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Author Topic: problems after lateral release- HELP!!!!!  (Read 5409 times)

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Offline ls

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problems after lateral release- HELP!!!!!
« on: March 28, 2003, 04:34:26 AM »
 ??? I had a nastly dislocation (my fifth) and afterwards had to have a lateral release and shaving of tissue on underside of knee cap. Now I have an extensor lag of about 30 degrees (I can't lift my shin to the straight position but it can be staightened manually fine) and I just found out from my MRI's that the kneecap has dropped and the patellar tendon has shortened(patella baja). Can anyone explain to me what is going on and how to fix it?????
12/02 lat. release, chrondoplasty. Post-op- bleed, arthrofibrosis, patella baja, extensor lag. 5/03 debridement, chrondoplasty, closed manipulation, cpm. Post-op quad atrophy, extensor lag.

Offline Heather M.

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Re: problems after lateral release- HELP!!!!!
« Reply #1 on: March 28, 2003, 06:58:52 AM »
Talk to your doctor about arthrofibrosis, which is basically excessive amounts of scar tissue.  The extension issue is probably due to scar tissue under the kneecap.  The patellar tendon contracting and resulting in patella baja is classic scar tissue stuff.

I had the exact same thing happen after my lateral release, and there is frankly no easy way to fix it.  I've had several surgeries to correct the problem, which was actually worse than the stuff that led to my lateral release.  I'm still in the process of rehabbing from my last surgery.  The theory is that my body just produces horrendous amounts of scar tissue after the insult of surgery.  Most people have excessive scarring problems because they were immobilized or had an infection after surgery, so there is a good chance that you can recover and not necessarily be doomed to adhesions forever.  

The important question is how long has it been since your lateral release?  Arthrofibrosis and patell baja are really difficult problems to deal with--do you have a GREAT orthopedic surgeon?  Mine specializes in problems like this, and there are several others in the US who do the same (not sure where you are located).  

You should do some research.  The best place to start is in the 'Soft Tissue Healing Problems" section, because that's where people have been posting about scar tissue and adhesions problems.  There's not really an easy way to fix it--the general approach of the doctors I've met who deal with this problem is that the adhesions have to come out surgically as soon as possible.  Best results occur when the surgery to remove adhesions is done within 6 months of the procedure that caused them--this is because the longer your kneecap is in the wrong place, the greater the chance of the change being permanent or of having secondary arthritic change set in due to poor mechanics.

I've literally been posting on this problem and what we have done to address it for over a year--ad nauseum, I'm sure!  So I'd recommend looking up key words like lateral release and scar tissue; arthrofibrosis; patella baja and patella infera (proper name); adhesions; fibrosis or fibrotic adhesions and knee; 'infrapatellar contracture syndrome'.  You can do these searches both on the kneeguru page and on www.google.com

When I went in search of a fix for this problem last fall, I was offered three choices by 6 doctors:  1) leave things alone, after four surgeries I was just going to have to live with scar tissue; 2) Have a Maquet procedure or Fulkerson TTT in order to lift my kneecap into a better position; 3) Have arthroscopic lysis of adhesions and do an INTENSIVE rehab protocol for 3-6 months (that was my choice).  You can read about what I've done in my 'lysis of adhesions' thread in the soft tissue healing section.

Please feel free to contact me--you've got a lot of research to do, but don't be too discouraged.  I'm now better than I was before the last surgery, so there is hope.  I'm still working on getting back to normal and have every intention of getting there.

