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Offline Ianh

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Newbe question
« on: May 29, 2006, 10:50:05 PM »
Hello all
I have visited this site a few times but never posted before. After my slow recovery I thought I would ask for some help and assistance from those who know best.

I had a serious motorcycle accident last July in London. The result was a totally smashed tibia plateau and multiple fractures to my right radius and Ulna (bones came though my arm at accident)

I spent nearly seven weeks in Charing Cross hospital after my smash and it took around ten days before the surgeons decided what to do with my leg. Firstly I had a ‘Hoffman’ frame put on then about a week or so after I had the Ilizarov frame put on. The frame was bolted to my thigh and my knee was set in a sort-of off-from straight position and it was kept like this from July to November. This seems to be a short period of time to some other wearers.

The thing is this, I have a 70º bend now but it seems to be VERY reluctant to go any further. I did go in for manipulation three weeks ago but it didn’t seem to go too well. My surgeon said that he did get it to go to 90º but then there was a block (not sure if it was bone) I attend occupational therapy three times a week using a quad switch to get my leg straight, but my problem is the bend, so far its taken from November to now to increase my range by 15/20º

My knee aches like hell! And before you ask I stopped pain-killers just after the frame was removed as they were doing me in!

What tips/help can you offer me? I am considering acupuncture anyone tried that?

Sorry for this being so random. :P

Offline lesleyjh

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Re: Newbe question
« Reply #1 on: May 29, 2006, 11:11:58 PM »
Hi Ian , I havnt tried acupuncture myself, but a friend of mine is having it at the moment for siatica (not sure if thats spelt right!). She is very impressed and it is helping her. She had tried everything and nothing helped, but she says the acupuncture is. Might be worth a try.Good luck.Lesley.
Arthroscopy-excision of synovial plica  24th April 06 (left knee)

Offline Heather M.

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Re: Newbe question
« Reply #2 on: May 30, 2006, 06:48:35 AM »
Acupuncture is great, but it won't break up adhesions or physical blockages that prevent you from bending your leg.  Likely, you've formed excessive amounts of scar tissue.  Check out the "soft tissue healing problems = arthrofibrosis" section and read all about it.  Often, until the scar tissue is removed, you won't get full flexion back.  But your situation is pretty unique in that you've had a devastating injury.  I have tons of experience of having a leg frozen by scar tissue, but mine was due to my body's overreaction to trauma...yours seemingly is due to trauma that it seems may even have been limb-threatening....

Anyway, manipulation is something I'm pretty negative about.  You can read my posts to see why, but basically it's the philosophy behind it that bugs me...the leg freezes and forms tons of scar tissue due to extreme the doctor's BEST plan to address this is to knock the patient out and bend the ever-loving s**t out of the poor leg?  Seems completely bass-ackwards to doctor is a specialist in dealing with scar tissue in the knee and he does NOT do these so-called 'closed manipulations.'  He always removes the scar tissue with a scope and then verifies that the leg has full range of motion by GENTLY bending it.  If the patient's leg does not bend fully and easily, he goes in and removes more adhesions or does a posterior capsule release.  He does not knock the patient out and bend the snot out of the limb, indiscriminately tearing adhesions and potentially muscle and soft tissue/ligaments as well!!!  That is just crazy, IMHO.  Or not so humble, as the case may be  ;D  I feel perfectly comfortable in saying that, though, because I had a manipulation and it did NOTHING for me in the long run.  At first I thought it was going okay, and I was working my behind off to keep up with the motion...but it slowly started getting tighter and more painful, and within six weeks I had ANOTHER surgery to remove another boatload of scar tissue.  That was all caused by the manipulation---I had the manipulation done on a 'clean' leg which had had scar tissue removed four weeks prior.  So I had a surgery on Feb. 23 and then a manipulation on April 1 or so.  At that point, presumably, the knee was 'free' of scar tissue because it had been physically removed by the surgeon--I saw pictures, and there was nothing in the joint.  But in the end of May I had another surgery because the manipulation didn't work and the doctor photographed and then removed actual BANDS of scar tissue.  These were caused, I am sure, by the manipulation--it is a very traumatic procedure, one that left me bruised and swollen and with terrible muscle spasms.

