Serial casting or MUA or Something more needed ??

[catwoman88]

Hello,

I thought I should start a new post on this for my on-going saga....

I saw the OS yesterday and I almost got my leg cast (luckily I drove, so I got out of it) as the OS is so worried about my extension (he does not mind about the 115 flex). He is now talking about serial casting my leg each week for I don't know how long - each week they extend it a bit more and cast again - yikes (I did read another post on this). I asked what my other options were and he said a MUA and then he'd cast me. I forgot to ask if he would only do a MUA, or a scope and MUA as I've read people's experiences with MUA and I’d rather have a scope and MUA - I'd rather he look in my knee to see if there's any issue going on with it. I see another PT today and then I go back to see the OS in 2 weeks and we'll revisit this. I really would rather have a scope with MUA compared to the serial casting. BUT silly me I now realise that if it’s an AF problem wouldn't casting the knee be the opposite thing to what is meant to happen - to get mobility right away!?. I also wondered if I should be asking him about a Posterior Capsule release as the pain behind my knee is getting worse even when I am not trying to extend the knee and my extension has not changed for 3 weeks, its stuck solid. I know I keep posting on this site but obviously as I now know more about this problem I realise that maybe the options he gave me may not be enough to fix this issue?.

We'll see what the PT can do though for the next 2 weeks - I will explain to her the over zealous methods used by my previous PT and hope she can get results. If not I’d like to know my options when I see him and if a Posterior Capsule release would be a better option? (it's been 5 weeks since my surgery) or scope with MUA, I don’t really like the sound of just a serial casting or just MUA and cast?.

Thanks as usual to everyone for their adivce and taking the time to share their thoughts and experiences with me.

Lianne

[Jaci]

Hi Lianne,

To get started, look in the In-depth insights section for an article in 2000 by Dr. Noyes. He discusses the protocol used at his clinic for rehabbing post-ACL surgery. I know you didn't have ACL recon, but the ROM goals and early intervention recommendations would also fit for someone who had a basic scope. It gives some good info on when and how serial extension casts are used. Here's a link:

http://www.kneeguru.co.uk/KNEEnotes/guest-contributors/dr-frank-noyes/2000-prevention-permanent-arthrofibrosis-after-anterior-cruciate

I have the full article and another one by Dr. Noyes that I think gives some additional info. I can email them to you if you're interested.

There have been few, if any, people who post here who had serial casts done in the manner recommended by the true experts on the subject. Dr. Noyes' general recommendation is that it is used very early post-op and for relatively small loss of extension-- 10 degrees or less I think. Also, it's not simply a matter of forcing the knee straight and slapping a cast on it. The literature describes using highly padded casts to prevent injury and they increase the straightening slowly by using wedges. The cast is left on for a short time, only 36-48 hours-- not days or weeks at a time. If done incorrectly (too late, too large of extension deficit, cast applied too long) it can cause damage to soft tissues and articular cartilage. The articles will give you a good explanation of what proper use of casting should entail.

There are many discussions of MUA on the bulletin boards and they include varying experiences and opinions on the subject. Personally, I don't think that MUA is an inherently bad procedure. In the hands of an OS who has considerable experience treating AF it can be effective. Unfortunately, it seems that most OS have little, if any experience, with arthrofibrosis so they make mistakes. One of the main problems with MUA is that OS wait too long to intervene, thus they end up using too much force to bend the knee. Remember from the tutorial that adhesions start out sort of wispy and the further you are post-op the more fibrous the scar tissue becomes, making it difficult to break. Plus, if there is a large amount of adhesions they tend to glom back together and continue to inhibit motion. Dr. Noyes talks about how adhesions form and mature and the implications in parts 5 and 6 of the tutorial. Also, keep in mind that MUA is generally not effective for extension loss.

