knee replacement timing

New advice not to delay your knee replacement

It goes without saying that the decision to undergo a total knee replacement procedure is a decision not to be taken lightly, and there is a lot to think about before taking the plunge.

For many, it is uncertainty about the recovery period and its implications that play a role in making this decision: roughly six weeks before being able to resume a normal life, and anything from four months to a year to fully recover and feel the full benefit of the surgery. Consequently, many people are inclined to put off the procedure for as long as possible.

However, a report published in the Journal of Bone and Joint Surgery recently spelt out that knee replacement timing is everything. Leave surgery too late, and you run the risk of not reaping the full benefits of the procedure. Conversely, have it too soon and you may run into complications and ever require another replacement.

The study, conducted by the Feinberg School of Medicine at Illinois’ Northwestern University, deployed an algorithm that incorporates joint function, pain, radiographic assessment, and age to best determine the optimal time to have a knee replacement. It was based on information from 8,002 people who had or were at risk for osteoarthritis, who were followed up on for up to eight years.

According to the report, a lack of timing – and its knock-on effects – is rife. Around 90 per cent of patients with knee osteoarthritis are waiting too long to have the procedure, while 25 per cent of people who don’t yet need it are having the procedure done too soon, and consequently only experiencing minimal benefits.

Knee replacement timing: what’s the problem with waiting too long?

Well, while you’re waiting for the most convenient time to have your knee done, osteoarthritis doesn’t hang about. As it continues to flourish, the function of the affected area continues to deteriorate, which can impact upon exercise and activity, which inevitably leads to knock-on effects, both physical and mental. Not only that, but the longer they leave it, the less function will be restored when the procedure actually happens, and mobility levels are reduced considerably compared to those in patients who had the procedure done in a timelier fashion.

Knee replacement timing: what’s the problem with going too early?

Patients who have surgery too soon ramp up the risk of developing complications and increase the chances of having to undergo revision surgery somewhere down the line. And as any surgeon will tell you, revision surgery procedures can be more difficult, and often result in poorer outcomes.

While the researchers are more than aware that many people can’t just drop everything and go under the knife at the perfect moment, their hope is that their algorithm can be honed and adopted by the wider medical community to give future TKR patients the clearest advice for the best possible outcome.

To discuss your knee replacement options in more detail, call either our London or Bristol knee clinics:

Bristol: 08450 60 44 99 | London: 0203 195 2443

artificial meniscus

Potential new treatment: the artificial meniscus

The meniscus is a crucial part of the knee: it’s a piece of cartilage which sits between the thigh bone and shin bone – two in each leg – which acts as cushions between the two bones. As you can imagine, it’s not a part of the knee you’d want to come to any damage, but it can, quite easily, and especially through sporting activities such as hard tackles and sudden pivots or stops. As time goes on and our bodies age, even low-level activities such as getting up from a squatting position can cause a meniscus tear if you’re really unlucky.

Symptoms of a meniscus tear are manifold and problematic. They include swelling, difficulty in moving the knee, locking and catching in the knee area, and the feeling that the knee is unable to support one’s weight. In low-level cases, RICE can get you through, but you may require pain medications, physiotherapy, and injections directly into the joint to relieve pain. After that, you will have to wait until the cartilage has deteriorated severely, to the point where the entire knee needs to be replaced with a metal and plastic implant.

A breakthrough device

However, a new development from two medical centres in Israel points the way towards a less painful and less complicated way to perform knee surgery – the artificial meniscus.

The NUsurface Meniscus Implant – a polyurethane-carbonate implant created by an Israeli research team – has already been welcomed across the medical world, and has almost immediately been granted ‘breakthrough device’ status by the US Food and Drug Administration, who have scheduled clinical trials scheduled to be completed next year and in 2023.

The implant essentially mimics the biomechanical function of the medial meniscus by protecting the cartilage from overload but also prevents further degeneration of the cartilage that happens when part of the meniscus is removed after a tear.

More importantly, as the implant isn’t attached to bone or soft tissues, the required rest period is severely reduced, meaning patients can be fast-tracked into a full recovery with minimal risk of post-surgery complications. And crucially, the chances of continued pain post-surgery are vastly curtailed.

Who would be the prime candidates for an artificial meniscus?

