The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: pmull90 on December 27, 2005, 02:17:48 PM

Title: new problems post acl reconstruction
Post by: pmull90 on December 27, 2005, 02:17:48 PM
I write with hopes that someone can help me identify what in the heck is going on with my right knee.  Please bear with me as this post is a bit lengthy. 

I am 20 months post acl reconstruction, partial lateral menisectomy, and OATS procedure to the lateral femoral condyle.  My ortho did a patellar tendon graft for the acl.  I am very active and just three months prior to my surgery I ran my third half marathon.  The pain after that race is what resulted in my doctor visit.  I also cycle pretty aggressively and surf.  I had partially torn my acl in 1992 and it was not reconstructed then.  My recent ortho said he needed to reconstruct it to restore stability in my knee to reduce movement in the joint to slow the articular cartilage damage.  It sounded good to me so I did it.   

Anyway, the doc took photos during the surgery that revealed that I did not have any problems in the patellar groove or on the back surface of the patella.  Also, based on the photos, all the problems were in the lateral side of my right knee.  During rehab I experienced much pressure behind the patella and jumping of the patella when I bent and straightened my knee.  I also experienced some "catching", for lack of a better description, on the medial side of my knee - not in the joint, but rather on the outside of the knee joint on the medial side. I think the best description would be that it felt like some of the ligaments or tendons in the mcl area were catching on the outside surface of the joint.  This was most apparent when riding my road bike.  I reported these problems to my physical therapist and my ortho but they never really seemed concerned with them.  In fact, at one point in my PT I was still limping due to the pressure on the back of my patella and the therapist insisted that I "stop limping" and walk normally despite the pressure. 

Recently, at 19 mos. post surgery, I experienced more pain and swelling so my ortho scoped my knee to see what was going on.  He found MUCH scar tissue in the joint.  He also found articular cartilage damage in the patellar groove (which was pristine in the first surgery as shown by the photos.)  He also found a bone spur on the medial area of the knee around the area where the "catching" was occurring.  This area was also unremarkable at the time of the first surgery.
I'm really concerned because now I'm five weeks post arthroscopy and the catching is getting worse, not better.  Every revolution on the bike causes something to feel like it is dragging over the bone on the outside of the knee joint (medial).  Also, the pressure and tightness in my patella is getting worse.  I never had these particular problems before my acl graft was harvested from my patellar tendon.  Also, the damage behind the patella, in my lay opinion, seems linked to the sensation of tightness and pressure on the back of my kneecap during my rehab.  I never had problems with patellar tracking and now the "jumping" continues as well. 

I am at my wit's end.  I've had to stop running entirely and now this "catching" or "dragging" on the inside of my knee joint prevents me from riding my road bike.  If anyone has any idea, please let me know.
Thanks a million.
Title: Re: new problems post acl reconstruction
Post by: Heather M. on December 28, 2005, 05:23:57 AM
Hop on down to the soft tissue healing problems section and read all you can about arthrofibrosis.  That's the official name for excess scar tissue in the joint.  There are dozens of threads and posts where many of us have literally written everything we know about and have experienced with this condition.  So I don't want to be repetitive here, but am very happy to answer any questions you might have after you do the initial reading.

Arthrofibrosis is a fairly common complication of OATS procedure, and this is one type of arthrofibrosis patient:  someone who formed excess scar tissue due to a traumatic procedure and/or post-op immobilization.  The other type of scar tissue patient is someone who continues to reform scar tissue even after 'relatively minor' scope procedures--like a scar tissue cleanup.  This is a much tougher problem to deal with.  Many OS's will never see more than a few serious cases of recurring arthrofibrosis in their careers.  Other OS's specialize in really tough cases like this.  The thing to remember is that the rehab protocol is almost more important than the surgery required to remove the scar tissue (as a starting point for recovery).

Unfortunately, when a patient has a serious scar tissue problem it can bind down the kneecap in a condition called patella baja and/or infrapatellar contracture (depending on which way the kneecap has 'dropped,' either into the joint or down toward the tibia).  And this can lead to rapid, irreversible cartilage destruction.

Honestly, it sounds like you have a very complicated case.  I would recommend that you see a *specialist* who deals with both OATS and arthrofibrosis.  Off the top of my head, I can only think of one (Dr. Noyes in Cincinnati), but I imagine some of the OATS giants out there will have seen arthrofibrosis before.  The problem for you is that you need to fix the mechanics (i.e. get the scar tissue out and keep it out) before you can decided if that is what's causing your pain or not.  It is obviously the most logical source, especially if the scar tissue is causing patella baja and bone on bone contact in your knee.

Hope some of this information helps.  Read up on arthrofibrosis, because that is likely what you will have to tackle first.  The good news is that the new damaged cartilage may or may not be causing any pain--no one can say why some arthritic lesions hurt and others don't.  It's a mystery.  But it's good news for you, and I think it's reason to hope that you will have an amazing recovery once the scar tissue is out and you can rehab without reforming it.  This is quite a feat, I'm afraid.  There are a handful of doctors out there who have the right program to do this...but their numbers are even smaller when you add OATS into the equation.  I think my current OS is wonderful, but he doesn't do OATS (that I know of), he does microfracture instead.  So he could likely help you with the scar tissue and comment on the state of your cartilage, but he doesn't do the procedure you had done.  Dr. Noyes does.

Anyway, read up on arthrofibrosis.  It's literally one of the toughest challenges you can have in orthopedics, about as tough as a bad infection.  Here is an article about ACL recon and arthrofibrosis: