Soccer player- ACI & Meniscal transplant diary and the road to recovery

[cfranc]

Ouch!!  I've had some frustrations with PT as well (now 6 wks out).  The hospital set up in home PT right after I got out of the hospital.  Only I assumed it was a nurse not a physical therapist.  So when he came the first couple times and only checked my vitals and the incision I thought nothing of it.  Then going into the second week he tried to get me to do SLRs and was all concerned about doing quad sets, etc.  but said almost nothing about ROM (which I was really struggling with). 

I refused to SLRs indicating I was specifically told not to.  He then began his rant about 6 yrs of education and did I think I knew more than him.  I had even given him the website for Gomoll's/Midas' protocol...but apparently that was a stretch for him to review on his own.  Needless to say he only came a few times and walked out extremely irrated. 

Thankfully I started going to a regular PT right after..I wish I had started earlier.  I am now going in for a scope to remove scar tissue as I can't get past 90 ROM.   

At my PT I work with a couple of different therapists, but the lead therapist has worked with ACI's before so for the most part they have been good in starting me slow.  But even still I confirm any exercises with Gomoll if I am uncomfortable or questioning whether it is too much.  He has been great with providing his email and answering questions timely. 

I am bummed about having to go in to remove scar tissue as it certainly puts a hold on my recovery...though I can start weight bearing and SLRs etc.  From experience with a prior TTO, you would be amazed at how much you can build back the mucsle with SLRs and similar exercises.  So don't be dismayed...

[ajschnelk]

That's too bad about having to have a scope.  I know I've mentioned this before, but I was at 90 degrees up until around week 7 and around 100 by week 8.  I am now at 3.5months and I got to 135 today.  his your OS pushing you to have the scope now or are they saying to maybe wait a few more weeks?  IMO, 6wks post seems early to give up on ROM and have a scope, especially since you're at 90...60 or 70 would be a different story. 

[ajschnelk]

Here is something else; has anyone one else come across this?  I was given a handout after I left the hospital that states “Anti-inflammatory agents (ibuprofen, aspirin, Aleve, Naprosyn, Vioxx, Celebrex, etc.) are not allowed for at least 6-9 months because of their adverse effect on cartilage growth.”  While I was in the hospital I had been given large doses of intravenous anti-inflammatory agents.   I have not asked the surgeon about this, but it is on my mind. I just don’t want to alienate the staff by acting like I am a know it all.  But based on what happened with PT, I fear the worse.

Best wishes to you Paul. 
Keep us posted.
Dennis

Dennis,

This has been discussed here quite a bit and it seems as though most OS don't feel the same as Minas.  many were on an anti inflammatory post aci and had a successful outcome.  My OS told me it was okay to be on celebrex and ibuprofen and not to worry.  However, since I researched heavily prior to my aci, i was aware of Minas' opinion on it and  I have decided not to take anything other than the ibuprofen I took during the first week.  There is research where NSAIDs have reduced tissue growth in animals, but nothing regarding cartilage specifically.  There are other studies that show NSAIDs reduces the healing process with torn muscles and pulled ligaments while also reducing swelling, so this is why it feels as though things heal, but i guess it keeps the body from healing to it's full potential.  I'll try to post the link that discusses the study.  Again, according to some, there's no evidence showing that it impedes cartilage growth.   

As slim as it may be, i have decided to take zero chances.

[Rennschnecke]

Hi Dennis & cfranc

I was nodding when I read your posts about PTs.  Unfortunately, it is now fashionable to encourage patient self-management but the language used remains that of dominant healthcare professionals doing to a passive (empty-headed?) patient and this leads to certain attitudes.  However, the situation is more complex than who has the power.  As a patient who has researched the topic of knees to high heaven and still comes here to learn from all you lot who have loads of knowledge and experience I still find that I don't have enough context to assess the information appropriately.  But I think I've been lucky to have had clear issues to slow down PT, i.e. scar tissue.  This is a common complication although my arthrofibrosis is now at the outlier stage.  Still, I've continued to be conservative an just hope (pray) it will work out in the end.

For me, I think that it is essential to have the most appropriate PT to work with.  They do exist and they will either be knowledgable about ACI or prepared to learn and consult with others.  They will listen to the patient and liaise with the OS at key stages.  They will adopt a conservative approach based on the combined procedures and assess your individual needs rather than just follow the same old progression.  It's really sad to hear when this doesn't happen – makes my blood boil remembering similar experiences and also (guiltily) glad that I'm not alone in this .

Re. anti-inflammatories – I had the same concerns.  I was prescribed anti-inflammatories post-MACI at hospital by the anesthetist.  I continued to take these until I came across the protocol from Minas, at which point I discontinued their use (around 1 month post-op).  Should I be concerned?  Well, when they scoped me at 14 weeks my cartilage looked excellent and well-integrated and far better than they expected.

