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Author Topic: Lysis of Adhesions--Scar tissue surgery  (Read 34548 times)

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Offline Heather M.

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Lysis of Adhesions--Scar tissue surgery
« on: December 27, 2002, 10:53:10 PM »
Hi all.

I just had my fifth scope to remove scar tissue from my knee.  This surgery was with a brand new doctor who sees a lot of this stuff, and my post-op protocol is different than anything I've ever done before.  I thought I'd post some information and keep up on my progress, hopefully to encourage anyone else out there having problems with adhesions.  They are a nightmare, I know.

Pre-op:  I had developed patella baja (aka patella infera) and my kneecap was smashing into my shinbone and the underlying joint through ROM.  The pain was debilitating, though taping helped for a day or so.  My knee would also lock up, I was missing about 20+ degrees of flexion and 3-4 degrees of extension.  I walked with a limp.  My main complaint was pain that nothing would address except icing, elevating, and narcotic pain meds.

I had the arthroscopic lysis of adhesions on December 20.  Within two minutes of waking up in post-op I was placed in a CPM bending between 30 and 70 degrees.  The pain got so bad I was given fentanyl, dilaudid, and finally a small amount of morphine.  The first day and night were the worst.

What was done:  The doctor basically used a shaver and laser tool to remove scar tissue from all around the knee.  The worst scarring was  below the kneecap--my patellar tendon was completely scarred down (immobile) and my IT band was adhered to the bone as well.  The entire empty space that is supposed to be beneath the kneecap was filled up with scar tissue.  Removing this is called an anterior interval release.  Then the doctor cleaned up some damage on the back of my kneecap and we were done.

Here's a summary of the first week post-op protocol.

*I spent 24 hours in the hospital for pain control and IV antibiotics

*NO WEIGHT-BEARING WAS ALLOWED, no exceptions.  I was allowed to use crutches as long as I didn't put my foot down, but ended up renting a wheelchair because I was so exhausted (altitude) and drugged that I was pretty unstable.

*My first PT session was on the afternoon of my surgery--OWWWW.

*Starting the day after my surgery, I had PT two times per day, for about 90-120 minutes each time.  The main focus has been getting ROM back and preventing swelling.  I started with wall slides, quad sets, and patellar mobilizations.  I have to do these four times per day at least.  Then I have another set of strengthening and stretching activities that I do twice per day.

*I will keep the CPM and sleep in it for 2 weeks, set at 0-70 degrees.  This is supposed to keep me from getting stiff during the night (tell it to my back).  

*If something causes sharp pain, irritation, or swelling, then we stop doing it.  I have to ice and elevate multiple times per day.  If I feel the knee getting hot or starting to puff up, I have to stop whatever I'm doing and ice/elevate.

*We have used a number of treatments to reduce inflammation and pain, including ultrasound, air pressure, TENS, and a cryo-cuff.

*The pain has been pretty intense, especially since I'm doing PT twice a day.  Despite that, my knee is hardly swollen at all and the kneecap remains fairly mobile.  The worst bit is below the kneecap, and it is quite painful to do the mobilizations on this spot.

*I have to take aspirin and wear anti-embolism stockings (very fashionable) for 9 days after the surgery.  I must keep the incisions covered with gauze and a tube bandage for 9 days as well.  My incisions are all new (he didn't use any of the old ports) and are closed with dissolving stitches and steri-strips.

*I'm happy to report that within 48 hours of my surgery I had 140 degrees of flexion and 0 extension--I can even hyperextend a few degrees, though it does hurt.  I'm able to do many of the passive stretches I wasn't able to do before (piriformus, hamstring, ITB), so my knee is gaining flexibility in that way as well.  I essentially have full ROM, and have been able to keep it.

This is a completely new protocol for me, unlike anything I've done before.  It's very frustrating for me to be in a wheelchair, especially since this town is not built for people with disabilities.  I'd love to ditch the chair, but I've never been non-weight-bearing for an extended time on crutches, and at 8200 feet, it's a pretty exhausting proposition.  However, I think that not putting any weight on the leg post-op has made a huge difference in my recovery, because I have almost no swelling and very little bruising, plus full ROM.  The idea is to keep the joint moving, but it has to be 100% passive motion.

I'd love to hear from anyone else who's had a similar surgery.  I'll try to keep posting for my own record and everyone else's--arthrofibrosis is a very rare and frustrating problem.  It's also tough to treat--my surgeon believes there is a 40% chance I'll have to have another scope to clean up further adhesions.

That's all for now.  I'm off to PT.....

