Patella baja, infrapatellar contracture syndrome and arthrofibrosis after intramedullary nailing
Arthrofibrosis is a terrible, terrible, unrelenting condition.
I've had arthrofibrosis since Sept 2000. It started with a broken leg in Aug 2000, and lack of knowledge on arthrofibrosis in ALL levels of the medical community. I broke my tibia and fibula while horseback riding. I was jumping at the time, getting ready for a competition. My horse fell upon landing the jump,I was thrown off to the right side. I landed with my left leg crashing down on the lateral side. I saw my leg actually break in half, felt it snap, heard it snap...just like a tree branch. My lower leg was externally angulated. If I hadn't been wearing chaps, the fracture would have been an open fracture, where the bones ends break through the skin. It was surreal to watch and I didn't feel any pain when it happened. That lasted all of 10 secs, then horrendous pain set in, the worst I've ever felt. I yelled down to the trainer, to call 911.
When I was in the ER, I had to be put to sleep to straighten the leg enough to place it into a splint. I had 2 displaced fractures, transverse and oblique to the distal tibia, I had a displaced fracture of my lateral mallealous (ankle) and I had a non-displaced comminuted (many pieces) fracture of the proximal fibula. The next day I had surgery for closed reduction. This is where the OS manipulates the fracture into correct position and puts it in a long leg cast, from hip to toes. I was supposed to be in this cast 16 weeks as long as the bones stay alighned. Weekly xrays showed the bones coming apart.
After 3 1/2 weeks in the cast, I went back to surgery to have a tibial nail, also known as an intramedullary rod. This rod is placed down the tibia, to hold the bones in correct position, while they heal. It was locked in place with 2 locking screws, one distal and one proximal. My ankle was fixed with a plate and 8 screws. The nailing procedure involved cutting thru the front of my healthy knee and thru my patella tendon, splitting the tendon, so the rod could go down the tibia. I was immobilized another 2 weeks in a plaster splint. Between the cast and splint, I was in immobilization for a total of 5 1/2 weeks.
When I came out of plaster, I had severe quad atrophy. PT did not begin for an additional 7 weeks. Now my knee was very painful, swollen, hot, and had little ROM. My patella was very tight, I had poor flexion and extension. When I became full weight bearing, my patella would sublux and lock up. I was not able to go down stairs or up stairs like a normal person. It was very painful to walk with the knee.
To make matters worse, my leg had healed in a malunion. This is where the bones heal malaligned. I had 40 degrees external rotation to my lower leg. Upper limits of normal are 25 degrees. This malrotation of my leg caused additional pain to my knee and a rotational torque to the knee when I walked. I was taken back to surgery, 2 1/2 mos after the tibial nailing, because I was told my knee pain was probably due to a torn posterior horn of the meniscus. The scope showed my meniscus was fine, but I had a knee with synovitis. There was scar tissue noted anteriorly where the nailing took place.
Surgery for the complications
It was now 6 months after my accident. I had to go back to surgery with a different Dr to have the leg rebroken.This doctor was a tib-fib specialist. This surgery is called a tib-fib derotational osteotomy. Osteotomy means to cut the bone. This surgery involved cutting thru my knee again and thru the patella tendon, to remove the tibial nail. All the hardware in my leg was removed. The Dr then cut my tibia and fibula in half, derotated the leg back to correct alighnment and secured that alighnment with 2 plates and several screws to the tibia. My fibula was left apart, to grow a bone bridge.
Once again I was immobilzed for 2 weeks. Then I came out of plaster and went into a black boot-cast. I was non weight bearing for 4 months while the bones healed. I was still having knee problems with poor flexion and extension, pain, swelling and tight patella. When I had healed enough from the osteotomy, my Dr sent me to a knee specialist. This was 11 months after my accident.
I was diagnosed with patella baja/infera (this is a patella that is too low), infrapatellar contracture syndrome (my patella tendon had contracted from scar tissue, became shortened and thickened). I had developed scar tissue so bad that it had permanently contracted my patella tendon which in turn pulled my patella down too low. This was all confirmed by xrays, MRI and physical exam. My patella had little mobility when the doctor examnined it. I went thru PT to try and build my quad, hoping this would cause the patella to come up. It did not. I had to have surgery to repair this ,which came 18 months after my accident.
Before this surgery took place, I was still under the care of the Dr who repaired the malrotation. At 9 mos post op from the derotation osteotomy, I had developed saphenous neuritis to my lower leg. My leg was red, swollen and painful to touch. He felt one of the tibial plates was putting pressure on that nerve. I had surgery to remove the smaller plate, that was compressing the nerve. This surgery relieved that problem.