There are also varying opinions on posterior capsular release. I believe Dr. Noyes and Dr. Steadman both do posterior capsular releases, however I think it is one of the last stages of the procedure they do. They try to resolve the motion limitations by removing adhesions from other areas of the knee, then check the motion, and only do the posterior capsule release if needed. The article on rehab of the arthrofibrotic knee give has a short explanation of the nine-step arthroscopic surgery process that Dr. Steadman uses. I recall from another poster (Nick_Knack I think) that Dr. Shelbourne (one of the other well-known AF guys) feels posterior capsule release is dangerous and unnecessary. That area of the knee has lots of nerves going through it, so it's probably not something that you'd want an OS who hasn't done a quite a few to do. (missmyknee recently posted a link to a book with some good nerve diagrams.) I have a journal article on the arthroscopic surgical approach used by Dr. Steadman and some of the other AF specialists. Last thing, having a lot of pain behind the knee doesn't necessarily mean that's where the scar tissue that's blocking your motion is.

At 5 weeks post-op you're still pretty early post-op which is a good thing. Unfortunately none of us can tell you whether you are still in the 'safe zone' for getting results with serial casting or MUA. There's no way for any of us to know if you have new scar tissue or if your OS didn't remove it during your surgery. I know I mentioned this before, but it is not unheard of for a less than knowledgeable OS to completely miss obvious scar tissue or to see it and not know what it is or do anything about it. I've been through that myself and know of many KNEEgeeks who have as well.

I think you're wise to do your homework and learn as much as you can. Then you'll have to check your comfort level with your current OS's knowledge and experience and decide what to do.


Best wishes,

Jaci

[catwoman88]

Hi Jaci,

Thanks as always for coming through for me with great information, you must think I’m a complete disaster with all these questions. I have to admit after seeing the OS on Thursday I came home and disintegrated into an emotional mess not knowing if these were the best options and even consoled myself with a glass of wine - I hardly ever drink

That article was a great read and yes anything else you have on this would be great if you could please email them to me?. The way my OS told me the serial casting would be done once a week for X amount of weeks - not much pressure would be applied each time - so a pretty long process then. The MUA he said would be done to get the leg straight and then cast it - this sounds like it could be soooo painful as like I said the posterior knee pain with knee even bent is painful and to go to straight (if it will anymore - as its now about 16cm off and rising) and then be cast could be totally unbearable? - he also did not say how long the leg would be in a cast for going down this route?.

Like I said I’d rather (like the choices are great!) go down the MUA route as his serial casting method sounds like it will take many weeks - probably many months - my good knee is getting sorer by the day due to my gait and I really cannot see me lasting this way. But I will discuss the possibility (by then I'll be 7 weeks post scope) of an open MUA with him and not closed - as I would hate for an MUA to be done and then the leg cast and AF to be present and causing problems and be back to square one once the cast is off, also the knee is still swollen and I don't know if it should be cleaned anyway?. Reading the articles I cannot see anywhere if it's an option to have an open MUA and then be cast - do you know if this is an option?. Also do you think it unreasonable if I do ask if he can do an open MUA on my knee?.

Thanks again

Lianne

[Jaci]

Lianne,

I'll go ahead and email the articles. I'll have to come back later to answer some of your questions.


Jaci

[Jaci]

Lianne,

Thanks as always for coming through for me with great information, you must think I’m a complete disaster with all these questions.

Well, yes, I've been meaning to tell you....    Just kidding, of course, that thought has never even entered my mind. I remember back when I was first trying to find info on the monster that had taken over my knee and didn't even have a name for the condition. I was so relieved to find this website that I stayed at my office until 1 or 2 in the morning reading through some of the threads. I learned so much from reading those threads and, later when I started posting, many people offered advice; I've felt compelled to try to help others who are dealing with this condition.

At that time there were no tutorials, clinical casebook,article reviews, or the other content that KNEEguru (Sheila) has amassed over the last couple years. I couldn't sleep due to severe pain so I spent countless hours using medical journal search engines (PubMed for instance) and sharing abstracts with others here. I finally ended up using a medical document sevice to obtain the articles I had found. I found other articles by going through dozens of google searches and wading through hundreds of results. I figured I might as well put my sleepless nights to good use.

Getting back to your knee: I had to convert the 16 cm to inches--> That's 6.3 inches and is probably far more than 10 degrees, my guess is 25-30 degrees, which is way too much for extension casting based on Dr. Noyes' protocol/ recommendation of no more than 10 degrees loss of extension.