Now at around 9 months post-MACI and 6 months post-debridement I have had a steroid injection as I still have extreme pain flare-ups.  I am worried, but the surgeon reassured me that at this stage the worst outcome is an infection and after that that the procedure has no effect and is essentially a complete waste of time.  My research indicates that evidence for cartilage degradation with NSAIDs and steroids is mixed.  The evidence for the degradation effect of NSAIDs on cartilage appear to be in vitro studies, whereas in vivo studies give rather different (positive) outcomes.  The same appears to be true for steroids.  The findings also appear to be associated with frequent use over prolonged periods rather than isolated use.  Still vaguely worried but I had no choice as the surgeon wants to settle my knee before possible further surgery to treat the arthrofibrosis.  I may update on the state of the MACI post-op.  Unfortunately, if the cartilage is damaged it is difficult to attribute this to the steroid since I also have scar tissue and patellar contracture which increases the forces at the knee.

That's too bad about having to have a scope.  I know I've mentioned this before, but I was at 90 degrees up until around week 7 and around 100 by week 8.  I am now at 3.5months and I got to 135 today.  his your OS pushing you to have the scope now or are they saying to maybe wait a few more weeks?  IMO, 6wks post seems early to give up on ROM and have a scope, especially since you're at 90...60 or 70 would be a different story. 

I agree with AJ here, 6 weeks is a bit early to be definitive about a need for debridement.  There probably is scar tissue around the joint – it is part of a natural healing process.  The concern is whether it impedes your function.  However, the surgeon is probably just priming you to expect further surgery if you don't improve.  I had the same warning at 8 weeks post-op (which was the 6-wk appt); I was reviewed at 12 weeks to determine whether it was necessary and I was scoped at 14 weeks.  I thought I'd reached 90 degrees but the surgeon reckoned it was 80 – he didn't measure it, I think he just drew on his experience and thought it wasn't enough.  Besides that I was getting more pain – a classic sign of scar tissue.

Scar tissue is pliable for the first 3 months or so which gives you the timeframe for stretching the joint through ROM exercises and patella mobilisations.  After that it begins to tighten, although I've found that it is necessary to keep mobilising after the three months to avoid it tightening more than it needs to.  Research seems to indicate that once you can get past 90, you will eventually get further just by working on it diligently and will not need surgery.  I've heard of people who have got to 95, plateaued then had step-wise breakthroughs over the next year.

Anyway, at 6 weeks it's early days (you're probably sick of everyone saying this to you!) and all your ROM work is worthwhile to see how far you get.

Best of luck to everyone!

[tremy1977]

Hi everyone.

great posts about all the PT stuff. I can't help but agree that something has to be done. I've had 2 PT appointment's now and both PT's had never heard of ACI surgery nevermind the meniscal graft done at the same time.
Regardless of this im not worrying to much at the moment as i'm still only doing the routine leg raises and 45 degree bend on the knee. The worry i have is that i don't really know when i can start swimming and stuff  and how i progress to the next stage. Dennis sent me some great stuff so i've begun following the outline of Dr minus's rehab notes.

Just to back track a little on my last PT appointment. The PT started to explain my operation like i didnt know a thing and proceeded in explaining the microfracture surgery to me. I had to tell him that he'd misunderstood the notes, so I then explained the ACI surgery to him..thank god i'd done my research on here...I go back in a few days for another appointment i hope he's kept to his word and researched ACI rehab a little unless i may have to call the OS and explained my concerns.

anyways a little update on the injury. Im only just getting to 45 degrees bending the knee as its still really stiff and swolen, but on the plus side i'm FWB on the crutches and managing a to walk tentativly around the house when the brace is off. I'm stiff getting the dull ache but its not as bad as when i first came out of hospital. I noticed last week that on the end of my scar i've got the end of a wire stitch sticking out. The PT has said i need it removed or clipped back. He's probably right but i've called the OS to confirm first so just waiting for a reply.

Thank you for all the post, the more info on here for everyone the better.

Paul

[cfranc]

Hi all..

I did see my OS last week and he has suggested a scope for the scar tissue.  It will be done next week (8wks out)....I hear what everyone says about maybe being too early.  I am working with Dr Gomoll and as he works closely with Dr Minas I am fairly confident in his decision.

As I've also gone through 2 other major surgeries (VMO and TTO/VMO) which kept me in straigt leg braces with no mobility for 6wks plus and had to work through getting back ROM in each, I am also fairly confident that without significant force I am essentially stuck where I am.

I hadn't gained any ROM between week 4 and 6 (and in fact it seemed to have a slight reduction)...I think the concern was that exerting any more force to increase the ROM might damage the graft...so here I am. 

Although I am temporarily out of PT, I am at least able to work some of the muscle related protocol...SLRs etc...and have found that the pain I previously had disappeared almost entirely after only a few days of SLRs...yippee!!

The bummer is I am not FWB and close to being 100% free of crutches...but will have to take a step back and go back on crutches after the scope....ah!!  If we could all only snap our fingers and be 18months out running around

I will check out some of the other posts on arthrofibrosis just to do my homework though

[ajschnelk]

As I've also gone through 2 other major surgeries (VMO and TTO/VMO) which kept me in straigt leg braces with no mobility for 6wks plus and had to work through getting back ROM in each, I am also fairly confident that without significant force I am essentially stuck where I am.

