The REHAB DEPARTMENT > Soft Tissue Healing Problems - Arthrofibrosis

Arthroscopic removal of scar tissue

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Lynette:
Hi

I am waiting to go in for an arthroscopy to remove the scar tissue in my knee.  After open knee surgery last November as well as two previous arthroscopies a few months earlier I am left with a knee that will hardly bend.  My flexion is about forty degrees.

The surgeon wouldn't answer any of my questions I had about the operation.  But by ringing the appointments clerk I have found that I will be staying in hospital over night.  This is unusual for arthroscopies [in England] as you are usually chucked out of hospital two hours after the operation even after open knee surgery.

I mentioned to the surgeon about the rehab after the operation as usually you stay in hospital for three days and are put on a CPM machine.  He didn't know what I was talking about.  I asked if this operation would deal with the patella baja I have but he said he'll talk about that after the operation.

What does the operation involve?  Why would I be kept in over night?  Are you on crutches afterwards or not?  Will the removal of the scar tissue help my knee cap return to its normal position [ie, get rid of the patella baja].  i just don't know what to expect.  I've had so many cartilage operations and one lateral release but I've never had this type of operation.  Will my scar tissue return?  You hear so many stories on this site of people having many operations to remove scar tissue as it just returns.

Any help or advice would be appreciated.

I know many of you will say I need to get a surgeon that is an expert in scar tissue but I don't have any choice.  If I changed surgeon which I can't [there's no-one else to go to] I would have to wait a year before my first appointment never mind nine months for the operation.

Thanks
Lynette

Linds:
Hi Lynette,
Goodluck with the surgery.   I have never had a scar tissue surgery so I can't exactly tell you what to expect.
However I have my suspicions that the reason they would keep you in over night is to hopefully get you started on some heavy duty PT to try to prevent this adhesion thing from happening again. :-[ I don't know for sure though..I am just guessing.  
I hope this brings you much needed relief, And I hear ya on the not changing surgeons thing.   I have tried that before, it doesn't work well. :P
Goodluck and take care
Hugs and Hope
Linds ::)

Heather M.:
Lynette,

It's very hard to respond to your post, because you've listed a bunch of reasons why you have no choice but to have surgery with someone who doesn't communicate and apparently doesn't know scar tissue...your own words indicate that you are apprehensive about both the surgeon and the type of care you will receive.  At least that's what I read into your post...I will tell you that in my case just going in to remove the scar tissue, especially when you already have patella baja, is really not the answer.  The scar tissue always came back, because what I was missing was the intensive, highly specialized rehab after the surgery.  This rehab goes counter to just about every published knee protocol, but was the *only* thing that has worked in 15 months and five surgeries.  Once I got this specialized rehab, I was able to keep my knee from filling up with scar tissue again--what a victory!  Of course, by then I had permanent mechanical changes in my patellar tendon due to the baja, and now have a seriously messed up knee.  I wish I'd seen a scar tissue expert before I'd had four other procedures to deal with it, and before I'd developed patella baja that lingered over 18 months.

It sounds like you're in a difficult situation and you feel like your hands are tied in terms of who you can see, but I wonder if you can look at things in terms of the big picture--you only have two knees.  Your quality of life is being seriously impacted.  If your patella baja is anywhere near as painful as mine, you undoubtedly are dealing with a whole series of lifestyle adjustments, depression, chronic pain, and the frustration of having a problem that less than 1% of doctors out there know how to deal with.  Try not to let the obstacles get in your way--be positive about the power that you have to impact your own care.  

You *do* have choices and you can take matters in your own hands, but you will have to buck the system to do it.  I had to travel 1,000 miles, pay out of pocket (thank God for credit cards!), and stay out of state for a month to have surgery with a specialist.  But it was so worth it to hear him say "I've seen this before and I know how to improve your quality of life."  The PT's at his clinic knew just what to do and were a lifeline for me--I saw them twice each day, and was able to see the doctor in the PT setting at least every other day as well.

Anyway, if your health system in the UK is anything like the insurance companies here, the goal is to keep costs down and not spend many dollars per patient.  That often means giving patients the runaround, making the system extremely inflexible, and herding patients in the direction of doctors who are in on the plan.  It also means putting limitations and restrictions on who you can see, when conditions can be treated and when they have to be ridered, waiting lists, etc.  This is often not to provide patients with the best care, but to reduce costs.  I'm sure this is something you're well aware of.  

It sounds like you're uncomfortable with the idea of with a surgery and post-op plan, the details of which you had to wrest from someone other than the surgeon.  And you should be wary, because patella baja is a complicated thing--I'm not going to lie to you.  I'm seeing one of the top knee surgeons in the world--a real pioneer who developed microfracture, cutting edge treatments for arthrofibrosis, and cool new diagnostic devices.  As experienced as my surgeon is, he's still not been able to work magic with my patella baja.  The scar tissue is under control, though, and that's a big start.  Now we can address the mechanical problems like patella baja that the scar tissue left behind.  That's why it's so important to get the adhesions dealt with properly, because they can cause a whole host of other problems that are worse than whatever cause you to have surgery in the first place.