I'm not a doctor, don't work in the medical profession, all I know of knees is what I've learned from my own experience, reading about others' experiences, and researching through dozens of medical journal articles. Having said that, I can't imagine that your extension loss is going to be correctable with anything other than surgery, especially because the extension loss continues to increase, which has me think that either more scar tisue is growing or what is there is starting to change form and tighten up. Lianne, I went through that after the surgery that started the scar tissue. At 4 weeks post-op I had extension of 38 degrees and flexion was 68 degrees. My PT was very forceful-- leg being tied down and forcefully bent like your PT. My OS#1 endoresed those PT tactics and had me try a DynaSplint, which was pure hell, and only seemed to increase the swelling and inflammation. And he kept giving me all kinds of lame explanations for why my knee was stuck.

At least you're ahead of the game with an OS who seems to at least recognize that the problem is not your fault. However, based on your OS's current recommendations, it's hard to determine the extent of his experience with AF. When I was faced with making decisions about my treatment, I found it useful to compare what my OS was saying against what I found in the articles written by more knowledgable OS. I read articles all the way back to the early 1980's and found that the authors were already cautioning against overly aggressive PT and too forceful MUA and other such measures for used to treat motion loss. They also were already identifying possible causes of AF-- such as joint bleeding, prolonged immobilization, and lack of PT. Frankly, I was surprised because there are so many stories from so many people who's OS use approaches that were identifed in the early 1980's as contributing to AF and possibly even worsening the condition. That's more then 25 years ago!! Seems like plenty of time for an OS to have at least read or heard about appropriate treatment of AF, however as we've stated before most OS see few if any cases of AF. And, whether they treat the one or two cases appropriately is another matter. Many OS will use the incorrect measures,which makes the case of AF even worse, and eventually tell their patients that nothing can be done.

5 weeks post-op is probably earlier than most OS would perform another surgery. I know in my case, Dr. Steadman generally waited about 12 weeks or until there was no active inflammation and little to no swelling before he would do another scope. Active inflammation is present even at rest and with no activity and indicates that the inflammatory healing process is still going and scar tissue is still forming. Surgery should be avoided until the inflammatory process has subsided.

For early intervention Dr. S uses a procedured called insufflation. It's done under general anesthesia, but you're only out for about 15-20 minutes. No incisions are required because a really large syringe and needle are used to inflate the knee capsule with saline. A normal knee will hold about 180 mL of saline. In the notes from my previous insufflation it mentioned that he could feel the plunger pushing back after injecting about 100mL of fluid. Once resistance is felt they gradually add fluid by injecting 20mL then backing off 10mL, until they feel adhesions break; it takes about 10 minutes. The needle is left introduced and the saline is then withdrawn from the knee. With my procedures they could hear loud snapping from my knee which was presumed to be adhesions breaking. The removed fluid had lots of scar tissue fragments floating aound in it. I resumed PT the following day and used the CPM for a few weeks after the insufflation.

Dr. Noyes and some other AF specialists use MUA early post-op. Frankly, I would have no concern about Dr. N or one of the AF specialist doing an MUA. If someone else was suggesting it, I would consider how far post-op I was and I would ask specifically how much force the OS would use. The answer I would want is that very little force should be used, I think Dr. Noyes mentions somewhere that the knee often bends under gravity and he generally uses less than 2-fingers pressure. And, that the OS would not resort to forceful bending if the knee did not bend with gravity or little pressure. I have read stories on the board of an OS climbing on the surgical table and using his weight to force the knee and ended up breaking the femur in the process. So what you want to hear is little pressure and will stop if the knee won't budge.

I also wanted to comment a bit on using an extension device other than casts, but I'm running out of steam. I'll come back later and post more.

Also, are you using crutches? If not it might be a good idea to go back to them. Throughout my treatment Dr. S stressed that there was no hurry for me to get off crutches, since doing so leads to limping and adaptive postures and habits that are very difficult to break. However, when I used crutches he wanted me to move in as natural a manner as possible, even if it meant moving very slowly. I was able to maintain a pretty normal gait pattern through it all.

I'll post more in the next day or so.

Jaci

[catwoman88]

Wow Jaci,
Thanks for the great post, no wonder you ran out of steam!, its inspiring to know how much time and effort you've spent researching all of this especially in the days before any of the info on Knee Geeks was available.
 
