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Author Topic: Room 101's December 2, 2008 ACI (**January 31, 2011 update**)  (Read 32148 times)

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Offline Room 101

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Room 101's December 2, 2008 ACI (**January 31, 2011 update**)
« on: January 05, 2009, 08:19:46 PM »
I will be 5 weeks PO January 6.  I am back to work after the holiday vacation time, and I'll give you my story, but I kind of want to know if not being able to do a SLR is normal at this point.  It seems to be pain behind the kneecap that is stopping it and weirdly it's shutting down the muscles... I'll give you the scoop and apologize for it being long, but I have not had inet access... we're not wireless, yet  ::)

I had AMZ, etc. in Feb. 2008 and ACI in Dec. 2008, so I've seen enough of crutches & a knee brace for a while.

December 2 was the ACI.  It went really well.  Patella lesion around the size of a 1/2 dollar or something.  Surgery was more involved and took longer than expected, but I am fuzzy from the drugs and don't have pics yet so that part is a bit vague, haha.  I was on vacation for 6 days and back at work (computer geek) at 7 days PO, although I saved 3 weeks of vacation and this will be my first 5 day work week since before Thanksgiving.  We moved in November, thankfully a 15 minute commute instead of over an hour.  It's nice on many levels. 

From a post-op pain perspective, the ACI was nothing.  I kicked the drugs after a few days, and maybe there-in lies the problem, haha...  the only real pain was behind the knee making it so I could not lift the leg.  My post op appt. was 9 days after and all was well.  No infection or anything.  I was told to open the brace to 45 degrees and move from 40 to 60 degrees on CPM starting at the 3rd & 4th week and begin weaning from crutches.  I also cleared it that working out w/ my trainer brace on was fine as long as no weights were involved.  I began training w/ him at 10 days PO doing massage table leg lifts & core and seated w/ my leg up resistance training for upper body.  I can do anything on my side or my stomach w/ my surgical leg.  Those muscles are actually really strong.  I can also do quad sets on my side w/ my trainer manually resisting.  Any position where I don't hit hyper works just fine.  We do a lot of muscle activation and 6 second holds for exercises.  Isometric holds and tons of core.  I have even come to the point where we can do some modified cable work because I can fully put weight on the surgical leg.  I still need to use one crutch due to some pain, but with one crutch I can go heel to toe and feel a good stride.  My PT was on vacation over Christmas, so I have only had 2 appointments as of today (Jan. 5).  Some great massage and manipulation and stim, but I cannot do an SLR to save my soul.  The kneecap pain is bad, and I don't know if that is normal.  I feel as if things are progressing, and I was actually really strong prior to this surgery which was good.  The docs complimented that actually, even though I failed at phase 3 of ACI rehab.  Kudos to my trainer and therapist for that because I still couldn't even walk a mile without repercussions before the ACI.  I go back to the OS Thursday for a follow-up, so my questions will be answered then also, but what's the scoop from the experienced?  Is the lack o fSLR ability while lying on my back normal?  It seems so now, but who knows.  It's just weird.  I can sit and get myself in and out of the CPM or in and out of bed with the brace on, but as soon as I lie down and try it, things just don't function.  I haven't pushed it because it seems to just make things regress a little.  Maybe I need to try the pills again, but I just haven't needed them for anything else.  Minus being sick of sleeping in the brace, I sleep well and on both sides easily.  I am really stiff in the morning and the cpm takes a few reps to feel good, but all in all, that stuff is actually soothing. 

So, the summary and Cliff's Notes version is at 5 weeks post op: Patella lesion around 1/2 dollar size.  I am working out 2 days w/ my trainer, therapy 2 days a week.  I am to move from 60 to 90 on CPM (I am at 75, and hopeful for 80 today).  My PT RoM is at 70 easily, so only 5 degrees off the cpm.  I am not supposed to push past that at all.  That was very specific.  My brace is open to 45 degrees and I walk w/ 1 crutch.  I don't take any meds and see the OS Thursday.  I cannot do a solid SLR supine w/out pain behind the kneecap, and I still have some trouble just lifting the leg up from being down, but walking and all is fine.

If there are any hints or suggestions, I am open to stories.  I love the stories.  I actually feel normal in this group rather than old & broken like "normal" people see me...

Hope everyone had a nice holiday & New Year!

