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Lower Limb

The ACL, or anterior cruciate ligament, is found in the knee. Running diagonally across the knee, its job is to provide stability to the knee joint avoiding forward/backward movement.

An ACL tear can leave a knee very unstable and make even simple daily tasks very challenging. Tearing an ACL can happen in many different ways but often we see them linked to sports especially skiing, football, rugby and tennis.

So how does an ACL tear happen? An ACL tear can occur when the knee twists or if the lower leg over extends such as when changing direction rapidly or unexpectedly (like a football or rugby tackle), stopping suddenly or a sometimes even a bad landing. This can result in extreme pain, an unstable knee and reduced range of motion.

 

How do we go about treating this? Not every patient with an ACL tear will need surgery. Depending of the severity of the injury and the lifestyle of the patient a tear can be managed conservatively with rest and physical therapy. That said, those individuals with an active lifestyle, who do lots of sport or have a severe ACL tear may need reconstructive surgery. Unfortunately, the ligament can’t simply be stitched back together. So, what we have to do it use a graft. We take a bit of ligament from the hamstring or patella tendon and once we have removed all the old torn ACL we replace it with the grafted tendon. In most cases this is done through tiny keyhole incisions.

 

Whilst success rates for this are high the surgery, like all surgeries, comes with risks including blot clots, infection, pain and stiffness. A full recovery can be 6 months with some individuals taking up to a year as recovery is a very individual thing and it will usually take about 9 months to return to contact sports.

We hope you found this post insightful and interesting…keep an eye on the blog for plenty more upcoming content!

 

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

Osteoarthritis is a very common type of arthritis – there are many types of arthritis though. It is a condition which gets worse over time or with age which is called degenerative. Although we do see arthritis in younger people it’s often linked to an injury rather than joint wear and tear over time.

 

The hip joint is a ball and socket joint made up of:

  • Bones that form the joints (the femur and the acetabulum)
  • Cartilage – a smooth, firm tissue at the ends of the bones
  • Joint fluid to lubricate the joints
  • Tendons and ligaments to stabilise the joint
  • Muscles for movement

In osteoarthritis it is the cartilage at the joint which wears down and essentially doesn’t do its job very well. If this happens the hip joint becomes painful, swollen and stiff. Often this linked to aging but can also be attributed to trauma, fracture, dislocation and in some cases may be hereditary.

 

Hip arthritis can have varying symptoms which can include:

  • Problems with walking
  • Pain and stiffness
  • Reduced range of movement (usually linked to pain)
  • Clicking or creaking sound
  • Swelling

 

How could we treat hip arthritis?

Although there is no true cure for arthritis there are things that can be done to help ease the pain and improve the movement of the joint. These range from conservative manag

 

ement which includes exercises, resting the joint, medication, physical therapy and, if applicable, losing excess weight. If these fail to have any effect there are surgical options which your consultant would discuss and talk through the range of options available.

 

We hope you found this post insightful and interesting…keep an eye on the blog for plenty more upcoming content!

 

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

A kneecap or patella dislocation can be incredibly painful. The kneecap usually sits straight over the knee joint at the front. A dislocation of the patella happens when the knee cap comes out of the groove it sits in on the end of the femur (thigh bone) and ends up on the outside of the knee joint.

A first-time patella dislocation usually happens as a result of a significant injury but the kneecap is more prone to displacement following the initial dislocation. This is because when the patella is dislocated in the first instance the soft tissues (ligaments and tendons) holding it in place are stretched or torn meaning they are less supportive. The most important one of these ligaments is the MPFL (medial patellofemoral ligament). When this ligament tears (which is does in a patella dislocation) it often can heal but not with the correct tension which means that the kneecap is unstable and can pop out of position more easily – recurrent dislocation.

In some people there can be other underlying causes for the knee cap to dislocate repeatedly, like malalignment of the knee joint or the groove not being well developed, which would need to be corrected surgically for successful treatment.

A dislocated kneecap can be fairly obvious as the dislocation causes significant pain and deformity of the knee joint – it will look very out of place and at an unusual angle. Other symptoms can include:

  • A painful popping sensation
  • Unable to walk
  • Unable to straighten the knee
  • Sudden swelling of the knee joint especially the front

It is important not to confuse a patella dislocation with a knee joint dislocation which is where the femur or thigh bone displaces from the tibia (shin bone).

How do you treat a patella dislocation?

Often a kneecap dislocation will pop back in by itself, but it is still worth getting it checked by a doctor if you think you have suffered a patella dislocation. Sometimes it won’t pop back into place itself do not try to put it back yourself as this can cause more harm – at this point it is best to phone an ambulance and get it looked at by the hospital doctors.

