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Author Topic: MUA....Yes/No/NEVER?  (Read 10192 times)

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Offline Megwi

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MUA....Yes/No/NEVER?
« on: July 18, 2006, 09:17:46 PM »
Guys,

Help, I'd really value your input to my predicament.

I am struggling with ROM. Have -5 to 120. Still having heavy duty PT, still in pain.

When I last saw OS in May he said if I didn;t have good ROM by next week he wants to do an MUA on Friday.

However, my questions are thus:-

1) Should MUA be first option? I have had no xrays/scans since surgery. Should he not scan it first to eliminate possibility that hardware is working out and preventing ROM?
2) Is there a time limit for getting back ROM? If its coming back do I need to rush into MUA before anything else, cortisone injections etc.
3) Can I do anything to help myself
4) I have heard nothing good about MUA. Is this right?

HELP!! I want to tell him to %$^& off and I don't want any more surgery, but I just don'y know what to do for the best.

Meg
Ski fall Dec '05
MRI scan Jan 06
Surgery Feb 06 (TPF with ACL 1 screw, arthro meniscus removal)
Out of immobiliser May 06 and into PT
Scar tissue/ROM issues.
57 PT sessions.
Finished PT Jan 07 with nearly full ROM PT said "youve got more than I ever thought you'd get."

Offline Texicansoccer88

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Re: MUA....Yes/No/NEVER?
« Reply #1 on: July 18, 2006, 10:57:59 PM »
An MUA in combination with debridement seems to be the most effective method in treating arthrofibrosis, followed by agressive therapy to regain motion. 

Offline hottubpam

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Re: MUA....Yes/No/NEVER?
« Reply #2 on: July 18, 2006, 11:51:13 PM »
I think MUA is rarely the appropriate treatment for arthrofibrosis.  It may be appropriate in response to scar tissue related to TKR.

Most of the "arthrofibrosis specialists" do NOT perform MUA for scar tissue, especially if you are more then a few WEEKS post op.  MUA's are dangerous and traumatic procedures.  The trauma of an MUA often (usually) results in re-growth of scar tissue.

Please read the articles on arthrofibrosis by Dr. Noyes on this web site. 

I had an MUA (not by my current OS), I consider it a barbaric procedure and believe it is at least partly responsible for my continuing knee problems!!!!!!

Pam
ACLR, Menisectomy 3/04; ACL resection, Cyclops lesion removal, LOA & MUA 10/04; LOA, LR & AIR 12/29/04;#4&5 surgery on 2/9/05 & 3/2/05 debridement, irrigation & lavage, portal closure; #6  LOA, AIR, LR & other releases 12/9/05; #7 surgery 1/18/06 portal closure, lavage, debrid etc #8 skin graft 3/06

Offline pgmigg

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Re: MUA....Yes/No/NEVER?
« Reply #3 on: July 21, 2006, 04:49:00 PM »
Meg,

I guess that every patient case is unique! And there cannot be common words that MUA is good or bad. I red a lot of posts about MUA and why it does not work. I was afraid a lot this procedure. But now I see that it works, at least for me…

In the my particular case with very aggressive arthrofibrosis diagnosed in four months after TKR (October 2005) I had second TKR (revision) at the end of April 2006 because scar tissue was found outside, inside, and around the joint. During two months between replacement surgeries I loose my ROM from 7 – 93 to 25 – 65.

After second TKR I loose my ROM again from 3 – 90 to 10 – 72 during first 8 weeks.

My OS decided to make MUA but not a one – a few small MUAs. He could bend my knee up to 140 degrees in a one MUA but he did it in the end of June up to 105. Probably my OS will repeat MUA up to 125 in a month. I was discharged from a hospital with CPM and during last four weeks I have been spending 4 hours per day in an average on this machine. The procedure was done under epidural anesthesia and then I took pain medications as needed during a one week. The pain has not been bothering me too much.

My current MUA experience was successful – I have now an active ROM 3 – 98 and passive 10 – 92. And I continue my very hard full time job over the knee - regular physical exercises, bicycle, swimming with fins, walking for one mile per day, DynaSplint, sleeping with braces, etc.