Kim
« Last Edit: January 31, 2011, 06:18:08 PM by Room 101 »
February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

jonhark

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Re: Room 101's December 2, 2008 ACI
« Reply #1 on: January 05, 2009, 09:45:25 PM »
I believe we had the same OS--Dr. Cole in Chicago, correct?

Anyways, take my suggestions with a grain of salt as I was told I could run my protocol as I see fit being that I had my other knee done and it was successful(verified with a scope on Dec 16th)

Half-dollar size patella defect is pretty large. In fact that is almost the entire area of the patella. Patella has approximately 25 cm^2 surface area. At your next visit try and ascertain the size of the defect (cm^2)

I had my last knee done separately for AMZ and ACI as well. I had an AMZ and microfracture that failed in Jan of 07. I had the ACI six months later.

Is it unusual to have pain under the kneecap with SLR's after ACI? I didn't when I started doing SLR's at week 2. But my defect was a little larger than a nickle.  My hunch is that your subchondral bone is pretty irritated from all the rehab you are doing.I wasn't nearly as aggressive as you have been. Things as simple as iso quad sets can irritate the patella. That being said, the first six weeks are the phase in which the chondrocyte cells proliferate...so it is good to stimulate them with plenty of smooth movement and motion.

Every surgeon has different rehab protocols. I generally used the most conservative one out there==Dr. Tom Minas out of Boston. He did my original AMZ and he has done more patella ACI's than anyone in the country. Here is the link to the rehab protocol:

http://www.cartilagerepaircenter.net/fileadmin/user_upload/pdf_files/Rehab_Templates/ACI_-_PF1.pdf

He keeps patients at 40 degrees in the CPM for six weeks. Brace is locked at full extension for six full weeks. Heel slides are fine. Strengthening exercises are good but shouldn't be causing any pain. I didn't attempt walking until week 8. I really don't think the graft or your leg muscles will be ready at week 5.

The first three months post op are critical in this recovery as the graft is at its weakest state (somewhere between water and yogurt consistency).

An e-stim machine or TMES is critical for early stage iso and SLR's. It forces you to fire your quad muscles...therefore taking stress off your graft.

Again, take my advice with a grain of salt. I know many that have been aggressive in rehab and just as successful as myself. Likewise, there are many that have been just as conservative and done well.

I'm at week three for ACI/AMZ done on Dec 16th. All I'm doing is CPM to 40, side leg raises and hip extension with straight leg in brace along with quad iso's with e-stim and ice.

This thing is a marathon and not a sprint. I really think you can do the majority of your knee rehab exercises sans trainer. Get a good routine that doesn't irritate the knee and stick with it. Increase duration and intensity every few months and see how the knee responds. You probably won't see your best result until 36 months post-op....

Let me know if you have anymore questions.

Jon












Offline Room 101

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Re: Room 101's December 2, 2008 ACI
« Reply #2 on: January 05, 2009, 11:08:35 PM »
Yes, Dr. Cole is my OS.  I know he is fairly aggressive.  I have not strayed from his protocol at all, but it is certainly good to hear others.  I will be going to check your link right after posting.  I have followed your diary, and I did catch up some today as I have been sans inet since the surgery.  didn't know what to expect w/ this, but honestly it's just different from the AMZ because after about 8 days that was nothing beyond flexion stiffness and once the bone healed you could be aggressive.  I think working with my trainer is mentally good, plus he has some great ideas on quad strengthening out of the supine/straight leg plain and I can get some reasonable upper and core work with him doing the resisting. Again, it is all brace on and mostly on a massage table, so it doesn't involve the legs at all.   It's also a 100% pain free environment.  I don't think pain is your friend after ACI, but maybe mistaken here as well.

One big difference is definitely the cpm degrees and walking.  Being that they told me to wean from crutches at 9 days post op.  I felt like I was behind or something was wrong, but it sounds like all is probably good, and that the SLR problem will resolve in time... even though that is weird.  I could do all that immediately after AMZ and got full extension back in days.  The lack of SLR strength is a surprise to me, but I'll try not to freak out any more until after Thursday, hahaha.  It's just bizarre how it shuts down.

The ISO quad sets were irritating, so I backed off.  I will definitely be asking about that this week when i go back to Dr. Cole. 