Anyway, I guess the reason everyone will probably tell you to see an arthrofibrosis specialist is because that really is the best first step.  Scar tissue is very unpredictable and knees that have it do not respond the way normal knees do. For example, it is logical to think that a knee with scar tissue should be kept moving after surgery, so that adhesions don't have a chance to form.  But aggressive PT is actually the worst thing you can do--in people with our problem it leads to heat and swelling, which turns into scar tissue.  I've read people who wrote that their doctor forced them off of crutches and made them to intense PT every day...while that treatment plan seems logical and is well-intentioned, it can actually cause more harm than good.

You asked what to expect.  Several of us have done post-op diaries after our lysis of adhesions protocols.  They varied a little from specialist to specialist, but there are several key tenets.  I'm out of space here, so I'll do another post below.

Heather

Heather M.:
Here are the principles my surgeon's post-op protocol after lysis of adhesions (arthroscopic surgery to remove scar tissue).  I wrote this in a private message to another arthrofibrosis patient--hopefully he doesn't mind my cut and paste here!

**************
The rehab protocol after this surgery is extremely specialized.  And what's really funny about it is that it goes contrary to most of the accepted rehab protocols for knees...a lot of doctors don't get this fact, and think if they just remove the scar tissue and send the patient to any phyiscal therapist three times per week that somehow this time the adhesions won't grow back.  

A couple of the principles of my doctor's rehab regimen:

1.  Immediate passive motion.  I woke up in the CPM in recovery, 0-70 degrees.  I kept this machine on up to 20 hours a day, even sleeping in it at night.

2.  Immediate, non-weight-bearing rehab.  I had my first PT session one hour post-op.  I did quad sets, ankle pumps, and gentle ROM work with the CPM.

3.  Non weight bearing--not so much as toe touch.  This lasted over a week, then I increased 25% weight-bearing each week.  If I had a flare of pain or swelling, back on crutches.

4.  Formal PT twice a day for a month post-op.  My surgeon had me stay in Colorado for this (1000 miles from my home).  I had two formal sessions each day with a PT very experienced in arthrofibrosis and this protocol, and then I did an additional 2-3 PT sessions at home.  The cornerstone of the immediate post-op program is wall slides, CPM, spinning w/no resistance on bike, quad sets, hamstring curls on the table, straight leg raises (seated for first 7 weeks, then prone), and above all, patellar mobilizations.  These were done for at least an hour a day, and generally have to be done by someone other than the patient.  These hurt.  I continued formal PT once a day for almost six months, in addition to my home exercises.

5.  Delayed strength training.  The priorities are to get the heat and swelling out of the knee, achieve full flexion and extension as soon as possible, keep the patella mobile, and to do a variety of non-weight-bearing stretching and isometric exercises.

6.  Pain control is critical.  This is a very painful surgery, and yet if the patient is having a lot of pain it can lead to immobility, ineffective PT, and even quad inhibition.  This is a disaster if you have patella baja!  The goal is to strengthen the quad in pain-free range so it can pull the kneecap back up into the right position.

Now many doctors will want a patient to aggressively rehab if there is a problem with scar tissue--weight-bearing immediately, strength work, quad exercises, treadmill stuff, getting off crutches ASAP, but only in formal PT 3 times a week.  My OS feels this doesn't work, and I have to say that it hasn't in my case.  This last surgery, with the specialized protocol, is the first time I haven't grown back wads of scar tissue.  Too bad I have mechanical changes from the 18 months I did have a knee full of scar tissue....

Anyway, there are many details of this protocol in my posts and Laurie's--we have the same doctor.  This regimen really works.  She had a much longer rehab than I did, and was lucky enough to avoid the permanent changes like patella baja and infrapatellar contracture syndrome.  Still, I'm much better than I was.  The pain is what's getting me down now, and that's probably due to arthritis.  Check out our posts going back to the first few pages of the soft tissue healing problems section.  Hopefully, there will be lots of info.

************************

Also, check out Janet's posts in this section on her protocol.  Several other people have posted about what not to do as they went through ineffective rehab, and they are now seeking treatment with other doctors who are specialists in this field.  My posts of what not to do are in the archives--I had four surgeries with bad results before I finally saw a specialist.  Right now, I'm much worse than I was before my first surgery (lateral release and partial menisectomy), so I definitely wish I'd known then what I know now!

I know everyone is different, and so I hope that you are able to buck the trend with the scar tissue and patella baja.  It's tough when you are in a health care system that is so restrictive.  In my case, I had to go out of the system both for my last surgery and for the treatments that help me deal with the complications of having had a knee full of scar tissue.  These treatments include acupuncture, pain management, special PT, and myo-fascial release.  My insurance does not pay for any of these, but they make my life more bearable and allow me to keep living alone and working almost full time.

Hope this information helps.  We will try to answer any questions you still have about the actual procedure after you've read through the post-op diaries.

Heather

Lynette:
Heather

Thanks for your very detailed reply.

It's enlightened me as I thought the more aggressive I am after the operation the more likely the scar tissue will not reform.

It's given me a lot to think about.  The surgeon has put me down as urgent but I will still have to wait four to six weeks for the operation.  In the meantime I can continue with my research.

Thanks again
Lynette

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