Remove arthroscopic portal "lumps" of scar tissue?

[Hopesmom]

I have had two surgeries this year to remove scar tissue from the "fat pad" inferior area of my right knee, including the anterior interval.  The last surgery they also removed a suprapatellar plica that was supposedly compressing 1/3 of my knee capsule.  The problem is that now it seems I have come full circle back to my original complaint - pain in the lateral "fat pad" area - the area that bulges out of the lateral side of my patella tendon.  Since they supposedly removed most of the fat pad, I unfortunately have a large lump of scar tissue there now in its place that is a result of the two arthroscopic portals.  My gut tells me that I need to have open surgery to remove that large lump of portal scarring.  The tissue injury from all the work they do with the portals just leaves me with more scarring.  My gut also tells me that this large lump is rubbing against the synovium and causing synovitis.  It is a very painful situation, on weight-bearing and walking.  Is my gut right?  And would this surgerical remedy be possible?

[Rennschnecke]

I don't know whether scarring at the portals can help make things better.  I too have lumps around my portals and have been massaging these to try to break down the tissue.  Some of the lumps are fairly deep and I have been wondering whether it would be impossible to get rid of these surgically as any surgery would lead to some scar formation and possibly more than could be removed.

If you do find anything out about this, please post it here.

[Hopesmom]

I tried the deep friction massage per PT's after my first LOA in January of this year, and it made it worse!!!  Irritated the heck out of those portal lumps and made them hard.

My gut is telling me that possibly a simple open procedure to just remove the lump might do it.  I'm going to get an opinion from an OS.

I think that, at least for me and I can't speak for anyone else, the arthroscopic portals areas have so much tissue damage from the tools doing all that work in those areas.  And I am just left with lumps of scarring each time.

Dr. S in Colorado did tell me at my second surgery in August of this year (LOA again), that occasionally they have to remove those lumps.  But we never addressed it further as my main complaint/problem at that time was my tendon was stuck down and adhered to the scarring under it.  Fortunately that has been resolved but I am still left with a lateral portal that burns on weight-bearing.  This was my original complaint before these two surgeries, but it was my fat pad at that time.

[prech]

I have had two surgeries this year to remove scar tissue from the "fat pad" inferior area of my right knee, including the anterior interval.  The last surgery they also removed a suprapatellar plica that was supposedly compressing 1/3 of my knee capsule.  The problem is that now it seems I have come full circle back to my original complaint - pain in the lateral "fat pad" area - the area that bulges out of the lateral side of my patella tendon.  Since they supposedly removed most of the fat pad, I unfortunately have a large lump of scar tissue there now in its place that is a result of the two arthroscopic portals.  My gut tells me that I need to have open surgery to remove that large lump of portal scarring.  The tissue injury from all the work they do with the portals just leaves me with more scarring.  My gut also tells me that this large lump is rubbing against the synovium and causing synovitis.  It is a very painful situation, on weight-bearing and walking.  Is my gut right?  And would this surgerical remedy be possible?

Sorry to hear about your predicament.  Just brainstorming out loud, but if the source of the pain is portal scarring, and that 'lump' of scarring is all the way at the synovium, then it's quite deep (if I recall, from the skin's surface, through the dermal and adipose layers, it's possibly one inch before one would reach the synovium).  As such, if an open procedure were to be performed, it would seem a larger, more invasive incision would be necessary, so likely to incur even more scarring.

If the 'lump' is present, perhaps it/they would be visible on MRI.  Perhaps the thing to do is getting a newer post-op MRI (it's approaching 5-6 months now?), and sending the images to either Dr Steadman or someone who might provide a free consult (Drs Eakin and Millett have been known to respond to emails personally). 

Brainstorming out loud again, but if the 'lump' is localized, a radiologist/orthopedist might be able to do an ultrasound targeted diagnostic injection (i.e. ropivacaine/Marcaine) to see if that alleviates the pain and points to that as the source of your pain.  If the diagnostic injection works, perhaps the radiologist/OS could even attempt to break it up with a large gauge needle -- this has been done with ossifications/calcium deposits that form in soft tissues (tendons mostly) for a number of years.