I hadn't gained any ROM between week 4 and 6 (and in fact it seemed to have a slight reduction)...I think the concern was that exerting any more force to increase the ROM might damage the graft...so here I am. 

cfranc,

I had the same thoughts as you regarding damaging the graft.   i still don't know, but my PT and OS did not think forcing the joint would risk anything as long as the motion was passive.  Did Minas/Gommel state that they were concerned about damaging when attempting to increase ROM?  You now have me concerned that maybe i damaged something when i pushed my range during the 6-8wk point.  I had a few times where we really forced my ROM and where it was very painful.   

[cfranc]

Gomoll is my OS.  He seems to be very conservative and play things on the safe side.  I was keeping him abreast of my progress via email and had a pretty extensive routine going in terms of trying to push my ROM.  So I guess he felt that with all I was doing if I still couldn't get it to move then it probably wasn't going to go. 

Minas is supposed to be the best out there though and so if you have either of them, I wouldn't worry about it. If they told you to push things then I am sure they were confident it would not damage your graft. 

 

[ajschnelk]

My OS is Dr. Cole which I believe is right behind minas in the number of ACIs performed along with farr, gommoll, and others.  I actually have my 4mo appointment tomorrow, so I'll be sure to ask this question, again. 

[cfranc]

Good luck...

Where are you again on your ROM (...45?) ?  How are you doing now WB and walking?  I am so dying to lock my crutches away somewhere and never see them again. 

Let me know how your appt goes and what your OS has to say. 

By the way, I just read your OS's bio...does the guy ever sleep?

[ajschnelk]

yes, it's amazing how many titles he wears.  My appointment went well...he was very impressed with the overall condition of the knee and had no concerns.  Based on what he saw today, he strongly believes that I have a good chance at making a full recovery. The unkown is still killing me, but I guess that's part of it.  However, given my limited pain prior to surgery, he said that it will probably take a full 8-12months before I feel improvement compared to my pre surgery condition. 

My range is currently at 135 degrees.  As far as WB and walking, I am pretty much back to normal.  There are times when I may sport a limp depending on the day and how long I'm on my feet.  THe knee is still very stiff and sore in the morning and becomes quickly stiff and sore when I'm on my feet for any length of time.  OTherwise, it feels pretty much normal with basic walking. 

[cfranc]

That's great....sounds like you are well on your way. 

The surgery part certainly isn't very fun...but I feel like the toughest part is really yet to come. I think the real challange will be when our knees are feeling better but we have to sit on the sidelines.    Going to have to find some new hobbies for awhile. 

[tremy1977]

Hi everyone

5 weeks post op now, things are going fine, im about 60 degree's bending my knee, but its still really really stiff, i could probably go further with help. The problem i have is my quad and my calf have pretty much wasted away, I'm litrally having to lift my leg off the couch once its been raised its that weak. I was hoping to do some kind of work in the swimming baths this week but last week i fell over !! I twisted my bad knee quite bad, after hearing a pop and then being in extreme pain i ended up back in hosipital with a torn medial ligament. I had to count my blessing though that i didn't damage the ACI or the menisical graft. It was quite a heavy fall so it must take quite a bad one to tear anything. Has anyone had a nasty fall after ACI surgery ??
Since the fall i've had a pulling sensation thats been hurting me once im trying to flex my knee out straight ? The surgeon in Oswestry after all the check up tests was happy i hadn't damaged anything, so im confident its just the healing process thats hurting me.

I'm looking at maybe doing some light bike work in the gym in the coming weeks as i really need to get this quad muscle back.

My follow up appointment is in 3 weeks so i'll keep updating.

Paul

[cfranc]

Hi Paul..

I am so sorry to hear about your fall.  I can only imagine how frustrated you must be.  But really good news you did not damage the graft. 

I had a small bump in the road too...at 6wks I halted all progress in my ROM and had to go in for scar tissue removal this past Friday.  I was stuck at 90 and it was obvious I wasn't going to gain any more without significant force or intervention.  The good news...before I even started PT today I was at 115 and can now use a stationary bike!!

Until I was able to start strengthening my quads I had some significant pain whenever I moved/lifted my leg and had to support it with my hand as well.  But as soon as I was able to do SLRs it disappeared quickly. 

I still have a ton of swelling after the scope Friday so it is still my main concern/focus..getting rid of it.  I still ice regularly..but noticed that once I was able to start moving around more the swelling begins to go down. 

Best of luck and let us know how you are getting along. 

[Rennschnecke]

Paul
Sorry to hear that you've had a fall.  I hope you manage to get back to where you were soon.  Just a question: did you get checked out by your OS who did the ACI?

Chris
I believe that mobilising the joint helps pump the fluid around and out.  Couple with elevation and NWB, ball rollouts are just brilliant for getting swelling under control combined with icing if possible.

It's great your scar tissue was caught early and I hope it all goes smoothly for you from here on in.