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Author Topic: AF after fat pad debridement - should I have surgery to fix?  (Read 11995 times)

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Offline josowiam

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AF after fat pad debridement - should I have surgery to fix?
« on: March 02, 2011, 06:27:11 PM »
Hi all,

I hope some of you who have gone through similar experiences as me can help me make some tough decisions.

In November, 2010 I had a "routine" exploratory scope to try to determine cause of sharp, antero-lateral pain that I would experience only while running.  Other than this pain during running, my knee was fine and strong.  During my consultation prior to surgery, I explained to the ortho that autoimmune diseases run in my family and asked if that should be considered before surgery.  He did not indicate any reasons to avoid the routine scope.  The scope lasted 10 minutes and involved debridement of my fat pad which was slightly hypertrophic.

Beginning days after surgery, things began to go wrong.  My knee swelled up like a grapefruit for several weeks, I was not able to walk at all for 2 weeks and was not able to walk down stairs properly for up to 2 months.  I began doing PT the week after surgery and nobody suspected that I could be forming scar tissue in my knee.  In fact, I was able to gain virtually full ROM in both extension and flexion.  However, as time went on, I noticed large lumps around my patellar tendon, extreme knee stiffness, and an inability to do any quad strengthening exercises.  For the first 2 months following surgery, my ortho was completely unavailable and would tell me to speak with his PA who would just tell me that everything is fine and to be patient.

Fast forward to today and my knee has continued to worsen.  I am beginning to lose some ROM in flexion and the knee is extremely painful when pushed to full extension or when attempting a quad set.  When attempting a sitting knee extension I can not bring the leg back to a resting position without extreme pain and loud popping/crackling throughout the knee.  I can not do a squat without a great deal of pain and certainly can not run, etc.  In the weeks following surgery I was able to do a stationary bike but even a bike now seems to cause a lot of kneecap pain.  I do however still have virtually full ROM, granted this comes along with pain.  I have some patellar mobility but it is very limited as compared to the good knee.

I recently had an MRI that showed "extensive fibrosis" in both my lateral and medial fat pads and the fat pad fibrosis has become fused to my patellar tendon.  After discovering this website, I recently sought an opinion from Dr. Noyes in Cincinnati who immediately recommended an open debridement with proximal Z-plasty.

As I do still have nearly full ROM, I am wary to rush into another surgery.  I can currently walk, still work full time, etc. and I am very scared that an additional surgery may result in new scar tissue being formed making my situation even worse!!  Without surgery, can I expect my knee pain, ROM, etc. to get worse and worse or are there any non-surgical things that I can do at least for the next few months to see if I can avoid another surgery?  My ortho who conducted the surgery seems to have very limited experience with AF and has been little help.  Is surgery really my only option?  Has anybody had luck with other non-surgical treatments/PT to improve AF?

Any feedback would be greatly appreciated!!

Offline Rennschnecke

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #1 on: March 02, 2011, 06:46:58 PM »
Non-invasive options that may provide some relief include deep tissue massage, ultrasound and possibly acupuncture.

Aside from that you should seek further consultations to enable you to come to some decision.  Many people have gone to Dr Steadman's practice.  I don't know if this is an option for you, but they do arthroscopic treatments as well.  If I were you, I'd leave an open procedure as a last resort as the recovery is hard and the risk of AF is higher.

If you haven't already done so, try working your way through this board to benefit from the experiences of others, especially those who have been successful and are much less likely to visit frequently.

HTH
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline josowiam

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #2 on: March 02, 2011, 06:57:33 PM »
Thank you very much for the response.  I am scheduled to see Dr. Steadman on 3/31 so I am hoping that he has some better news for me!  Is an arthroscopic removal of scar tissue typically as effective as Noyes' open debridement?

My PT currently uses suction cups around my knee to squeeze the soft tissue in an effort to break up the scar tissue.  He has also tried acupuncture but things just seem to be getting worse.  Dr. Noyes was not very receptive to these treatments as to be expected from a surgeon but I will continue with these treatments to see if there is some improvement. 

My original ortho recommmends that I begin using Celebrex for an extended period of time to see if that helps.  I am just concerned that the long term use of Celebrex would just temporarily mask the problem instead of solving it..