Heather

PS There are a lot of things to be done by a physical therapist that can make you more comfortable, be sure to check those out as well.  Patellar taping has been a lifesaver for me.
« Last Edit: March 28, 2003, 07:29:48 AM 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 ls

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Re: problems after lateral release- HELP!!!!!
« Reply #2 on: March 28, 2003, 07:15:51 AM »
 :)Heather,
Thank You so much for your reply, I'm glad to hear from someone else with the same problem. The extensor lag is causing me major stability problems, if my knee gets slightly bent when walking I just fall, I have no way of catching myself. My surgery was less that 3 months ago and I am in the Los Angeles area of the U.S.. My doctor is top notch but I am a little concerned because he's not sure what's wrong. He thought my quad tendon might be torn causing the extensor lag but MRI's show it's not and now he is sending me to another doctor to make sure I don't have Reflex Sympathetic Dystrophy (I'm sure I don't) and then nerve tests. I will look up your old discussions and I would appreciate any info you can give me. I just want to walk right, I am 31 and I feel like an old woman tottering around on a cane!
Thanks,
Laurie
12/02 lat. release, chrondoplasty. Post-op- bleed, arthrofibrosis, patella baja, extensor lag. 5/03 debridement, chrondoplasty, closed manipulation, cpm. Post-op quad atrophy, extensor lag.

Offline Heather M.

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Re: problems after lateral release- HELP!!!!!
« Reply #3 on: March 28, 2003, 07:29:23 AM »
Here are some other links to start with:

http://www.ortho-u.net/oo1/50.htm
http://www.patellapain.com/Patellar_malalignment.htm
http://www.aaos.org/wordhtml/anmt2003/sciprog/290.htm this is a summary of the results of a study where 'anterior interval release' was performed for scar tissue.  This is what I had done, and my doctor was one of the stud authors.  
http://wheeless.orthoweb.be/o12/2334.htm
http://wheeless.orthoweb.be/l9/94.htm
http://wheeless.orthoweb.be/oo1/51.htm
http://216.239.57.100/search?q=cache:CLkmOKpEBGoC:www.soy-foa.org/sot-lehti/1-2002/34.pdf+%22patella+infera%22+treatment&hl=en&ie=UTF-8&client=lgtech-kb


Here's a quote about the importance of dealing with this problem quickly.
Quote
Arthrofibrosis can be successfully treated - but only if early progressive treatment is initiated. Once a severe limitation of motion occurs, the literature appears to support that treatment must occur rapidly - after about 6 months, a severe limitation of motion appears to be permanent. That's not to say that some progress can still be made, but normal motion (or at least 0 to 135 degrees) probably won't be achieved. We have patients referred to us by other OSs who, 6-8 months postop, have a severe limitation of motion. These individuals usually are not able to regain much more motion at this point, and also commonly have additional problems such as patella infera and severe quad atrophy



*I forgot to mention that this problem is normally seen in patients who have had ligament reconstruction--principally ACL.  You'll find lots of ACL references, just keep reading, because the treatment for the scar tissue is pretty much the same, regardless of what caused it.

I have tons of other stuff...I'm a pack rat, and save all sorts of emails, web addresses, medical studies, etc.  Then I pester my doctor with questions....

Heather
« Last Edit: March 28, 2003, 07:45:32 AM 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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Re: problems after lateral release- HELP!!!!!
« Reply #4 on: March 28, 2003, 07:38:51 AM »
Laurie,

Definitely read my stuff.  You'll see that on my knee journey I discovered that this is a very rare problem...one that most doctors only see a few cases of in their entire careers.

Are you willing to travel for treatment/evaluation?  If so, I would strongly recommend my doctor in Vail, CO.  I'm in Phoenix, but traveled to have surgery with him because he had the plan I was most able to live with.  I know there's another Heather on the board with TONS of scar tissue problems, and she is in LA.  Perhaps she can recommend someone...but she traveled out of state for opinions as well.  There's also an excellent OS who specializes in this in Salt Lake City, and he does surgery once a month in Las Vegas, so that wouldn't be too far for you to travel.  Let me know if you want names and contact information.

It's frightening how similar our stories are, by the way.  I frequently dislocated and lived with it.  When I was 31, I tore the lateral meniscus and my surgeon found so much damage to the back of the kneecap that he did a lateral release.  That was over 18 months ago, I'm 33, and I feel like I'm 80!  

I was also sent for a battery of tests, including multiple MRI's and an RSD test.  Negative for all.  Scar tissue doesn't show up on MRI, the only way to verify is with a hands on exam and then arthroscopy.  I was seeing the best OS in Phoenix, and he tried FOUR times to fix my knee, but it just got worse and worse.  I strongly urge you not to mess around with anyone who doesn't know exactly what the problem is and the very best way to deal with it....just my advice.