Two months after the plate removal, I had surgery with the knee doctor. My Dr first did an arthroscope, to remove the scar tissue. He found this was not enough, so he proceeded to open the knee up and do an anterior interval release. The debridement was not enough, my patella tendon was completely adhesed down to the tibia. He proceeded to do a procedure for patella baja called a Delee osteotomy.
A Delee osteotomy is a tibial tubercle transfer for patella baja. The part of the tibia where the patella tendon is attached, is cut away. This bone cut is deep and angled a special way. This piece of bone, with the tendon attached, is then brought up proximally. The angle of the bone cut allows the patella to come forward/anteriorly, to bring it out of the joint space.The area where the bone was cut was grafted with cadaver bone. The Dr also did a z-plasty to the lateral retinaculum for patella decompression and a chondroplasty, which is smoothing out the cartilage damage to the backside of the patella. The patella, in baja position, caused it to scrape the backside out. My doctor said it was like an icecream scoop, scooping it out.
When I started PT, my therapist said I only had about 15% of my quad. I went thru extensive PT for a yr. My doctor told me that patella baja and infrapatellar contracture syndrome is one of the worst conditions for a patient to have and for a physician to treat.
More scar tissue
I developed scar tissue again 8 mos after the Delee osteotomy. My knee was becoming stiff, painful and the patella was catching. I went thru PT again, ultrasound and iontophoresis. While researching information on iontophoresis, I came upon the KNEEGURU website. I couldn't believe there was a website totally devoted to knees.I gained so much valuable information that I have used thru my knee journey. I also did a round of synvisc shots. I saw no improvement.
At 39 mos after my accident, the Dr took me back to surgery for a scope - he removed scar tissue and my fatpad. The fatpad had become scarred down, hard and fibrotic. My patella was impinging on it. He also did an extensive chondroplasty. Now the size of my patella damage had become 15x11. I was told nothing more could be done. I was still in pain and having problems walking.
A physical therapist I had gave me the name of Dr Frank Noyes. She said I needed to see this doctor because he took care of complex knees and handled scar tissue problems. I felt I had no choice but to have him see what could be done to my knee. I was interested in cartilage replacement. I got an appointment to see him. I had to drive 10 hrs to see him.
He said my knee and leg had been thru an extensive amount of trauma. He gave me 3 treatment options to the knee. The first was to have a patellectomy where the patella is removed. He did not recommend this as it caused a 40% decrease in quad strength. The second choice was an osteochondral allograft. He said he would need a piece of tissue large enough to cover the entire backside of my patella. He did not recommend this as he woud only give it a 50/50 chance of success. He said my only option was a TKR.
Five months after I saw Dr Noyes, I had been experiencing pain in my lower leg around the fracture sight. It had been hurting while doing my rehab exercises, particularly the leg press and hip aductor. I was awakened during the night in terrible pain down where the tibial fractures were. It kept me up all night. I had a hard time bearing full weight. I called my Dr who did the derotation surgery. They told me to get back in my boot cast and I needed to come in to the office. I was examined. The area just above the remaining plate was extremely tender to touch and swollen. Xrays were inconclusive for a fracture. I had a bone scan. The Dr felt I had a small stress fracture at the top of my plate. I ended up being in the cast for 8 weeks. It was felt that the fracture was caused by my rehab routine for the knee, particularly the leg press and hip adductor. It placed too much stress to that area of my leg. I got out of the cast 2 weeks before my TKR.
So 4 1/2 yrs after my accident, 7 mos after I saw Dr Noyes, I had the TKR and thought this would be the end of a very long, painful journey with my leg and knee. But it was not to happen. I was doing very well with rehab. I had 120 degrees flexion and 0 extension when I went home from Cincinnati, 2 weeks post-op. I did fine until about 6 weeks post op. I developed a snapping pain in back of my knee and lateral knee pain. My hometown Dr said it was nothing and would go away. It persisted and got worse. The snapping turned into sharp pinching pain. The lateral pain was getting worse and my knee was getting stiff. I saw Dr Noyes for my 6 months post-op check. He said I had fallen into the 10%, who get this type of excessive scar tissue reaction. He gave me a cortisone shot. I came back 4 weeks later. I had no improvement. Xrays showed I had a fabella bone behind my knee. A fabella bone is an extra sesamoid bone that only 10% of the populations gets. It's about the size of a pea. Dr felt it was impinging in my prothesis. I got another cortisone shot and was told I would be having a scope and a posterolaeral exploration surgery when I was 1 yr post op from the TKR.