This new technology is geared towards people between the ages of 35 and 70, but especially those who are considered too young for a total knee replacement.  It’s also intended for people who have already had current meniscus surgery and are still experiencing knee pain or are not suitable for a traditional meniscus allograft transplant.

Two artificial meniscus implant surgeries were performed in Israel last November – one in a private clinic and the other in a public hospital – and so far, the results have been encouraging. While the device is already being marketed in Belgium, Germany and Italy, the nod by the FDA to fast-track its development and review process for the device means that it could a regular procedure for knee surgeons by the middle of the decade.

A cadaveric meniscal transplant is an option if the artificial meniscus is unavailable. Leading London knee surgeon Mr Jonathan Webb can discuss all possible options with you during your consultation.

knee injury and arthritis

Link established between knee injury in early adulthood and onset of arthritis

If you’ve indulged in any long-term sporting activity, you’ve taken your fair share of knocks. And that’s OK when you’re younger – the body can take it, and damage can be healed. But are they storing up a welter of problems in later life?

According to a recent study conducted in Sweden, they probably are: the study, which was released at the end of last year, contends that young adults who have had knee injuries are much more likely to develop arthritis in the knee by middle age than their uninjured peers, especially if they have broken bones or torn connective tissue.

Six times more likely to suffer knee OA

The study, conducted by the researchers at the Lund University, analysed the data of almost 150,000 adults ages 25 to 34 – 5,200 of which with a history of knee injuries for almost two decades. Their findings? Compared to the people who never had knee injuries, those who did were nearly six times as likely to develop knee osteoarthritis during the first 11 years of follow-up, with more than triple the risk over the next eight years.

We already know certain risk factors that bring about osteoarthritis: they include being overweight, older, female or having a job that puts a lot of stress on the joints. When it comes to a history of knee injuries, however, the picture is muddier; we know it’s a risk factor, but we’re currently not sure whether certain types of injuries might be more likely to lead to osteoarthritis than others.

The research findings have helped to clear the waters a little. After 19 years of follow-up examinations, 422 of the study group who suffered from knee injuries (11.3%) went on to develop knee osteoarthritis. Compare this to the 2,854 (or 4%) of people without a history of knee injury who went on to develop knee osteoarthritis.

A matter of balance

Why is this? According to study leader Barbara Snoeker, it’s a matter of balance – or lack of it. “Injuries that occur inside the knee joint, for example in the meniscus or anterior cruciate ligament, may alter the biomechanical loading patterns in the knee,” she claimed. “Such injuries may lead to an ‘imbalance’ in force transmissions inside the knee joint, consequently overloading the joint cartilage and leading to increased risk of developing osteoarthritis, compared to injuries that mainly affect the outside of the knee joint, such as contusions.”

While medical experts around the world have already picked holes in the study – pointing out limitations such as a lack of data on patient’s body mass index (BMI), and how patients were rehabbed after their procedures – it’s clear that people who have suffered from knee injuries in early adulthood need to be looked at with a weather eye as they progress into middle age. Clearly, the quality of rehab that young athletes are receiving is a key factor – but so are lifestyle choices which are out of the hands of the medical community.

running knee injury

Don’t change a thing: no benefit found in adopting a new way of running

It may be midwinter, but we’re already a mere four months away from one of the biggest dates in the running calendar – the London Marathon. Which means that for the more serious runners amongst us, the training programme starts now.

The winter stretch is usually the less intense part of the year, physically, but it’s also the time that many runners focus on the fundamentals – especially the mechanics of running. And right at the top of the list of considerations is changing the way we run, especially if you’re a heel-to-toe runner.

We’ve all heard the stories about heel to toe being more dangerous than toe to heel, and how running on the balls of the feet can prevent sore knees, shin splints and other maladies, and many runners have switched to it, with the encouragement of coaches and medical experts. But a new review of the available data on running styles suggests otherwise.

Should you stay on the back foot?

The review, released at the beginning of the year by the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia, analysed 53 studies which looked at the impact of forefoot, rearfoot and flatfoot running patterns on injury, running economy and running biomechanics. Their conclusions: there is no evidence to suggest running on the front of your feet reduces injury risk or improves performance.

According to Dr Christian Barton, a La Trobe injury researcher and physiotherapist who led the study, the only major change that occurs when a runner changes from heel to toe to toe to heel is a shift in body weight from one area to another – but it doesn’t make the weight disappear.

