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Author Topic: ORIF Patella and Patella Alta - Complication fr Ruptured Patella Tendon Repair  (Read 7804 times)

Offline randoknee

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Well I'm now at about 43 weeks post surgery.  I've been zapping the patella with my bone growth stimulator every evening for nearly two months.  I've been taking my calcium supplements and also taking the Cissus supplements.  The knee is feeling much better, but the hardware is causing alot of irritation in the soft tissue and the patella alta also causes a fair amount of pain at times. 

I've been getting out on my bicycle as the weather has allowed.  It's been very cold and wet here in Bellingham and the knee just doesn't do well in the cold.  I've been riding with my Ibex wool knickers and an extra wool knee warmer on the left gam.  I was finding the pins in the knee became really painful after about 8 miles out on the road.  I shortened up my left side crank length by another 1.5 cm, thereby reducing the amount of bend of the knee at the top of my pedal stroke.  It really helped reduce the soft tissue irritation and Yesterday I managed to do almost 38 miles without feeling too bad at the end of the ride ;D. My longest ride since my injury.  Still, I spent the evening with my leg elevated. Per my therapist's suggestion all of my left side pedaling is mostly quad free.  Hip flexors, hamstrings and calves only. 

Next Monday I go see my Surgeon to see if the patella is finally healed up enough to get the hardware removed.  I suspect that the x-rays will show the the patella fracture is stitched pretty well and hopefully I can schedule surgery to get the metal out!   How pathetic is that... I'm looking forward to having surgery ?

 If the doc says it's healed up enough, I may have another surgeon take out the hardware.  I'm confident the surgeon who pinned my patella back together is who I'd want to do any revision I may need to fix my patella alta down the road.   I'd like a patello femoral specialist and not a general orthopod do the work.   I figure if they've got to crack open the knee to take my hardware out, who ever is most likely to fix the patella alta should get a chance to do some hands on and eyes on recon on the condition of my patella and tendon.    If anyone has any thoughts or perspective, I'd love to hear it.

Dan
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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Had my appointment with the Doc today.  I'm 8.5 months since my fracture and repair.   I still have a very visible fracture line visible on the anterior X-ray.   I was really confident that my patella would be all healed up.   Wrong!  I have been zapping my patella with my Exogen bone growth stimulator every night for the last two months.  2400 mg of calcium.   More than enough D3.  I'm taking about 3200 mg of Cissus and have cut out processed sugar and cut back on caffeine.

My ROM sucks and the final 15 degrees of extension is very painful  due to my the hardware and my patella alta. 

So what's next?   

My Doc thinks that my patella has more substance than the X-rays show.  So I'm going to have a CAT scan of the patella as soon as I get pre-authorization from insurance.  Hopefully that will give a better view of what is really going on.  Then maybe replace the pins and wires with permanent screws if mechanical fastening is still necessary?  After I get the CAT scan I'll get a second opinion before I have any procedure.

I'm getting tired of this s**t.    I hate my knee.
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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I went in and had the CAT scan done today.  It took less than 5 minutes.  I asked the tech if I could see the images.   He wouldn't let me see them... some B.S. about too many other patient images...  blah, blah.  So I have to wait till I see my Dr. Next week.   I did order a disk with the images so I can take them to another Doc for a second opinion.  I'm really interested to see what is really going on with this damned patella.

Yesterday was a nice day weather wise, so got out for a bike ride in the afternoon.   Managed to ride nearly 50 miles.  Kept it flat with few hills... less than 700 ft of climbing total.  Happily my left knee isn't too angry today.  The forecast for Saturday is looking pretty good so I may be stupid and try to manage 100 kilometers.  I have a really flat route up to the Peace Arch at the Border with a nice breakfast joint at 50km and less than 800 feet for the whole 100km.     Cycling with a crank shortener on my bad leg keeps the pain in the knee at bay.  I cycling in a manner that doesn't engage my quads at all on my bad leg.  My right leg (good) is doing about 80 percent of the work anyway.