You can send me a private message or we can keep the conversation public so that it gets archived and hopefully helps others in our position in the future.

Let me know what you need to get started with your research.

Heather

PS did I mention I was also born and raised in So. Cal.?  
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 Janet

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Re: problems after lateral release- HELP!!!!!
« Reply #5 on: March 28, 2003, 04:20:59 PM »
I am also dealing with the same problem. I originally had a torn quad tendon which was repaired with open surgery. I had scar tissue removed six months later, but didn't seem to be progressing. So I changed to a knee specialist who diagnosed the patella baja and other problems. I eventually had more surgery which did give me some relief, but now am back in the same boat.
Unfortunately this is a very difficult problem to deal with....and not many options are available.

I agree that you need to find a top-notch surgeon who specializes in these kinds of problems. I am now seeing Dr. Wojtys in Ann Arbor, MI. He has done a lot of research and spoken all over the world about arthrofibrosis and patella baja (also called patella infera). At my next appointment, we will talk about surgical options and decide on a treatment plan.

Good luck. Try to get in to see a specialist soon. Everything I have read suggests that the longer this is allowed to continue, the harder it is to treat. If your surgery was only three months ago, it may be in your favor. My patella baja wasn't discovered until I changed doctors 18 months after my surgery.

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 ls

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Re: problems after lateral release- HELP!!!!!
« Reply #6 on: March 28, 2003, 05:50:40 PM »
Janet,
It sounds like we have the same problems only my quad tendon is not torn? The doctor was sure that it was because I have major atrophy and an active extensor lag of about 30 degrees. I don't know what would cause that kind of extensor lag and the patella drop other than the torn quad tendon? The extensor lag causes major walking instability, if my leg bends a little when walking I just fall. It's like my VMO is paralyzed. When he fixed your quad tendon did the patella baja go away? Do you still have any active extensor lag?
Thank You so much for responding, I already feel like I've gotten alot more information from you and Heather.
Laurie  
12/02 lat. release, chrondoplasty. Post-op- bleed, arthrofibrosis, patella baja, extensor lag. 5/03 debridement, chrondoplasty, closed manipulation, cpm. Post-op quad atrophy, extensor lag.

Offline Janet

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Re: problems after lateral release- HELP!!!!!
« Reply #7 on: March 28, 2003, 09:15:03 PM »
Laurie:

My original injury was the torn quad tendon. The arthrofibrosis and patella baja occurred after surgery for that injury. It is my understanding that all the patella tendon became scarred down, causing it to shorten and pull the patella out of place. Even after the scar tissue was removed, the patella tendon (from the bottom of the patella to the top of the shin) was still short and the patella could not move back to its original position. I have also read that quad weakness leads to patella baja.

I no longer have an extensor lag. But I have had four years of surgeries, PT and treatments. I can straighten my leg when lying on my back. I can straighten my leg from a sitting position. However, I cannot straighten my leg from a sitting position if I have to hold it up from the hip (hard to describe, hope that makes sense). I also have a hard time getting to complete extension when standing.

When my patella baja was first diagnosed, my VMO was completely shut down and the quad wasn't firing. A MRI and ultrasound confirmed that they were intact, just not working. So I had LOTS of physical therapy (about two years' worth). While my quads were never able to strengthen back to normal, I do have about 50-60% strength in my quads now and my VMO is firing. I walk with a limp and get fatigued and sore very easily--after about 15-20 minutes.

You are only 3 months out from surgery. Are you in PT? Any quad strengthening you do is important.  How is your range of motion (ROM)? What does your doctor say about the MRI results? I really think you should see a super specialist to help minimize long term problems.