Sincerely,
Ilya
Right Knee:
1/90 - Complete meniscectomy
9/90 - Cleanup - open surgery
9/94 - Arthroscopy cleanup
10/05 - TKR
2/06 - Diagnosed with arthrofibrosis
4/06 - TKR (revision)
6/06 - MUA (ROM was 20 - 65, in 2 month 17 - 95)
8/06 - MUA (act. ROM 10/10/6 is 6 - 107)

Offline Jaci

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Re: MUA....Yes/No/NEVER?
« Reply #4 on: July 21, 2006, 07:48:46 PM »
Hello,

Yes, every case is unique and timing is critical. In Ilya's case the OS intervened at about 8 weeks following the initiating procedure (TKR) and (planned to)performed a series of very gentle MUA. But Meg's surgery was 5 months ago (if I'm reading your signature correctly), that's a huge difference!!!! According to the literature, scar tissue begins maturing around 12 weeks post-op, which means that the tissues become stronger and more fibrotic. That's why most of the known experts on arthrofibrosis do not recommend MUA at such a late date, they generally prescribe a scope to remove the offending scar tissue. There are some well-known published OS who do not do MUA at all because it can cause damage to knee structures including cartilage. And, the well-known highly regarded OS who uses MUA only does so within in weeks not months following the initiating procedure, and then only very minimal pressure is applied.

Also, TKR is very different from other surgeries or injuries. There are increased concerns for infection because of the prosthesis so OS are less inclined to do a scope to clear out scar tissue. From what I read elsewhere on the board it sounds like Ilya went to an OS who specializes in tough TKR cases. That OS has unique knowledge and experience in dealing with post-op arthrofibrosis as evidenced by the planned approach for handling Ilya's case. That's very different from waiting months to intervene. (Sorry, I don't mean to disparage Meg's OS.)

I know this arthrofibrosis stuff is very confusing and there is a lot of conflicting info out there. My recommendation is always the same: do lots of research especially using medical journal articles (use Google or one of the medical journal sources like PubMed) and go to the most qualified OS for dealing with YOUR particular problem.

Best wishes,

Jaci

PS—  A few links to help you with your research:

Dr. Noyes arthrofibrosis course

http://www.kneeguru.co.uk/KNEEtutor/doku.php

Dr. Millett article

http://www.casebook.kneeguru.co.uk/index.php/knee/issues/arthrofibrosis_of_the_knee/

KneeGuru literature review (look under problems with healing)

http://www.kneeguru.co.uk/insights/doku.php

 

« Last Edit: July 28, 2006, 07:42:43 PM by Jaci »
10/03 Twist injury
12/03 Menisectomy- tears ACL, MCL, & LCL missed by OS
Arthrofibrosis ROM 38-68
3/04- 4/08 Multiple scar tissue procedures:
6 scopes w/LOA, AIR, LR, chondroplasty, synovectomy, bone spur & plica removal
3 insufflations, many injections
Chronic AF, patella infera, IPCS

Offline Megwi

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Re: MUA....Yes/No/NEVER?
« Reply #5 on: July 21, 2006, 08:06:15 PM »
Jaci,

Thanks for your post I appreciate all your comments. You are right, my surgery was 5 months ago. In that time I have seen my OS twice, once at 6 weeks post op and then again about 2 months ago. At no point since surgery have I had any scans/x-rays to check my surgery was succesful, (chunk of bone with ACL attached fixed back to the tibia with a screw), he also removed some damaged medial meniscus.

I may be cynical but I don't believe the first move is to have another surgery. He is a Private OS so more or less has a blank cheque as long my insurance agree to cover it.

My PT says I am making progress but he wants me to have a scan just to check that scar tissue is what is preventing my ROM coming back.

I guess I'll see what he says on Thursday, but I will go in armed with all the literature I have printed off from knee guru to show him before I agree to anything!

Thanks again

Meg
Ski fall Dec '05
MRI scan Jan 06
Surgery Feb 06 (TPF with ACL 1 screw, arthro meniscus removal)
Out of immobiliser May 06 and into PT
Scar tissue/ROM issues.
57 PT sessions.
Finished PT Jan 07 with nearly full ROM PT said "youve got more than I ever thought you'd get."