12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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I went in a picked up the disk with the C-scan study of my patella today.  I ordered it to take to another Doc to get a second opinion... no mater what my doc says.   I read the radiologists report and tossed the disk in the computer for a quick look see.  I'm not a doc and don't even play one on TV but even I can tell my patella looks like s**t. It's got holes, tunnels and the top surface looks cavitated.   The radiologist seems to be a half full kind of person and while she noted the fracture is a non union but there were "a few small areas of osseus bridging."  After 9 months.... big whoop!   I don't think a half full bag of s**t is better than an empty bag of s**t.   I see my OS on Friday for his analysis and plan.  When I saw him on the 4/11 he was thinking about taking out the pins and wires and putting in permanent screws.  The question that comes to mind after looking at the bone is: Do I have enough good bone for a reliable solid placement of screws.  Regardless of what he suggests, I will get a second opinion from a knee specialist in Seattle.  I'm feeling a bit depressed right now. 
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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So I met with my surgeon yesterday morning.  After 8.5 months, I am a non-union. 

The only portion of my patella where the fracture appears to have fused back together is on the upper part just in front of the articular cartilage.  As a point of reference it's less than 25 percent of the fracture.  The surface of my patella looks cavitated, like someone took grooves out of it using a router.   The questions that spring to mind are many.  The biggest is: Why is it not healing?  The pins and wires appear to be very stable.  The patella pieces are in good close proximity.  I'm taking a butt load of Calcium and Vitamin D. I've been zapping my knee with the bone growth stimulator now for 78 sessions.   I don't smoke.    My doctor suspects that the historical injuries are the cause.  While he has previously said the bone is not "dead", he suspects that my prior tendon rupture resulted in some compromised bone nourishment.  Also the tendon repair involved the drilling of three sizable holes through the patella from top to bottom, which removed a significant volume of bone tissue.  The fact that the holes never back-filled with bone tissue is instructive.  The lack of structure led to the fracture of the patella... so why the hell should I expect that it would heal properly? 

So here's his plan for me:   First he wants to remove my existing hardware (pins and wire).  Insert a pair of permanent canulated screws through my patella into what appears to be sound bone tissue.  Through the holes in the screws, cross a tension wire, with the wire twisted at the side for a permanent hardware installation.  Along with all this s**t, he wants to install more bone grafts set in a BMP (Bone morphogenetic Protein).   He says that this hardware is not as "strong" as my current hardware but acknowledges my poor range of motion and pain issues caused by the hardware sticking into my patellar and quadriceps tendon coupled with my patella alta issues indicate making some improvements.  I'd really like to get the pins out of my knee.

Questions that pop into my mind:  What is my patellas bone health?  Does it stand a chance in hell of actually healing?  Do I have enough good bone for he screws to have a good hold? Is my patella alta putting different force loads on my patella contributing to my poor bone healing?  With the insertion of this permanent hardware, how will that effect the long term prospects of correcting the patella alta down the road?

 The soonest that he could do it is in about 4 weeks.  The surgery would only be about 1.5 hours.  I'd be up and walking the next day.  For the first 6 weeks post op, physical therapy would be limited to range of motion only with no strength work.  I asked him if he'd ever had to deal with a crappy patella like mine before.  He said no.  He's had some bad healers... typically someone who is about 20 years older than me that's had a TKR and subsequently busted their patella.  Maybe it will work but I'm concerned he's grasping for straws as much as I am. 

So here's my plan right now.  I'm going to get a second opinion from another OS who specializes in knees in about two weeks and get another perspective.  In the meantime, I'm trying to find a patellofemoral specialist in the Seattle area.   I plan to get a third opinion from from a patella specialist.  If anyone knows of one let me know.  I'll call the UW sports medicine clinic and see if they have anyone who specializes in the patella.  If I can't find one in western WA, I'll travel to find someone who can give me confidence that they can tell me what's going on and give me a reasonable chance for success.   I can't bear the thought of having to have my knee cut open every 10 to 24 months for this crap.
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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We don't like the "N" word.   Avascular Necrosis.     

