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TKR 16+ weeks out and ROM of 90 degrees!

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Hi,

I have now received the answers to my questions that I put to my OS before I have the MUA.

In his opinion, the clear reason for my stiffness/limited ROM is adhesions caused by my allergy to strong pain medication. He goes on to say that this probably hindered my ability to do the exercises and required bends post TKR. (what the hell does he know about it and how hard I have worked! My PT says no-one could have done/tried more) OS said he has looked at my x-rays again and is adamant that everything he has done is fine. (whoopee do)

He says the MUA will put me back on crutches for a week or two and cause more swelling and pain. I am to be in hospital on a CPM for 24 hours and he suggests I hire one for at home and use it for at least 8 a day for 2 weeks and that I should be off work for between 3 - 6 weeks. (he obviously thinks I have a money tree in the garden and do not need to work for a living!)

I have organised a week off work post MUA and that's it. I have to get back. I cannot afford to lose my job. I have spent about £1,800 on physio, a bike, a peddler an aerobic step, painkillers etc., and can't afford anymore expense.

I have read the articles about MUA and the chap that refused one who was better off at 1 year than some of those that underwent the MUA. If I thought this would be the case (its a shame we don't have a crystal ball) I would not put myself through it. I am still verging on cancelling.

I am convinced, that as my knee is still swollen that of course, it won't bend fully and I am also convinced that I have much more healing to do yet. (I have been a bit slow to reach most milestones). Can I put the MUA off until after a year? I have followed up with this question to my OS and waiting for his answer.

I am much improved than before the op. so should I just be grateful for what I have and get on with my life?

Sorry for whinging on about this. As you can tell, the decision is crushing me.
Any advice would be welcome.
Thanks again
 
I am sorry not to have any information or opinions to offer but I wish you the best at this difficult time.:flwrysmile:
 
Undermedicated pain is believed to be a risk factor for adhesions. I however do not understand why this is so. I've seen several professional papers that suggest that some of those with adhesions were "unmotivated" in PT. And they believe aggressive PT after intervention is the appropriate rehab.

As you say, you did adequate (and probably more than adequate) PT. So this goes back to the point I try to convey to everyone struggling with adhesions and arthrofibrosis: no one really knows why this condition happens, and there are few treatment options.

If indeed your ortho got good ROM on your leg after he installed your knee in OR, that leaves adhesions or its more serious form, arthrofibrosis, as the culprit. Arthrofibrosis involves chronic inflammation and effusion (joint fluid), which could explain your swelling so far out from TKR. (BTW You need to change your signature to reflect the correct year of your TKR.)

Doctors say the adhesions mature into tougher material as time goes along, and that does make logical sense to me. You'll have to check to see if there's someone who would do MUA at one year. The difference between you and me is that I very much wanted decent bend. You on the other hand are happy with what you have. Considering that, I can see why you don't want to do the MUA. But if you are to do it all, I think now would be the time.
 
sparkie said:
Hi,

I have now received the answers to my questions that I put to my OS before I have the MUA .

In his opinion, the clear reason for my stiffness/limited ROM is adhesions caused by my allergy to strong pain medication. He goes on to say that this probably hindered my ability to do the exercises and required bends post TKR. (what the hell does he know about it and how hard I have worked! My PT says no-one could have done/tried more)

I am convinced, that as my knee is still swollen that of course, it won't bend fully and I am also convinced that I have much more healing to do yet. (I have been a bit slow to reach most milestones). Can I put the MUA off until after a year?

I am much improved than before the op. so should I just be grateful for what I have and get on with my life?

Sorry for whinging on about this. As you can tell, the decision is crushing me.
Any advice would be welcome.
Thanks again
Click to expand...

Hello, and sorry your OS is making you think that a reaction to pain meds could be the cause for adhesions. :scratch:
You have the right to decide when if ever you have an MUA though!
If it is swollen, I would suggest, elevating, icing and taking something for pain if it is painful. If you can, take that month off the job to do nothing but let your leg heal! It is still healing, and working and exercising will keep it inflamed. If you can't afford to miss work, can you prop your leg up with ice packs while you are at work? It is worth a try to avoid more surgery! :console2:
 
I have wisdom or advice but please know that we are all behind you in your decision.
I am filled with compassion for you.
Maggie May

PS. How could an allergy to pain Meds cause adhesions?!