Heather
« Last Edit: December 27, 2002, 10:58:08 PM by hmaxwell »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline Linds

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #1 on: December 28, 2002, 04:13:28 AM »
Wow Heather, sounds like you are doing well..I am glad you have found someone who knows how to help you. ;) I can't imagine being in PT right after surgery like that..but I am sure it's the thing to do. :-/
I was totally non weight bearing after my LR for 3 weeks..so I can totally relate to that. :( I hope you continue to recovery as well as it sounds like it is going.
Take care, keep us posted
Linds
1997 Scope RK
2002 LR RK
2002 Scope and hematoma evac RK
2004 LR LK
May 06 Fall from Horse, partial ACL tear and meniscus injury, Tibial plateau injury
2007 Scope, Plica Excision and Debride LK
2009/2010- Possibly Ankylosing Spondylitis?

Offline Sharon

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #2 on: December 28, 2002, 11:57:19 PM »
Heather,
It sounds like things are going pretty well for you after the surgery! I'm really glad you found an OS who seems to be helping you with your knee :) It must be hard to have to be in such intensive PT right after surgery but it seems like it's good for you-140 degrees right after surgery is great news!! I really hope your recovery keeps going as well as it seems to be right now! Good luck and keep us all posted on how you're doing!!

Sharon
Left knee:
LR-5/99 & 9/01
Distal realignment and LR 7/02
TTT revision 6/03
screw removal/MUA 10/03
d/x with severe patella baja
7/05 patellar tendon replacement w/piece of quad tendon
4/07 OATS

Offline Cari

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #3 on: December 29, 2002, 06:11:41 AM »
Heather,

I do not share the same problems as you do but I wanted to wish you well and tell you to hang in there you will get through it !!!

I am glad you found a Dr to finally help !!

Feel Better

Cari
open lateral release 10/85, various scopes 1994-1998 for debridement, medial release 11/98,  TTT(Fulkerson)& lateral release 11/30/99, screw removal 6/27/00, tibial repair 2/13/01, dx RSD 6/25/01

Offline SueJ.

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #4 on: December 29, 2002, 07:34:17 AM »
Hi Heather,
I'm glad to hear from you, I had been thinking about you and wondered how things were going. Sounds as if so far things are looking on the up side lets hope it stays that way!
Maybe you can get some cute Ski guy to help you around ::). I'm sure some tall tale of a massive skiing accident would be very believable!
Good luck with your recovery and keep us posted when you can in between PT visits.
By the way have you seen the doctor since surgery yet?
Is he happy with your recovery so far?
Are you in a brace of any kind?
I remember that CPM and what a pain it is to sleep in! But you gotta do what you gotta do!
This whole scar tissue thing is such a pain, and who would have known we would have a problem with it ahead of time. But I must say that since my problem I have heard of a few more people around with the same problem and then of course there's always someone with a friend of a friend of a friend that had the same problem. But people still keep asking me why did it happen in the first place. It's like it just can happen, everybody heals differently.
What more can you say...
Keep smiling and bending!
Sue
TTT left knee May 17, 2002;  Arthroscopy with Lysis of adhesions,  revision of LR and screw removal left knee 10-10-02.

Offline T_bone

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #5 on: December 29, 2002, 08:13:28 AM »
Hi Heather,

Glad to hear you're on the mend.  Hopefully this one will be the charm and you'll be back to your active self shortly.
;D

Offline daisey

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #6 on: December 29, 2002, 02:38:03 PM »
Hi Heather,

    Glad to here that things are going in the up direction after the surgery.  I was really glad to here that you found an OS that had options to help.  I know that PT has been tough, especially twice a day.  It sound like your OS has you on the road to recovery.  Hang in there and keep us posted on your recovery.

Daisey
05-2002 Chondroplasty and plicae excision Rt knee
07-2002/11-2002 multiple rounds of physio
11-2002 Open MPFL reconstruction
11-2002/05-2003 Physio
07-2003 Cortisione injection due to return of pain
2005-2007 Cortisone injections bilateral knees
2007 LR LT knee
5/6/2010 TKR scheduled LT Knee

Offline Tizzy953

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #7 on: December 30, 2002, 12:12:39 AM »
Heather,
It is sooo good to hear that you might have found the answer.  Even though constant motion has got to hurt you have got to be so excited that you are bending this much.  How does the knee feel?  You have to feel like there is just tons of room in there after being so strapped down like you have.  Hopefully this is just the beginning to the end and won't have to go through it all over again!  Enjoy the time in the snow and enjoy New Years!  When do you head down to AZ again?  Hope all is well!

