Ligaments are strong soft-tissue structures in your body that attach one bone to another, they play a vital role in stabilising bones or joints in the body. These structures are very tough and have limited elasticity, and in conjuction with the muscles, tendons, and bones in your body allow you to stand upright and mobilise or function day to day.

In younger people, more commonly in females, the ligaments in the body may have greater laxity, and this often disappears with age. Certain soft-tissue disorders can also result in overly lax ligamnets, but these are quite uncommon, and Dr Ihsheish will be able to assess for these and discuss them with you accordingly.

The term ‘ligamentous laxity’ is a specific medical diagnosis that can be made by the surgeon depending on the patient's ligaments fulfilling a defined and recognised set of findings in the clinical examination, in many cases this is not associated with any specific disease. It is importnant to recognise, as it may result in loose joints, and this may manifest clinically as instability (for example a joint may dislocate easily). Dr Ihsheish will also discuss with you the importance of this in relation to treatment options.

The patella (knee-cap) is the small bone found at the front of the knee. The patella is an important part of the knee and mechnically it improves the leverage of the muscles that move the knee joint.

The patella glides in a groove (the trochlea) as the knee is flexed or extended, and is held in place by a complex set of factors that include the shape of the bones, the positioning of the patella in relation to the knee joint, the integrity or the laxity/tightness of the ligaments or muscles that attach to it. When any of these factors is abnormal they can result in patella instability, or patella dislocation. Traumatic dislocation, for example in a heavy fall, can of course occur even when all the above factors are normal and a large force is applied to the patella.

Dr Ihsheish can assess your knee joint clinically and radiologically following a patella dislocation. Early treatment after a patella dislocation often involves rest, ice, splinting of the knee, and use of crutches and pain-killers for pain relief. Further specific management can be discussed with you by Dr Ihsheish depending on your individual case. Damage to the ligaments, bones, or cartilage that occurs during the injury may require surgical intervention or monitoring, and physiotherpay referral is often arranged to help you regain function gradually.

Dr Ihsheish will discuss with you the long term consequences of patella dislocations, which include the after-effects of any joint damage sustained, and ongoing instability symptoms in this joint.

This benign condition is a type of so-called  ‘traction apophysitis’.

During skeletal growth, children or young teenagers, often those involved in jumping sports such as basketball, may develop pain and a prominent lump (bone) at the site of insertion of a tendon. Tendons are the structures that attach a muscle to bone.

Over-activity, or heavy and frequent exercise, can result in excessive tension at the site of a tendon insertion, such as below the knee. The recurrent ‘pulling’ of this tendon causes inflammation, and results in pain and excessive bone formation in the affected area. The lump that is felt is hard and can be tender, and often impedes the child’s ability to kneel or continue participation in their sport. The term "jumper's knee" is hence the other name for this condition, although is is important to recognise that the 'traction apophysitis' process may occur at other tendon insertion sites in the body.

Dr Ihsheish can make a thorough clinical and radiological assessment of your signs and aymptoms, and discuss the most appropriate management options accordingly. In the majority of cases the most appropriate management is modification or reduction in the inciting activity, and while this sounds simple it is actually quite a challenge - as these patients are often very keen to continue in their chosen sport or training. In severe cases bracing the affected joint is required to adequately rest it. Surgery is rarely required.

A ‘bursa’ is a normal anatomical structure. It is a collection of fluid found over parts of the body that may be frequently exposed to physical pressure, such as over the knee cap (prepatella bursa) or over the point of the elbow (olecranon bursa). The bursa can be thought of as a small ‘lubricant bag’ that cushions parts of the body, and allows the skin to glide smoothly as the joint is moved.

Bursitis – is inflammation of this bursa. It can result from excessive pressure (eg excessive kneeling such as in a carpet layer) or actual infections (bacteria may get into a bursa and cause infections after skin cuts or abrasions). These result in pain and dysfunction, and may cause the patient to be unwell if an infection reaches an underlying joint or spreads into the body.

Treatment of bursitis aims to reduce the symptoms (such as by the use of anti-inflammatory medications) and treat any possible infections (this usually needs antibiotics, and for severe cases may require surgery). Dr Ihsheish can assess and provide the appropriate management, although for severe cases the patient is advised to present to the local hospital for assesment.

A cyst is a fluid filled cavity. This collection of fluid (Baker's cyst) is found behind the knee joint. It is often found on imaging of the knee joint (eg ultrasound or MRI scans). Most often in adults it is an indication of a problem within the knee joint (such as arthritis or cartilage damage), rather than a problem behind the knee.

While many cause no symptoms, Baker’s cysts may result in a feeling of fullness or discomfort behind the knee, large ones may cause tightness or difficulty flexing (bending) the knee joint. Baker’s cysts under pressure may rupture, although this is not usually dangerous, many patients complain that it is quite uncomfortable or painful. If this happens it is treated with pain killers, ice packs, and gentle exercises to mobilise the knee joint.

Because they often indicate a problem within the knee joint in adults, the treatment is aimed at diagnosing the internal knee joint problem and treating it. Aspirating the cyst directly is less likely to work and the aspirated cysts often re-occur, and surgically dissecting out the cyst is not necessary. Dr Ihsheish can assess the cyst clinically and radiologically and discuss with you the findings and relevant treatment options.

