Rehab and Flexion Questions

[zafzo]

Hey guys and gals,

I just found this site and have found some excellent information. Thanks for that already. Now I have a few questions as my OS has me a little worried after my appointment yesterday. First a little background:

Shattered my patella on 3/7/05 in a motorcycle accident. (OS's exact words were "You flattened it like a pancake")
He immobilized it at slightly less than full extension and waited two weeks to see if it would heal together on it's own.
Unfortunately my quad pulled quite a few of the fragments up higher into my leg. So I had surgery on 3/21/05 where he detached my quad, removed the pieces, screw/wire to hold what's left together and stretched and reattached the quad to the lower half of my patella that was still halfway usable. I started rehab two weeks after surgery with my brace range 0 to 30 and a goal of full extension by my next OS appointment on 4/14/05. I managed to do this through PT twice a week and on my OS visit on 4/14/05 I had full extension and flexion of 58 degrees. He set my brace to 0 - 90 on 4/14/05 and said get 90 degrees by my next visit on 4/28/05. Plus he gave the go ahead to walk with my brace on. So I went to visit him yesterday for my 4/28/05 appointment with full extension, 84 degrees flexion, and I'm walking easily, stairs and all(except going down). Now I thought I was doing well being able to walk well and go up stairs but he didn't seem happy because when my knee is being bent, it basically stops like it hit a brick wall at that 84 degrees. He said he may have to put me under anasthesia and force it to bend or go in arthroscopically to remove scar tissue that he thinks is the cause of the stop. He has given me a week(until 5/5/05) to really bust my butt in rehab and get it bent or he wants to do it himself. So since yesterday I've been really bending it and causing myself extreme pain and discomfort but I've gotten it from 84 to 90 in a day. But it seems just so incredibly stiff and unmovable that it won't go anymore. Is this normal? I am 5 1/2 weeks out of surgery and thought I was doing well. I don't particularly want to go back under the knife so I am wondering what your thoughts and experiences are. Thanks in advance and get well soon everyone. :-)

Ryan

[sparkle999]

I don't have injuries even remotely similar, but it seems rash to do another surgery when you are still making progress. You said you managed to push it really hard to 90 in a day, which is fantastic ( I know because I have flexion problems too)

Perhaps he would agree to trying 2 more weeks PT first?? You're only 5.5 weeks post op so any scar tissue may not be REALLY tough yet. Also, if he wants to bend it while you are under anaesthetic, I have been told this not a good thing to do unless you have a scope at the same time (some people think it's a bad thing to do full stop).  Also, if the max your brace has been set to is 90, your knee is only getting limited opportunity to settle beyond that flexion. Ask him why he won't give you more time in PT.

I'm really not well informed, but your OS should be able to explain why he wants to do stuff and what benefits there will be. He should understnd your concerns and discuss alternatives(or lack of them) with you.

One more thing, I know you don't want another op. But a scope is a small, keyhole procedure that actually gives the OS lots of information about what's going on in your knee. I know I want as many facts about my knee as possible before my OS makes any treatment decisions!!

Good Luck
xx

[Janet]

I agree that you should ask your OS to put off surgery if you are able to make progress on your own. If the time comes when you are not making any progress after several weeks, I would ask him to do the scope. Don't let him do the manipulation under anesthesia (MUA) without first doing a scope. The MUA is a very traumatic episode for the knee, and the body responds to trauma with more swelling, pain, etc. which can cause the scar tissue to return. If you go down the the Soft Tissue section below, you'll find a lot of discussion about these exact issues.

Janet

[Julieat22]

Hi Ryan
although my injury and surgery were quite different to yours, it seems to me that it is still very early days for you and your knee and that you have done really well to get as far as you have done in such a short space of time.  I was in a ROM brace with the flexion being increased just 10 degrees per week with the aim that I would get 90 degrees flexion back.  Because the increase was so gradual and my surgeon was happy for me to get the mobility back slowly (provided every week there was an increase) I now have over 120 degrees flexion.  I would hold off any surgery unless you find your knee gets so far and there is no improvement for a few weeks.  Everyone heals at different rates.
Take care, good luck and I wish you a speedy recovery
Julie

[MHB]

Hi Ryan,

The fx patella I had was different from yours a bit -- mine broke into two half-moon pieces and displaced a lot. Had surgery same day with screws and wire fixation, then immobilizer for 5 weeks. Was not allowed to "bend" the knee at all during this time -- just did the straight leg raises a bunch in the meantime.

At 5 wks, when I finally got out of the immobilizer, extension was about 2 and flexion only 40 or so degrees. I was not allowed to climb/descend stairs in the "normal" way until 12 wks out from surgery, and also was not allowed to do any PT exercises that put weight on a bent knee (not even stationary bike riding with no resistance) -- a conservative OS, but wow is he good.

So, you see, my rehab was quite different than what you describe. Anyway, after getting out of the immobilizer, exercises brought back the extension and the flexion in about 3 wks -- 0 to 140. Oh, getting there required regular, several times daily work at home, but basically, not too uncomfortable at all and it worked fine.

So, at 5 and half weeks form surgery, you're right where I was when I started bending the knee again. I dunno, if yours rebels at 90, won't progress, and your OS wants to do the MUA, ask him about LOA (scope surgery to remove scar tissue) instead of the MUA, which can be pretty hard on the whole knee system. In addition, if you are a person who forms more than the usual scar tissue in response to injury recovery, an MUA can aggravate that condition, and the scar tissue can return quickly with a vengance.

Posters here have had extensive experience with overactive scar tissue response, and what has worked best for them is an LOA coupled with very specialized PT during rehab -- routines that do not aggravate the recovering knee into producing even more scar tissue. You can do a search on these forums for "arthrofibrosis" and learn lots about it.

Best of luck for a complete and comfortable recovery -- MHB

[zafzo]

Thank you all for the information. I really appreciate it. I'm beginning to think that my OS was trying to scare me to get me to work reallly hard at PT. Well it worked. I'm past 90 by a bit right now and it's loosened up quite a bit since my post a couple days ago. Thank you again for all of the info and I'll let you know how the progress goes and what happens with my OS next Thursday.

Ryan