Neuroma Excision and Open Scar Tissue Debridement
"The next step is to schedule surgery." This was the message in an email I received from the doctor's office, after reporting no improvement from the nerve blocks and cortisone shot. I had been having severe nerve pain on the medial side since my surgery in Oct 07. This is a continuation of my blog titled, Nerve Entrapment, A Second Time. Because of this, I was now scheduled for surgery on April 2nd, for Neuroma Excision. This surgery is almost 6 mos to the date from my last surgery in Oct 07.
I was now busy making preparations to travel to Cincinnati and stay for 2 weeks to do rehab at his specialized PT dept. I contacted the executive housing people to arrange rental of one of their furnished apartments. This would be the 3rd time I have used them for surgery. Renting the apartment has really been nice to stay in. It's difficult to stay cooped up in a hotel and harder for the caregiver, who is with you. The apartment provided a bit of normalcy and home-like atmosphere for those lengthy stays for surgery.
My surgery was several weeks away when it was scheduled. During that time, I noticed the small amount of crepitus I was feeling under the patella tendon and above the patella was becoming more prominent and coarse. As time went by, it became quite audible with flexion and extension. It was becoming painful and my PT was noticing my patella mobility was getting tight. I was loosing flexion. This would need to be addressed during my pre-op appointment.
It was finally April and time for surgery. I got everything arranged once again with the family for my trip. Going out of town is a monumental task that takes a lot of planning. Not only do I have to get the family situated at home, but I have to get all the planning done to stay in Cincinnati.
It was a busy day, the day before surgery. I had to do pre-op testing at the hospital, Dr's appointment and PT appointment. The hospital testing went with out a hitch. I have had a history of UTI's showing up on the urinalysis part, so I had asked my PCP for a prescription of antibiotics prophylactically, to take 1 week before surgery. I did not want this problem showing up again. I left the hosptial and headed to the Doctor's office. I met with Dr Noyes and the Fellow. They went over the surgery for neuroma excision. We went over all the trigger points on my knee.This was not going to be an easy surgery to go thru all the nerves and find the trouble spots. I brought up the progression of scar tissue since I last saw them in January. They examined the knee and felt the scar tissue and patella mobility. The decision was made to also debride scar tissue too. The surgery was going to be a combination open surgery and arthroscopy. My previous incision would be opened once again. I would be in the hospital overnight then go directly over to PT to begin ROM. When I finished with the doctor, I went down to PT for further instructions. I've been thru this so many times , I know them by heart.
Surgery time has come. I am all checked in and ready to go. The Fellow came in and went over the surgery again. He then proceeded to mark all the trigger points with surgical marker on my knee. These would be the areas they would pursue on the nerve. There were several areas marked all on the medial side of my knee. The time had come to be wheeled down to surgery.
I found out surgery took about 3 hours to do. This was a very painstaking surgery using micro surgery on the nerves. Nerve conduction needles were used to find hot spots on the nerve. Once a neuroma was found, it was cut out, the nerve ends were cauterized. These nerve ends would balloon up and the ends were embedded in the muscle so the nerve would be inactive. I found out they excised six neuromas in the knee. No wonder I was in so much pain , burning, needle jabs in so many spots. One neuroma is painful enough , but to have six !!! I found out scar tissue was debrided from under the patella tendon once again and from the suprapatellar pouch.
My knee was wrapped in a large compression dressing with many layers. I was immediately started on high dose Celebrex, an anti inflammatory, after surgery, to keep the inflammation down, plus icing and elelvation. Later in the day, I noticed I was having an area of burning in the medial crease of my knee. I told the Fellow about this burning when he did rounds.
When I saw Dr Noyes he said the nerves around the area are irritated and it should calm down. That was one of the things Dr Noyes had said before surgery, that when you do surgery on nerves, the neighboring nerves get very irritated. He said if it didn't calm down, I would go back on the medication, Neurontin, for a period of time to settle it down. He said he did a very thorough job with micro surgery, going thru every nerve.
I am now 5 weeks post-op and over the past 5 weeks of rehab, the knee has gotten progressively tight and flexion is decreasing to 105 degrees after getting to 117, despite many sessions on the ERMI flexionator and a stretch called the Thomas Stretch. No sooner do I get stretched , then the knee immediately tightens up like shrink wrap. I have gone thru many sessions of patella mobes and deep tissue massage for scar tissue, but it is making a come back. My medial knee is getting the putty/hard feel to the tissues despite all the massaging and the medial hamstrings are getting tight. When I went back to Cinci for post op check , they first used ultra sound to soften the scar tissue then did deep massage popping and breaking several areas of scar tissue, some were quite audible.They pointed out how one of my scope portals was deeply dimpled which meant it was scarring down. When I was 4 weeks post-op I started a flare up of inflammation. My knee started having intense periods of heat and swelling lasting several hours. I was still on high dose Celebrex but it wasn't helping at this point. I thought I might be able to stay out of this inflammatory phase with the Celebrex prescribed right out of surgery. Prior to the 4th week post-op, I had little problem with heat in the knee. Because of this inflammatory phase, I have been placed on a medrol dose pak for 1 week, then I go off for 2 weeks, then back on a dose pak. During the time off from the medrol dose paks, I will go back on the Celebrex. The medrol dose pak will hopefully stop the inflammatory cycle which promotes the growth of scar tissue. It should help relieve the heat and swelling and also help soften and loosen the scar tissue. I was also placed on Neurontin for 1-2 months because of the persistent nerve burning. This should help calm the nerve irritation.
These next weeks will be critical with the inflammatory process and if it can be controlled with the medrol dose paks. PT will consist of ultra sound to soften the scar tissue, patella mobes and deep tissue massage to the tight medial tissues and hamstrings, flexion work to stretch tight tissues and quad strengthening.
To complicate matters, I ruptured my plantar fascia on the same leg, 12 days post op. I also have lateral plantar nerve palsy diagnosed by the fact that I can't move my 4th and 5th toes and have something called Lateral Stress Transfer because of the intense pain and pressure on the top of my foot. The possible cause for this is all the gait and weight bearing changes I have been thru from being on crutches for 15 mos. I am in a CAM walker boot cast for 3 weeks to immobilize my foot. The OS treating this said it will be a challenging problem......... just the words I wanted to hear.