PLC reconstruction or can I live with my knee as it is? Advice please

[fuzzybob]

I saw my OS today, 7 months post op from my HTO, to discuss my rehab and recovery so far and to review the need for my PLC reconstruction. You will see my brief history from my signature at the bottom. I was suppose to have my PLC reconstructed at the same time as my HTO in March this year, but unfortunately I suffered the rare complication of a lateral tibial plateau fracture during my HTO; so my OS decided not to proceed with the PLC reconstruction.

It has been a long, slow and gradual rehab so far. So far PT has been gradual, progressive and quite conservative because of my TPF etc, but I have made good progress with my balance and strength. I can row and do stationary bike and leg presses and in this respect my knee is improving and progressing well according to my PT. My OS rehab protocol so far has restricted my programme to closed chain exercise only; with no impact, twisting or pivot work allowed so far. As my knee improves so has my mobility and walking improved; but at the same time my instability and symptoms I suffered pre surgery have now returned.

My PT has tried twice to progress my walking on a treadmill, but each time aggravating my knee causing pain and swelling. She has removed this from my programme and I have needed the help of hydrotherapy as well to help my rehab.

My OS hoped that may be the HTO will have helped my instability and in particular my hyperextension but with my recovery from the HTO with increasing mobility and walking; it appears my instability problems and my feeling of hyperextension and varus kick out have returned, causing me increasing discomfort and pain, leading to increased swelling and inflammation and aching etc. A vicious circle!!

My OS was clearly disappointed that my instability problems have returned and today seemed more reluctant now than previously to go back in to try to fix my knee. He emphasised today that doing the soft tissue correction may not help at all and may leave me worse off. The question he has asked me is- can I live with my knee and accept my lot or am I willing to take the risk?

I am also suffering hardware problems and I am likely to need removal at the one year post op mark if my symptoms continue. If I still have instability then it would seem sensible to do the PLC reconstruction at the same time as the HTO hardware removal March / April next year?!

Walking is the one activity that appears to cause me most instability problems, equally I do not like stairs, slopes or uneven ground – all elements are fundamental to everyday living. At this stage I am not considering returning to sport (I was an active sportsperson). All I want to do is walk again!

To fellow PLCers – are my symptoms typical pf problems you have experienced? Is this normal despite the fact I appear to be able to row and cycle with few problems?

I am fully aware PLC injuries are rare and are notoriously difficult to, not only diagnose but also treat; especially chronic as opposed to an acute PLC injury. In addition once diagnosed the guarantees of a good outcome are no where near those of say ACL reconstruction etc.

My dilemma is should I proceed with a PLC reconstruction or not? Is it worth it? My OS is reluctant to put me through more surgery and a long rehab with no guarantee it will help with a high chance it may potentially make things worse – particularly with my track record so far! Basically I feel I have lost a year and back at square one. I will have spent a year recovering from my HTO / TPF, then to spend another 12 plus months trying to recover from PLC reconstructive surgery – and still not walk or do thing any better than now!?

I do Trust my OS and he is well respected and experienced in PLC surgery. Clearly he wants me to go in with my eyes open and not to give me false hope. I have been through all this before hand and I feel a sense of deja vue……..starting from scratch again next march to try to solve my problems. He has given my PT the green light to progress my rehab slowly but anything that causes me pain not to progress! He will see me in 3 months time to review if I still have hardware and instability problems and see if I need more surgery or not.

If I decide not to have the PLC reconstruction and live with my knee, clearly I need to change to a non active lifestyle, but will everyday life activity continue to damage my knee more?

I am not sure I have the mental, physical or emotional strength to go through this, particularly as at the moment the odds appear stacked against me. Is it worth still fighting to try to get a near normal knee as possible or to accept what has happen to me and learn to live with it?
Sorry to rant – just not sure what is right anymore.

[queeny]

What a nightmare, it really seems as though you been through it.

I know you said your doctor is experienced and well respected, but is it worth getting a fresh pair of eyes in the form of a 2nd opinion?

It's really difficult to know what to do, part of my thinks that you might always think "what if" and wonder whether you might have had improvement.

But if you you do go through with it are no better, or even worse, are you going to spend the rest of your life regretting having it done?