Sent from my iPad using Tapatalk - now Free
 
Thanks for the good wishes. They mean a lot to me.
I did not explain myself very well - I am allergic to the stronger types of pain medication (my blood pressure goes dangerously high and I swell up and itch all over) so I could not take them. Therefore my OS believes that my pain must have not been under control meaning I couldn't do what was required of me! And due to a kidney condition, I have not been allowed any anti-inflammatories.

I also didn't make clear that I am not happy with how my knee is. I am better than before the op', but am finding living with +5 to +90 knee is causing me simple problems such as not being able to walk downstairs properly, wash my foot in the shower, put some shoes on, get in and out of the car etc. I am still not putting the weight on both of my legs to sit or stand up again. And to top it all, my other knee has started to hurt. My walking has improved a lot, but I am still slow (faster than I was before the op') with a bit of a limp.

I would have the MUA if I knew it would improve things. I didn't expect the OS to tell me I would be back on crutches again and that I should pay for the hire of a CPM machine. (How long do I stay on it per day and for how many days? if I can find one or afford it even?)
Is there an alternative to the CPM? Such as a bike or will this be too painful?
I HAVE to work. The week I have arranged to have off is a part of my annual leave.

I cannot believe that the OS has recommended a CPM with no intention of the hospital loaning me one or telling me where I can hire one etc. I have been absolutely on my own with this. He hasn't even seen my knee close up since it was done. He looked at it, in July, from across the room while I sat on a bed about 15 foot away from him. How would I know if it joint fluid? Should/Would the PT have known/told me if it was?

I appreciate he is clever individual and appreciate his skills, but I don't appreciate the sheer arrogance of the man.

Sorry to bend your ears again. Thanks for letting me.
Best wishes to you all too.
 
Oh doctors can be so arrogant, can't they? So if an arrogant doctor interacts with you a certain way, even if he was right on the money, you'd have a hard time trusting his judgment. I'm too lazy to go look, but did you get a second opinion?

Now that you've clarified that the knee limits trouble you, I'd say consider doing the MUA. As Josephine pointed out, you "risk" more ROM and certainly would not end up with less. Plus I don't recall using crutches after my MUA or arthrolysis, and I was not laid up in the way he described. It amounts to a muscle pull, really. But I completely understand your feelings about not knowing if the MUA will work or not, because I had the same sense of uncertainty.
 
sparkie said:
I am convinced, that as my knee is still swollen that of course, it won't bend fully and I am also convinced that I have much more healing to do yet. (I have been a bit slow to reach most milestones). Can I put the MUA off until after a year?
Click to expand...
Of course you can! I've known people have an MUA 12 months post-op. And the principle cause of low ROM is swelling rather than adhesions. Adhesions are relatively uncommon by comparison. And you are at 90 degrees of flexion which is a good place to start at. Most knee surgeons won't consider MUA if the patient is achieving that so be encouraged. You can still improve a LOT in the next few months.
sparkie said:
Is there an alternative to the CPM? Such as a bike or will this be too painful?
Click to expand...
An exercise bike would be perfect and is usually the only device most people use, me for one! It is much more effective than a CPM as it also exercises the muscles which a CPM does not do. Hence the name Continuous PASSIVE Motion machine.
maryo52 said:
Undermedicated pain is believed to be a risk factor for adhesions. I however do not understand why this is so.
Click to expand...
This is a good question and one that deserves and answer.

Scenario 1. when pain is unmanaged, the leg gets swollen and painful (obviously) and if the pain cannot be managed, due to intolerance of drugs for instance, then the swelling becomes chronic (acute and chronic issues) leading to such problems as sparkie is experiencing.

Scenario 2. when pain is rampant, muscles and other soft tissues get angry, inflamed and HOT. Hot angry tissues can also be dry in which case they are a good set-up for being sticky which is another way of describing adhesions - stuck together tissues. However, this is not an inevitability, just a possibility.
maryo52 said:
If indeed your ortho got good ROM on your leg after he installed your knee in OR, that leaves adhesions or its more serious form, arthrofibrosis, as the culprit.
Click to expand...
Actually no it doesn't. It just means that the ROM that is obtained 'on the table' is achieved both while the patient is unconscious and before the post-op swelling has got started. That's all. 98% of all these issues are due to simple swelling and pain resulting from the surgery.
 
Actually, Josephine, Sparkie is at 6.5 months. The thread was started at 16 weeks.
 
Right TKR April 11, 2013 - So she is. :doh: Thanks for the heads up there, Mary!
 