Offline Jaci

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Re: MUA....Yes/No/NEVER?
« Reply #6 on: July 21, 2006, 08:38:15 PM »
Meg,

Please take a look at Dr. Noyes' course. The problem is that the first move should have been made a long time ago! I don't mean to be negative or pessimistic. Your case may be different. But, early detection and intervention is generally the key to successful resolution of arthrofibrosis. In many cases surgery can be avoided if appropriate treatment is begun very early on. Dr. Noyes talks about the rehab goals that he and the PT he works with use to monitor a patients progress; if the goals aren't met they begin immediate measures in an attempt to remedy any motion loss. He hasn't gotten into the techniques he uses (I hope he will), but there are some good articles in medical journals. One has a title like "Prevention of permanent motion loss after ACL reconstruction: a study of 443 patients..." by Noyes et al. I realize your surgery doesn't fit in the strict defintion of acl recon, but at least the article will give you an idea what appropriate treatment looks like. Sorry, I don't have the article in electronic form, so I cannot email it too you.

Also, a scan (MRI?) may or may not show scar tissue that is present and many OS and radiologists do not recognize it when it does show. A knowledgeable OS can usually diagnosis arthrofibrosis on the basis of a physical examine and patient history. An MRI may be done to confirm the diagnosis and check for other issues.

Jaci
« Last Edit: July 21, 2006, 08:43:41 PM by Jaci »
10/03 Twist injury
12/03 Menisectomy- tears ACL, MCL, & LCL missed by OS
Arthrofibrosis ROM 38-68
3/04- 4/08 Multiple scar tissue procedures:
6 scopes w/LOA, AIR, LR, chondroplasty, synovectomy, bone spur & plica removal
3 insufflations, many injections
Chronic AF, patella infera, IPCS

Offline Lissa

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Re: MUA....Yes/No/NEVER?
« Reply #7 on: July 22, 2006, 12:14:11 AM »
The choice is obviously up to you whether or not to get an MUA.   I too had one and it did not work.   Actually, I think it made it worse.  There is a risk of further damage with an MUA and I wish I took the advice of Hottubpam.   It is painful (at least for me it was) and recovery sucked!    It also gave me a false hope of recovery.   Long story short, after surgery to repair my meniscus, then an MUA  am still at 15 degrees extension and 110 flex.   Good luck with your decision and just do some research before making your choice.     

Melissa

Offline ArthroConquerer

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Re: MUA....Yes/No/NEVER?
« Reply #8 on: July 28, 2006, 01:52:27 AM »
MUAs can help you.   I had 5 and finally got my range from the muas and not knee surgery.   Be careful they can also cause more scar tissue.  I got from 15 degrees and a year and half of immobilization to 140 degrees through a variaty of methods.  I will put them up soon at a separate web site to help people.  THE DOCTOR who does it is EXTREMELY IMPORTANT, ask them about their success rates, get one who is known for his success with MUAS. I am still heavilly involved in therapy everyday so I cannot spend the time yet but I will when my knee is back.  For all of you dealing with arthrofibrosis, at times you will have slow progress or stagnation, keep innovating ways to work on your knee, you have to be your own advocate, doctor and therapist.   Know that it will get better through extremely hard and painful work but you will get better so don't get depressed.  I know it is frustating but you have more fortitude of character than many people for your fight on this problem.  What got you to where you are in your progress, if you experience stagnation, is not going to be what gets you to the next stage, creativity, knowledge, discipline and relentless determination will get your mobility back.  I was in bed for a year, immobilized on my right leg for 8 months and a year and a half on my left.  I am know snow skiing, wake boarding, mountain biking and salsa dancing.  You to can get from an extremely severe problem to having fun again.  Every doctor I meet said I was the worst case they EVER had and because of my perserverance I am back.  I has taken 2 years but I far surpassed my doctor's expectations, they said at the most I would get it 90, now they say I practically did the impossible.  You can do it TOO!!!
« Last Edit: July 28, 2006, 01:55:35 AM by ArthroConquerer »

Offline Megwi

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Re: MUA....Yes/No/NEVER?
« Reply #9 on: July 28, 2006, 06:46:01 PM »
Guys,

What a turn around, I am still in shock!

Saw OS yesterday and he has discharged me! I have -5 to 120 and a "very loose" knee, but am on my own with the PT now!?! Doesn't think MUA required as my motion is returning slowly.......