Or should you stay on the ball?

“Our comprehensive review suggests that telling someone to run on the ball of their foot instead of their heel may make them less efficient, at least in the short term,” said Dr Barton. “Additionally, there is no evidence either way on whether running on the balls of your feet reduces injury.”

There’s always a massive temptation to tinker with – or even completely change – our running style, particularly when we’re going through a period of downtime but, in this case, the main message from the La Trobe report is ‘go for what you know’.

When it comes to running style, some experts say, there is no correct answer – the way an athlete runs is as unique as their fingerprint. And while there are certainly pros and cons in each main style, there is no such thing as the best technique. Because if there was, we’d all be using it.

And as Dr Barton pointed out, toe to heel running isn’t necessarily safer, either. “Running toe-heel might help injuries at the knee, where loads are reduced. However, it may cause injuries to the feet and ankle, where loads are increased,” Dr Barton said. “Put simply, when it comes to running style: If it ain’t broke, don’t fix it.”

skiing after knee replacement surgery

Can you go skiing after a knee replacement?

There’s always one on any skiing holiday: the poor soul who came a cropper on the slopes and has to spend the rest of the week incapacitated, staring out of the window, looking mournfully at the piste while sipping on a hot chocolate. No shame in being that person – it can happen to the best skier.

But what happens if you’re a regular skier and you have to go through a procedure as serious as knee replacement surgery? Are you going to have to stay on the sidelines forever?

If you are a regular skier and you’re thinking about knee replacement surgery, you might have even given the slopes a pass this season: total knee replacement candidates usually suffer from little to no mobility and experience a great deal of pain, and nothing puts pressure and strain on the knee as much as skiing does. But when the operation’s done, will you be able to return to your favourite winter hobby? Let’s try to address your concerns…

Skiing after knee replacement: are you experienced?

If so, there’s no need to panic, because most knee surgeons will encourage experienced skiers to get back on the slopes… eventually. If you know what you’re doing on the piste and are prepared to undergo a well-managed period of rehab, you won’t have to give up skiing (and that goes for virtually any sporting activity that doesn’t involve intensive running).

Skiing after knee replacement: your first on-piste experience

However, there’s a downside: you’re going to have to accept that you won’t be able to hop back on the slope and continue as before. Most importantly, you’re going to have to be a lot more selective about the days you go out and the terrain you ski on. Soft powder = good. Icy conditions = bad. And be extremely careful about obstacles, because fractures around the knee area can cause a wealth of problems for knee replacements.

Skiing after knee replacement: about recovery time

You already know that you can’t just get up and go about your regular business after total knee replacement: you’ll need the use of a walker or crutches for a few days, a cane for a few weeks, and – usually – you’ll be walking about unaided in about two or three weeks. Add another six weeks or so of physical therapy, you’re good to go for normal routine activities.

However, you’re going to need more recovery time if you’re aiming to be ready for the next skiing season. The minimum amount of time you should wait to ski after knee replacement surgery is three months, and you are advised to undergo a course of dry land training, in order to regain the adequate balance and strength for skiing. You’re also strongly advised to start on groomed surfaces for an hour or two at a time, to help get your endurance levels back up.

As a regular skier myself who has just undergone his own knee replacement, this is all positive information. I have every intention of returning to skiing but think I’ll be pushing it to even consider returning after three months, so I’ve set my sights firmly on next season.

If you’d like more advice on returning to skiing, or any other sport, after a knee replacement, call  08450 60 44 99 to arrange a consultation with Mr Jonathan Webb at either his London or Bristol knee clinic.

knee OA

UK study finds listening to noisy knees can help with knee arthritis diagnosis

If you’re hearing a snap, crackle and pop and you’re nowhere near a breakfast table, welcome to the world of knee crepitus. It’s a term for the sounds the joint makes, and in a lot of instances it’s nothing to worry about – it’s just tiny gas bubbles that have accumulated in the synovial fluid bursting, which is a natural occurrence.

However, certain sounds can also be the first indications of a damaged knee joint. So, the results of a new study from Lancaster University have caused a lot of people in the medical community to sit up and, well, listen.

The study in question, which was published in the medical journal PLOS ONE last month, has advanced the idea of a new way of diagnosing and assessing knee osteoarthritis, which involves attaching small microphones to the knee and detecting high frequency sounds from the joint components as the person being evaluated does nothing more strenuous than performing simple sitting and standing movements.