Once the kneecap has been put back in place by the doctors the treatment can start. This begins as conservative treatment with rest, a brace, crutches and then, once the swelling has gone down, physical therapy.

As previously mentioned a high percentage of first time patella dislocations will progress to recurrent dislocations. At this point there are surgical options available. These can include:

  • MPFL reconstruction
  • Tibial tubercle transfer
  • Corrective osteotomy

We hope you found this post insightful and interesting…keep an eye on the blog for plenty more upcoming content!

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

 

 

Upper Limb

Shoulder arthritis, specifically osteoarthritis, is a condition which gets worse over time or with age which is called degenerative. Although we do see arthritis in younger people it’s often linked to an injury rather than joint wear and tear.

The shoulder joint is made up of:

  • Bones that form the joints (acromioclavicular joint and glenohumeral joint)
  • Cartilage – a smooth, firm tissue at the ends of the bones
  • Joint fluid to lubricate the joints
  • Tendons and ligaments to stabilise the joint
  • Muscles for movement

 

In osteoarthritis it is the cartilage at the joint (usually the acromioclavicular joint) which wears down and becomes less effective. This means that the shoulder can become painful, swollen and stiff. Often this linked to aging but can also be attributed to trauma, fracture, dislocation and in some cases may be hereditary.

 

Arthritis in the shoulder often presents with pain, particularly when moving or just after moving it. Other symptoms can include reduced range of movement (usually linked to pain) and sometimes even a clicking or creaking sound.

 

So, how do we go about treating arthritis of the shoulder? First of all, we will try conservative treatments. These can include: rest, heat/ice treatment, physical therapy, range of motion exercises and sometimes medication can help (NSAID – Non-Steroidal Anti-Inflammatory Drugs). If conservative management fails to help we can look at surgical options which include: decompression surgery, shoulder joint replacement or humeral head replacement. Each patient is different so the consultant will help to choose the right option for the individual patient. x

We hope you found this post insightful and interesting…keep an eye on the blog for plenty more upcoming content!

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is the commonest form of nerve entrapment and occurs when the median nerve is compressed at the wrist in the carpal tunnel. It needs timely treatment to prevent avoidable, irreversible and disabling loss of feeling and power in the hand.

The median nerve and finger bending tendons pass through a tunnel across the front of the wrist. The tunnel is made of wrist bones covering the floor and walls and the roof is made of a strong fibrous ligament. Normally the pressure in the canal is very low. The increase in pressure in the tunnel could compress the nerve, compromise the blood supply to the nerve and cause pain/numbness and tingling.

 

What are the symptoms of CTS?

This is usually felt as pain, tingling or numbness in part of the hand, usually the thumb, index and middle fingers. Sometimes the symptoms are felt in the whole hand. The intensity of pain, tingling and numbness are often quite variable in severity. The symptoms are typically worse at night and with certain daytime activities such as driving, cycling and reading. Shaking the hand may relieve the symptoms. One or both hands can be affected.

 

Why does it occur?

In most cases, it’s not known what causes the median nerve to become compressed, although the following increase the risk of developing CTS.

  • Family history
  • Health conditions – diabetes, an underactive thyroid gland or rheumatoid arthritis and obesity
  • Pregnancy – Many cases resolve after the baby is born.
  • Injuries to the wrist
  • Certain activities
  • Playing a musical instrument
  • Assembly packing
  • Work that involves manual labour
  • Work with vibrating tools, such as chainsaws
  • Other
  • Cysts, growths or swellings in the carpal tunnel
  • Some drugs used to treat breast cancer – such as exemestane (Aromasin)

What happens if nothing is done?

As carpal tunnel syndrome progresses, you may feel you are losing coordinated movement of your fingers. You may notice weakness in your fingers that makes it hard to do daily tasks, such as buttoning buttons. The symptoms of pain/numbness will increase and most people are particularly troubled by night waking often in the early hours of the morning. If left for too long permanent numbness and muscle weakness could reduce the hand function considerably.

Investigations:

How is it diagnosed?

Carpal tunnel syndrome is diagnosed by a hand specialist based on an evaluation of your symptoms, physical examination and if needed an electrophysiologic test. The surgeon will also examine the patient‘s neck as this can give numbness and tingling in the hands similar to CTS.

Nerve conduction study/Neurophysiology/EMG – This is performed at a later date by a specialist (Neurophysiologist). Mild electric shocks are sent up and down the arm and the strength and speed of their conduction is measured. The test measures the electrical signals passing through the median nerve and how the muscles that are supplied by the nerve are being affected. It can show if the nerve is compressed. Like all tests it is not completely reliable so it can be normal although the patient has CTS and it can be abnormal when the patient does not have CTS. Your Hand specialist will interpret the results in the light of the previous description of symptoms and examination and advise you accordingly.