God knows! I know my injury is a bit of a rarity and research I've done seems to indicate recovery is very slow compared with a straight forward ACLR but I'm at a bit of a loss now....

Meg
Ski fall Dec '05
MRI scan Jan 06
Surgery Feb 06 (TPF with ACL 1 screw, arthro meniscus removal)
Out of immobiliser May 06 and into PT
Scar tissue/ROM issues.
57 PT sessions.
Finished PT Jan 07 with nearly full ROM PT said "youve got more than I ever thought you'd get."

Offline celinenj03

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Re: MUA....Yes/No/NEVER?
« Reply #10 on: July 28, 2006, 07:36:22 PM »
You say you have pain still, is it a "pressure" kind of pain, like the kneecap is going to pop off when you bend it? That could indicate something stuck in the joint.

Otherwise, I would go with the "wait and see" approach. Dare I say, too many people jump into MUA's and even scopes before they give themselves enough time to gain the ROM on their own. If you are still making progress and not STUCK, why not just keep trying to gain it? Your ROM isn't awful, it shows promise that you might be able to get it on your own. I know it is hard work and very painful. I'm still trying to gain my hyperextension back (2 degrees) and sometimes I feel like I never will. I'm not saying NOT to push for aggressive treatment, but perhaps to give yourself a little more time to work it yourself.

Do you still have any swelling?
Terrible Triad - 1/16/06 - Basketball
3/15/06 - Scope/Cleanout of to achieve full ROM
5/3/06 - Surgery-ACL Reconstruction-Allograft
9/12/07 - Large Loose body removed;Grade 4 Lesion on LFC
9/17/08-Microfracture, Lateral Release (all right knee)

Offline Megwi

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Re: MUA....Yes/No/NEVER?
« Reply #11 on: July 29, 2006, 04:05:27 PM »
Hi,

Yes I do still have swelling. I ice for several hours a day and it is going down. OS said he thinks it may take up to a year to disappear completely if it ever does.

My whole knee feels very tight, a lot of the pain is muscle I think, but it just feels like my knee is packed full of concrete. I don't feel like my knee cap is going to pop.

I suppose I was shocked because I had convinced myself I was going to need further surgery. OS said he was pleased with my progress although he understood that from my perspective it would seem like it was going very slowly.

I have to wait for my insurance to agree to pay for more physio or face the fact that I may have to pay for it myself....yikes!

Thanks for all the input though guys, it is most appreciated.

Meg
Ski fall Dec '05
MRI scan Jan 06
Surgery Feb 06 (TPF with ACL 1 screw, arthro meniscus removal)
Out of immobiliser May 06 and into PT
Scar tissue/ROM issues.
57 PT sessions.
Finished PT Jan 07 with nearly full ROM PT said "youve got more than I ever thought you'd get."

Offline favouritesearcher

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Re: MUA....Yes/No/NEVER?
« Reply #12 on: July 30, 2006, 10:31:04 AM »
Hi Meg,

Things start to get difficult when you go to different doctors and they all give you a different opinion about what to do and what is a good outcome and what isn't; 20 years ago, what you have would have been considered an adequate result.  From memory you've been stuck at 120 for a few weeks now.

When I was 5 months post-op with a rom of 20-70, the three doctors I spoke to had quite different opinions.  One said that there was nothing anyone could do and I would have a permanent disability; another suggested an MUA, and the third said that an LOA was the best option because at 5 months, I was unlikely to improve any further with just physio.  I was also told by one of them that recovery was "slow" but I'm still 100% satisfied that the decision to have an LOA was the right thing to do.  I remember that when the third surgeon discharged me at 125 degrees, I didn't know whether to be happy at avoiding surgery, or to feel down because 125 was all I was ever going to get.

Dr Shellbourne is an arthrofibrosis expert and in his 1994 article (a bit old, later ones have better results) his patients had an average flexion of 130 degrees after an LOA, ranging from 120 degrees to 150 degrees.
http://www.udel.edu/PT/clinic/journalclub/old/caserounds/01_02/sep01/shelbourne94.pdf

I think that when the surgeon says that your knee is "loose" that might mean that the muscles are weak and he can easily move the joint; but the tightness that you feel might come from the kneecap being difficult to move because of the adhesions.  Personally I have doubts that the swelling will go away, and it is the swelling that is probably making your knee look worse that you would like, and I also have doubts that your rom will get significantly better because as it gets to the 5 month mark the adhesions can be quite rigid and difficult to break.

