Rehab Diary for Patellar Tendon Lengthening Surgery - Month 1

Below is a consolidation of personal e-mails and KneeGuru posts that were made during my rehab after reconstruction of my patellar tendon by Dr. Noyes. I was suffering from severe arthrofibrosis and severe patella baja with a very short patellar tendon. Prior to the surgery I was in severe, constant pain and limited flexion (105 degrees with overpressure and 80 to 90 actively). I thought it would be beneficial to compile them all in one place so that others who are battling a painful rehabilitation can share my ups, downs, frustration, and ultimate success. I would like to express my sincere gratitude to the staff at Cincinnati SportsMedicine (CSM) for the treatment that I received. Their dedication, patience, and endless words of encouragement were greatly appreciated.

7/16/07 - Mom flew into town yesterday and the airline lost her luggage, some how it was sent to a completely different airport. After many phone calls Sunday evening, the luggage was found and put on the first flight of the day. Not wanting to wait on delivery, we went to the airport, picked up the bag, and headed out of down. We arrived in Cincinnati this afternoon and settled into a furnished apartment about 5 minutes from the CSM office. It was similar in cost to a hotel, but much more spacious. It had a full kitchen and washer/dryer, so we didn't have to save quarters to do laundry. The grocery store was around the corner and the drug store was up the road, so we were good to go. I'm scared to death about doing this.

7/17/07 - Today was the pre-op visit with Dr. Noyes and there was a minor change in plans. The surgery that was originally scheduled for 8:00 am at one hospital is being changed to noon at another hospital. The freezer where the cadaver tendons are stored at Hospital #1 is broken and the doctor wasn't informed until yesterday. Most of my appointment today was spent waiting for the office staff to juggle surgery times with other patients and the OR time at Hospital #2. Once we found out what was happening, we were a little worried about having to delay the surgery until next week since Dr. Noyes does surgeries on Monday and Wednesay. I have to commend and thank Donna for making this all happen.

7/18/07 - Today was the big surgery day. We got to the hospital around mid morning. The surgery started some time around 1 pm and took about 3.5 to 4 hours and they only needed to use my hamstring tendons (autograft) from both knees. They could split what was left of my patellar tendon and use that, so they didn't have to use cadaver tendons (allograft). They ended up lengthening the tendon about an inch. The old screws were removed because they were in the way. Now there three wires looped through the patella and tibia. There are actually three separate wires; two looping through the patella and top of the tibia in an "O" configuration and the third is a figure 8 from the tibia to the quad tendon (I think it crosses around the bottom of the patella). Each wire is twisted closed (think twisting two electrical wires together). Two of the twisted wires are on the medial side and one is on the lateral side of the patellar tendon.

The recovery room nurse was surprised at how alert I was when I woke up. I was asking all kinds of questions about things. Dr. Noyes told Mom that I would probably have to spend an extra night in the hospital because of how late the surgery was, how long the surgery took, and that I would be in a lot of pain. I told everyone that would listen before the surgery that morphine had no effect on me. Usually hospitals don't listen and I have found this out the hard way with 5 previous surgeries all at different hospitals. This time I was actually listened to, so the doctors gave the recovery room team several options to get the pain under control and they did so very quickly. The femoral nerve block in the left leg was great for killing the pain in the left knee and the anesthesiologist did it so quickly, I didn't know that it was happening and it was over in an instant. However, I could feel a lot of pain in the right leg where the doctor did the hamstring tendon harvest.

7/19/07 - Day 1 post-op and I was discharged from the hospital about 15 hours after the surgery was completed. We spent the night staying a head of the pain game so the doctor (actually one of his fellows) released me from the hospital this morning and wanted me to get to PT as soon as possible. The pain is tolerable (unless I move, then it goes up quite a bit), so I didn't have an issue with being released. Actually, I was having food security issues. I hadn't seen breakfast when the doctor came by, so I was chomping at the bit to get out and find food. It took them several hours on Wednesday evening to find me a room so I didn't get dinner and had to exist on crackers. 24 hours without something substantial to eat is quite a long time for me.

We drove straight from the hospital to PT, where they changed the dressing and started my therapy (hamstring and calf stretches, ankle pumps, quad sets, e-stim, and ice). Also, Dr. Noyes made a round through the PT room and stopped by to check on me. In the future I will refer to this as a "PT fly by". Dr. Noyes was very pleased with the results of the surgery. For now, I will hold back on sharing in the excitement because my first OS was very pleased when he repaired the fracture. Dr. Noyes was surprised that the pain was under control enough for me to be discharged. The anticipated PT routine is being modified as we go. It was anticipated that I would be non-weight bearing for 4 weeks, but they are letting me partial weight bear when the leg brace is locked in extension. This makes getting around a lot easier. However, getting in and out of the truck (4x4 extended cab) is a comedy. I'm 5'8", so with my leg locked in extension and no quad strength to lift it up pretty high, I have to slide in butt first (almost into the back seat) and then pull my leg in. Usually my shoe gets stuck on the door. I'm starting to get better at it. If they would just give me some motion in the brace it would get a lot smoother. The range of motion will be limited early on during PT so that the tendons have a chance to heal.

