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Author Topic: Surgical Tactics for Fat Pad Impingement and Arthrofibrosis  (Read 182 times)

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Offline CaliCoast

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Hi All,

I've been unable to walk (no pain, but -15 extension) for 14 months due fat pad impingement and scarring from a meniscectomy and fat pad trim in March '21. I'm now seeing 3-4 arthrofibrosis specialists and each surgeon is proposing a radially different surgery while saying the other surgeons are suggesting irresponsibly dangerous treatments. It's making my head spin. I travel 12-24 hours to new cities and the surgeons always rush me out of their office after ~30mins of evaluation. I rarely get more than 10 mins to ask questions.

I'm realizing I need to become an expert on the surgical procedures they are proposing. So, I'm writing this message hoping someone can shed light on these popular methods.

  • Anterior Interval Release. What is being "released" and how? Does this include cutting anything out? I heard the term "release" means that no tissue is removed and no cutting?  Is this area only between the tibia and the fat pad or does this also include the area between the patellar tendon and the fat pad? Is the scope of this procedure different to each surgeon? Is a release ever accomplished by injection, radiation, or other low trauma option?
  • Lysis of Adhesion. Is this surgical removal of scar tissue? So this will include cutting out tissue with a scalpel, increased blood drainage, possible nerve damage, highest form of tissue trauma? Is this procedure ever done with an instrument besides a scapel? Is AIR typically used for milder AF cases, and LOA is used for major AF cases post knee replacement?
  • Manipulation Under Anesthesia. Is this as simply as pushing the knee into full flexion and extension while asleep? How much pressure are they applying and how long? Since basic weight bearing exercises exacerbate arthrofibrosis, why on earth would any surgeon think this is a good idea?
  • Portal Entry. My fat pad swells by simply standing on it, so cutting portals through it sounds disastrous. Does anyone know the name of other portal areas in the knee that can be used that don't disrupt the fat pad?
  • Instruments. I heard references to a scalpel, cauterizer for burning off tissue or closing blood vessels, and a "gun" for hitting scar tissue with radiation (perhaps this a method of cauterizing??). Does anyone know the tools that surgeons use?
  • Other methods? Have I missed any popular surgical methods or tools?

You may ask why I don't ask these questions to the surgeons when I visit. I do! Yet, traveling a day for 10 mins of questions isn't working and I have some many Qs still unanswered. Hoping this forum can supplement my knowledge. Thank you for your help!


Offline vickster

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Re: Surgical Tactics for Fat Pad Impingement and Arthrofibrosis
« Reply #1 on: May 25, 2022, 07:58:48 PM »
There’s information in the learning portfolio which might be useful
Eg https://www.kneeguru.co.uk/KNEEnotes/articles/general-articles/2019/all-about-arthrofibrosis-knee
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline Wildgoat3

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Re: Surgical Tactics for Fat Pad Impingement and Arthrofibrosis
« Reply #2 on: May 26, 2022, 03:42:53 PM »
Hi Calicoast,

I don't know if I can offer a great deal of information and have to emphasize I am also in the process of learning all this so might not have some of it right but will offer what I can. First, I totally empathize with your feeling of needing to "become an expert on surgical procedure" and your frustration with not getting your questions answered, the minimal time in a visit, etc. What I have done is educate myself as well as I can, going back to the doctor armed with my knowledge, and the other doctors opinions and asking them to further explain their thinking. It is a slow process, with a co-pay each time that I get furious about. It is clear to me that Arthrofibrosis is so poorly understood by most Orthopedic Surgeons, and I sense, something they do not like to deal with, that I no longer trust their opinions on face value. The more I learn, the more I realize I need to take the time to figure this out right because, with AF, things can easily be made worse.

I don't know much about the Anterior Interval Release but I think what happens is scar tissue binds the fat pad, and/or patellar tendon down to the tibia and the cut or remove that scar tissue to free things up. As to your question: Is AIR typically used for milder AF cases, and LOA is used for major AF cases post knee replacement? I don't think it breaks down this way. I think the AIR is what they do for that particular region of the knee and I know the LOA is done for folks who have AF separate from a replaced knee. The LOA addresses scar tissue in all areas of the joint capsule, not just in the Anterior Interval but along the sides and above the patella. Not sure what is meant by portal entry other then I think this is how they refer to the openings the arthroscopic tools go in and also that the placement of these openings in relation to the fat pad, and working around the fat pad, is critical and needs to be considered. I forget where I saw this addressed but make sure you read the section of the International Arthrofibrosis Foundation website on the Hoffa's Fat Pad

Anyway, her is what I know. The LOA procedure is a arthroscopic procedure, not an open surgery, so no scalpel but rather a shaver and a radio frequency wand, that cauterizes, or burns the tissue. The shaver cuts and tears the scar tissue so that it can be flushed out of the site and the wand more burns the tissue. The radio frequency wand is mush less traumatizing to the tissue and since pain and blood are triggers to AF, the wand is a much better implement for the job. But even the best surgeons will use the shaver some if there is a lot of scar tissue since the wand is not capable of handling big amounts of tissue - I think - I am not certain on this point. The next step for me is the LOA so as I learn more I can let you know.

The Manipulation under Anesthetic, when done as a separate procedure from the LOA, is simply the knock you out and bend and straighter your leg to tear all the scar tissue. I had this procedure done and it did no good and have since learned, mostly from this site, that it is a terrible procedure if you have AF. Not only is there the risk that they tear or break something besides the scar tissue, like a bone, but also it is very traumatizing to the tissue - again, creating pain and blood, two thinks you have to minimize if you have AF. I maybe gain 5 degrees in my ROM through this procedure which is a drop in the bucket of what is needed. I have also read that they sometimes do a MUA in the context of doing a LOA but I am unclear on this. I completely agree with your thoughts about the use of the MUA and would rule out any OS who recommends this treatment approach.

Hope this helps and I wish you the best.

Offline CaliCoast

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Re: Surgical Tactics for Fat Pad Impingement and Arthrofibrosis
« Reply #3 on: June 01, 2022, 04:54:53 PM »
Thank you, I  appreciate your response. I'm starting to get the impression the term "release" is not specific to the instrument (shaver vs cauterizer) so will start inquiring about what factors determine what instrument needs to be used when I meet with surgeons. (Whereas "lysis" seems to imply only radio waves or another tool to break down cell walls.)