I really must ask my new PT what the extension lack in degrees is - no one's ever told me hence I use the great cm measuring tool!. My new PT did say she does not agree with over aggressive therapy as I told her I'd leave if it gets too much as I'd had enough of that with the other PT. In the last few days when I am driving I find that I have to told the back of my bad knee pant leg as my knee is hurting back and front and I have to change the position sometimes (like it gets stuck), I’ve started to put a blanket under it for more support – weird. Like you said Serial casting is not used when the extension lacks more that 10 degrees and I really think the serial casting will take ages at the bent state my knee is in - so that’s not something I really want him to attempt also meanwhile my flex will not be being worked on at all. I know he says 115 is good but I really would like to attain a bit more. (I know there's people posting here who would love to have 115 flex - so I'm not complaining but It would be nice to have a bit more and last night I could not even get to 115). MUA sounded good till I realised going from my bent knee state to straight and casting will be pain like I could not imagine - someone at my work said that they had this done (their extension was better than mine) and after 4 days they had to cut the cast off themselves as it was so painful!! - while I'm cast I reckon they'd have to give me some major drugs and I am not sure how long they are talking about casting me for. I will ask the OS about what pressure he'd apply for the MUA as I also read the post about someone's femur getting broken - kind of scary - and if he cannot get it to straight with little pressure then will he stop?. I also wondered if he'd flex the knee during the MUA also but then if he's talking about casting it straight would this make any sense?. When I go back to see him I'll be 7 weeks post Op so maybe he'll decide on a slightly more aggressive route - well not aggressive to the knee - but one that will get this extension loss back maybe quicker. Although I know you said normally 12 weeks is an acceptable timescale for going back into scope (I assume you mean a LOA and MUA?) but I think my knee inflammation is not going to go down anymore - I only say that as all of last year it was pretty similar, I mean it went way down from what it was when I got the original bursitis but then after about 6 weeks it plateaued and stayed the same. Also if the OS does agree to a LOA and MUA would he still cast the knee or not?.
 
At the moment I am using one crutch - still my good knee gets so worn out and aches so much, yesterday I did cheat and use both crutches when I went to the stores - I keep forgetting how much they take out of you and I start quick thinking I'm some sort of Olympic athlete and then I tire quickly and have to keep resting.

Anyway better get on with some work

Thanks

Lianne

[catwoman88]

Okay so I thought I’d just write a quick update for any last minute advice before I see my OS this coming Thursday......
I had PT yesterday and finally I asked for a measurement instead of my normal cm measurement!. My extension is at 35 degrees - that was after 10mins of massage and heat and pushing - gentle this time!. My flex is not really being worked on - I try at home still but I would say its now about 110 degrees. I have also noticed and my PT agrees that my leg does not look straight – not sure if this is just due to muscle wastage or my gait – she says the thigh is fine it’s the lower leg that’s a bit twisted out now.

I have read all the articles Jaci posted and emailed me and also anything else I can find on serial casting and MUA's. It’s still so confusing, many OS say they won't do a closed MUA for fear of damaging ligaments etc and serial casting I reckon for 35 degrees extension loss will be too long haul. So I think I’m going to ask if he’d do a MUA and not serial cast me due to timescale and pressure on the good knee. I am just not sure if I should be asking for a closed or open MUA, if I do have AF tissue in the knee would an open MUA be better to check for this and get rid of it before he casts the leg?. I still have the weird pinching feeling below the patella, knee pain (I have to sit forward in my chair at work or put something under my knee to support it) and pain at the back of the knee. 

Sorry for going on but I want to try and make the right decision otherwise I’m worried this could turn into an on going saga like it is already for many people out there who post here.

Many Thanks

Lianne   

[Jaci]

Hello Lianne,

I've been thinking about you since your post on the 25th and trying to formulate a response. I have several things that I want to explain, but it may take a couple posts for me to keep my thoughts straight and get through all of it.

Arthrofibrosis fits into 2 broad categories-- primary and secondary. In the tutorial Dr. Noyes explains that AF is considered secondary when there is an identifiable cause-- prolonged immobilization, joint bleeding, infection, poor surgical technique, inappropriate PT and so on (you can reread the tutorial for the full list). Primary AF is believed to be a genetically-based exaggerated healing response; Dr. Noyes mentions that around 1% of patients have AF that falls into this category and such people will require major surgery to correct residual problems from AF.