Sounding out knee OA

The signals – known as ‘acoustic emissions’, are then analysed on a computer in order to harvest data on the health of the knee. The analysis is based on sound waveforms during different movement phases. It’s the first technique of its kind in the field of knee OA analysis, and the results are encouraging to say the least: not only can the technique distinguish between healthy and OA-afflicted knees, but it also can be used in both a general practice and hospital setting.

The research project has been running since 2013 and has been conducted by a large multi-disciplinary team led by Lancaster University, with assistance from the Universities of Central Lancashire, Manchester and Cumbria, as well as the NHS in Lancashire and Cumbria. It has also leant upon the expertise of two businesses that specialise in technologies for acoustic sensing and cartilage measurement. And the goal is to create a fast, convenient and effective method of detecting the causes of knee crepitus – be they common-or-garden knee OA, chondromalacia patella, patellofemoral syndrome or any other knee-related injury

Faster, bigger, better?

“This work is very exciting because it involves scientists and clinicians working together as a team to develop an entirely new approach,” said Emeritus Professor Goodacre of Lancaster University, who led the research. “Potentially, this could transform ways in which knee OA is managed. It will enable better diagnosis and will enable treatments to be tailored more precisely according to individual knee condition. It will also enable faster, bigger and better clinical trials of new treatments”.

If all goes well, we could be seeing the development and production of a non-invasive and portable device which could be used by the medical community to detect any changes and possible ailments in a patients’ knee with minimal fuss or discomfort, providing a faster, more cost-effective, more convenient and more refined assessment than any other method available at present. We’ll definitely be keeping an ear to the ground on this one.

To arrange a consultation to discuss your knee OA options, including robotic assisted knee replacement, call us on 08450 60 44 99 for my Bristol knee clinic and 0203 195 2443 for my London practice.

prehab before knee replacement

Prehab before knee replacement could lead to better results

We’re all aware of the necessity of rehabilitation after knee replacement surgery, but what about the steps we can take before we even go under the knife? It’s something that’s been on my mind throughout the year, as I’ve been preparing for my own knee replacement procedure later this month. And according to a study in New York that was published in November, it seems that a ‘pre-habilitation’ programme – which involves being counselled by a peer coach – could really help patients and lead to a better, faster recovery.

The study found that using a peer coach – deemed as a patient who has already gone through the procedure and has been trained to provide personalised pre- and post-knee replacement support – can make a huge difference to a patients’ mind-set, can openly discuss what happens before, during and after the operation and steer them towards developing good habits.

It’s a methodology that has worked very well in other areas of medicine, particularly in the field of diabetes. And although the two issues are very different, the thinking goes that both issues require a radical change of lifestyle habits and a positive attitude – and nothing works better than having close contact with someone who has already been through the procedure.

Thirty-one patients were examined during the study, ranging in age from 65 to 89 – all of whom had undergone a knee replacement at least 12 months earlier with a good outcome. They were questioned on a range of issues, notably their experiences with a peer coach. The study group’s discoveries were as follows;

The fear factor

Many patients with osteoarthritis delayed knee replacement for many years, often until the pain became very bad. Not only that, but the majority had no idea about the best way to prepare for knee replacement surgery, and ultimately didn’t prepare at all.

Second-time patients are better prepared

Many of the patients were about to undergo their second knee replacement procedure – and this time they felt they had learned what was expected of them this time around. “Patients with high outcome expectations who had undergone a previous knee replacement learned from their first experience and reported feeling motivated to engage in physical activity for muscle strengthening before their second knee replacement,” said Dr Iris Navarro-Millan, principal investigator of the study. “They expressed that their own experiences made them more informed, self-efficacious and physically active to prepare for their surgery.”

First-time patients are prepared to listen

Understandably, the people undergoing knee replacement surgery for the first time were very keen to listen to other patients about preparation and recovery and being given the opportunity to talk to patients who had gone through the procedure removed a lot of apprehension about surgery.

A thumbs-up for peer coaching

Not only were new patients more than open to the idea of peer-coaching, but the study discovered that certain patients were already doing it off their own bat – and were finding it very rewarding. After all, doctors can only tell you what’s going to happen: people who have already undergone the procedure can tell you what to really expect.