A joint is the site of articlation of two or more bones in the body, it allows mobility and function, whilst being stable at the same time and allowing weight bearing, an example of this is the knee joint or the hip joint. Septic arthritis is an infection involving one of the joints in the body, most commonly infection involves only one joint, but it can affect more than one joint simultaneously.  All native joints and prosthetic joints are at risk of infection.

What is it caused by?

Most cases of septic arthritis in humans are caused by a bacteria called staphylococcus aureus. This bacteria is normally found on human skin (is is part of the normal bacteria found on human skin and is therefor termed comensal bacteria). It may entre the body through a break in the integrity of the skin (such as cuts or scratches). Septic arthritis can also be caused by other types of bacteria, viruses, or fungal organisms. The very old, very young, or those with suppression of the immune system or certain disease (such as diabetes) are at greater risk of infections in general.

How does it present?

Infections anywhere in the body generally make the patient unwell, often they are associated with temperatures. Locally the infected part is painful and swollen, and thus impedes function (for example an infected knee will make it difficult to walk). In severe infections the patients may become unstable and require hospitalisation.

It is important to diagnose and treat septic arthritis early, to avoid local damage to the joint from these infections, and harmful effects to the patient in general.

Many cases of septic arthritis require urgent surgery. Surgery aims to remove fluid build-up in the affected joint and lavage the joint, and relevant medications (ie antibiotics for the specific bacteria). Further surgery may be required to wash out infected joints, or to replace prosthetic components, Dr Ihsheish can discuss your case individually with you, it is important to be aware that the treatment with antibiotics is for several weeks at least.

Not all infected joints make the patient severely unwell, some low grade infections will be relatively mild in presentation, but if you have any concerns you are advised to make an apointment as soon as possible.

What is a meniscus?

The meniscus is a specialised piece of cartilage that sits between the top and bottom bones in your knee (femur and tibia). It has a tough rubbery consistency and is attached to the side walls of the joint.

The meniscus has several important functions in the knee joint:

• shock absorption
• distribution of load bearing over a larger surface area of the joint
• stability of the knee joint
• spread of lubricant fluid in the joint
• proprioception (contributes to allowing your brain to sense and control knee joint movement)

Obviously this structure plays a number of important protective functions in the knee joint, and it is worth preventing injuries to it or managing them appropriately

What symptoms does a meniscus tear cause ?

It is important to note that a meniscus tear can be present without too many symptoms. However, they may cause

  - bleeding (internal) / swelling

  - pain

  - locking (where the knee joint sticks or jams)

  - or a sense of instability

The location of the pain is often, but not always, located at the site of the meniscus tear.

Patients with chronic tears may have intermittent symptoms.

WHAT CAUSES A TEAR IN THE MENISCUS?

From the functions of the meniscus listed above, it is obvious that this structure does alot of work as the knee is functioning.

Meniscus tears can result from heavy impact on or around the knee, or from twisting injuries to the knee. Often there is rapid swelling but this does not always occur. Externally the knee may appear swollen, and the patient often experiences pain, instability, difficulty weight bearing, and the knee may be difficult to move (ie locking).

The structure of the meniscus often weakens with age, and the accompanying arthritis or other inflammatory disorders such as gout for example, and these will increase the risk of meniscal tears with knee trauma.

How is a meniscus tear Identified and managed surgically?

From the above information it can be seen that this structure is important to retain in the knee joint if possible. 

As meniscal tears can cause pain and dysfunction they may require analgesia, activity modification, or surgery to alleviate the symptoms and allow a return to function.

Diagnosing a tear on the meniscus can be achieved with a clinical examination by Dr Ihsheish and if the diagnosis is suspected but further information is required (such as the location or type of tear), then adjuncive investigations may be undertaken, such as an MRI scan. Dr Ihsheish does not recommend ultrasound scans of the knee when looking for meniscal tears.

The decision to intervene surgically is usualy made if other treatment options have failed and the symptoms are still causing dysfunction.

Meniscal tears essentially result in the torn part becoming unstable and casuing pain and irritation, and therefor surgical management is aimed at transforming an unstable meniscal segment into a stable one. A successful repair is preferable, as this allows the retention of this importnant structure in the knee however not all meniscal tears are repairable, and some torn segments have to be removed (debridement) to alleviate of the symptoms. Dr Ihsheish can talk to you about your specific meniscal tear and the most suitable treatment option.

If the tear is repairable then sutures are placed through small incisions in the skin (see knee arthroscopy), and you will be required to wear a brace and use crutches for about six weeks generally to protect the repaired segment as it heals, thereafter you will be required to undergo some physiotherapy to regain movement and strength in the knee joint.

On the other hand, if the menical segment is simply debrided (cut out), you will be allowed to weight bear and function as tolerated, but one or two weeks rest is generally advised.

In general the knee will be swollen and stiff for 1-2 weeks after arthroscopic knee surgery.

Dr Ihsheish generally uses absorbable sutures (no suture remval required), but you will be seen for a wound check a 10-14 days after the operation, at which time the operations details will be discussed with you.