Kenzie
11/93-R ankle recon; 10/94-L ankle recon, 2/96-R shoulder stabilization+3 screws, 2/97-dislocated jaw, 11/99- LR L knee, 5/02-diagonstic scope L knee, 1/14/03- TTT+LR L knee, 9/9/03-L knee hardware removal, cartilage cleanup

Offline Janet

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #8 on: January 02, 2003, 04:03:18 PM »
Dear Heather:

Wow! That's an interesting rehab protocol. My scarring wasn't as extensive as yours, but my patella was completely scarred down, also causing some patella baja. My medial and lateral gutters were completely scarred down. After doing the lysis of adhesions, I also needed a LR and partial medial release because of all the scarring.

My PT protocol was more "classic." I started home exercises the same day as surgery (quad sets, ROM). I began PT within three days, going three days a week for five weeks. I then went to two days a week for another 2 months. I was able to regain some ROM pretty quickly, but continue to have other problems. 18 months later, I have to say the surgery was a success. I no longer have the tight, pulling pain all the way through my hip. And my ROM is better than before (about 120 flexion, almost full extension). The worse part was getting the patella tendon to work again. It had been scarred down so long, they say it wasn't really moving, the scar tissue was just stretching. My patella can actually move now, but I still have the burning pain in my patella tendon.

I hope you continue to have such good results. Being non-weight bearing is interesting. Maybe it will make the difference between not producing scar tissue again. Keep us posted.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline Tizzy953

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #9 on: January 02, 2003, 10:26:06 PM »
Hey Heather,
I haven't heard from you in a while and I was wondering how things were going?  Is the knee getting any better?  How was your New Year?  We went up to Seattle and stayed at the Westin hotel (same chain as the Phoenicain)  It was great we had a beautiful veiw of the Space Needle and saw the show from there.  Went walking around Seattle the next morning, I really need to stop doing that, my knee is getting a lot worse and walking that much doesn't help.  I usually have to take the entire next day just to recover.  12 more days until surgery.  Please keep you fingers crossed that it doesn't get cancelled.  I don't know what I would do if that happened, it has gotten so much worse in the past 3 weeks.  

Again I hope you are improving by leaps and bounds!

Kenzie
11/93-R ankle recon; 10/94-L ankle recon, 2/96-R shoulder stabilization+3 screws, 2/97-dislocated jaw, 11/99- LR L knee, 5/02-diagonstic scope L knee, 1/14/03- TTT+LR L knee, 9/9/03-L knee hardware removal, cartilage cleanup

Offline Laurie

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #10 on: January 06, 2003, 10:34:54 PM »
Well congrats Heather!

You sound much more positive.  No infection I hope.  He's the man, isn't he.  They give you a lot of attention and show you what to do exactly.  There is a reason why everyone ends up with him.

Remember though, the battle has only begun.  You have got to keep the scar tissue from coming back.  Passive movement, patellar mobs ( can't do enough of these), wall slides.  Keep the heat out, ice, ice, ice.  My only advice at this point is if you feel the scar tissue coming back, then don't hesitate to get the cortizone shot.  It stops it from spreading.  It was between 2 - 3 weeks out of surgery that it started to come back.  You'll know when it starts to come back.  It'll start to get hot again and stiff.  Stop it before it starts.


I am currently 14 months out of my last scar tissue removal and I am now at about 90%. I had to ride the bike for roughly 8 months with no resistance before he cleared me for any strength training.  Once you start strength training it will come back fast.  But if you push it too hard too fast, you will only build more scar tissue.  Your knee has been messed up for so long and with 5 surgeries it's probably not happy.   It's a long haul, but there is light at the end of the tunnel.  I fully expect to run and ski again with no pain.  Don't give up and don't get depressed.

I'm happy for you.

Laurie :)
Laurie :)

Offline snowcat

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #11 on: January 15, 2003, 06:23:34 PM »
Hey Heather--

Haven't heard from you for a while.  Hope you are still doing well!

snowcat
5/00: partial lateral menisectomy (R)
7/01: LR, partial lateral menisectomy, cyst draining (R), followed by ongoing problems with illiotibial band syndrome & adhesions
6/04: Much better!

Offline Heather M.

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1-2 WEEKS POST-OP -- Lysis of Adhesions
« Reply #12 on: January 20, 2003, 10:22:49 PM »
Hi everyone.  I just got back online yesterday after a month away from my internet connection, so it was great to see the messages of support.  I really appreciate it.

I've been in the 'why the heck did I have surgery again' phase for about the last two weeks--any multiple surgery veteran knows what I'm talking about.  So I thought I'd post about how things went at certain milestones during the critical first 4 weeks post-op.  It was an eye-opening experience for me.