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 ls

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Re: problems after lateral release- HELP!!!!!
« Reply #8 on: March 28, 2003, 11:26:08 PM »
Janet,
I have been in PT for the last 2 1/2 months. My range of motion has improved I am at -2 degrees extension and 118 degrees bending. Not great but not terrible. My VMO is not firing. My active extensor lag is about 25 or 30 degrees, meaning when I sit with my legs at a 90 degree angle and try to straighten from the knee I can only straighten to about 30 degrees. You can pick up my foot and staightn it with your hand but if you let go it just falls to that 30 degree point where I can grab. Do you know if the Patella baja can cause the extensor lag and VMO shutdown(one pt thinks it can), or the other way around, that the weak quad(shut down VMO) after surgery caused the Patella Baja? I have also heard that if the possible scar tissue is removed quickly the Patella Baja can correct itself, do you know if that's true? I am seeing a specialist monday.
Laurie
12/02 lat. release, chrondoplasty. Post-op- bleed, arthrofibrosis, patella baja, extensor lag. 5/03 debridement, chrondoplasty, closed manipulation, cpm. Post-op quad atrophy, extensor lag.

Offline Heather M.

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Re: problems after lateral release- HELP!!!!!
« Reply #9 on: March 29, 2003, 01:13:09 AM »
Janet--

You described it perfectly--I can do all kinds of extension, and even hyperextend, but I have NO control over bending and straightening my leg if it's hanging in the air.  I find it very strange that I can do straight leg raises with weights on for 3+ minutes, but I can't lift my leg up, then bend and straighten it while it's in the air.  Not one single time.

This is due to the scar tissue, I'm told.  The space underneath my patella was filled up with scar tissue, so it pushes all the other structures out of alignment.  The patellar tendon has contracted and pulled the kneecap out of place, so when you try to bend and straighten it's not correctly located in my joint...leading to pain and eventual inhibition.  We are fighting this tooth and nail with e-stim and patellar taping.  The PT actually visibly lifts my kneecap into the correct position and holds it in place with tape.  It cuts my pain in half, especially that horrible pain at the top of the shinbone where my kneecap impacts when it's not taped.

Laurie,

As for which came first, the patella baja or the scar tissue....I believe the scar tissue.  If you read up on patella baja, you'll see that it is nearly ALWAYS the result of trauma or surgery.  It's always found with scarring around the patellar tendon and anterior interval (space under kneecap).  Because it fundamentally alters the knee mechanics, then you start getting cartilage damage, pain, physical resistance (bone on bone, in my case patella on tibia) that leads to the other problems.  Your quad has to work twice as hard and it still doesn't manage to pull the kneecap up correctly...this leads to a vicious cycle.  I actually had quad tendinitis after my LR surgery from trying so hard to keep walking and doing PT (I also had scarring at the base of the quads!).

I firmly believe that the scar tissue and patella baja are the problem, and that any quad problems, extensor lag, weakness, or inhibition come as a result of the scar tissue and baja.  I say this because right now my quad is very strong--excellent definition of the VMO, good tracking of my kneecap in the trochlear groove--and yet I still have a slight patella baja.  I also base this opinion on what my doctor has told me--that all the therapy in the world wouldn't have helped solve this mechanical problem.  I think Janet is an excellent example of this, as she's dedicated herself to PT for years and still had no resolution.  Improvement, yes.  Resolution, no.

I hope this information helps you in your appointment.  Please let us know what the new doctor has to say--we scar tissue sufferers have to stick together, because the VAST majority of surgeons simply don't know what to do with our poor knees.

In the meantime, talk to your PT about taping (I can describe more the way it's done if you want) because it really helps with the instability walking and the sharp pain.  I wasn't able to get rid of the limp and instability until I had surgery, because only then was I able to completely straighten my leg on my own.  Your scar tissue is new and pliable, maybe you'll be able to beat this thing without further intervention.

Heather
« Last Edit: March 29, 2003, 01:18:56 AM 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 ls

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Re: problems after lateral release- HELP!!!!!
« Reply #10 on: March 29, 2003, 02:12:28 AM »
Heather,
The surgery that helped, was it simply the cleaning out of the scar tissue or did they have to alter the patellar tendon the resolve the baja?
Laurie
12/02 lat. release, chrondoplasty. Post-op- bleed, arthrofibrosis, patella baja, extensor lag. 5/03 debridement, chrondoplasty, closed manipulation, cpm. Post-op quad atrophy, extensor lag.

