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Author Topic: I have question for fellow patella tendon graftees....  (Read 3655 times)

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Offline bmx85

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I have question for fellow patella tendon graftees....
« on: November 24, 2008, 09:28:08 PM »
Did your surgeon leave the defect in the tendon open or closed? I was under the impression that the tendon is always left open so that it can fill in and regenerate. However, I found out after my surgery that that my OS removed the middle strip of the tendon than just sewed it back together. I am not sure why he did this because most studies I have seen show the tendon to regenerate. I am kinda freaked out about having to go the rest of my life with a giant chunk of tendon missing. I have been experiencing some tendonitis that i hoped would go away as the tendon regenerated. Is there anybody else here who had their tendon shut after the procedure? If so is it causing you any issues? For those that had the defect left open did it ever grow back? I would appreciate any feedback.

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #1 on: November 24, 2008, 09:34:55 PM »
In the 2-3000 patellla tendon repairs that I have been involved with, it is alway reapproximated.  I am sure, someone, somewhere leaves it open.  In the States, reapproximation of the tendon is standard, but I shouldn't have answered this because, so far my factory ACLs have stood up.

Offline bmx85

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Re: I have question for fellow patella tendon graftees....
« Reply #2 on: November 24, 2008, 09:57:04 PM »
Dr. Mark, what is the benefit of closing the tendon? Am I mistaken in in thinking it would have regenerated?

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #3 on: November 24, 2008, 09:59:48 PM »
I don't think that there is good data as to why.  The though is is the herniateion of the fat pad into the defect could be painful and that it assists in regeneration of the middle third.

Offline bmx85

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Re: I have question for fellow patella tendon graftees....
« Reply #4 on: November 24, 2008, 10:22:27 PM »
"I don't think that there is good data as to why.  The though is is the herniateion of the fat pad into the defect could be painful and that it assists in regeneration of the middle third."

I am kinda of confused. Are you saying that sewing the tendon back together actually helps it regrow? This doesn't make sense to me.  If the middle third has been closed how can it regenerate? The reason I am  so concerned about it is that my PT told me that I have a high q-angle and that my legs rely more on the patella tendon for support which is probably why I have been getting alot of tendonitis. It seems like it would be impossible for the remaining 2/3 to carry the load without becoming inflamed. Is there anyway I'll ever have a normal patella tendon after this?

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #5 on: November 24, 2008, 10:48:44 PM »
Again there is no good Level 1 data on repair of the defect or leaving it along. Is really dealer's choice.

The tendon will however hypertrophy to its original size if it is properly stimulated by closed chain quad exercise.  This has been well proven by Dr Shelbourne's studies. 

However, despite all the talk about the Q angle, there is NO medical evidence that it is associated with patellofemoral problems.  The whole deal with the Q angle seems to be an old wive's tale.

You can expect to be symptom free from the extensor mechiniism if you regain knee extension on that side absolutely equal to the other side, and do the exercises as noted earlier in this post.  It can take as much as one year, but is usually complete is six weeks.  Absent full extension, you will never be free of pain.

Offline BigSkyGirl

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Re: I have question for fellow patella tendon graftees....
« Reply #6 on: November 25, 2008, 02:16:05 AM »
I know it is important to regain full extension right away.  I had it but now it seems as if I am about 2 degrees off.  I am hoping it's just measurement error but I do feel that the leg is not fully straight at times.

The knee is still swollen after all this time, the lower outer part looks like there is a table tennis ball in there.  It doesn't hurt just feels "full".  Does this mean I am going to have problems?  Am I still too soon, I have a friend that had same and she said it took her a good year to get right.  It is super uncomfortable to kneel, will it ever get better or is this just the way it's going to be?

When I read about AF it scares me to death, the PT said even with the 2 degrees everyday activities are not affected that much, if I want to run again that could be a problem.  I try not to scare myself, I do the prone hang every night and have been icing more than usual, it doesn't seem to help with the swelling tho'.  I lost 2" on my quad and that really has caused me alot of work, I am still having trouble going down stairs but it's getting better.  I almost feel like I could break into a slow trot when on the treadmill.