What's worse, wondering whether it might have worked, or wishing you didnt have it done?

Unfortunately you seem stuck between a rock and a hard place and I wish you luck in your decision.

[lenorem9]

Hi Fuzzybob, So sorry to hear about your ongoing problems.  You've been through so much already only to find out you might have to start over with the PLC too.

I can't speak for everyone but I will say if I had to make the choice I'd do PLC surgery again.  Pre-op I was able to run, hike, bike, walk but if I pivoted my knee gave out and I would fall down.  I wasn't ready to settle for that for the rest of my life.   I'm 11 months postop and still whining and complaining but I'm a success story for sure.  I can do almost everything I did before. 

I've only read about one person on here that had a PLC surgery fail.  All the other stories I've read are very encouraging.  If you have an OS that's confident about doing it I'd say go for it.  You'll have a much better quality of life in the end.

As far as having the emotional and physical strength to go through another year or more of recovery... I can't even imagine.  That's a decision you have to make for yourself.  Just know that we're here when you feel like ranting some more.   We know where you're coming from. 

Good luck and let us know how you make out.

[fuzzybob]

Hi,

Thank you all for your words or encouragement and support. Sometime has lapsed as not a lot to report until now. So thought I should up date you all on the latest in my saga!

Following my last OS consultation and spending the past 3 months working hard in PT. My strength and balance etc has improved, but I have no improvement, and in some respects has got worse; including instability and hyper extending issues etc.

Saw my OS again on Jan 22nd. This was probably the most ineffective and strangest consultation to date! He is really getting cold feet with me now! He briefly examined me and took a very brief summary of my progress and told me that the HTO/tibial slope correction should have corrected all my problems and from his (i.e. a surgical) point of view this has changed the biomechanics to fix the problems! But from my complaints about my functionality etc, clearly it has not. He concluded that surgery has been unsuccessful and that there is nothing more he can do for my knee!

I was so stunned to hear this! After gathering my thoughts I asked is there nothing else that can at least be attempted? Why book me in for PLC reconstruction last year if there is nothing wrong or you really thought it would not help? What has changed? Last year we discussed at length the fact it was contentious treatment plan, risky, major surgery, long rehab and no guarantees of success, but it was something that could be attempted to try to fix at least some of my problems to alleviate my symptoms and the only chance to try to get back to some physical activity!. So after a considered approached I said I understood and wanted to take the risk and the one opportunity to try to fix my knee to give myself the best possible chance! I still stand by this – so what has changed; surely reconstruction should be tried, now I have recovered from the HTO and tibial plateau fracture?

He didn’t answer directly but re-considered and said clearly he understood why I wish to make sure no stone is left unturned! He agreed my metal work from my HTO is causing me discomfort but then blathered on that he was worried about my bone strength and wanted to give it a few more months to heal! Then see how the knee is!

So plan is. I am scheduled for hardware removal early April and at the same time he will do again another diagnostic arthroscopy and evaluation under anaesthetic (EUA) to assess my ligaments etc. He also wants to check out my tibial plateau and fracture site. Afterwards to discuss the results and based on the scope and EUA will decide if PLC reconstruction is needed and if so will schedule to do later in the year!

So I am now faced with surgery no.3 for this knee/injury, some 28 months since injuring my knee and possibly another surgery afterwards! So looking at least another 1-2 years rehabbing! Part of me is relieved that my hardware is coming out; so hopefully this will remove some of my pain and discomfort, but as for sorting out my instability issues; I can't believe my OS will not do reconstruction at the same time and instead wants to go in and have another look. He did this in July 2007; so he has ignored his original scope/EUA findings so why I was offered PLC surgery last year? I am really baffled! He is being very conservative, careful and cautious but I am now back to where I was 2 years ago!

God know what my physio will say and she was adamant that I need reconstruction as I have plateaued and she can’t take me any further!  My PT is on holiday currently so don't see her until Feb 6th. So will be interested to hear what she thinks! I am thinking about another OS opinion but keen not to change just yet; as want my hardware removed. So I suppose I will see what he finds and decide then what to do!