So surgery to was scheduled for June 1st.   After getting the second opinion, I shared what I heard from Doc 2 with my surgeon.   Doc 2 suggested a different plan of action.  He says that it appears the anterior half of my patella has avascular necrosis.   :o  He suggested that I not have surgery right now,  No new holes and screws inserted.  He saw no evidence that the fracture line is moving at all,  he said the only real reason to put in new screws would be to try to bring the fracture margins closer together.  He said the margins are close already and new screws aren't going to help.  He suggested I wait, keep zapping the knee with the bone growth stimulator and keep taking my supplements.  He suggested that at the anniversary of my original ORIF that I have the existing hardware removed and have bone grafts and a BMP treatment and hope to hell that it works.   He said if my knee re-fractures I'm pretty well screwed and that the patella will have to come out... the good news being that if I don't have a patella, I won't have patella alta any more.

Well Hell! :(   Both docs seem to be saying, they have no real confidence that my patella will heal and that BMP will do the job.  They don't know, but think the BMP is my best chance.  It seems like they both are proposing to chuck some mud up on the wall and hope it sticks.

After sharing the info from Doc 2 with my surgeon,  he too finally admitted to me that he suspects I have AVN.  I have canceled the June 1 surgery.

Long distance endurance cycling is a passion of mine and I hope to be able to get back to riding really long distances (up to 300 miles in a day).  I fired of a quick email to a cycling coach out of Boulder Colorado, gave him some of my background and asked if he knows of any long distance cyclists who do so without a patella.  He too had been through some serious injuries and had come back to ride again in RAAM and in 5 paris-brest-paris rides but didn't know of anyone who did this type of cycling without a patella.   He suggested that I consult with a surgeon down in Utah.  I emailed the surgeon who is an olympic gold medalist and former pro bike racer and one of his partners who is a patello-femoral specialist and have an appointment in a couple of weeks.

If my patella is in jeopardy I want to know.  If the patella health is bad now with 5 holes running through it, I can't imagine it will be any healthier with 7 holes.  If I have avascular necrosis, sitting and waiting before doing anything for an anniversary date seems very random and arbitrary to me.  I don't want to be "disabled".  I want to be able to get on my bike and ride my bicycle anywhere I want to go, across mountain passes, across the state or across the country!    That's not too much to ask.   Will report on what I find out and what I decide to do.
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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I've been busy since my last post. 

Last Friday, I flew down to Utah last Friday, grabbed a rental car and drove over the hill to Park City and saw Eric Heiden.  That afternoon I popped back over the hill to Salt Lake and was evaluated by Phil.   Long story shorter....   I'm so glad I did this.   I'm really glad I canceled the surgery that my OS here had proposed for Last week!

Both Dr's feel my patella isn't going to fly apart if the hardware is removed.  Refreshingly, Phil says wants to get more information before proposing any significant revision or reconstruction.  I'm going back down to Park City in a couple of weeks where Phil will take out my hardware and scope my knee.  Doing so will give us the ability to evaluate how much of my pain and discomfort is related to the hardware and whether or not there is some soft tissue component contributing to pain behind my patella.  It also will give him a good look see.    Also getting the hardware out will allow for MRI diagnostics which are now impossible.     

Logistics are coming together.   Airline reservations made, rental car reserved and a condo rented for the week in Park City.  My wife will come down with me through the surgery and a friend / neighbor will also come down to help me out after my wife has to head back home and back to work.   My Doc here at home has agreed to coordinate with Dr. Davidson for my follow-up visits.  Hopefully it will be a good learning opportunity for everyone.   

A couple of fun facts...   My Left patellar tendon is 3.5 CM longer than my Right one.   My leg circumference is 6.5 cm smaller on the left leg above the knee compared to my left leg.
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline Suejs14

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Hi Rando,
Your saga is a difficult read.  You've been through Hell and are on your way back.  Wishing you the best for your upcoming surgery; and even more of the best for your healing.
SJS
4/04 R knee partial meniscectomy
4/24/11 L patella comminuted fx
4/27 ORIF (2 of @ 6 pieces pin & wire together)
5/10 Staples out
6/7 from full leg immobilizer to brace set at 70 degrees flex
6/16 begin PT with 45 degrees ROM
7/14 75 ROM
7/21 81 ROM
8/2  102 ROM
11/30 127 ROM

Offline randoknee

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Thanks Sue,
Finally finding a Dr. who seems to be really proficient with the knee system is a relief.  I know I've got a long way to go but feel I finally have a path that will get me progressing.
   