A person can have primary AF, secondary AF, or both. Unfortunately there is no way to know which category you fall into because there are no tests for primary AF. So the AF you have could be from some secondary cause, it could be from genetics, or it could be from a combination of the two.

>>>>>”I’m worried this could turn into an on going saga like it is already for many people out there who post here”.>>>>>

From my experience and research I've concluded that there are two things (in a broad sense) that lead to AF turning into an ongoing saga: Improper treatment and genetics.

You have no control of the genetic aspect, there is nothing you can do to change it or to even know if that's what you have, it often comes down to multiple surgeries with the best AF experts. In other words, you cannot change your genetics, but you can manage certain aspects of your care to increase your chances of a better outcome.

Then there's improper treatment-- This is what you can control or impact. The ideal way would be to go to one of the known AF experts. However, I understand that not everyone can do that, hence my (and other's) constant recommendation to learn everything you can about AF, then interview your OS and weigh everything the OS says against what the experts say. If what your OS is proposing contradicts the experts-- thus falling into the improper treatment category-- you have some choices to make. You may have to take on the role of educating your doctor about AF and being an active partner in your treatment-- that includes NOT agreeing to certain types of treatments. Some doctors are amenable to such partnerships and some are not. Another choice is to seek a second, third, forth, etc. opinion until you find an OS who is knowledgeable about AF, again you will have to become an 'expert' on AF so that you can gauge whether the OS you interview is fully informed and experienced to not only perform the surgery, but also to manage the inflammatory cycle-- including knowing when and how to intervene--, provide adequate pain relief, and ensure that you have appropriate PT. 

I think most of us live in cultures where we are taught to revere doctors and to accept their advice/ opinions without question. This sort of abdication works fine for common, everyday, run-of-the-mill conditions or illness, but can be disastrous for conditions that are not all that common-- like arthrofibrosis. Thus, once again, the AF board mantra: Learn everything you can so you can be an effective advocate for your care.

From time to time a person has posted that their OS is saying that genetically based AF is very rare, so it's probably not what they have. I'm always dumbfounded by such a statement. The relative rarity of a condition is not a basis for ruling it out. My feeling is that all AF must be treated as if it is genetically based until you know otherwise. That means that every possible secondary contributor must be eliminated/ prevented. How you know otherwise is that every possible secondary contributor was avoided and you had a successful recovery from surgery without an exagerated inflammatory response and scar tissue regrowth. Many, many people recover from AF with only one surgery and proper rehab, most likely those people had secondary AF. Then there are those of us-- like me for instance-- who have been treated by one of the best of the best and continue to have exaggerated healing response and over-growth of scar tissue; we most liklely have primary AF. For primary AF the goal becomes getting to a point where your knee is more livable and functional and less bad than before; generally the only way to do that is with surgery and after-care with one of the experts. 

35 degrees extension and 110 flexion is a very significant loss of motion. It is beyond early intervention such as over-pressure or extension casting both in terms of time post-op and the amount of motion loss that you have.  In the various articles and the tutorials there is discussion of using post-op range of motion goals. Most have a goal of reaching full extension within the first week or 2 post op. Over-pressure to gain extension is generally the first line of intervention and it can be successful if instituted early-- i.e. at the point where the goal was not met. Remember-- early wispy scar tissue (it kind of looks like cobwebs) can be broken up. But if it's not dealt with early--measured by both time and amount of motion loss-- it can become established in as little as a month. (Part 5 and 6 of tutorial) So, if there ever was a chance that you would have been helped by over-pressure or extension casting, you are way beyond that. Similar info in Table 5 of Dr. Noyes article "Prevention of permanent AF..." from 2000. Every knee that was treated with an extension cast had less than 10 degrees extension loss. In other words the extension loss was dealt with BEFORE it progressed to be more than 10 degrees. Dr. Noyes 1992 article "The early treatment of motion complications..." includes very detailed description post-op goals and intervention, see Table 1 and Table 2 for a brief overview.