So, what advice would I give you, as someone about to undergo surgery? Well, I’ve been seeing a personal trainer this year – partly to put off having to have the replacement for as long as possible, but now that surgery is imminent, to ensure my muscles are as good as they can be because when it comes to as swift a recovery as possible, you can’t have enough muscle.

Post-surgery, I’ll be able to give advice both as a surgeon and fellow patient. For more advice on knee surgery and robotic knee replacement, call 0203 195 2443 to arrange a consultation.

Robotic Knee Replacement Advantages

Robotic knee replacement advantages and disadvantages

One of the biggest developments in orthopaedic surgery in recent years has been the introduction of ‘robotic joint replacement’. The first misconception that we often have to clear up is that this development does not replace the orthopaedic surgeon and that the robotic arm is not actually performing the surgery independently. Robotic joint replacement technology such as the industry gold standard Mako system is aimed at improving the patient outcome by ensuring more precision.

The Mako Robotic-Arm Assisted Total Knee replacement is for people with mid to late-stage knee osteoarthritis that is causing them pain and a lack of mobility. A CT scan of your knee is taken, which is then uploaded into the Mako System software. A 3D model of your knee is then created, which is used by the surgeon to work out a plan of action.

When it’s time for surgery, the Mako system comes into its own. In theory, the surgeon follows the plan to the letter by guiding the system’s robotic-arm to remove diseased bone and cartilage within the pre-defined area – and best of all, the system ensures that the work needed is kept within the pre-planned boundaries. I can’t stress this enough: the surgeon is always in control of the procedure and can even override their original plans if necessary.

What are the pros of robotic knee replacement surgery?

The most important of the robotic knee replacement advantages is that it gives orthopaedic surgeons the opportunity to create a more bespoke plan of action with greater accuracy than before. Furthermore, it allows surgeons to individually optimise each particular replacement joint, giving them a better chance to create a perfect fit first time, significantly lowering the risk of post-surgical complications and the need for a second procedure. The risk of blood loss is reduced and there is an improvement in safety levels, as the system only allows them to perform the procedure within the area mapped out by their pre-op plan.

For the patient, the two most significant benefits are a shortening in rehab time (as less of an area in the knee needs to recover, due to no superfluous areas have been operated on), and the reassurance of improved safety and a reduction in post-op complications.

What are the cons of robotic knee replacement surgery?

Robotic assisted knee replacement is relatively new technology, particularly in performing total knee replacements, so although the clinical studies performed so far are encouraging, more longer-term studies are needed.

The procedure takes slightly longer to perform than a conventional joint replacement so the risk of infection could be slightly increased, although to what amount is uncertain at present.

More importantly, by leaning harder on a computerised system, some surgeons have already pointed out that any system is only as good as the data it uses and the people who process it, meaning that the quality of the scans used need to be of the highest quality and extra time and resources are going to have to be funnelled into the training of staff to get the optimal effects with the Mako system.

The cost of the procedure is also slightly more than a conventional joint replacement because a CT scan is required of the joint to plan the procedure.

For more advice on the pros and cons of Mako robotic knee replacement, call 08450 60 44 99 to arrange a consultation at my Bristol clinic or 0203 195 2443 for my London knee clinic.

recovery after robotic knee replacement

What is the recovery like after robotic knee replacement surgery?

Robotic joint replacement surgery has been trending across the medical community in the last few years and is an example of how technology is transforming the way hip or knee replacements are being performed. The recent addition of the Mako robotic knee replacement system to both my London and Bristol knee clinics offers patients a number of advantages, including a potentially shortened recovery process.

In a nutshell, the Mako system converts a CT scan of a knee joint into a 3D map, which the surgeon can use to map out a plan of action. Then – with the use of a robotic arm – the surgeon can conduct the procedure with optimal precision, while the system ensures any work is done within the parameters already mapped out.

Naturally, the system is being welcomed by many professionals, as it could potentially take a lot of guesswork out of the procedure and reduce the risk of human error. And those advantages are passed onto the patients; experts claim that recovery times after a Mako procedure could shorten by as much as 30 percent, with a reduced risk of post-op infections and complications, and therefore a similar reduction in requiring a secondary, revision procedure.