It was nice weather this weekend so I got out for a couple of good bike rides.   I did 62 miles on saturday and another 50 today.   The knee is a bit on the angry side tonight and since my good leg is doing most of the work on any little hills, that one is a tad on the tired side.  I figure I'd better get as much riding in as possible before my upcoming surgery as I'll be off the bike for a while afterward.   

I had a fleeting thought of using a non-adapted bike today, but I know the hardware irritation would be unbearable after about 10 miles.  For those who are using cycling as part of their re-hab, here are some of the adaptations I've made to turn my pedals with limited range of motion and a couple of pins and wires in my patella.  The basic strategy is to reduce the required angle of flex in my left knee at the top of the pedal stroke.  First, I worked with my physical therapist who's a bike fit expert.  We raised my seat about an inch above where it normally would be.  We added a stack of shims under my bike shoe cleat on my good leg to make up most of the inch. On my bad side, we added a plate extender that brings the cleat back on left shoe about 3/8" further toward the arch, reducing the required angle of knee bend.  The biggest adaptation is installing a crank shortener on the left crank which effectively reduces the length of my left crank arm by an inch and a half.   This reduces the leverage that I can exert on the pedal but most importantly, significantly reduces the required knee flex on my left side.  In addition my therapist installed some cants to deal with some pronation in my feet and some pedal spindle extensions to improve my leg alignment in the pedal stroke.    All of these changes make it possible for me to get out and ride which is the most effective anti-depressant I can imagine. 
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline floridanightingale

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Hey Rando!  I hope everything goes great in SLC.  I am rooting for you!
4/10 -- comminuted patellar fracture, same day ORIF surgery
4/13 -- released from the hospital in a brace, on crutches
4/22 -- brace removed; 5/20 -- down to one crutch
5/26 -- begin PT, ROM 94
6/3 --  ditch crutch, hello cane!!
7/9 -- full ROM, walking unassisted
11/16 -- hardware removed

Offline randoknee

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Thanks Florida,
Everything has gone great!  ;D Of my three surgeries on my L knee this has been by far the best experience.  I had the procedure done at the Park City Hospital.  They don't have patient rooms... they're guest rooms.  Even coming in from out of town the whole process was much smoother than having surgery in my home town.  I had my pre-op appointment on Friday and Surgery on Monday.  Checked into the hospital at 10:00 and was headed back to our rented hotel suite by 3:00 that afternoon.  I had a femoral block that lasted till Wednesday afternoon.  The knee is pretty swollen and I have some incision pain but overall the pain is greatly reduced in the knee.  I had my pos-op appointment today and will fly home tomorrow evening.  Park City has been a good place to hang out before and after the surgery.    The plan forward is to recover from this, work on strength and ROM over the next three months and we'll evaluate progress on my delayed union and what the pain levels.  If necessary and feasible we'll address the Patella Alta and possible resurfacing.   I'm going to have to come back here in the winter sometime down the road and go skiing. ;)
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline Suejs14

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Great news Rando!  Glad you are on the rehab route - now for some bone-healing magic.  What did the Doc see when scoping your knee? 

You'll be back biking soon, I hope.

Sue JS
4/04 R knee partial meniscectomy
4/24/11 L patella comminuted fx
4/27 ORIF (2 of @ 6 pieces pin & wire together)
5/10 Staples out
6/7 from full leg immobilizer to brace set at 70 degrees flex
6/16 begin PT with 45 degrees ROM
7/14 75 ROM
7/21 81 ROM
8/2  102 ROM
11/30 127 ROM

Offline randoknee

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Thanks Sue,   I should be back doing some light pedaling soon.   

The scope of the knee revealed a fair amount of tissue on the back of the patella.  My doc shaved it down and cleaned things up. The back surface of the patella is pretty beat up and appears "thin".  Correspondingly my femoral groove is also beat up and the cartilage there is also thin.  The fracture line is visible on the back side of the patella too, and is a slight "step".  The ends of the femur and tibia look beautiful.  The meniscus looks good as well as my ligaments.
 