This is just dragging on and on and I am getting so depressed about all of this now. Not sure how much more I can take. I want to get my knee sorted! I respect him for is considered and careful approach but this is now starting to frustrate me. Sorry to rant

[lenorem9]

More waiting, more pain, and more not knowing....the dreaded wait.  Not fair fuzzybob.  I'd say definitely get another opinion.  At least OS is going to look at PLC again but if you're still that unstable seems like they should do the surgery while they are in there anyway.

I feel for you.  Since my last post here I've been struggling again.  I developed scar tissue all through my knee and had a scope to get rid of that but still having problems.  Hopefully it will be resolved.  This knee crap sure seems to be never ending sometimes and I too wonder how much more I can take.

Hang in there and don't give up.  Who knows, maybe a 2nd opinion will tell you something good. 

[Silkncardcrafts]

Hi there,

Been reading your postings with interest as I also have a problem with my PLC at the moment.

I totally agree with Lenore. Reckon you should get another opinion. I am currently waiting to see my OS in 8 days to find out the next steps as it keeps hyperextending backwards. Not fun at all. This all just happened a week before Christmas. It's a different injury what I've had before with my knee. Just want some answers on the next steps.

Just don't understand OS's that won't do what needs doing if they find more needs to be done when they do the arthroscope. If my OS finds more damage he always does what he needs to instead having to put the patient under again. When I've had surgery my surgeon I've always had to sign a consent form that says that I agree for additional work to be done if necessary. Makes more sense to me rather than putting the patient under more stress by having to go under again.

Let us know how you get on.

[tennis girl]

Hey Fuzzybob,
Sounds like the os has changed his mind on you.  I am going through the same thing right now.  When I went in for surgery, I signed off on a PLC recon.  I woke up with an ACL recon.  I respect the OS taking the less evasive route, but now I am back to an unstable knee with hyper-extending.  OS blames it on muscle firing issues.  He has not brought up the PLC at all.  Not since Nov.  I don't know what to think???  Like you, I like my OS, but can't figure him out at all.  Do the OS take a class on how to "baffle" their patients? 

You seemed confused on if you should fix the PLC, or not.  I was thinking the same thing earlier, but now that I'm through the pain of the ACL surgery, I still have "everyday" issues, sooooo I am pursuing until I get it right.  I want to have a stable leg and I think I can find somebody who can help me.  Sometimes, don't you feel alone in all this?  Especially when you think the OS is thinking along the same lines as you, and then BAM!!!!, they totally throw you a curve ball.  Hang in there Fuzzybob.  Feel better, and keep searching, for you.  Don't you want to have a time when you don't have to think about your knee?  You will not be able to move on if you are having instability and hyper-extending.  My worst episodes are when I pop up not thinking, and WHAM, back goes the knee. 

[Silkncardcrafts]

Hi Fuzzybob,

Appreciate what you are going through. Is so hard when they change their mind or find out it is something different. The worst part is not knowing what is going on. I see my knee surgeon in a week and looking forward to getting some real answers. Have a long list of things to ask him. All my problems are with the PLC.

Just want to say you are not alone and understand how you feel. Can make you feel really depressed. I have been really down in the last couple of weeks due to not being able to do much because of my knee and not knowing what is going on. Now that I am back in the hydro pool and gym it is helping my mood and motivation. Just hard to keep motivated sometimes.

Chin up, it will get better.
Try and do something nice for yourself today.

[sarebear10]

FuzzyBob,

   I am new on this website and i actually stumbled upon it while researching about PLC reconstructive surgery. I am a 17 year old junior in high school and am coming upon my 7th knee surgery in 5 years this march. In the beginning, they were just small surgeries for plica syndrome, and  torn cartilage. Then my freshman year in high school i tore my meniscus and my OS opted to not repair it, instead he "roughed it up" to improve blood flow and hopefully heal more quickly. At my post op visit, my mom and i asked if we should do some PT and he said "sure if you want that garbage." lets just say that we didn't see him ever again.
   Over the next year, my knee strength declined greatly, and every doctor i saw put me in a larger brace than the last, thus creating more instability. MRI's showed nothing, EMG's showed nothing and I really couldn't even name all of the different types of doctors and surgeons i went to and the many, many times they told me that "it is all in my head." I even had one neurologist try and drag me down the hall telling me to run (which was nuts because i couldn't even walk) and he then sent me out of the room and told my mom that "sometimes teenagers use a brace or injury as a cushion to the stresses of teenage life." This was definitely not the case with me, prior to my knee problems i was very active in sports, i have amazing friends, a job, and really a blessed life.