Scar tissue after TKR
I had surgery 1 yr post-op TKR. It was not a scope, but an open surgery. I had developed terrible pain in the MCL area , 2 mos before this surgery and could not tolerate any pressure to that area.When the Dr examined it, he said that was classic for nerve entrapment. I had scar tissue removed from all the collateral ligaments. The MCL was encased in scar tissue. I had scar tissue compressing the infraptellar branch of the saphenous nerve. The Dr had to do a very painstaking debridement,decompression and partial removal, of the nerve. Scar tissue was all over the poserolateral and lateral ligaments. The fabella bone was removed from the gastrocnemius tendon and he did a z-plasty to a tight IT band
Setbacks and scar tissue
Thinking this was finally the end, another disaster happened, I laterally dislocated the knee 2 weeks post-op, from a twisting injury, getting out of the car. My knee was painful and unstable. I had about 8mm of joint space opening on the lateral side. Once again I had surgery where the Dr did a posterolateral reconstruction, removed the damaged PCL, the femoral component was revised to a PCL sacrificing one, the spacer was revised to a thicker spacer, and I had scar tissue removal and synovectomy. I had some problems regaining extension , so I had to do hanging weights. This involved placing my ankle on a 4 inch foam block and hanging 10-15 pounds of weight, just above the knee. I had to do this 6 times a day, for 10 min each time. This is done to get the tissues behind the knee to stretch. I developed more painful scar tissue about 12 weeks after this surgery. It was anteriorly and in the suprapatellar area. It sounded like knuckles cracking or velcro, when I bent and straightened my knee. The Dr was going to remove it in a few months, to give my knee a break from surgery.
As luck would have it, disaster once again struck. I fell down stairs, 6 mos after the last surgery, tearing the MCL. I iced, elevated and stayed off the leg for 2 days. When I began ambulating, my knee was unstabile and painful. My knee would thrust out medially when I walked and my foot wanted to turn outward. I called Dr Noyes office. I was told to get on cutches and get there ASAP. Not an easy thing to do since I am 700 miles away. I did manage to see him 3 days later. I had an emergency appointment with Dr Noyes. He said I had a 3/4 tear to the MCL. He placed me in a cylinder cast for 8 weeks. 5 of those weeks the cast was made so I could remove it, to do ROM exercises. This is known as a bi-valve cast. The MCL did not heal, so I had to go back to surgery. I was told surgery was for a possible MCL allograft, but I ended up with a spacer exchange to a thicker spacer - I now have the thickest spacer I can have. When the knee was opened ,the Dr could see that the MCL had healed enough and did not require the allograft. However the MCL and LCL were very stretched out. He placed a thicker spacer to take up the laxity and the scar tissue was removed.
More scar tissue
My knee was very painful from day one after that surgery. The patella tendon area and below the patella was very painful, swollen and hot. It was first thought I had a bad case of patellar tendonitis. I was placed on diclofenac and ultrasound to the tendon. I did icing, modified PT, crutches and iontophoresis. Once again I had to do the over pressure program of hanging weights for extension and the ERMI for flexion. The pain worsened and I was losing some flexion. The knee was still hot. I was beginning to suspect I was developing scar tissue as soon as 3-4 weeks post op. I was feeling stuck down anteriorly at 5 weeks post op. I saw the Dr for a 7 weeks post-op appt. He confirmed my suspicion....scar tissue. I went thru a round of high dose Celebrex and asprin, cortisone shot, medrol dose pak, more icing, and modified PT. There was no improvement. The knee was still getting swollen, hot and painful. I was losing more flexion. I went from 120, at 2 weeks post op, to about 105 on flexion. I had blood tests to rule out any infection. I saw the Dr again and I will be going back for my 12th surgery. This will be an open surgery for scar tissue removal, scheduled for Oct.
My arthrofibrosis journey
My arthrofibrosis journey began with several factors:
I had a surgical procedure, TWICE, thru my extensor mechanism,the patella tendon.
I had prolonged immobilization in cast, splints.
I had severe quad atrophy
I had delayed physical therapy by 7 weeks.
I had synovitis.... an inflammatory procees going on in the knee.
These events set off symptoms of pain, swelling, heat, loss of flexion, extension, tight patella.
These events cascaded down further to permanent damage to my patellar tendon and patella in the form of patella baja/infera, infrapatellar contracture syndrome and patella articular cartilage damage. If the medical community had recognised the symptoms of arthrofibrosis in my knee and knew how to treat it, I most likely would not have ended up with a knee replacement in 4 1/2 yrs time after my accident.
I want to try and help others who are in the early stages of their knee journey - injuries, surgeries or fractures - and are looking for information for problems they might be encountering, with pain, stiffness, loss of flexion/extension, swelling and heat. I hope by reading my story you will see the importance of early recognition and treament of scar tissue/arthrofibrosis, before it causes a life long, debilitating problem.
Arthrofibrosis is a terrible, terrible, unrelenting, condition.