Arthrofibrosis following total knee replacement.

[David Wright]

http://kneearthrofibrosis.com/ gives information for patients with knee arthrofibrosis specifically following total knee replacement. This is in contrast to most of the other sites which are focused on arthrofibrosis following arthroscopic knee surgeries like ACL reconstruction and surgeries for meniscal tear.

[Clarkey]

Thanks for the link David, Arthrofibrosis is hard to eradicate despite modern medicine advances it still a great mystery how to find a cure. KG member DogfacedGirl has exceptional knowledge and personal experiences coping with Arthrofibrosis after TKR in both her knees. Kay is writing a review paper on arthrofibrosis of the knee, in collaboration with the head of Pathology and Laboratory Medicine at a university.

Kay link to her research asking a series of questions that are can be found in the link below.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=71241.msg661491#msg661491

Kay's KNEEtalk membership link, I am sure she will not mind sharing her research into Arthrofibrosis.

http://www.kneeguru.co.uk/KNEEtalk/index.php?action=profile;u=51296

Hopefully, a cure or prevention during surgery can be found in the future that wrecks the knee once the excessive scar tissue reaches chronic level.

[email protected]

[DogfacedGirl]

Thanks for the link David, the website has useful information. And thanks for your kind words Clarkey 

There are a couple of points that I disagree with on the link. The first is the use of the word "aggressive" for physiotherapy. Physio (and all exercise) must be adjusted carefully according to how the knee reacts to it, and all care must be taken to not push too hard, or the situation can become permanently worse.

And I can't agree that CPM is useless. I personally depend on the CPM to maintain my ROM, without it I would be a lot worse off, but I have to use it daily. The Flexionator that is mentioned as being helpful is just a cruder machine that does the same job as CPM, but is less controlled.

Other points, such as MUA and open lysis of adhesions/revision TKR are very controversial. These procedures can cause serious damage, are technically difficult, and open surgery is particularly risky for TKR knees, because the risk of infection is so much higher, and the ability to control infection so much more difficult on a prosthesis. Injecting corticosteroids into TKR knees is also associated with a relatively high risk of infection, however oral use can be helpful.

Thanks again for the post, it's good to see a surgeon putting information out there so that people can understand the condition better.

Kay
 

[Clarkey]

Hi Kay,

What are your thoughts towards Mr David P Johnson surgical technique and post-op recovery guidelines? According to his website, he was the first OS to perform Arthroscopic Decompression for Patellar Tendonitis since 1994.

http://www.orthopaedics.co.uk/boc/patients/patella_tendonitis_surgery.asp

http://www.kneeandsportsinjuryclinic.co.uk/patient-information/sports-injury/patellar-tendonitis-arthroscopic-surgery/

This is what I will be going through five weeks tomorrow on Friday 9th February with my OS performing the same surgery that a risk and gamble! I tried all the none invasive methods of treatment without any success. A diagnostic arthroscopy at the same might show up other problems that the MRI images failed to pick up accurately. Think he will be doing a 2nd AIR procedure at the same time.

Thanks for the link David, the website has useful information. And thanks for your kind words Clarkey 

There are a couple of points that I disagree with on the link. The first is the use of the word "aggressive" for physiotherapy. Physio (and all exercise) must be adjusted carefully according to how the knee reacts to it, and all care must be taken to not push too hard, or the situation can become permanently worse.

And I can't agree that CPM is useless. I personally depend on the CPM to maintain my ROM, without it I would be a lot worse off, but I have to use it daily. The Flexionator that is mentioned as being helpful is just a cruder machine that does the same job as CPM, but is less controlled.

Other points, such as MUA and open lysis of adhesions/revision TKR are very controversial. These procedures can cause serious damage, are technically difficult, and open surgery is particularly risky for TKR knees, because the risk of infection is so much higher, and the ability to control infection so much more difficult on a prosthesis. Injecting corticosteroids into TKR knees is also associated with a relatively high risk of infection, however, oral use can be helpful.

Thanks again for the post, it's good to see a surgeon putting information out there so that people can understand the condition better.

Kay
 

I agree that aggressive physiotherapy is the last thing needed after AIR Surgery that happened to me after my AIR surgery in July 2014 after enduring an aggressive physiotherapy session. Up to that point was recovering well-doing friction massage therapy and patella mobilisation. A slow and gradual increase in building up the muscles is the better option to consider to avoid any long-term damage adding more costs to the health services for future treatments that could have been avoided with gentle physiotherapy sessions.   

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[Clarkey]

Hi Kay,

A more detailed post-op PDF on Rehabilitation Protocol for Arthroscopic Decompression for Patellar Tendonitis guidelines by David P Johnson MD giving better information than the previous links.

http://www.kneeandsportsinjuryclinic.co.uk/wp-content/uploads/2015/05/Rehabilitation-Guidelines-for-Decompression-of-Patellar-Tendonitis.pdf

Experience has shown that this initial three week period of gentle range of motion exercises results in the pain and swelling to settle and the patellar tendon to heal sufficiently for normal activities of daily living and physiotherapy to be started after three weeks although impact exercises and jogging should not be started for a full three months. During the initial three week period gently straightening exercises, straight leg raising and knee flexion should be undertaken. This will ensure that the full range of knee motion is regained and that the knee does not become stiff.