So my point is that a lot of doctors look on the MUA has having potential to 'cure.'  But a lot of us folks with scar tissue have found quite the opposite--not only did it not resolve anything, in most cases it made things worse.  And I truly can't comprehend doing a manipulation on a leg with recent severe fractures, since the number one complication of an overly vigorous manipulation is BROKEN BONES.  If your poor bones were barely knitted together, well....jeez, I wonder what the manipulation did to those areas?  OUCH.  I can't even think about it.  And to do this ten MONTHS after the original injury, when no doubt your adhesions were like iron ropes...?  I would personally take your surgeon out behind the barn and shoot him or her.  But unfortunately this is the method that most OS's are taught.  I personally have strong philosophical problems with that, but it's neither here nor there.  The fact is, manipulation hasn't worked for you...and even then, it only got your leg to 90 degrees.  That's not functional, unfortunately, and so you obviously need more dynamic intervention.

There is a protocol, both surgical and rehab, that deals with people who form excess amounts of scar tissue.  It is described extensively in the section I referred you to.  Here is a good article on arthrofibrosis, the condition where too much scar tissue forms in the joint.

Keep in mind that your particular injury makes your situation very unique.  So I'm sure there are implications of arthrofibrosis in severe traumatic fractures--especially when an internal fixator and muliple surgeries are involved.  But the laws of physics still apply--matter cannot occupy the same space at the same time as other matter.  Meaning that until the scar tissue is removed from your knee, chances are bending will be very tough.  If not impossible. 

Another thing you said concerns me--the painkiller issue.  Proper pain management is critical when dealing with a knee with arthrofibrosis.  If not, the muscles can actually close down and the brain will engage in guarding behavior--not letting the knee move in a range of motion that is painful.  Then, as time goes by and the knee doesn't move much, it starts to develop more adhesions and contracted soft tissue...pretty soon, that leg doesn't bend at all.  So in some cases it's better to deal with the inevitable pain of moving a recently operated limb rather than white-knuckle it with no painkillers and have the body do some of its unhelpful compensating freezing the leg in a semi-neutral position (neither fully bent nor fully straight).  Not good--not good at all.  So I know lots of people don't like painkillers, but they are a useful tool when the leg MUST be moved in spite of post-op pain.  Try different prescriptions, try taking half as much (dosage) twice as often (say 5 mg of hydrocodone every 2-3 hours as opposed to 10mg of hydrocodone every 4-6 hours), try piggy-backing other meds like Toradol or Voltaren or anything in the heavy-duty anti-inflammatory category on top of analgesic stuff, or adding in muscle relaxants during the day and sleep medicines at night to provide a boost to the analgesic properties of your primary painkillers...there are lots of ways to attack the problem of pain.  OS's are notoriously bad at managing pain--I've found it easiest to have my trained pain management physician take care of my post-op issues rather than throw myself on the mercy of my wonderful but painkiller-shy OS.

Anyway, check around and keep pushing it in PT.  Read about some techniques to sneak up on the knee and coax it to bend rather than force it to do so.  Rocking back and forth on a bike and holding it at the point of an intense stretch can be very helpful, as can wall slides and patellar mobilizations.  Myo-fascial release can do great things, too.  Acupuncture can be a huge part of the equation, but as a stand-alone treatment I haven't found it helpful....thought I do it at least once a month for swelling, it does not dissolve scar tissue, and that's what it would take to get your leg to bend!

One last thing, here is a web page others in your position have found helpful:

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

Offline Ianh

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Re: Newbe question
« Reply #3 on: May 31, 2006, 11:16:44 PM »
Heather -
Thank-you very much for your response,it was all very helpfull and I will look at the sites you mentioned. I will post again as soon as I get some kind'a update from my surgeon.

Thanks again