>>>>>It’s still so confusing, many OS say they won't do a closed MUA for fear of damaging ligaments etc and serial casting I reckon for 35 degrees extension loss will be too long haul.>>>>>

At this point the issue with extension casting is not the long haul, it's that extension casting should have been done way before you got to 35 degrees extension loss, even if that meant using an extension cast in the first few weeks postop. Most likely your extension did not suddenly go to 35 degrees, it was less than that at some point and was probably in the less than 10 degrees loss at some time as well. That was the point when the extension intervention treatment program --first over-pressure then casting if over-pressure was not successful-- should have been instituted. Also, in addition to recommendations related to timing and amount of extension loss, Dr. Noyes gives very specific instructions on how extension cast are used, including spliting the cast, slowly wedging it increase extension by slowly stretching tissues, only applying the cast for 36-48 hours, removing it to work on flexion, and so forth. All of those details should be addressed when an OS is suggesting extension casting.

About MUA-- really same conversation as above. MUA must be done early both in terms of time and amount of motion loss. Intervention should occur before one gets to 35 dgrees extension and 110 flexion. 

Sorry I don't mean to be negative or pessimistic-- I am simply overlaying the info from the articles over what you have said about the state of your knee and your OS recommendations. Remember these are the things you have control over and they are also things that can prolong your saga if done incorrectly.

There are a couple other things that I want to address,but I need to stop and take a break. I'll come back later to comment on the following:

>>>>Although I know you said normally 12 weeks is an acceptable timescale for going back into scope (I assume you mean a LOA and MUA?) but I think my knee inflammation is not going to go down anymore - I only say that as all of last year it was pretty similar, I mean it went way down from what it was when I got the original bursitis but then after about 6 weeks it plateaued and stayed the same.>>>>>

>>>>>I am just not sure if I should be asking for a closed or open MUA, if I do have AF tissue in the knee would an open MUA be better to check for this and get rid of it before he casts the leg?.>>>>>


Hang in there. Keep asking questions. We know how difficult treating AF can be, so we're here to help you in any way we can.

Take care,

Jaci

[catwoman88]

Hi Jaci,

wow.........I read your post and all the information and promptly went a had a couple of drinks I know you weren't being negative in anyway and I didn’t read it like that at all, I asked for help and advice and you as always gave me the best information and advice. I only have a few days left to get my head around this and know the facts before my OS tries to slap a cast on me and possibly cause me more problems down the line!. I now feel way more confident to question my OS and tell him what I now know (hoping he's the sort of Dr who does not mind me questioning him). I went back did my homework and re-read the Prevention of permanent AF..." from 2000 Noyes article and I do see he's saying anything over 20 degree's of extension loss should have an arthroscopic debridement (LOA I assume from what he also goes onto say) and then intermittent casting. So from this article just an MUA or serial cast like you said is not at this stage an option. I just have to hope my OS has heard of AF and recognises that my knee's in trouble at this stage and is amenable to changing the treatment he's proposed for this. I don't think there's anyway to contact him about this before Thursday otherwise i'd ask him sooner.

Interesting that you mentioned about primary and secondary AF - sorry to hear that you have the primary kind, I am not sure obviously what I have but I am wondering like I’ve posted earlier if I could form adhesions more easily due to my Endo problem and subsequent surgery and still having pain - maybe this is also partially adhesion related now too?.

I look forward to the second part of you post Jaci - I hope you didn't wear your fingers or kbd out typing the first part, it had so much great information in it - thanks for taking the time to keep re-educating me on this as i know i keep asking the same questions over and over!.

Lianne

[Jaci]

Hello Lianne,

Okay, here's the continuation of the response I started yesterday.

You asked:
>>>>>I am just not sure if I should be asking for a closed or open MUA, if I do have AF tissue in the knee would an open MUA be better to check for this and get rid of it before he casts the leg?.>>>>>

One of the points I tried to make yesterday is this: If the early goals extension and flexion are not met, then intervention should be instituted at that time. Once you've gone beyond that point-- both in terms of time and amount of motion loss-- you have missed the opportunity to intervene using conservative measures such as over-pressure (also called low load prolonged stretching) and use of LLPS devices-- JAS, ERMI, Dynasplint, extension boards, and use of extension casts if over pressure failed to restore full extension. The same applies to use of MUA (without a scope).

