My AF story- now seeing Dr. Wojtys

[hoc11]

Hello,

I am new to posting to these boards, but have been reading around here ever since my ordeal began this past January.  I recently sought out Dr. Wojtys  in Ann Arbor, MI after reading a lot of the info on these boards. I had a left patella dislocation with MPFL tear and large (2.5cm) chunk of cartilage torn off of my patella from a hockey injury this past January. I was immobilized from the first night in the ER until the surgery ~ 3 weeks later, but I could not bend my knee anyway, which I assumed was from the loose body in the joint and the massive swelling.  I had surgery 1/26/12- MPFL reconstruction, loose body removal. I was put into a hinged brace locked at 0 and given a cpm the following day. I could not get past 35 deg. on the cpm and began pt about 2 weeks post op.  I spent a month in the original pt, which involved gentle stretching and strengthening but I could not get past about 35 degrees flexion, which was a hard endpoint from day 1. I had full extension at that point. OS then ordered loa/mua for early March and insisted I do pt in his clinic. My ROM was improved after this and I was immediately able to get to about 115 on the cpm that day, and began pt ~3 days later. PT consisted of aggressive and excruciating ROM, which never progressed past about 115 degrees of forced flexion, which was excruciating. My active flexion was only about 70 deg, and my extension was now -5. I had a persistent feeling of pain and binding in the area of my patella tendon throughout this whole process. After about a month of little to no improvement past the forced 115 mark, the OS wanted to do an mua without the loa as he was afraid to cut me and inflame the knee. I had the mua in early May and was in extreme pain after, even worse than the loa/mua.  I did the cpm again and could eventually max it out at 120, but my active ROM was still the same and the pain/binding was still there around the patella.  I also noticed a large mass of scar tissue forming over the patella. My patella has basically not been visible this entire time and I felt that my patella was just binding my knee up when I bent it. Finally I insisted to my OS that something was wrong with my patella and my OS said nothing was wrong. He showed me current and old xrays to verify. When I asked him if it was in the right place (I was pretty sure it was in baja after doing research and based on what I felt) he measured and said I in fact had patella baja, but that was to be expected and he did not recommend any more surgery.

This led to me finally seeking the help of an AF specialist (Dr. W). I had my first appointment with him 6/19/12, and he immediately told me I had AF, which my first OS never officially was able to identify my problem as (even though I knew it was from reading here).  He cringed when I told him what my previous PT consisted of.  He told me my patella was not normal, but not sitting terribly low either, which I guess is a good thing, but that forcing flexion was increasing contact forces on the patella and doing more harm than good. He prescribed me an e-stim for home and 1 day of pt at his clinic to prepare for surgery to get my non-existent quads as strong as possible.  I go back to see him tomorrow 7/31/12 and he will evaluate my progress and determine whether to wait for more strength or do surgery sooner.  I guess I feel somewhat comforted knowing that I am in good hands now, even though I don't blame my first OS for anything as he was very respected and very nice, I recognize that this is not a common thing for an OS to see.

I just hope Dr. Wojtys can fix me. It has been quite an ordeal to literally in an instant go from an active, athletic, and healthy 29 year old to a disabled 29 year old that can't do any of the things that I previously found satisfaction in. My life has literally completely changed. Anyways, I hope to post my progress from here on out if anyone replies with interest. If anyone could give any insight on what to expect post-op with Dr. Wojtys that would be great too.

[missmyknee]

Hi Hoc

One thing that's hard to do is welcome a new poster to the AF section. You know what they have gone thru, by the time they make their way to this board, because we've been thru the same thing. I'm glad the information on this website helped you identify what was happening to your knee. The sad thing is, you knew what was happening and your doctor didn't. This is a major reason why arthrofibrosis happens is that doctors and PTs do not recognize this devastating,life changing complication of surgery. The life long damage is immense. AF needs early recognition and treatment in order to obtain the best results. Patients endure PT that is painful and aggressive which makes AF worse. MUA without a LOA just breaks scar tissue and causes micro tears to tissue which sets off a cascade of inflammation and scar tissue formation. If your patella is too low/baja, you can damage the cartilage behind.