Offline Heather M.

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Re: problems after lateral release- HELP!!!!!
« Reply #11 on: March 29, 2003, 02:52:16 AM »
I've only had the scar tissue removed, not sure what you mean by altering the tendon.  I didn't have the tenolysis (I know I spelled that wrong) that people with severe patellar tendinitis have--that's where little razor cuts are made in the tendon OWWWW.  My surgeon just performed an anterior interval release, which involves using a microscalpel and laser to remove all the scar tissue from the space under the kneecap.  He also had to debride the patellar tendon, and that was very painful for about 6 weeks--he cut away the scar tissue, then took an instrument shaped like a little rake and scoured the tendon to promote healing.  He didn't remove all of the scar tissue because it was pretty extensive, and he was afraid of causing lots of post-op irritation and swelling...which in me just leads to more scar tissue forming.

Heather
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 ls

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Re: problems after lateral release- HELP!!!!!
« Reply #12 on: March 29, 2003, 03:02:02 AM »
Heather,
I can't recall where I read it, I searched patella baja on yahoo, but there is a procedure to lengthen the patellar tendon but it sounds nasty- involves wiring to the bone(yuk!). Did your baja placement improve with debrisment, did the patella move to a more normal position? And do you know for sure if Patella Baja can cause an extensor lag, and if so can the taping you were talking about alleviate that?
Laurie
12/02 lat. release, chrondoplasty. Post-op- bleed, arthrofibrosis, patella baja, extensor lag. 5/03 debridement, chrondoplasty, closed manipulation, cpm. Post-op quad atrophy, extensor lag.

Offline Heather M.

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Re: problems after lateral release- HELP!!!!!
« Reply #13 on: March 29, 2003, 07:57:20 AM »
Laurie,

I did not have the procedure to lengthen the tendon--that sounds pretty scary.  It's never been recommended to me and I thought after seeing 6 doctors I've heard it all!

You asked if the patella baja improved with the debridement.  Each time I had surgery, my kneecap did return to it's original position immediately.  But I got post-op infections twice, which led to lots of swelling and the formation of more adhesions.  When the scar tissue beneath the kneecap and around the patellar tendon became more fibrotic as it 'matured,' the kneecap was pulled right back down again (usually within 3 months).  This last surgery, I managed to avoid infection and the kneecap is only slightly lower than the other.  I see my surgeon next week and we'll chat about what that means.

As for baja causing the extensor lag, I'm not sure.  It's something I've had, and my doctors have all attributed it to the scar tissue itself, not the position of the kneecap.  It's important not to confuse the symptom (patella baja) with the root cause (scar tissue or fibrotic adhesions).  Every doctor I met had a plan to tackle the scar tissue, and I was told that the patella baja would probably be corrected immediately with the release of the adhesions, and maintained in its new position through strong quads and PT.

You should really ask your new doctor what could be causing the extensor lag in your case--I just know that this was the first thing my new doctor looked for to confirm that I had more scar tissue.  In my case it was scar tissue underneath the kneecap that interfered with extension.  

The patellar taping helped with the pain that was caused by my kneecap being out of place.  I still limped with the tape on, though, because I lacked full extension due to scar tissue under the kneecap.  I'm not a doctor, but it would be my guess that you have scar tissue throughout your knee, and the patella baja is just the immediately visible physical manifestation of this scar tissue having affected your patellar tendon--but that doesn't mean it's not in other areas, too.  

Next time you have PT, ask the therapist to get the knee model out and look at the kneecap.  The space underneath is meant to be empty of all but fluid.  When scar tissue fills it in, you will see that it can impact full extension.  The law of physics says that matter cannot occupy the same space at the same time as other matter--if you have scar tissue in this anterior interval, your kneecap has no place to go when you straighten.  This causes pain and extreme instability.  

Heather
« Last Edit: March 29, 2003, 07:58:19 AM 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















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