If you look in Dr. Noyes 1992 article "The early treatment of motion complications..." his protocol is to begin hanging weights (over pressure) in the first post-op week if extension lacks 10-15 degrees and he performs gentle MUA the 2nd post-op week if the patient lacks 70 degrees flexion. (I realize the article is about rehab post ACL recon, however the same intervention protocol would apply to a less invasive procedure like what you had. It's also the same rehab protocol that they use for AF. This was explained to me by Sue Barber Westin, one of Dr. Noyes researchers, in emails we exchanged  back in 2004.) So, based on Dr. N protocol, you have missed the opportunity to use MUA as a treatment-- too large of motion loss and too late in terms of time.

So the option at this point would be arthroscopic release of scar tissue followed by appropriate rehab. Arthroscopic release is sometimes called debridement and also called lysis of adhesions (LOA) and the article/ technical note from Arthroscopy August 2004 "Arthroscopic treament of the arthrofibrotic knee" explains a detailed 9-step approach that is used by many of the AF experts. The approach does not include use of MUA. The term 'open' is generally used for surgery that involves actual incisions rather than being done arthroscopically (i.e. with a scope).

The LOA should be followed by appropriate PT such as that outlined in Dr. Noyes articles and the article "Rehabilitation of the arthrofibrotic knee". You could use over-pressure with weights or an extension device such as JAS, ERMI, or an extension board.  

>>>>Although I know you said normally 12 weeks is an acceptable timescale for going back into scope (I assume you mean a LOA and MUA?) but I think my knee inflammation is not going to go down anymore - I only say that as all of last year it was pretty similar, I mean it went way down from what it was when I got the original bursitis but then after about 6 weeks it plateaued and stayed the same.>>>>>

I don't ever mean LOA and MUA. I was treated for AF by an OS who does not do MUA, ever. And I had a bad experience with MUA because before going to Vail, CO for treatment, my OS did it very aggressively before he did a scope. My patella was severely scarred down, it felt like cement was holding it in place. Force bending my knee and forcing the patella to move around caused massive bruising and swelling which, of course, triggered a severe inflammatory response. I never would have agreed to doing the MUA before the scope had I known that was his plan-- I made a bad assumption when he said he would do an MUA with a scope. Since that time I've learned a lot more about AF and can tell you that I would not agree to an MUA with anyone who is not well-versed in AF and it's treatment, such as Dr. Noyes. Dr. Noyes mentions in his articles that performing MUA when you have severe motion loss and frozen/ stuck patella can result in damage to soft-tissue and articular cartilage.

With regard to LOA, it's important that it not be performed on a knee that is still in the active inflammatory cycle. This is a known, well-identified contributor to an exaggerated healing response and excess scar tissue. So you want your knee to be as calm as possible before going through surgery. And, your OS needs to have a good plan in place for dealing with post-op inflammation.

>>>>I still have the weird pinching feeling below the patella, knee pain (I have to sit forward in my chair at work or put something under my knee to support it) and pain at the back of the knee.>>>>

The weird pinching below the patella could be due to adhesions in an area called the anterior interval. It's the area between the fat pad, the top of the tibia, and the patellar tendon. It's a common area for scar tissue to form and it's also one of the most critcial to properly remove adhesions from. Adhesions in that area can pull the patella down and tether it to the tibia whcih will inhibit knee motion. It also causes slack in the patellar tendon which over time can lead to shrinkage of the tendon and permanent lowerinfg of the patella, a condition called patella infera.
 
When I had severe motion loss I had the same problem of having to sit forward in a chair or put something under my knee. I thing it just happens when you can't fully bedn and straighten your knee.  It should improve when your knee motion is restored.

Okay, I'm out of steam again. I'll have to come back later and tie this all together.

Take care,

Jaci

[Jaci]

Hey Lianne,

I've been working on the next installment for a bit and it looks like you were writing at the same time.

Funny you mention the couple drinks. I had meant to suggest that you might need that after reading my last post.


Jaci

[Jaci]

Lianne,

For your appt with your OS, I would highly recommend taking him copies of the articles. I would also approach it from the standpoint of being an active partner in your care-- something that any doctor worth his salt would want from a patient, IMHO. You don't want to come across like you are being disrespectful.

I think I emailed you 2 articles from Dr. Noyes-- "Prevention of permanent AF..." from 2000, and "The early treatment of motion complications..." from 1992. The earlier article has very detaiiled goals, protocol, and intervention laid out in two tables that are easy to reference. I beleive it's the protocol that he built on in his later article in 2000. Let me know if I didn't email it to you and I''ll send it your way.