[sarebear10]

i accidentally hit post too soon on the last one so i will continue here:

Our search continued until we heard about a really good OS and when we saw her, we were amazed. She walked in the room, took a few looks at my knee and the way i walk/wobble, and said "I know what the problem is! and i can fix it!" she told me that i have an extremely elevated Q angle which was causing my kneecap to sublux frequently and the alignment threw off the way i was walking. A few weeks later she did a Tibial Tubercle Transfer/osteotomy. Prior to surgery she had talked about a possible PLC reconstruction but when she was operating she opted not to do that because the exam wasn't as bad as she thought. Rehab started at 2 weeks post op, other than quad sets and straight leg raises i was doing at home. It went really well. Then, one morning as i was getting ready for school, i was trying to put my socks on while standing up on my crutches-probably not the brightest idea i have ever had- and i fell forward onto my leg and snapped the bottom part of the bone left attached to my tibia off of the bone. Thankfully the screws held it in place and no repair was needed.
   A month and a half later, i was finally off of crutches and doing pretty well. It was winter time and snow had been tracked into the school hallway. I slipped and fell, fracturing my tibia, and pulling the bone off of the screws. The next week my OS did a repair and i continued with my rehab. My quads built back up, my balance improved amazingly and i was able to ride the stationary bike with no problems. My walking was even a lot better for a few months.
   6 months post op, my OS wanted to do a hardware removal because i had 5 very large screws, and they were causing a lot of irritation. That surgery went well and i was back in PT for a while because my strength and instability had declined slightly, not alarmingly though at this point. As the weeks continued however, the terrible wobble came back. When i went back to my OS and showed her, she freaked. She explained that she had no idea why my knee was doing this again and that the TTT should have stopped the wobble. She sent me for another EMG and of course it was normal. I went back again and pushed for her to examine me better and when she did she found that there was a  lot more laxity in my PLC than there was before and that we should probably do the reconstruction now.
 Really the whole point of this blog is to let you know that your not alone and i really am surprised as to how similar our stories are. I have never heard of anyone having the same problem as me, and it can be very discouraging at times. Sports have ended for me, its hard to even do normal day to day activities such as going to school because of how painful it can be.
   I am now scheduled for a total PLC reconstruction on March 20th. Hang in there!!

[lenorem9]

Sarah, I sent you a PM.  I'm so sorry you've gone through all you have and are facing more.  It does help people like fuzzybob to hear your story.  Non kneegeeks just don't understand how hard it is and can't believe there are really knee struggles like this.  So many of us are walking around in pain, trying to get answers, and wanting our lives back again.

Fuzzybob, how are you making out?  Post an update when you get a chance.  Hope you're doing better.

[fuzzybob]

Dear all,

Thank you all so much for your responses and my apologies for not responding sooner. Your kind and supportive words and stories are much appreciated. But I basically wanted to give myself some time out to apply some thought and objectiveness and wanted to chat with my PT also about my situation.

I am a bit calmer now and see things a little clearer.  I am the sort of person that needs to understand the reasons and logic behind decisions and this is the one thing my OS, who is usually very good, didn’t do at my last consultation.

Looking back, I can only surmise that because I also have a posteromedial capsular rupture as well as PLC, and since this area cannot be reconstructed unlike the PLC, my OS had hoped by doing the HTO; primarily to unload my medial compartment due to the massive impact damage to my medial femoral condyle, this would also help tighten up both the posteromedial as well posterolateral areas. But as this surgery has not helped even a little bit, this might be why my surgeon feels even with PLC reconstruction, because of the posteromedial damage; I would go though big surgery with risks, alongside another period of long rehab with no real gains and potentially be even worse off! This may be why he has said he feels there is nothing more he can do for my knee! If this is the case, all he had to do is say that’s why; because this makes sense. But he didn’t. However this is a question I will be posing to him next time I see him.

My PT was surprised but then went into usual professional etiquette mode and focused on trying to pick out the positives to try to make me feel better! I work in the NHS myself and I am just as guilty doing this myself with patients, but all very different when on the other side! Any how, she listened to my reasoning and reckoned this is a good possibility, but clearly I would have to discuss this with my OS. In the end we both agreed that clearly he was having a bad day as this is out of character for him, from both of our experiences.