Offline Rennschnecke

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #3 on: March 02, 2011, 07:22:43 PM »
I can't see how Celebrex could mask AF.  Celebrex is an anti-inflammatory that is apparently effective for chronic inflammatory conditions.  It isn't just a pain medication.  It could help reduce the risk of you getting worse.  However, diclofenac and naprosyn might be suitable as well if your gut can take it.  Naprosyn was suggested to me by one OS.  I'm just sensitive to diclofenac so my GP was against naprosyn.

Whether arthroscopy would be just as effective as an open procedure depends on where the adhesions are.  Can't be black and white about this.  :-\
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline Stasha83

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #4 on: March 02, 2011, 07:30:51 PM »
Hi Josowiam

I have AF as a result of fat pad removal and imobilisation last June. I suffered from severe constant pain, my ROM was 80 flexion and I had an extension lag of 10 degrees. I had a fixed flexion deformity and lower limb rotation. My hip has now also rotated inwards from compensating for the past 8 months.

Throughout this time I had constant physio and regular OS appointments. I saw a new OS in December and was finally diagnosed. We attempted all non-surgical options (including acupuncture) and nothing worked. I had a LOA and MUA last Friday and so far so good. My patella was stuck down and my patella tendon has shortened. The front of the knee was full of scar tissue. The patella has been released and mobilised and the scar tissue released/removed. This was done by arthroscopy.

I am also on Celebrex. My pain specialist put me on it in January and my OS has recommended that I carry on using it (along with a cocktail of other drugs).

Obviously I couldn't say if this would work for you but my OS would only perform open surgery as a last resort. You will be in good hands with Dr Steadman. I am in the UK but he would have been my first choice if I lived a little closer!
June 2010 - R knee TPF & Hoffa removal
Dec 2010 - R knee- Arthrofibrosis
Dec 2010 - L knee Myxoid degeneration of meniscus
Jan 2011 - R Knee 11 steroid injections & Synvisc1
Feb 11 - MUA & LOA
June 11- Steroid inj, EMG & nerve tests
Aug 11 - MUA & LOA
Feb 12 - R Knee denervation

Offline josowiam

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #5 on: March 02, 2011, 09:50:23 PM »
Rennschnecke, thank you again for your response.  I had been taking Naproxen from Dec - Feb but stopped taking it when Noyes said that it would simply mask the problem and that long term use could cause liver/kidney issues, etc.  I think I am going to start taking it again as the pain has gotten worse.

Stasha83 - it sounds like the drugs/PT did not do much to help.  Even though I am in a lot of pain during extensions and squatting, etc. I am still able to pretty much function day to day.  That is why I am so afraid of another surgery that may make me worse, not to mention 1 year + of recovery and not being able to work, etc.  What kind of post-operative measures is your OS taking to ensure that you do not re-form scar tissue in your knee?  Has he given you a likely long-term prognosis (i.e. back to normal/running vs. walking and light recreational activity)? 

Thanks again for the responses!

Offline Rennschnecke

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #6 on: March 02, 2011, 10:17:50 PM »
Yes, long term use of naproxen can cause damage to your digestive system particularly.  All drugs can affect the liver with long term use at high dosages.  I've been reassured that the doses I take are safe, but I've noted that the dosages used in the US is twice that allowed in the UK.

While rehab from AF surgery is intense, you don't need to be off work for a year.  You could return after 2 weeks although going for the max of 6 weeks is good.  Have you read the postings for JakeM's AF op.  He is an example of a successful recovery.  Also HeatherM and Laurie who went to Steadman.  There are other people who have succeeded following a visit to Steadman for AF surgery lots.  You would probably find them by Googling Steadman in the top right corner.  That will give you a good idea of the range of protocols leading to recovery.

Please note that procedures undertaken by OSs vary on a patient by patient basis as needed.  I don't think anyone can guarantee you will not reform scar tissue.  Scar tissue is part of a natural healing process; the aim is to minimise the impact on function.  Whilst OSs can indicate the risks involved with a procedure it's difficult to predict return to activity.  The aim is always to help people back to a relatively pain-free existence while performing activities of daily living.  Bear in mind that the figures are based on the OS's experience and your own history, e.g. surgeries, current ROM and history of recurrent adhesions.  Hence one person's prognosis may not match your own.  BTW I got two risk assessments one by my OS, one from his 2nd opinion and my own OS was much more pessimistic than the 2nd probably because he knows my track record intimately.
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline missmyknee

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #7 on: March 03, 2011, 01:23:22 AM »
Hi

I am a patient of Dr Noyes. I had the surgery he is suggesting to you, done in Oct. 2007. Here is the link I posted about it.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=39153.0

Dr Noyes is top notch and a pioneer in AF research and methods for treatment, post op protocals and rehab. He's written over 240 articles. I've been with him since 2004. I've had 6 surgeries with him. I will not let anyone touch my knee but him. He used to use Diclofenac, but switched to Celebrex . I was put on Celebrex once I was awake in the recovery room. I've been on it since my last surgery with him in April 08.