Seems like sensible good advice apart from three months post-op returning to running is too soon adding another three months totalling six months or longer. Should only do high impact exercises for a short period of time. My personal opinion if you have problems with Arthrofibrosis after surgery, we all recover at different time rates after surgery.

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[DogfacedGirl]

Hi Clarkey,

Yes, the advice sounds good, and they have a cautious approach to physiotherapy. Be particularly careful with straight leg raises post op, and stop if there is pain. Physios often assume that no damage can be done with straight leg raises because it seems like an easy no resistance exercise, but the weight of a leg is considerable, so there is stain on the patella tendon. The tendon has just undergone a procedure that causes inflammation and is delicate.

My patella tendon became severely inflamed from doing straight leg raises following a patella tendon realignment. The physio didn't believe there was a problem and told me to push through the pain, until my quads stopped working. Then they did a scan and found that the patella tendon had shrunk by 1/3 and had scar tissue, it took 2 years before I could drive my car again, but the tendon will never fully recover.

All the very best for your surgery!!

Kay

[David Wright]

Great. But you seem to disagree with almost everything (aggressive physiotherapy, CPM, Flexionator, MUA, injecting corticosteroids into TKR knees, open lysis of adhesions, and revision TKR). I would suggest you to contact him at kneearthrofibrosis.com/contact-us, ask for explanation and post his reply here. It will be useful for every one. He replies promptly.

[David Wright]

Great. But you seem to disagree with almost everything (aggressive physiotherapy, CPM, Flexionator, MUA, injecting corticosteroids into TKR knees, open lysis of adhesions, and revision TKR). I would suggest you to contact him at kneearthrofibrosis.com/contact-us, ask for explanation and post his reply here. It will be useful for every one. He replies promptly.

[DogfacedGirl]

You have to satisfy yourself as to the best approach David. As a scientist I personally go on the science, not on any particular individual's point of view, which is why I like to reference what I say. But you can contact the surgeon yourself, just bear in mind that to some surgeons, the answer to everything is surgery. Lysis of adhesions helps some people, for others it makes things a lot worse - you can find that information on this website. More surgery is always a risk.

There have not been many clinical trials on the use of CPM, all I can tell you is that in my experience it was crucial in having a knee that still bends enough to get into a car etc. But it must be done carefully and well controlled, or you can do damage - also my experience, which is why I'm wary of Flexinators (which many surgeons like).

I don't recall saying anything about revision TKR or open lysis of adhesions, but my reading indicates that for fibrosis suffers, the risk of a bad outcome is high. I don't have time to reference this now, I have a paper on arthrofibrosis to work on before I go away.

Kay

[David Wright]

Since you claim that you are a scientist, I assume that you know “pubmed” which is THE resource for all medical publications. Before an article gets accepted by a pubmed indexed journal, it undergoes peer review process by people in the same medical specialty and they have to approve that the article has valuable information to be published. Multiple recent articles, each based on data from multiple patients, indicate that the CPM is not effective as it was thought before. We have enough data against CPM to conduct a systematic review or meta-analysis. It is not based on any particular individual's point of view as you mentioned. I do understand that you do not have time to reference and you have a paper on arthrofibrosis to work on before you go away. Best of luck with your research project with level V evidence.

[DogfacedGirl]

I don't engage in online disputes David. I won't be responding to any more of your posts.

Perhaps you would like to post some references about research into the use of post-operative CPM for the other readers. And bear in mind that the vast majority of people who have operations don't develop arthrofibrosis, and therefore don't have any need to use a CPM.
Kay

[David Wright]

The following are the recent articles that say the CPM is not as effective as it was thought before. The Journal of arthroplasty is considered the most respected journal for hip and knee replacements. The use of CPM is considered obsolete.
https://www.ncbi.nlm.nih.gov/pubmed/26165955
https://www.ncbi.nlm.nih.gov/pubmed/26878531
https://www.ncbi.nlm.nih.gov/pubmed/26486536
I agree that the vast majority of people who have operations don't develop arthrofibrosis but the CPM was developed to help with range of motion to knees after knee replacement in general, not specifically for knees with arthrofibrosis.

[David Wright]

The Flexionator machine is not cruder since the patient manually applies the necessary force as well as the range of flexion and the patient can immediately stop if pain arises. The CPM machine has to be preset to a specific range of motion and there is no provision to stop when the pain arises. Also, there is no control over the amount of force in CPM. Perhaps, the CPM might have helped you as a tool for limb elevation by reducing inflammation and swelling.
The risk of infection with open surgery for TKR knees is not "so much higher". For primary knees, it is 0.5-1% and for revision knees it is 1-2%. Thousands of knee revisions are happening safely annually.

[Stephen Smith]

Is that arthrofibrosis following knee replacement is same as arthrofibrosis following knee arthroscopy / knee injury?

[David Wright]

It is possible in regards to the magnitude of involvement of the knee.