7/21/07 - Day 3 post-op and I managed to survive the PT appointments so far and everyone is happy with the progress. I had two PT sessions yesterday. Straight leg raises, ERMI flexion device, and active leg extension were added to the routine. The knee is still very stiff and swollen, but with a lot of patience and stretching, the therapist got the ROM to 90 on day 2. The most painful areas of the knees are where the hamstring tendons were cut, but this is starting to settle down. Dr. Noyes is pushing to get the quad going so that the patella doesn't sink again. I do my whole routine about 4 to 5 times a day. So far pain has been manageable. My main concern right now is the heat being generated, but I'm trying to keep that under control with the ice. Just hanging out this weekend doing my home therapy routine. Next week will be more therapy twice a day.

7/26/07 - Day 8 post-op. PT has continued twice a day (3 hours/session) during the last week. X-rays were taken today and show the patella in the correct position, but the knee is very stiff and is difficult to bend. ROM is about 30 degrees flexion on my own, 60 degrees using gravity, and 90 degrees with manual overpressure from PT person. Going between flexion and extension is extremely stiff. Imagine trying to bend steel tubing in concrete and you have my knee. I have never been through childbirth, but I'll bet the pain is similar. In an effort to control the pain, I was given a Lidocaine injection on today. It didn't do a lot for me because my pain is in the soft tissue around the knee and not in the joint.

8/1/07 - Day 14 post-op. ROM is still very limited and I continue to go to PT twice a day working on strength and ROM. Since my knee isn't loosening up as expected, Tim is the one who manually works on my knee (patella mobs, tissue massage, and overpressure) for about 30 minutes twice a day. When he starts trying to bend my knee, I do a lot of huffing and puffing and would be screaming if there weren't 10 other patients around that would go hobbling out the building. Every time we struggle to get to 90 degrees. I can bend about 30 degrees on my own while on the table and about 60 degrees using gravity. The unfortunate part is that once we get it moving a little, the leg brace (locked in extension) goes back on and it's back to square one the next time. I seem to be maintaining extension. The pain has been fairly significant where the tendon was reconstructed. Fortunately, the pain at the two harvest sites is pretty much gone. I'm not sure which pain is worse, the patella being pinned in the joint (pain prior to this surgery) or the tendon graft. Hopefully the latter will ease in the next couple of weeks. Dr. Noyes is back next week, so I will see him sometime on Tuesday to see what he says. I think everyone is getting a little frustrated that it is still such an effort to get to 90.

8/7/07 - Day 20 post-op. The update for the week is it hurts like heck and is very stiff. ROM still isn't improving. PT is still 6 to 7 hrs a day at CSM and then my home routine in the evening. Right now, it seems like a whole lot of work for very little in return. I saw Dr. Noyes in PT today. He thinks the quad strength is improving, but that scar tissue is starting to take hold. I was sent for x-rays and everything is still in the proper place and the tendon length still looks good. In order to address the scar tissue, Dr. Noyes will do a manipulation tomorrow along with the injection of some steroids. As a result we will be at the hospital bright and early tomorrow and then stop off at PT on the way home so that they can continue to work on bending. The plan is to remain in Cincinnati through the end of the August and continue with PT twice a day. Also, they set the brace so that it can flex to 90 degrees. This way I can work on bending it while walking, however, I still have to sleep in it locked in extension.

8/8/07 - Day 21 post-op and MUA today. Well today did not go as expected!!!! During the manipulation, Dr. Noyes initially got my knee to 40 degrees flexion. With a prolonged period of stretching it he got it to 110 degrees. Instead being released from the hospital and going to PT this morning, I was placed on an epidural and kept in the hospital so I can work on bending it.

This is the second time that I had an epidural for pain control, but for some reason only my right leg was being affected. The drugs didn't work on the left leg after a few hours. By mid afternoon, they tried inserting the epidural 3 different times and I have spent most of the day in the recovery room trying to get this issue resolved. A fourth epidural attempt was made Wednesday evening and they finally increased the dosage. This finally provided a moderate amount of pain relief. I was no longer in tears, just making funny faces. To make a long story short it took over 12 hours to get the pain under control (only tolerable, not gone) after the MUA. To add to the challenge of moving my knee, the kept attaching me to all sorts of machines and things. My Mom didn't find the humor in the counter productive nature of this, especially when the oxygen line almost strangled me.

8/11/07 - Day 24 post-op. Released from the hospital yesterday morning after spending two nights in the hospital and went straight to PT. Even with all the tubes and wires attached to me during the hospital stay, I was working on moving my knee 30 minutes out of every hour using a rope around my foot to pull it towards me. Even at night, the nurses would find me working on moving my knee. My arms are pretty sore. I wasn't put on a CPM (this may fall in the misadventure category). I achieved an increase in ROM on Friday at PT (120 flexion) while the super drugs were still in my system, however that was short lived due to the extreme back pain that happened Friday evening as a result of the epidural attempts. I considered a trip to the hospital to relieve this pain, but my fear (rapidly approaching a phobia) of needles prevented me from returning to the place that caused such pain. There were several other misadventures in the hospital including an unexplained rash and IV tubing that got disconnected. I will spend the weekend working on bending with the ERMI machine as much as I can stand, but between the knee pain, quad pain, and low back pain, it's going to be a challenge. I'm also starting to loose my extension.

To be continued......

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