The was a study done using NSAID to prevent adhesions. Celebrex showed the best results. Here is the study

http://www.pslgroup.com/dg/24995A.htm

When I have had surgery with Dr Noyes, I've had to stay in Cinci for several weeks to go thru his specialized rehab program done in his office. I rehabbed everyday, twice a day, plus the exercises I did  where I was staying. Dr Noyes visits the PT room  every Tuesday and Thursday to check his post op patients. He does this twice a day. He is able to take care of any problem right away. His PT staff is top notch. They monitor the patient closely and modify the program when necessary and consult with Dr Noyes.

If you have questions about your consult with him, such as arthroscopic v.s. open procedure, email or call Donna so she can have him answer them. Better to get the answer from the him, than speculate the how's and why's.

If you have any questions , let me know.

Pam
4Fx Clsd red
IMrod fib plate
derotate osteotmy tibfib
AF
IPCS patbaja
DeLeeOsteotmy,LOA,LR Zplasty,bongrf,chondrplty
chondrplty,LOA,fatpad remvd
TKR
openLOA,neurectmy,ITB Zplasty,fabela
PLC recon,revison,LOA,synovec
MCL,revison LOA
openLOA,prox Zplasty
openLOA, 6 neuromas excised,synov
3 Fusions

Offline Stasha83

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #8 on: March 03, 2011, 09:35:36 AM »
I can understand why are you are afraid of another surgery - I was exactly the same although my quality of day to day life was very badly effected. I had to decide whether I wanted to stay as I was (constant pain, restricted ROM, limping badly) or attempt to get my life back. I choose the latter and although I am only 6 days post op I am thrilled with my progress so far.

Post-op I was given a femoral nerve block for pain control and was also given a Fentanyl drip which I could press when required. I was seen by the hospital physio about 5 hours after surgery and started on the CPM. This was delayed as I had a nasty fall an hour or so after my surgery and needed a few hours to get over the shock and pain of that! My OS also had to come back to make sure I had not done any obvious further damage and x-rays etc were taken. I was in hospital for 4 days and my OS and the physio visited daily and also ensured that pain was controlled. I was on the CPM throughout and have been discharged with the necessary drugs for pain control.

There is no denying that the rehab is going to be hard, painful and long. I am currently seeing my physio every day and the rest of my time is spent on a CPM machine. I spend all day on it (other than when I am at physio), with a half hour break for icing, elevating etc every 2 hours. I am also allowed to sleep without it in the evenings for 8 hours. My OS and physio speak weekly and any issues can be discussed as they arise. I am being reviewed by my OS on Monday. I have been advised that I will be off work for 2/3 months (I do an office, desk based job).

In terms of recovery I think it is too early to say. The OS got me to 140 flexion and 0 extension in theatre so this is what we are aiming for. I am currently at 105/110 flexion (passive) and maintaining 0 extension. Wether I will ever return to running and going to the gym daily I am not sure, but I would consider being able to function in day to day life without a limp and pain a success as I was so limited before.
June 2010 - R knee TPF & Hoffa removal
Dec 2010 - R knee- Arthrofibrosis
Dec 2010 - L knee Myxoid degeneration of meniscus
Jan 2011 - R Knee 11 steroid injections & Synvisc1
Feb 11 - MUA & LOA
June 11- Steroid inj, EMG & nerve tests
Aug 11 - MUA & LOA
Feb 12 - R Knee denervation

Offline josowiam

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #9 on: March 03, 2011, 06:31:25 PM »
Thanks for all of the responses - very helpful.

My job consists in large part of travel across the country.  I figure that another surgery plus proper recovery to prevent reformation of scar tissue will likely keep me off the road for one year - that's why I am trying to avoid the surgery if possible!

My biggest worry is that things seem to be getting worse.  Walking and sitting cause aching and pain around my patella and quad and I can feel new areas of crunching, etc. that were not there in the past.  When I see Dr. Steadman on the 31st I will definitely mention the possibility of getting a cortisone shot to slow down the scar formation process.