My short term plan is to work on ROM and Strength over the next three months.  I'll get back on the bike as soon as the surgical wounds heal up.  I'm cleared to do what ever with pain as my limiter.  With the hardware gone, i can evaluate how much of my pain was hardware related and how much is related to the beat up cartilage.  If my rehab goes well and I can tolerate my beat up cartilage, I'm golden.  If I continue to hurt, we''ll discuss possible resurfacing, but that is dependent on my patella continuing to heal up.  Any possible future correction of my patella alta is also contingent on my patella healing up and being viable to attach a replacement tendon.  Also with the hardware gone, I've got access to high resolution MRI to help in decision making.

In retrospect, if I'd have gone through with the procedure that my local doc wanted to back in early June,  I'd be totally screwed by now.  I'd have permanent hardware with no idea of whether or not I'd have any pain relief.  Id have all sorts of extraneous tissue on the back of my patella that would likely become very arthritic,  I'd have a total of 7 holes drilled through my patella which would likely compromise the ability for my patella fx to heal up.  I'd have been immobilized for the last 4 weeks and be immobilized for another 4-8 weeks hoping to get the bone grafts and BMP to take with no assurance that I would have any progress toward healing or pain relief.

The moral here is that second opinions are a good thing, and third and fourth opinions can be really helpful too.  When we are in pain and suffering from some degree of depression regarding the pain and complications from our busted knees, it's really easy to jump on the first confident sounding solution from some surgeon who my not really have a clue as to what they are proposing.  Stop and think about what you are being told.  Apply common sense and sesame street logic.    You are your own best health advocate and try to find the people who can help you collect the information you need to make the best decisions possible.
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline randoknee

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On monday I'll be 3 weeks post surgery (Hardware removal and knee scope).  Things are looking up!   The incision is healed up and the swelling is down.

I've been off the powerful pk's for about 10 days and can control the pain with 1000 mg of tylenol 2x/day.  My range of motion is improving quickly.  Last Tuesday i put my bike on the trainer and was able to get the pedals around.  I only had a tad under 90 degrees ROM but I have my crank shortener on the left crank so it allowed me to get around.  I did around 5 minutes.  Wednesday I had less swelling and rode for around 30 minutes.  By thursday I pushed it up to over an hour.  I moved my pedal out another 10 mm and my ROM is now up around 110 degrees!  Not bad improvement for 4 days.   The cycling is really great for getting the knee joint moving and helping to get the post surgical crap out of the joint.   

An observation regarding biking....  Using a road bike on a trainer is much better than using a spin bike with a heavy metal flywheel.  If you have any pain issues,  you can immediately stop and not get dragged around by the flywheel.

I plan on putting in another hour today with the bike on the trainer and if it stops raining, I'll go out on the road for a very easy 30 mile ride tomorrow.  No mashing, just light spinning.   I have my first PT appointment scheduled for next Friday.  I'll bring my bike to PT for fitting adjustments.

Since the surgery I am noticing another issue.  When I go up stairs in my gimpy fashion, my left leg(bad one) while weak is quiet and smooth,but my right knee (my good one) makes a very audible creaking grating noise.  It's been doing the lions share work for the last two years.  When I go back for a followup with my doc in a couple of months I'll get it checked out.  Time will tell if my fracture line continues to heal but I'm hopeful.
12/08 L patellar tendon rupture (mush) -ORIF  -  8/10  fx of L patella  - 8/10 ORIF L Patella 9/10  dx patella alta  - 2/11 dx "delayed union" - 6/11  L knee scope / HW removed.- 6/13  R Knee Scope - 11/13 R knee PFA - 6/14 Left knee PFA

Offline Suejs14

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Great to hear such good news!  So -- a trainer -- can you get one at a bike shop?  I don't have enough ROM yet to get around on any kind of a bike, but hope to soon and would love to be able to do it at home.  Sending lots of knitting, healing stuff your way -- hoping the patella soaks it up.

Sue JS
4/04 R knee partial meniscectomy
4/24/11 L patella comminuted fx
4/27 ORIF (2 of @ 6 pieces pin & wire together)
5/10 Staples out
6/7 from full leg immobilizer to brace set at 70 degrees flex
6/16 begin PT with 45 degrees ROM
7/14 75 ROM
7/21 81 ROM
8/2  102 ROM
11/30 127 ROM

 















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