At least he is willing to take the time and trouble to re evaluate my leg and may be having another scope and EUA at the same time as my hardware removal (which is something I need and will help alleviate some of my problems) is a sensible approach. I will see what the outcome is and take it from here.

Since my last post, I got a surgery date through for March 25th which was slightly earlier than I was expecting. Unfortunately my partner is way then and is not around to look after me for the first 24-48 hours. No one else around really at that time either, so I have had to cancel it. I was due to get a new date through within a week as the bookings office didn’t have the April rotas when I phoned, but 2 weeks later, still nothing, so I will have to ring up and chase tomorrow, just in case I have been lost in the system! I find not having a date is starting to annoy me as I really can’t seem to get on with sorting my life, work and pleasure wise! At the moment this whole knee crap is consuming me and my life and existence! I just want to stop feeling this way! I think once I get a date I have something to work too and with, as the next stage. At the moment I just feel in limbo!

I am also worried about my ankle and other knee. I have had ankle pain since early December and basically walking is what flares it up and this has not settling down. This tends to become very tender, sore with stiffness to the extent I limp badly and stairs are even worse! My PT and OS just said I must have gone over on it at some time and not to worry, but I am worrying now, because the problem still exists. Basically if I sit around and don’t do anything = fine. If I walk, even for 20-30 minutes = problems: pain and discomfort taking from a few days to up to a week to settle down!

And to top it all, last week whilst doing some bridging exercises, my foot slipped,my good knee fell to the side and I felt a pop and ‘squish’ sensation in my lateral part of my knee with pain. Upon extending it I had pain also and it has been really sore since. Following a session in the gym, I also had soreness medially, more so than my bad knee. I am worried I have now damaged my meniscus in my ‘good’ knee! God I am just falling apart! I need to speak to my PT about this latest development!

Lenorem = good luck with Dr Noyes. I really hope you get some answers as you have really been through it and you deserve to get your knee back and are always around to give good advice and support to all other KGs.

kjwilkin – glad you don’t have a PLC problem; but hope you too find some answers to whats the problem and it can be fixed.

sarebear10 - thanks for your story and yes it gives me hope that OS' can change their minds and that re evalaution after previous surgeries is a good thing. I wish you all the best for your forthcoming PLC reconstruction. Let us know how you get on.

Best wishes

[Silkncardcrafts]

Hi Fuzzybob,

Thanks for the update.

I had my OS appointment about 2 weeks ago. My OS decided to manage my PLC problem conservatively for the moment. It has improved a lot now. At the moment it's mainly pain that is a problem.

Hope you get another surgery date soon.

You have every right to feel concerned about your other knee and ankle. Definitely mention it to your PT. Ignoring them could make matters worse.

[fuzzybob]

Dear all,

Thanks for your posts and I have kept up to speed with your progress through your post op diaries.
Good luck Lenorem with your surgery. Hope you get a date soon and glad you have found an OS (although Noyes is a worldwide expert) that can help you.

kjwilkin – hope your knee continues to get better.

sarebear10 - surgey rapidly approaching, best of luck and let us know how you get on.

I have my re scheduled surgery date finally! Surgery will be on April 15th! I will have my metal work removed from my osteotomy site (plate and 4 large screws) plus a scope and EUA to re evalaute and assess my knee, see what damage there is and what can be fixed etc.

Any way April 15th is the day I hope my road to recovery will finally start! I will get rid of my hardware which is causing me so much discomfort and get rid of that stiffness and soreness. At the same time I will find out what other damage I have done to my knee - not only from the original injury but as I am now 2.5 years post injury walking round on my knee, I am curious to see if there is more damage to my knee or not? Then of course moment of truth.............can the instability problems be sorted and can my knee be fixed?

April 15th is a day I am looking forward to and dreading!

Keep smiling!

[lenorem9]

That's great news fuzzy.  April 15 isn't that far away.  They will fix you up right and you won't have any more stability issues.  I'm so glad you're moving forward instead of stuck in the waiting mode.

Good luck.  We'll be following your progress and wishing for all the best!