Thanks so much for the feedback.
Maryo52, thanks for the benefit of your experience. I am (almost) resigned to the MUA next week. I will post again once its done.
I am hoping it won't be too bad as my knee doesn't feel too bad at all. I have some stiffness, but my knee does bend to its 90 limit easier than it used to.
I am going to ask (no, tell) the OS to take it easy. I will use the Bonesmart mantra of rest, ice and elevate and use my floor peddler and bike to keep it moving in between.
How long do I have to I keep it moving before I know I am past the risk of more adhesions?
Much appreciation and kind thoughts from me to you
 
Well your last question was the big one for me. I had another intervention after MUA because of that issue. But your ROM of 90 degrees isn't that bad and suggests you don't have the aggressive scar tissue I had.

In the first two weeks after MUA your ROM will likely initially go backwards and will make you feel set back. Try not to up your game in PT as a result. Bide that time with BS mantra. I had arthroscopy a year ago (which was 2 yrs post TKR) and I went from 125 to 90 for two weeks from that, but had the benefit of experience not to get discouraged or push my knee.

So once you graduate from that initial trial, you should start to see your ROM slowly gain. That being said, I've noticed others on the forum who actually gained a lot pretty quick and kept it such as vnmarino_13.

Plus I'm here to hold your hand and talk you down off the ledge!!
 
Your kindness has bought tears to my eyes. Thank you so very much.
I may need a good talking to after next week. I am hoping so much that after the initial trauma/depression of the TKR, and knowing how it can be that I can manage to stay off "the ledge" and out of that pit of despair I experience in the early days?
I am determined to soldier through, doing the BS way.
It can only get better. Right?
 
I too was in the pits with discouragement. You get so you cannot envision your life any better or your knee ever being OK. But the odds are that at one year, believe or not, you'll be on par with other post-TKRers who didn't have complications. It's a turtle wins the race kind of thing.
 
I had the much dreaded MUA on Thursday 31st October. My fear was so much worse than the reality! I was so stressed and worked up, but the nurses and staff calmed me down and looked after me brilliantly.
My surgeon said he bent my leg to at least 125 degrees :happydance: breaking adhesions either side of my knee cap.
In PT yesterday morning, he measured my bend at 120 degrees. although I have lost a bit in straightening that I assume will come back once the swelling is under control?
I am walking un-aided and not in too much pain at all, but that may be due to the fact that I am back on the Tramadol to help me keep my knee moving.
Now here is where I need help - the PT said I must constantly keep moving and use heat and not ice on it. He says that ice will just make it stiff. However, my knee feels quite hot so I am icing.
Which is right? Heat or ice? Keep moving or ice and elevate with exercises 4 times or so a day?
It is difficult when advice conflicts but I would like to take advice from the people that have gone through this, which is you kind folks:puppysmooze: .
oh, and the PT said that the reason I can't do leg lifts it that something or other was ruptured just above my knee when it was replaced, in his opinion. it should get better the more I try apparently (as if I haven't tried all this time!)
Not sure how I feel at the moment. I am terrified of losing the gains and getting stuck again.
 
Your priority now is getting range of motion and defeating any further scar tissue. In a month when you're "out of the woods," then start strengthening. In fact, strengthening routines will only increase inflammation now.

For the swelling, we still have to ice and elevate. Ok, let's say the ice makes it stiff. So what? What many of these people who hand out advice don't realize is that hot inflamed tissues is where scar tissue grows. WHo wants to provide a comfy home for scar tissue? And if you bend 5 degrees less because they're cool, so what? In the end, your knee will bend just fine.

One forum member who had just had MUA was advised by her PT to stretch every hour (bending the knee and straightening the knee, but not to the point of pain) -- three times very slowly, holding the stretch. That is all you need to do.

What you want to see is the swelling go down and the ROM slowly climb after the initial backlash of swelling from the procedure.

And I too resent the comment that you'll be able to lift your leg once you try hard enough. Sheesh!

Josephine might be able to comment on your inability to lift your leg and the PT's remark that something above your knee had been ruptured during surgery? Maybe better to refer this matter to your ortho.
 
[Bonesmart.org] 16+ weeks out and ROM of 90 degrees!
sparkie, maryo's advice is spot on. And please do ignore that PT (who is not a doctor and has not had a TKR). Just follow the BoneSmart mantras:

- rest, elevate, ice and take your pain meds by the clock
- if it hurts, don't do it and don't allow anyone - especially a physiotherapist - to do it to you
- if your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again
- if you won't die if it's not done, don't do it
- never stand when you can sit, never sit when you can lie down, never stay awake when you can go to sleep!

Take care and keep us posted. We care.
 
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