Jon, if I can ask, what made you go to Dr. Cole over Dr. Minas?  Was it a location thing?  (I don't know where Dr. Minas is out of, although I know it has been mentioned here.  I just have CRS I guess)

Thanks so much for your input.  I think you can't ever hear enough stories or talk to enough people about these surgeries.

Take care,
Kim
February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

jonhark

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Re: Room 101's December 2, 2008 ACI
« Reply #3 on: January 06, 2009, 01:24:55 PM »
I chose Dr. Cole because I could get an appt and surgery date ASAP. Dr. Minas has a long waiting list. There also isn't much of a difference in how they do the procedure. The AMZ might differ slightly. Both of them are very competent and the top surgeons in ACI in the US. the actual sewing of the membrane and cell implantation is also fairly easy and they should have identical techniques. Chicago is also a lot closer to Denver and  outpatient instead of 3-4 days in the hospital which I didn't want to deal with. The rehab protocol is really what makes or breaks you in this surgery.

Couple more notes. You mentioned SLR's were attainable after AMZ. Keep in mind, you probably had some fibrocartilage left in your defect before ACI. They radically debride down to bone. The cells they inject under the membrane are viscous at week 6. Therefore, completely understandable to have increased pain compared to post-op. That is something I'm experiencing currently because I had 3-4mm of fibrocartilage in my defect. My pain levels weren't extreme before surgery but I was having catching and that nagging kind of aching after exercise along with some sharp pains on stairs. Without a doubt my nickel sized defect would have expanded to quarter and half-dollar size over the course of months and years given the level of activity. The larger the defect the more unpredictable the results.

Keep positive and you'll be amazed at how much better you'll be feeling ever 45 days or so.

Jon





Offline Room 101

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Re: Room 101's December 2, 2008 ACI
« Reply #4 on: January 06, 2009, 05:59:07 PM »
Hi, Jon.  Thanks for the insight.  I never really researched much beyond Dr. Cole when my other OS recommended him.  I wholly trusted my last OS as he had been my doctor since the late 90s.  I freaked some when he wanted me to see someone else, but then I researched Dr. Cole and went for my appointment and that was that.

I know the rehab is vital w/ this surgery, and it's amazing after reading Dr. Minas' protocol how different they are.  I only bend my knee in therapy or the cpm, but I am limited to a specific max.  I was told not to achieve 90 until 5-6 weeks.  But I was told to start weaning from crutches at 9 days.  Wacky.  I am doing their regimen to a t, but it varied from the papers he has online some.  I am sure it will vary more after Thursday.  They do individualize things at appointments.  You sound as if you go by your own routine, but you're and experienced person, haha.  -- I am a newbie.

The pain is definitely different now than pre surgery.  Not lingering or anything.  It's just when I move wrong, but it goes immediately away.  I try not to provoke that pain.  it doesn't feel good, hahaha.  But it isn't a pill worthy pain, if you know what I mean. 

I found it interesting reading about NSAIDs also.  No one had ever mentioned that to me to avoid them.  I assume Dr. Cole doesn't hold the theory that they are harmful to the cells.  But it's a good question to ask him for sure.

Thanks for "talking" to me, Jon.  You have been very helpful.

Take care,
Kim

February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

Offline Room 101

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Re: Room 101's December 2, 2008 ACI (5 week Dr. update)
« Reply #5 on: January 08, 2009, 09:26:52 PM »
Saw the OS today.  All is well. Incision and knee look great and feel great.  Not much swelling.  Lots of muscle mass loss of course.  My leg looks stupid  :-[

 My concerns on SLR were overdramatic  ;D -- I am 5 weeks and 2 days post today.  I get to ditch the brace at 6 weeks when I ditch the CPM, although as of now I can sleep without it.  After that, I should be able to wean from crutches.

I have no pain except w/ attempting supine SLR or extension.  I was allowed to hang my legs over the table today and it felt soooo good.  Doc wanted me to do an extension, which I got started but failed.  He said it was muscle shutdown from the pain and was normal.   Make sure to get stim at therapy and just keep working.  I am strong in other planes like vertical or on my side, but not supine.  Just keep working the different planes and trying the supine but avoid the pain.  I am at 90 on cpm and doc said to not go higher. 