My biggest question right now is around the surgical window.  At a certain point following my original surgery does the likelihood of success of an LOA surgery or z-plasty decrease?  At a certain point is open debridement the only option vs. arthroscopy?  I would also like to find out (if possible) when scar tissue stops forming?  I had surgery in November and the scar seems to keep growing and growing - when does this process stop (if ever)??

Offline Rennschnecke

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #10 on: March 03, 2011, 07:35:41 PM »
Your questions are very specific and medically focused so require expertise that is properly held by a Dr.  Most of us on this board might be 'expert patients', but our expertise is limited to our own experiences and research around our own conditions.  So this board is good for finding out about patient experiences.

I think you may get better answers by asking your OS.  As Pam suggested, contact Dr Noyes about your concerns.  He will have a better overview of the whole area and can draw on years of expertise and knowledge gained from his own practice and that of colleagues within the US and internationally.  I don't think you can beat that.  Similarly, ask these questions of Dr Steadman at your consult. 

Your anticipation at being off work for a year may be unfounded.  Some people have had surgery for AF and returned home within a week.  They can also return to work within 4 depending in their circumstances.  Every person here has had a different experience even from the same OS simply because their needs differed.  To find out what you should be thinking of talk to the Drs.  They can give you a much better answer having examined your knee.

1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline Clarkey

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  • Neil TheElephant knee packed up carrying his trunk
Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #11 on: March 26, 2011, 04:32:33 PM »
Hi There,

I had my fat pad trimmed and my medial plica removed in November 2009 and have been having problems since the surgery and my knee ended up worse rather then better and my knee felt better pre op then it does post op. I always wounder myself could it be AF after my scope as I always have swelling and pain around the portal on the medial side of my right knee. I had two cortisone injection pre op and post op and having IMS sessions but it not really helping reduce the pain and swelling. I am now thinking about having a 3rd cortisone injection as the pain has increased again but will be up to my OS if he willing to give me a 3rd cortisone injection!

Maybe another look inside my right knee is required as the pain is not getting any less and over 16 months post op and should have seen some improvements by now. I am finding it hard to find an OS that will take my knee problems seriously and do have an OS in mind who specializes is soft tissue problems of the knee. I will finish my IMS sessions then will ask to see this OS who seems to know more about AF and soft tissue injuries and problems.

I would love to be able to run again some day but at the moment get too much pain at the bottom of my knee as soon as I start to jog. I am from the UK and rely on the NHS but find it takes too long to get treated by them which is ashame as they not as bad as people make them out to be just a bit slow to treat their patients.

Even if heard of Dr Noyes who one of the Worlds best OS's for AF and would be the best person to see about your knee problems and know a KG member who saw him and got treated by him who had AF. For her the surgery did not make he knee any better and looks like she stuck with having AF all her life but it can be beaten if you do the correct aftercare that been instructed by your OS.

Nick :) {2011} :)





RK: PFPS, Arthrofibrosis, Tendinopathy, Five cortisone injections
16/01/18 Anterior interval release, distal patella excision, lateral meniscal repair
18/07/14 Anterior interval release  
16/11/09 Medial plica excision, fat pad trimming

Offline josowiam

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #12 on: April 11, 2011, 10:09:10 PM »
Hi all,

Visited with Dr. Steadman 2 weeks ago and unlike Dr. Noyes, he does not recommend an open debridement to treat the arthrofibrosis in my left knee.  Steadman wants to do an arthroscopic LOA and feels that proper rehab in Vail along with the arthroscopy is a better option for me.

Noyes earlier told me that my fat pads need to be excised since they are so scarred and that this is an open procedure.  As both Noyes and Steadman are considered AF "experts" I am having a difficult time choosing which OS to go with.  At the current time I think I am leaning towards working with Steadman as I have seen a lot of other posters on this forum consider him the expert on the issue and also because it seems to be that an arthroscopic LOA would be less risky in terms of making me even worse than an open excision.  Any thoughts??

Since my last post in March, my anterior kneecap pain has become so bad that I am struggling to walk at all.  I still have almost full ROM (according to Steadman I have a slight extension deficit) but the kneecap pain could very likely be cartilage damage that seems to be getting worse by the day. 

Again, I am leaning towards getting the operation with Steadman and then trying to spend a few weeks out in Vail to work directly with his PT clinic.  While it would be much more convenient to go to Cincy and see Noyes, from what I have heard, Steady is the best option.  If anybody could comment on my thoughts above it would be greatly appreciated!