While computerised and robot-assisted orthopaedic surgery is a relatively new development, it’s clear that is going to part of the future of joint replacement surgery, so let’s discuss what this all means for knee OA patients – particularly regarding the recovery period.

In the immediate aftermath of surgery, the patient experience will not differ – you will be encouraged to walk with crutches, given advice by a physio on your rehab exercises and by the nursing team on how to manage your wound, and then will be discharged from hospital.

However, experts predict that the Mako system will really come into its own in the secondary phase of your recovery, due to what happened during the procedure. So, let’s break down the potential positives…

Robotic knee replacement: less of an area to rehab

Because the Mako system ensures that the bare minimum area of the affected knee is operated on, with decreased trauma to the soft tissue and bone, there is obviously less of the knee which needs to mend. That – in theory – means that the recovery time is shortened.

In a recent clinical study, Mako patients reported lower pain scores six months after their surgery than those who underwent a traditional joint replacement procedure.

Robotic knee replacement: a greater opportunity for a partial replacement 

A partial knee replacement can preserve healthy anterior cruciate and posterior cruciate ligaments, meaning they end up with a more ‘natural’ joint which is far easier to get along with, speeding up the recovery time dramatically.

Robotic knee replacement: guaranteed bespoke service

In theory, the greater precision in diagnosis offered by the Mako system will allow surgeons to plan procedures in greater detail – and the fact that the system prevents surgeons from straying out of the pre-set parameters means that the healthy parts of the knee aren’t affected, meaning a reduced risk of complications.

For more advice on what to expect from a Mako robotic knee replacement, call 08450 60 44 99 to arrange a consultation at my Bristol clinic and 0203 195 2443 for patients interested in undergoing surgery in London.

return to play and re-injury risk

Footballers could reduce risk of re-injury with extra training before return to play

It doesn’t matter what sport you play, or at what level – the temptation to pull on the boots (or spikes, or cleats, or skis) after an injury is overwhelming. You’ve been put on a course of treatment, and you’ve been given a recovery schedule, but you feel that no-one knows your body better than you do. Big mistake, according to recent return to play research from the Football Research Group at Linkoping University in Sweden.

According to the study, injured footballers who skip a course of practice sessions before returning to full competition are more likely to aggravate their injuries – or even develop new ones – than those who are eased in gradually. And when it comes to the highest level of the game, professional matches have a seven-fold greater risk than practice ones for the returning player.

The research team went right to the top for their study: they examined data on 303,637 matches involving Champions League teams, and that data included 4,805 matches involving players returning to the field after moderate-to-severe injuries kept them in the treatment room at least eight days.

Their conclusions? Injury rates were 87% higher during players’ first match after an injury than they were for typical matches during the season. However, the study also discovered that with each practice session prior to the first match after an injury, players’ risk of another injury dropped by 7%.

So, what entails a proper practice session?

That’s not something the study was concerned with. “While we can’t say anything about the content of those training sessions, our data suggests that if they complete six training sessions after they have been cleared by the medical team to fully participate in all team activities but before they play a game, the risk of injury in that game is only marginally higher than the average risk in matches,” said Hakan Bengtsson, physiotherapist with the Football Research Group and lead author of the study.

[external link: https://bjsm.bmj.com/content/early/2019/08/28/bjsports-2019-100655.abstract]

According to Bengtsson, the biggest risk for repeat injury occurred with four practices prior to the first match, and made clear that he and the study team were aware that some players might not be able to wait for six training sessions due to various factors – but the results clearly demonstrate that rehabilitation alone may not be sufficient to prevent repeat injuries, due to the fact that most rehab procedures are conducted alone, away from the healthier members of the squad, and are no substitute for what they go through at the top of their game.

Let your team ease you back in

“When the player returns to full team training, it will be more similar to actual game play” he added. “And thus, full team training offers a better environment for the athlete to build tolerance to what he will be exposed to in matches.”

There’s a lot of truth in what the study team say, from my experience. All professional athletes who suffer an injury and go through rehab are champing at the bit to get back in the game as soon as any sign of progress happens. And even the most prudent coaches and managers don’t like to see their talent on the bench for too long. But in cases such as this, a gradual easing-in process is essential.

For more advice about returning to play after injury, contact sport injury specialist Mr Jonathan Webb. He offers clinics in Bristol (08450 60 44 99) and London (0203 195 2443).