My knee is still tight when it bends past 90 degrees and there is some pain when it is moved from flexed to extended because the tightness has caused the cartilage to be lost on the anterior medial tibial plateau and femur, and the back of the kneecap.

Early treatment usually works better, but that is not to say that it is impossible later on (eg JakeM).

For example, in this study on MUAs vs LOAs for TKRs, they suggested that MUAs be done within 8 weeks and LOAs within 6 months.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12610433&query_hl=7&itool=pubmed_docsum

This one compared MUAs to LOAs and also said that they were best done within 3 months.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3238083&query_hl=11&itool=pubmed_DocSum

Considering that having only 120 degrees is still very limiting, maybe you should think about getting another opinion or two so that you're satisfied that you're doing everything you can to get your knee back to normal?  And whilst you're waiting for that you can see if your rom can be improved.

One thing I found helpful with the limp was laying on my good side with the knees slightly bent, and lifting the bad leg up at an angle so that the long muscle going down the outside of the leg would strengthen.

John
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline Megwi

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Re: MUA....Yes/No/NEVER?
« Reply #13 on: July 30, 2006, 01:54:38 PM »
Hi John,

Whats an LOA? My OS hasn't mentioned that to me.

I think the OS meant loose as in my ACL was very damaged but didn't rupture. He did say that if I wanted to get back to previous levels of sport I may have to consider an ACLR in the future, but I have to say thats the last thing I want to think about at the moment.

I am a bit worried as all the course notes from Dr Noyes seems to suggest that aggressive physio could actually cause more damage so I don't really know what to do next. When I told my OS what my PT was doing he looked horrified but didn't actually say anything...PT sits me on the bed with my knee bent as far as it will go then sits on my foot and tries to seperate the joint by jerking it backwards and forwards for about 10 mins. Does this sound ok to you? I'm worried that if scar tissue is preventing my patella from moving properly it could cause more damage? How would a scar tissue diagnosis be made? Would they have to do another arthroscopy?

I have to wait now for a letter from consultant to my insurance so it may mean I won't have PT for a few weeks unless I pay myself...

I'm fed up with this now..I think I may just take my 2 weeks holiday coming up tomorrow to try and forget about it and then come back rested and refreshed and decide what to do! Isn't boring when all you can think about is knees!!

Thanks for all your help John, I will read all the links with interest and let you know how I get on. You seem to have had a similar injury to mine so your experiences are helpful for me....I think thats also part of my problem as my injury is so rare they try to go on ACLR protocals for rehab and that isn't necessarily correct!

Take care

Meg
Ski fall Dec '05
MRI scan Jan 06
Surgery Feb 06 (TPF with ACL 1 screw, arthro meniscus removal)
Out of immobiliser May 06 and into PT
Scar tissue/ROM issues.
57 PT sessions.
Finished PT Jan 07 with nearly full ROM PT said "youve got more than I ever thought you'd get."

Offline Janet

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Re: MUA....Yes/No/NEVER?
« Reply #14 on: July 30, 2006, 04:29:33 PM »
I, too, had an OS (my original OS) who thought I was progressing, very slowly but surely. But I could tell something just wasn't right in my knee. He listened, but just kept saying I needed to be patient and give it time. I eventually ran out of patience and sought a second opinion from a knee specialist (unfortunately, I hadn't found this forum yet....and even when I did about nine months later, nobody was talking about arthrofibrosis then). When I got the second opinion, that OS told me I had developed patella baja, my quads were extremely weak, my VMO wasn't firing at all, etc. I eventually had more surgery and my knee was full of scar tissue (even though I had about 110 flexion, but I did have an extension deficit).

I guess I am saying that even though my OS thought I was doing okay, I knew something wasn't right. If only I had gotten the other opinion earlier, my knee might be in better shape now. I know it's hard to decide what to do, but I think you should go with your gut as to whether to trust your OS and give it more time. And no, I don't think your PT should be pushing you that aggressively!

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.















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