Rarely X-rays, Ultrasound/MRI scans, blood tests are performed to rule out other causes of CTS

 

Treatment:

What are the non-operative treatments?

Wrist splint is often the first step in treatment. A splint can be particularly helpful for people whose symptoms are bothering them at night. Wearing a splint during the night can keep the wrist from bending or being extended while you sleep. That often relieves the nerve pressure and eliminates nighttime discomfort. Wearing a splint during the day also can be useful if symptoms persist during waking hours. Some people don’t like wearing a splint during the day, though, because moving the wrist naturally may be difficult.

Corticosteroid injection into the carpal tunnel may help reduce symptoms.

  • Corticosteroids lower inflammation and swelling within the carpal tunnel, which can relieve pressure on the median nerve.
  • Benefit may be temporary.
  • Rarely more than two injections are beneficial
  • If the symptoms are marked and established, surgery may be appropriate
  • Where the clinical picture is unclear a positive response to an injection helps confirm the diagnosis.

 

What does the operation involve?

The operation is called a carpal tunnel release (CTR) or decompression (CTD). The operation is usually performed as a day case surgery (means, you won’t have to stay in hospital overnight.) under local anaesthetic.

 

On the day of surgery

A local anaesthetic is used to numb your hand and wrist, but you’ll remain awake throughout the operation. General anaesthetic is rarely advised (patients with needle phobia). A tourniquet, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated by our patients. Before the surgery, the arm is painted with an antiseptic and covered with sterile sheets, to help minimise the risk of infection.

The surgeon checks the skin for numbness and if needed injects more local anaesthetic. Once the skin becomes numb, the surgeon makes a cut over the front of the wrist, and the roof over the tunnel is released, so that the nerve has more space in its tunnel. The skin is then stitched up usually with stitches. A supportive dressing is applied and the patient’s arm(s) elevated.

The total time in hospital is usually 1-2 hours. For most hand conditions surgeons avoid operating on both hands at once as it can be significantly disabling. The decision to release both sides at once is a decision between the patient and the surgeon.

What happens after surgery?

The care of the hand in the post-operative period is very important in helping to achieve a good result. The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain. Initially the aims are comfort and elevation of the hand in a bandage for a couple of days, and you may need to wear a sling. Gently exercise your fingers, shoulder and elbow to help prevent stiffness. You may be able to start these gentle exercises on the day of your operation.

After having surgery for CTS, you can use your hand to do light activities that don’t cause excessive pain or discomfort. Try to avoid using your hand for more demanding activities until it’s completely recovered, which may take several weeks.

The bandage can be removed after 2-7 days, leaving a sticky dressing beneath. The patient or GP practice nurse can do this. The patient is reviewed in clinic around 2 weeks following the operation for wound check and removal of sutures.

The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar related complications (tenderness, helps scar to mature). Hand therapy for scar management will be needed in few patients.

Most patients can drive after the wound has healed (usually 2 weeks). Most patients return to work in 2-3 weeks, but this varies with occupation; heavy manual work usually takes about 6 weeks. Patients should avoid pressing heavily on the scar for 3 months following the operation as this will be quite painful.

Are there any risks?

Any operation can have unforeseen consequences and leave a patient worse than before surgery. For CTD the risks are small but include:

  • The scar may be tender in about 20% of patients. This usually improves with scar massage, over 3 months.
  • Aching, especially on gripping. This occurs in about 4% of patients and also improves with time. Grip strength can also take some months to return to normal.
  • Stiffness may occur in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below).
  • Numbness over the base of the thumb, caused by damage to a branch of the nerve, happens in less than 4% of patients. This rarely causes any functional problems.
  • Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
  • Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which very slowly improve.
  • Injury to the main median nerve can occur extremely rarely, resulting in permanent numbness and weakness in the hand.
  • Failure to fully separate the roof of the carpal tunnel during surgery, usually resulting in persistent CTS symptoms
  • In rare cases, the return of CTS symptoms long after apparently successful surgery

 

What are the results of the operation?

The overall success rate of carpal tunnel open surgery is more than 95% with a complication rate of less than 3%. Most patients have very rapid or immediate relief of their pain. Symptoms of numbness or weakness may well never resolve particularly if there was continuous numbness or weakness prior to surgery (permanent damage to the nerve even before the surgery). Nonetheless most patients gain significant benefit in these symptoms, which may improve for up to 2 years from surgery.

 

Is surgery a permanent cure?

Yes, in majority of patients. However the reported recurrence rates after carpal tunnel decompression are between 0.3 and 12%.