[Rennschnecke]

This is interesting, Prech.  I recall that one of my pain consultants gave me a cortisone injection into the scar tissue in one portal as he thought this was a trigger point for pain.  I got some relief for about 5 days, but it went after a PT session.  Since the relief was so short, they have abandoned the idea of giving me a botox injection at that site.  But from what you say there may be alternatives.

What you've mentioned would make more sense than an open op which is more invasive and more likely to lead to scar tissue formation.  The only way I can think of to remove portal lumps surgically is to make new incisions (portals) and I guess the risk is that you end up with bad scarring at the new portals but hope that it isn't so bad as when they've gone into the same portals 5 or 6 times.

[Hopesmom]

I emailed my OS's assistant and I wanted to post his reply:

1.   Sometimes we do have to open up the portal sites where you have had your scopes and remove any scar tissue from those areas.  We usually then close them up with no absorbable sutures as that can actually be the cause of your problems sometimes.

2.   Before we would go with #1 we can actually just try injecting those areas with cortisone and that is sometimes enough to break up the tissue in those portal areas.  I know you aren’t a fan of cortisone because of your reaction to that but it would be the least invasive besides just massage which my guess is hasn’t worked.

3.   It may be that for your joint you would benefit from just a cortisone injection in to the joint for the ongoing soreness.  We do have another procedure that Dr. Steadman may or may not have talked to you about and that’s called an insufflation.  Essentially we put you to sleep in the OR and we inject your knee with saline to distend the joint.  We then take it through range of motion and lots of patella mobility as we gradually draw off the fluid taking it back down to a normal joint volume.  We subsequently do a cortisone injection in to the knee while you are asleep.  This can be very helpful for patients in your case because it is not a very dramatic surgery and can do wonders for the knee.

I really do not want another surgery at this point, 6 months out.  I want to try everything I can conservatively and give it a year or two.  I have been advised and encouraged by others with AF that time is a big factor.  So I'm actually going to try another round of iontophoresis with dexamethasone treatments as they helped me get over a flare before.  Then if that doesn’t help, I’ll try a cortisone injection into the portals.

The insufflation sounds promising, but I wonder if I’m too far out postop.  Also, it would be very costly to fly back to Vail.  Has anyone had huge permanent(?) success from insufflation?

I will post on my progress after the iontophoresis.

Karen

[Hopesmom]

I had my iontophoresis treatment yesterday, so far so good.  I had an interesting conversation with one of the PT assistants who I hadn’t seen since after my first surgery last year at a different PT place.  Anyway she said so often, post knee surgery, when anyone complains about pain, they ask them where the pain is, and they inevitably point to the portals.  Then they call in to the OS and they reply, "Oh yeah, the portals; just give it a year."  I find this very telling.  It’s just too bad there isn’t a better way – I guess arthroscopy is supposed to be the better way, but it has problems of its own, one being a lot of tissue damage from the instruments tunneling around.

[sjc87]

How did the insufflation work out in the long term?  I also had an AIR/ LOA at the Steadman clinic , hoping they could get rid of the portal bump, but it remains post surgery, sadly.  Hope youre doing well!

[Clarkey]

Removing scar tissue completely around the portals can be reduced greatly if you do deep friction massage therapy within 6 weeks post-op. This should hopefully help reduce any excessive scar tissue from building up deep into the portals that can go deeper into the knee. My OS told me after my AIR surgery in July 2014 to make sure I break down the scar tissue around the portals by doing deep friction massage therapy not being afraid to dig down deep into the portals to help break down any scar tissue.

Once scar tissue has set in it hard to reduce causing chronic knee problems, looks like the scar tissue is attacking the my patella tendon causing anterior knee pain, have not been able to run since January 2013. Cortisone injections does not really benefit my ongoing problems that's done for inflammation and not to break down scar tissue.

Portal bumps are hard to remove as opening it up again could increase it even more! The Sanders Clinic has had high praise from KG members with scar tissue problems. Dr. Mark Sanders is worth considering for a 2nd opinion.

http://sandersclinic.net/

Good luck.

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[sjc87]

Thank you!