At one week post-op, I was allowed to be 30% weight-bearing and go to PT once per day (plus three times at home), but pretty much did the same PT routine.  This included wall slides, patellar mobilizations, spinning with no resistance on a recumbent bike, seated quad sets and straight leg raises (lying on my back isn't allowed for SLR's until week 7-9 post-op...who knew??).  

I was able to reach 145 degrees of flexion on my own (just short of touching my heel to my rear end) and better than 0 extension by about 4 days post-op, which my doctor couldn't believe.  I think it has to do with immediate, passive motion and the variety of treatments that were done on me to prevent swelling and reduce pain (mentioned in first post above).  The ultrasound with analgesic gel was the absolute best.  The general philosophy for walking with crutches and any PT exercises was that if they caused pain or swelling, we immediately stopped them.  If I came in for PT and was swollen and hurting, the PT session would be focused on gentle ROM work and relieving pain with treatments.  For example, when we tried terminal quad stretches and forced ROM work with me lying on my stomach and the PT bending my leg, I had a very sharp flare of pain the next few days.  I haven't been allowed to do them since.

This is pretty much how things continued through the one-two week post-op period.  I was allowed to take of the anti-embolism stockings at 14 days post-op, and was allowed to get my leg wet in the shower about 18 days post-op.

Heather

« Last Edit: January 21, 2003, 10:14:43 PM by hmaxwell »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline Heather M.

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2.5 WEEKS POST-OP -- Insufflation Procedure
« Reply #13 on: January 20, 2003, 10:42:51 PM »
My PT continued and we tried to add more weight-bearing and a few new exercises, but were frustrated by pain flare ups that just wouldn't quit.  The kind of pain that two percocet tablets and four advils don't touch....after a week of this, with my knee hurting more and becoming more swollen, I was sent back to the doctor for an evaluation.   He was concerned by the swelling and said that normally he would do a cortisone shot (as Laurie had).  But due to my history of infection he would not give me any type of steroids to reduce the inflammation.  Instead, we had to try something else.

He also decided that new adhesions were already beginning to form in my knee, especially in the suprapatellar pouch (above the kneecap, base of quads).  He felt these were the cause of much of my pain; the rest of the pain was due to having my patellar and quadriceps tendons retracted and scraped with surgical instruments.  In other words, nothing to be done but wait it out.  But he recommended a procedure to help with the quad adhesions and overall inflammation, and I agreed.

The next day I went into the OR for an insufflation, which involves general anesthesia but no incisions.  Basically, they knocked me out and filled my knee up with a lot of saline solution under pressure, then left it there to stretch out the knee capsule.  Then they took a big needle and sucked out all the fluid they put in (as much as possible).  The doctor could actually see and hear the adhesions in my quad popping during the insufflation, which lasted about ten minutes.  Then I was taken to the recovery room, given a low dose of long-lasting morphine, and released downstairs straight to PT.  I don't remember too much, but I do know I was bending the knee to 145, riding the bike, and doing quad sets and mobilizations right away.  My quad felt immediately better, without the pain I experienced after my manipulation.  

This procedure is somewhat experimental and is not recognized by many insurance companies.  But my doctor felt it would be the best way to get the inflammation and early adhesions out without causing trauma that would lead to further scarring.  He said I would probably have to repeat the insufflation procedure sometime in the next 8 weeks, but this was my best chance to avoid a sixth scope in the future.  The insufflation only works when the scar tissue is very new--it won't work on fibrotic or hardened adhesions, I'm told.  When I asked, I was told that this procedure was half therapeutic, half preventive in nature.

The procedure set me back about 10 days in terms of crutch use--I had been weaning off of them.  The pain levels went up in some ways, got better in other areas (like my quad and the pain/tightness I had before on full flexion).  In all, it was fairly benign and I would sign up to do it again in a heartbeat if they thought it would help.

Heather
« Last Edit: January 21, 2003, 10:17:16 PM by hmaxwell »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline SueJ.

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Re: Lysis of Adhesions--Scar tissue surgery
« Reply #14 on: January 21, 2003, 09:15:35 PM »
Hi Heather,
Glad to hear from you,
Sounds as if you've had a busy month.
I hope your knee is doing OK, at least he seems to be very pro active in treating and preventing the return of the scar tissue. You sure have a great doctor!
Good luck and be careful on the crutches this board is full of people slipping and falling in the ice lately!
Keep us informed of your recovery,
Sue
TTT left knee May 17, 2002;  Arthroscopy with Lysis of adhesions,  revision of LR and screw removal left knee 10-10-02.