There have been several posters in the past who used Dr Wojtys and with very good results. Janet, Nick33, Katryn, JillM and Annie5790 are the ones I can think of. You can put "Wojtys" in the search box and bring up past posts about him and their surgery experiences. You can also private message them, after you get 20 posts . You can get 20 posts by going down to the games section of the website, and play a few very simple games to acquire 20 posts.

The E-stim is to get your VMO and quad firing. Sometimes the baja is from weak quads. By strengthening the muscles, it will help bring the patella back up and also if he is going to do surgery, to improve quad strength, going into surgery.

Did you get a chance to read all the information on AF in the information hub? Here is the link:

http://www.kneeguru.co.uk/KNEEnotes/taxonomy/term/71

Let us know how your appointment goes tomorrow. Good luck

Pam

[hoc11]

Thank you for your reply Pam. I actually learned of Dr. Wojtys from reading Nic33's thread, but I see that was several years ago. I will have to read over some of the other threads as well. My appointment with Dr. W went pretty well today. He was pretty up front that this is a tricky situation, which I knew already. I will be having surgery on the 20th of this month- loa, possibly open if the scar tissue is too dense, but I don't care, I just want this out of my knee.  He was happy about my quad strength and how much it has improved in the last month, and my extension I can get back to 0 with a little stretching, so that is good.

I asked about the baja and whether it was from scar tissue over the tendon, or the tendon actually contracting and he said he wouldn't know until he went in and released everything, but he wouldn't even address that if it was contracting during this surgery anyway. Hopefully it's not.  The plan is to go in either with a scope or open, remove the adhesions on the patella tendon and fat pad, and under the quads, and release the medial and lateral retinaculum to free everything up. Then PT twice a day for 2-3 weeks and I'm sure they'll give me a home PT program to do several times a day as well.

God, I hope this does it. I'm so afraid that the scar tissue will just come back. At this point I've resigned to the fact that my days of hockey are behind me. I just want to be able to sit in a chair, go up and down stairs, be able to ride a roller coaster, just be functional again and find new hobbies to enjoy life with. I'm hopeful Dr. W has the surgical skills that my other OS didn't as he mentioned he would ablate the scar tissue to stop it from bleeding and growing right back. Anyway, thanks for the input. Until next time.

Matt

[missmyknee]

Hi Hoc11

That's good news about the increased quad strength and the fact you can get to 0 on ext fairly easy. You've also seen an AF doctor pretty early, so hopefully once the scar tissue is removed and you rehab at his facility with PTs trained in AF rehab, plus your home PT , you will find you can eventually get back to an active life. It takes a lot of patience and dedication to rehab from AF. Sometimes a person will advance 2 steps forward and 3 back and start from square 1 again. That's why the patience. It sometimes takes a year or two to do this.

If he has to do an open procedure, he probably will do an anterior interval release to get at the scar tissue behind the patella tendon and deep recesses behind. Usually the doctor can tell by measurement on the lateral view of xrays comparing both patellas , how far baja and if the patella tendon has shortened plus an MRI sometimes will show changes to the patella tendon, to give a diagnosis of patella baja and IPCS (infrapatellar contracture syndrome)  My patella baja and IPCS showed up this way besides from physical exam and ROM but I had been in baja for 12 mos before my knee was evaluated and 18mos before surgery, the only thing they could do was a salvage procedure moving the patella and tendon up, to restore mechanics. Because so much time lapsed, my patella cartilage was severely damaged, I needed a TKR 3yrs after that surgery. Timing is everything.

Do you know if you will be in the hospital with an epidural to work on ROM or overnight then directly over to PT or outpatient?  Keep working on your quad so it is built up for surgery and your extension. Going into surgery with good extension will be a plus. If you haven't got one yet, you might want to get an ice machine or gameready ice machine for surgery.

Pam

[missmyknee]

Hi Hoc11

Don't know if you saw this article co-authored by Dr Wojtys on AF, in the Information Hub. Click on the "free open access" link, to view actual article.

http://www.kneeguru.co.uk/KNEEnotes/node/222

Pam

[Decruz]

I'm hopeful Dr. W has the surgical skills that my other OS didn't as he mentioned he would ablate the scar tissue to stop it from bleeding and growing right back.

Matt,
may you please explain what you meant when you wrote that Dr. W mentioned you "he would "ablate" the scar tissue to stop it from bleeding and growing right back"?

After tons of researches and many surgeries with the best AF specialists I've never heard of that.
A surgeon that knows about AF/scar tissues can just do the right job then minimize the bleeding cauterizing here and there (where needs to be done)ì but once you're "closed" post-op if you bleed they can let the post-op drains draining the blood in the first 24-48 hrs hoping you stop as soon as possible and about the possible growing back of the scar tissues no-one knows if it will happen or not, they can just make sure you do the best possible PT and basically pray it won't happen.
If the body keeps reproducing scar tissues again post-op there's no doctor that knows how to avoid it at the moment, as far as I know and I've researched about (and after talking with many AF experts) - so, if I'm missing something, please let me know!!!

Obviously when I say "if the body keeps reproducing scar tissues again post-op no doctor knows how to avoid that then" I'm saying it assuming that you've got the best possible surgery with a skilled AF specialist (as Dr.W as he's on the list of specialist on this bullettin) and the best specialized PT protocol for knee AF to fight the adhesions return.

Please, let me and us know about it.
Thank u, bye

[hoc11]

Pam, thanks for that article, I will take a look at it.  To answer your question, I will be having outpatient surgery. It is on a Monday at 2pm, so I don't know if I will start PT that evening or the next morning. How do you get one of those ice machines? Do I need a script or have it ordered by the doctor?

Decruz, at my first visit Dr. Wojtys said that you have to try to keep the scar tissue from bleeding when you cut it out and he wasn't sure if my first OS did that or not. He used the word "ablate", so I'm not sure if he meant that was the way to keep it from bleeding or not, but when I looked it up, ablate just means to remove something, so I'm not sure. Maybe he will actually cauterize it.  He did mention at my appointment yesterday that one of the reasons this is so tricky is because scar tissue can be very vascular and has the tendency to bleed.

Pam, do you know what Dr. W's post op pain management protocol is? My last OS used a femoral nerve block plus meds, but i feel that the block may have hindered me as it essentially shuts off your quads.  Also, is it standard to be given an anti-inflammatory?  I had to ask for them from my last OS because my knee was so hot/swollen.

[missmyknee]

Hi Hoc11

The doctor should be telling you when you are supposed to go to PT. Most doctors use the femoral nerve block for surgery. It will help you with ROM for the first couple days, where it is so important to achieve extension and flexion....extension being more critical in the beginning. Your e-stim will be used post-op, to get your quad firing and do lots of quad sets several times a day.

I got my last ice machine ( my 3rd one) from an internet brace / PT shop. I did not need a doctor's script to buy my last machine. My first two did require a script. They used to require a doctor's script ( because of liability from frostbite) now they have a disclaimer. It was cheaper than having the doctor get it or renting one. I had one provided for me, during one of my surgeries out of town ( I travel 700 miles to see Noyes), and found out it cost me $500.00 a week. I used it for 3 mos. I owned one but it had burned out. $1500.00 was a rip off since I could by one for under $500.00 !!! I had a Breg ice machine. A Gameready is an ice machine that also uses compression. I've used this at PT and I absolutely love it.......the compression combined with the cold felt very good. I think those can be rented with a doctor's script. I used my machine 24/7 , even while sleeping.

I'm not familiar with Dr Wojtys rehab protocal, since I am a patient of Dr Noyes. You might look thru past posts of those who used him , or he might have them on his website. A lot of times , doctors will post their rehab protocol on their website. 

Dr N had me take Celebrex for inflammation. I was started on the medication in the recovery room.