Last thing, for now anyway, your OS cannot do anything that you don't agree to.


Jaci

[catwoman88]

Hi Jaci,

You beat me to it this time with the post!. I will be sure to take along copies of the articles, I’d always want to back up anything I said to my OS.

This time I’m not going for a drink after reading your post's - I have to work tomorrow after all!. I won't write much for once! - going to go back and re-read in depth what you've written. Just wanted to say that my knee is probably just over 1/2inch bigger than the other one - that's probably not much more than it was all of last year. So I am not sure its excess inflammation, well no more than normal?.

Also could I just ask about a couple of things you mentioned...
1) You'd never have an LOA then MUA, I know with my scope my OS made sure after the scope he could get my knee straight, so you're saying that he should not do this?, so only do a LOA
2) Is an LOA an arthroscopic procedure as you mentioned that it was open surgery but arthroscopic too? (I did read the 9 point article but cannot see if it’s open or a scope) - maybe I do need a drink to understand this all!

I had a quick look through the articles that you'd emailed and I’d printed off and I cannot see the 2000 article "Prevention of permanent AF...", if you could email it to me that would be great - I’ll get out the yellow highlighter ready

Have a great evening

Lianne


 

[Jaci]

Lianne

>>>1) You'd never have an LOA then MUA, I know with my scope my OS made sure after the scope he could get my knee straight, so you're saying that he should not do this?, so only do a LOA>>>

Checking the range of the knee after performing the scope is not the same as MUA. Dr. S calls it 'ranging the knee'. If he is not able to obtain full range of motion following the scope it means that there is still adhesions inhibiting motion, so additional release of scar tissue is needed. If your doctor used any pressure to obtain full range of motion, than it's likely that the scope did not adequately release the scar tissue.

03/03 Edited to add: One other thing I want to mention is that lysis of adhesions does not mean removing every last shred of scar tissue. To do so would be too traumatic and is likely to lead to an aggressive inflammatory response. This was something I learned from Dr. Steadman, and Dr. Eakin touched on it in my consultation with him. Dr. S explained that during the scope they remove scar tissue that is inhibiting motion, it's done with electrocautery to control bleeding, and they observe the knee for certain signs like decompression of the patella and restored patella mobility. Those signs, together with restored range of motion let them know enough scar tissue was removed. Scar tissue is shaved with a certain pattern like scoring to help control where and the direction of scar tissue regrowth. The idea here is that it is likely that some scar tissue will reform, but the OS wants to control it and have it grow in such a way that it does not inhibit motion or joint function.

>>>2) Is an LOA an arthroscopic procedure as you mentioned that it was open surgery but arthroscopic too? (I did read the 9 point article but cannot see if it’s open or a scope) - maybe I do need a drink to understand this all!>>>

Lysis of adhesions can be done either as an arthroscopic procedure or as an open procedure. The 9-step approach is mentioned briefly in a table "Rehabilitation of the arthrofibrotic knee" and the text on the same page mentions that it is arthroscopic. I have antother article that explains the arthroscopic 9-step approach in detail. That article is called "Arthroscopic treatment of the arthrofibrotic knee" it was published in 2004 and has some really good pictures of scar tissue in it. 

I'll go ahead and email the 2000 articlle to you. Do you have the 1992 article from Dr. Noyes and the 2004 article on arthroscopic treatment?

Jaci 

[Sophiepl]

Lianne-

I have had a couple of LOA's and they have all helped significantly in returning my ROM and relieving the pain and tightness. The balance is keeping it calm afterward and keeping it moving, it can definitely take a while to find that balance. It is amazing how light my leg felt after they removed the restricting adhesions- like a different leg!

Jaci-

I haven’t posted a lot on this website but have been reading for over a year as I too have been suffering with AF and the battle has definitely been running me ragged.

I noticed in one of our posts above that one thing about removing scar tissue is waiting until the knee is calm and not irritated. I have read all of Dr. Noye’s articles posted here and if I am understanding it correctly, that the longer it sits in there, the firmer it gets. How have you and your surgeon walked that fine line, waiting until it is not inflamed but waiting too long so that the adhesions are firm and non-pliable anymore? What was your quickest scar tissue removal after a procedure?

I appreciate your thoughts!

Sophie