't necessarily a long time after a decent trauma.
Is she seeing a good physio? Not an expert, but I would have thought that the aim of physio early and up front is to try to minimise scar tissue (rings a distant bell from my own early post injury days); physio can also, maybe, help to break it down or otherwise assist mobility. The equivalent of "forced manipulation"maybe can be achieved by a physio? Other general physical activities may also help?
Or maybe the Consultant is just right? What or where is the scar tissue, have they said?
Have you tried phoning Wimbledon Clinics and asking for their free phone advice?
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Thanks for your advice Grizzler. She's phoning Wimbledon clinic today.
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