Pam

[hoc11]

I had my surgery with Dr. Wojtys yesterday. Everything went well and he sent me home for the night in a splint with my knee at 90 degrees. I saw him today for my post op checkup and he seemed very pleased and optimistic about how the surgery went.  He said there was a ton of scar that he had to remove. He released everything around my patella and under the quad tendon.  He also said the previous surgeon made the MPFL too tight, so he cut that and loosened it.

I was actually surprised by how optimistic he was. He said he got me to 120 on the table and would be disappointed if i couldnt get better than that, even full range by the end of summer. He even said I should be able to return to normal activities like hockey.  For the next few days he wants me to work on passive range at home by propping my heel up with a weight on my thigh for extension, and gently letting my knee bend with gravity while sitting in a chair for flexion, as well as estim.  I can get pretty close to full extension and about 90 while sitting in the chair, which is somewhat uncomfortable because of the swelling and tenderness.  I guess all in all Im pretty excited that Dr. W was so optimistic.  He and his team were very happy with the way things went, so that is encouraging.  I will try to post my progress as I go.

[missmyknee]

Hi Hoc11

Nice to hear from you. Things sound positive from the doctor and the real possibility to get back to hockey. The early 1-2 weeks are important esp to get extension to 0. Are you doing PT at his facility?

Best wishes on your recovery 

Pam

[hoc11]

Hi Pam. Yes, I will be doing therapy at his clinic. I will start on Thursday as long as the incisions stay dry. I can already get pretty close to 0 with extension. Flexion is a little more uncomfortable. I was able to get to 90 at the clinic right after they took the splint off, but at home I am just shy of it, can get close after a little while. I assume that is from the swelling though, as the binding feeling is gone that was there before.

I am a little nervous as to how long and often I should be doing the stretching vs. resting/icing.  Im afraid Im not moving it enough when Im resting/icing, and then at the same time Im afraid Im doing too much stretching and not enough resting when Im stretching. Just not sure exactly how to divide the time.  I figure I did about 5 or 6 stretching sessions today, going for about 10-15 minutes in extension with either a weight on the thigh or the estim on, and then going right to the chair for about 10-15 minutes of slowly letting it bend as far as I can without pain. I then elevate and ice at all times in between. I have the polar care, which has been great for me.

[missmyknee]

Hi Hoc11

Frequent stretching, just to the point of a good stretch , but not pain, for the 10-15 min, 5-6x is good. Frequent amounts like you are doing is similar to the amount of time when one uses the ERMI flexionator ( www.getmotion.com ), a great machine used for passive stretching for flexion. Frequent , short sessions allow a gradual consistent stretch.  He might have one in his PT room. I've used them at Noyes PT and I rented one for 3 mos. Some also use a CPM machine. My doctor had me use a cpm for most of my surgeries, but not for my last surgery and a friend did not use one with her last surgery. I believe he wanted people to not rely on it solely for flexion. Are you doing patella mobes? Important to get patella moving in all planes, unless he told you not to do them.

As long as you keep from inflaming the knee.....plus elevation and ice. Were you able to get an ice machine? Did he put you on any anti-inflammatories?

Pam

[hoc11]

I was sent home with a polar pack ice machine, which is great. He didnt say anything about the patella mobes, but i have been doing them.  My knee is pretty swollen, which is making the flexion hard I think.  It just feels really tight as i hang my leg over the chair.

[Decruz]

Was the surgery an arthroscopy or an open procedure?
Hope the best, bye

[hoc11]

The surgery was done with a scope, but he said the incision is slightly larger than a normal scope incision.  They said when they put the scope in they couldn't see anything because there was so much scar tissue blocking everything.  Even with all that, he said there wasn't anything that alarmed them and expect me to do very well, which I am happy about.

I had my first day of PT today. It was a pretty nice change of not getting cranked on.  They gave me a list of heel slides, patella mobes, etc to do at home.  I have been doing them throughout the day today, while icing as much as possible.  Flexion is still very tight with the heel slides and chair stretches, but I can get pretty close to 90. I hope that improves as swelling goes down.