Thanks!

Offline Rennschnecke

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #13 on: April 11, 2011, 10:59:41 PM »
An arthroscopic procedure would be less invasive and the risk of redeveloping adhesions is less than for an open procedure.

If the arthroscopic procedure doesn't work out then you could go for an open procedure then.

I'd certainly opt for an arthroscopic procedure over an open one.  The key thing to consider is whether you believe that the arthroscopic procedure will address your particular situation.

I know that removal of the fat pad can have variable results.  For some people it successfully removes the pain, for others it provides no relief.  As far as I can tell (not a medic), it seems akin to removing a meniscus but from the front of the knee.  I would personally put this off for as long as possible, but it might be that you are there.  Sorry, just wittering on with no real advice.

Essentially, both OSs are excellent but they do have different approaches.  If you have the time look up the posts by HeatherM.  She too had to choose between open and arthroscopy and felt she could accept arthroscopy more readily than an open procedure.  You may have to go with your gut feeling as to what you can bear.

Best wishes
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

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Re: AF after fat pad debridement - should I have surgery to fix?
« Reply #14 on: April 12, 2011, 04:20:41 AM »
I am pretty new to AF as well, just having found out that I had AF a few weeks ago when an OS in Seattle diagnosed me and suggested arthroscopic scar tissue removal. After I saw the OS in Seattle and I had done some research and was more familiar with AF and its consequences, I made a list of questions to ask the OS and called him back. The OS was very accommodating answering my questions but his answers made it clear to me that I needed to see an AF expert.

Doing research on this board has been very helpful for me. I particularly followed some of the knee guru posters histories and I decided that my top choices for doctors are Dr. Eakin (a former fellow at Steadman clinic), Dr. Steadman, and Dr. Millet (also of Steadman clinic). I decided to see Dr. Eakin first because I will be in Southern California at the end of April for other reasons and so it was convenient for me to see Dr. Eakin and I have an appointment with him on April 25. Dr. Eakin follows the Steadman protocol. However, if I am not satisfied with his answers and I want to see somebody else, I am planning to make an appointment with Dr. Steadman or Dr. Millet.

AF is a very scary thing and it is very difficult to get over it. I would like to be in the situation as well, where I could be comfortable with making the right decision to proceed with surgery, but I think that AF is not a condition where one can be 'comfortable' with it. However, I will do my best to do my research and to ask questions - I have made a list of them to bring to my appointment.

It looks to me as well that an open procedure poses more risk to develop additional scar tissue than an arthroscopic procedure. You might want to ask more questions to both Dr. Noyes and Dr. Steadman to get a better idea of why they recommend the one thing versus the other. It's always hard to come up with all of the right questions during the doctor visit and it's perfectly ok to check back with them. A good OS should be willing to answer your questions. Trust and a good rapport is a very important aspect as well.

Looking at past histories like HeatherM's who had to make a similar decision like you, as Rennschnecke suggested may be a good way of getting a better sense of the choices that you have. Some of the people have very lengthy posts but if you search on names of posters and subject matter you can narrow down some choices.

My last surgery was 18 months ago and my knee has been stable for several months now, so time is less of an issue for me. I notice though that stress causes my knee to re-act and I can only do so much reading about AF before I notice my knee pain more. So I have to dose my 'AF research'.

You might not want to wait too long with surgery though. From what I read, the surgery is easier if the scar tissue has not hardened as much and you are still within that time frame of 6 months to 12 months.

I don't think that there is a rule of when scar tissue stops forming. One of the posters that I have heard from got her AF back when she did a 12 mile hike 6 months after her AF release surgery and needed another release surgery. Then she was very careful with her re-hab and did not do anything into the pain for 1 year and she got over it and now she can downhill ski and hike again.

I had just a little AF after my big ACL surgery and got the really bad AF after a simple arthroscopic procedure that was done a few months later. I had a pretty good ROM after my second surgery but then it got worse and worse as I went into inflammation cycles. My OS at the time was not familiar with AF and I had rushed through re-hab though because I really wanted to do a planned international trip to Asia and Europe and I went into the second surgery with a swollen knee. I think that I am a slow healer but I think that both the aggressive re-hab and the inflammation at the time of the surgery caused the bad AF.

If you are planning to have surgery soon, you might want to be extra careful now and not 'test' your ROM and do anything that could aggravate your current situation.

Good luck with your decision and taming the AF beast! ::)