Meanwhile I will continue 2 days of PT and 2 days of training, which is also an extension of PT... or is PT an extension of training?  :P - I work out at a private training facility that has PT, so they work together and know each other.  My PT is more conventional and my trainer more new age, w/ muscle activation and functional training.  i call it wacky, but it works and I think the combination is killer.

Nothing was said about stationary bike, but I figure that will come in as soon as I get ROM back.  I was told that I could start working on full ROM at my PT appt. tonight.  I was limited to pain free before, which generally was 0 to 5 degrees off the CPM degrees.  I would hope to hit 85-90 tonight in PT as I am finally allowed to 90 on cpm.  Treadmill walking comes at 12 weeks, so right around my next visit.

On to the next step it seems.  I will see the OS again at 13 weeks.  Thanks to everyone for their help and for writing their experiences.

Take care,
Room 101
February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

dileigh

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Re: Room 101's December 2, 2008 ACI (5 week Dr. update)
« Reply #6 on: January 10, 2009, 04:53:35 PM »
most of the traditional exercising doesn't come until about the 12 week mark, didn't even go to PT until then.  I wouldn't be surprised if you couldn't make it all the way around the first time on the bike, but it will get easier.

This surgery makes you be patient, even if you aren't a patient person......


Diana

Offline Room 101

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Re: Room 101's December 2, 2008 ACI (5 week Dr. update)
« Reply #7 on: January 12, 2009, 06:03:44 PM »
Well, tomorrow (Tuesday) will be 6 weeks exactly.  It is the last day for the cpm machine.  Woohoo!  I did kind of like it as it kept my knee moving and fluid.  I hit 85 degrees in PT Thursday last week and today was still only at 85.  My knee is really stiff.  I kicked in major heel slides added to all 4 ROMs & ankle work I was previously doing.  I still can't do a SLR.  In PT Thursday I could do them on the down, but not the UP & down.  Today at PT I couldn't even do one rep without some serious patella pain.  Not the wow I'm stiff kind of pain either... but the breath taking holy crap that is really uncool kind of pain.  We stopped that and worked on stabilizing in the brace and transferring weight with crutches without the brace.  Massage and stim.  I feel really good except for the supine SLR.  Man... frustrating!  Also, being stuck at 85 for flexion after 3 days of working ROM didn't make me happy.  I can  do an isometric quad hold for 6 second holds each rep totally pain free which I could not do a week ago.  So that's an improvement.   I'll feel better when I bypass 90 RoM.  I am sure the SLR will come in time.  I feel good quad contrraction but it still shuts down when the pain hits.

Oh, well.  Another day down in the books.

Take care,
Kim



February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

jonhark

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Re: Room 101's December 2, 2008 ACI (5 week Dr. update)
« Reply #8 on: January 13, 2009, 03:45:23 AM »
Kim--

Some food for thought--when doing quad sets I focus on not hyperextending my leg and try to keep a small bend in my leg. This allows me to do quad contractions without putting too much force on the knee cap while contracting. Do the same when attempting SLR's. It is the opposite philosophy of doing quad sets with a towel under the knee and pushing against the towel.

I think SLR's are great once you build up the muscle to do the work. Otherwise it can be torture on the kneecap....as you are aware. Once your cells start to grow and mature youll be SLR's with no problem.

Using e-stim is huge as well. It really forces your quads to contract and has been a huge help to me over the past couple weeks.

Jon


Offline bsonday

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Re: Room 101's December 2, 2008 ACI (5 week Dr. update)
« Reply #9 on: January 13, 2009, 07:44:01 AM »
Kim,

Keep up the good work, and thanks for your kind words.  I couldn't do an SLR until at least week 8, so don't sweat it at all.  And congrats on being almost done with that darn CPM.

-Ben
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline Room 101

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Re: Room 101's December 2, 2008 ACI (5 week Dr. update)
« Reply #10 on: January 13, 2009, 04:38:02 PM »
Thanks fellas for the posts.  It's funny how every difficult part breeds some fear of doing something wrong or something going wrong.  Jon, I'll try your bent theory.  It's opposite of the usual, but clearly necessary.  I try so hard not to irritate the kneecap, but that's easier said than done, and when it happens, you just have to wait again until it subsides.  Unfortunately, I irritated big time in PT yesterday.  Oh, well, let's look on the bright side.  only 4 hours left of cpm!!  Sweet!