The knee itself feels very stable it's mostly quad weakness.  Sorry to hijack your thread BMX but I saw Dr. Mark on here so thought I'd post. 
02/11/08 - LK ACL/MCL tears, fibula fracture - skiing in CA
04/14/08 - ACLr PT autograft

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #7 on: November 25, 2008, 02:52:20 AM »
Two degrees is two degrees too much flexion contracture.  All efforts must be made to have equal extension.   One just doesn't see problem cases with equal extension of both knees.  Again equal mean equal, period.

Offline bmx85

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Re: I have question for fellow patella tendon graftees....
« Reply #8 on: November 25, 2008, 03:36:19 AM »
Dr. Mark, I am pretty sure I have equal extension on both sides. Last time I had my extension measured I was off by one degree. That was about six weeks post op. I am about 4.5 months post op now. I'll have my PT measure it next time to be sure. I am also missing about one inch off my quad so I do not know if that is a contributing factor to my tendonitis or not. By closed chain exercises do you means leg presses, lunges, step-ups,etc? That is mostly what I have been doing in PT. If I am still missing a degree of extension is it too late to get it back? Bigskygirl, do not worry about "hijacking" my thread, I actually would like to hear from other people who are working through the same problems as well.

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #9 on: November 25, 2008, 08:42:51 AM »
Sorry to correct you an everyone else, but it is not tendonitis.  There is no inflamatory cell infiltrate in the patella tendon.  Pain in the region is a normal finding and it resolves by continued exercise as you described.  Naturally you need ton contnue to work on stretching into equal extension.

The best way to avoid most of this problem is accelerated rehabilitaiton.  For example our patients are not issued crutches or a brace and start range of motion and PT in the recovery room.  Additionally, by harvesting the opposite PT for the graft, the big problem in one knee is divided into two smaller and surmountbable  problems in each knee. 

Offline BigSkyGirl

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Re: I have question for fellow patella tendon graftees....
« Reply #10 on: November 25, 2008, 11:43:56 AM »
Is it too late to get the 2 degrees back?  I see the OS on 12/4.
02/11/08 - LK ACL/MCL tears, fibula fracture - skiing in CA
04/14/08 - ACLr PT autograft

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #11 on: November 25, 2008, 12:21:13 PM »
No.
Google Elite Seat.
Get one.

Offline BigSkyGirl

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Re: I have question for fellow patella tendon graftees....
« Reply #12 on: November 25, 2008, 12:51:13 PM »
That does look effective, what about the don-joy braces?  My OS is not big on any braces, I never really wore one from the git go although I was wimping along on a crutch for awhile.  He wanted me to walk normally before I gave them up.  What to do about swelling other than ice?  I really think that is holding it up somewhat, my knee is so large and feels "full" of fluid.  Whenever I mentioned draining it he never really said anything but to wait.

I'm not in a big rush to get back here I just want to get back.  Do I just need to wait longer and keep working the quads and extension?
02/11/08 - LK ACL/MCL tears, fibula fracture - skiing in CA
04/14/08 - ACLr PT autograft

drmark

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Re: I have question for fellow patella tendon graftees....
« Reply #13 on: November 25, 2008, 01:13:50 PM »
I have had no luck with dynamic extension braces.  I have had much sucess with the Elite Seat and prone hangs with 15 lbs weight on the ankle.

Offline BigSkyGirl

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Re: I have question for fellow patella tendon graftees....
« Reply #14 on: November 25, 2008, 05:21:27 PM »
Thanks Dr. Mark, I do the ever popular and oh so fun prone hang with 10lbs but I'll up it to 15.  It's actually my other knee that is uncomfortable during the hang.  My op knee could lie there all day if I could also lie there all day.  At times when I am on the hardwood floors I can feel the back of my knee on the floor and then at others it's clearly not touching and that's when my knee is most swollen - I see this is something I will have to work at constantly.

I have been doing more cardio and floor work involving some kneeling - I noticed it has been very swollen and painful since I started that.  I take a day off every few days and am hoping it's just the increase in activity that's causing this right now.

I'll continue with the hang and other exercises and then see the OS on the 4th.  Thanks for commenting here, I really appreciate another opinion and advice.
02/11/08 - LK ACL/MCL tears, fibula fracture - skiing in CA
04/14/08 - ACLr PT autograft















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