Takre care,
Kim

PS - it's so nice to be out here where people get it... really.  Thanks to everyone for sharing the stories.  It's not such a lonely road out here.
February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

Offline Room 101

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Re: Room 101's December 2, 2008 ACI (Jan. 16 update)
« Reply #11 on: January 16, 2009, 05:50:09 PM »
So, CPM is gone!  It's so weird having time... mornings are no rush now and I'm not up until all hours finishing the time.  Plus, it's just more comfortable, haha.  I do miss it in the respect of movement though.  I reached 95 degrees last night in PT, which was 10 better than Monday, so that's good, but I'm a bit away from the bike.  i have full extension back, but I lack the quads to really do a proper SLR.  Based on previous comments I'm not even worrying about it (I just keep writing it  :P )

I discarded the brace pretty much and it feels good as long as I have some crutch support.  I don't sleep in it anymore, and that's gone well.    I still wear the brace outside in the ice and snow, but inside I feel comfortable.  We've mostly worked on ROM stuff in PT, w/ some beginning stability and basic walking w/ no brace, etc. 

It's not all that exciting, but for some reason it's such a milestone to say goodbye to CPM and the brace, hahaha.

I do a ton of heel slides and 4 way leg lifts (instead of supine SLR, I do them on my side or standing) -- are there any other suggestions for the even fluid motion the cpm gave?  I know the bike is great, but I am clearly not there quite yet.

I feel pretty good so far and have done a much better job of not irritating my patella this week.  In the long run I'll get farther along if I am nice to it.

The only other oddity is that I am getting a weird really quick nerve shot in my big toe... it started a few days ago when I do heel slides or bend.  It feels like it might be coming from the ankle or higher up.  Weird.

Take care,
Room 101
February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

dileigh

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Re: Room 101's December 2, 2008 ACI (Jan. 16 update)
« Reply #12 on: January 18, 2009, 05:18:40 PM »
you might check if it's ok to rock the pedals back and forth on the bike, but I think it might be still to early.

It seems like only yesterday that I got rid of the CPM and strangely missed it afterwards.  Keep up the good work!


Diana

Offline Room 101

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Re: Room 101's December 2, 2008 ACI (Jan. 22 update)
« Reply #13 on: January 22, 2009, 07:28:06 PM »
Ok.  7 weeks post this week.  Things seem to be progressing.  We had quit trying SLRs, and I imagine we will try again tonight at PT.  I think it will be at least more successful.  I ditched the brace last weekend, and it has gone well.  We haven't had any more snow, so that is very helpful in being outside to/from work.  The doc's orders are to go a week w/ 2 crutches, a week w/ one and hopefully down to 0 at just after 8 weeks.  I feel strength improvements for sure.  2 crutches is very easy, so i think one is doable.  Around the house I use one, but I start in w/ some shin pain, so I then go back to 2. 

In PT, I did the bike 10 minutes doing 3/4 rotations pretty much.  I am still only just over 100 degrees ROM.  We'll see tonight.  I'm still really stiff, but it feels ok and no kneecap pain.  We didn't have to push hard to get 100.   I was surprised we didn't push more, but we headed more towards stability and some balancing.  I would expect to add some more items to the list during tonight's session.

It all seems pretty standard and boring I guess.  I'll take it  :D

Take care,
Room 101
February 1 2008 - left knee AMZ/LR/Debridement/ACI biopsy
December 2 2008 - left knee ACI - Patela
May 25 2011 - Left knee mfx - trochlea  (ACI growth looked "pristine"), Right knee ACI biopsy
September 5, 2012 - Right knee AMZ/ACI - patella

Offline Gibbon35

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Re: Room 101's December 2, 2008 ACI (Jan. 22 update)
« Reply #14 on: January 23, 2009, 03:50:27 PM »
Oh the joys and pain of walking again. At 6 weeks i was only on 1 or 2 crutches as well. However i didnt get any shin pain. All my pain was in my damn foot. Literally i think the muscles in my foot just gave up during the 6 weeks nwb. And then when in started putting weight through it.....man oh man oh man. Little bugger!!!  :-X 
Im sure your physio told you but when you do the one crutch thing, remember heel first on the leg. Really work the quads when putting the leg forward and heel down. It will strengthen the VMO and quads and improve the limp im sure youll have to start with.
















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