MRI results -- OS says 'no arthrofibrosis visible'

[Douglas_Firs]

Quick background: TPF in 2017. +5 degrees extension/stiffness unchanged since 2017.

First visit with new OS on October 1. He stated that I have a stiff knee, seems like fibrosis, and prescribed PT and a JAS brace, with potential arthroscopy scar removal in the future if conservative treatment produces no results. Mentioned I had some 'mild arthritis'/mild joint-space narrowing on x-ray. I asked for an MRI, just to be thorough.

Second visit November 3: We review MRI report: all ligaments, etc, in good shape. No abnormalities other than the 7 screws and again some 'mild joint space narrowing.'

OS then says 'I see no arthrofibrosis on the MRI. So, no reason to ever operate. Your ROM/stiffness problem is probably a result of arthritis.'

Huh? First of all, my extension and flexion have been lacking from day 1 after surgery. I've had the same deficit, with minimal improvement since I was operated on in 2017. If arthritis is the cause of my extension/flexion contractures, how was it present immediately after surgery? This makes no sense. Nothing has changed in my knee in 6.5 years. The ROM deficits have been the same. Whatever the cause is, it existed before any arthritic changes, which could not have been instantaneous. I don't feel like 'mild joint space narrowing' is enough to cause major ROM deficits with my knee. And I don't really feel my knee is 'arthritic.' If anything, it is the lack of ROM/extension causing whatever mild arthritis is visible on x-ray.

Secondly, is arthrofibrosis or adhesive capsulitis visible on MRI? Is he just fobbing me off? He is another harried HMO doc who spent about 4 inattentive minutes in the examination room, hardly making eye contact. I don't think his diagnosis makes sense.

[The_KNEEguru]

I found this, which may be of interest - just scroll down to the Discussion - https://josr-online.biomedcentral.com/a ... 21-02700-2

[The_KNEEguru]

Any chance you could populate your Signature with dates of injury, surgery, etc?

Do you know how you graded with Schatzker type? https://www.kneeguru.co.uk/KNEEnotes/kn ... u-fracture

[Bella_Gamba]

Hi Douglas,

I had thought about replying to your earlier messages a while ago but with the new website transfer I had trouble getting into the site.

I saw one of your posts earlier about hardware removal. I remember my OS at the time agreeing to taking the metal out to prepare my knee for a TKR. Seems like so many of the Oss you saw did not recommend removal. So likely you will not need a TKR. This is good news!

I have not done an update for a while. Things have not changed much. I hope to still do an update at some point...

Take care and hope little by little all you are doing will find a solution for your knee issues.

Bella

[Douglas_Firs]

I found this, which may be of interest - just scroll down to the Discussion - https://josr-online.biomedcentral.com/a ... 21-02700-2

Thanks, KNEEguru.

I had a Schatzker Type V TPF. Bicondylar fraction. ORIF surgery with 1 plate and 7 screws. But my knee was operated on within 24 hours of injury. Also, there was no removal or repair of meniscus, etc. The TPF repair was the only issue and the surgery went well and I left the hospital the next morning.

So according to this paper, my injury is 'associated' with some higher risk of ROM less. But I'm not clear about the actual cause of ROM loss according to the paper? It was my understanding that ROM loss after surgery is caused by: 1) Arthrofibrosis or 2) Mechanical/Anatomical obstruction like a misplaced graft, MCL tear, etc. Is there something else that could be the cause?

What else could it be in my case? The MRI shows nothing unusual except 'minor joint space narrowing.' So I am confused. 'Tight capsule' is technically just fibrosis/adhesions, I believe. My knee bones and ligaments are all in the proper place, so I don't understand what is preventing my knee from straightening.

I also don't know whether I should accept my OS's pronouncement that I am arthrofibrosis-free based on his reading of the MRI.

[Douglas_Firs]

Hi Douglas,

I had thought about replying to your earlier messages a while ago but with the new website transfer I had trouble getting into the site.

I saw one of your posts earlier about hardware removal. I remember my OS at the time agreeing to taking the metal out to prepare my knee for a TKR. Seems like so many of the Oss you saw did not recommend removal. So likely you will not need a TKR. This is good news!

I have not done an update for a while. Things have not changed much. I hope to still do an update at some point...

Take care and hope little by little all you are doing will find a solution for your knee issues.

Bella

Hello Bella,

I'm so glad you found a way onto the new site. I feel like you are my TPF 'doppelganger,' since we both had our injury around the same time and posted about our long recoveries here on kneeguru.

You're right. I've now seen 4 OS and each of them told me not to have the hardware out (although, I am still contemplating having it removed anyway, just to exhaust every possible avenue in my quest to recover full extension). It seems several people on the TPF board reported being 10+ years out from surgery and never requiring TKR, despite being told initially by OS that it would be a certainty. So hopefully, with a little TLC and luck, we can both avoid TKR. That's partly why I want my 0-degree extension back. I feel I am really banging up my knee when I walk at +5 extension all day, which is what leads to TKR in the long-term.

I will get this knee straight one way or another. I am determined.

Please post an update when you have a chance. I am sure people will definitely want to read it.

PS -- And thank you again for the very useful info you shared with me on previous occasions/in PM.

[The_KNEEguru]

Grade V is a nasty fracture. I do understand your determination, but this paper https://boneandjoint.org.uk/Article/10. ... 87B9.16276# reports for a cohort of patients of mixed grades of TPF -

“39 (62%) had an extension deficit of < 5° at three months. By one year, 13 (21%) patients still had an extension deficit ≥ 5°.” (See Results)

I am not saying that you should not pursue a better result but for that grade of fracture you may be fighting the odds…

[Douglas_Firs]

Grade V is a nasty fracture. I do understand your determination, but this paper https://boneandjoint.org.uk/Article/10. ... 87B9.16276# reports for a cohort of patients of mixed grades of TPF -

“39 (62%) had an extension deficit of < 5° at three months. By one year, 13 (21%) patients still had an extension deficit ≥ 5°.” (See Results)

I am not saying that you should not pursue a better result but for that grade of fracture you may be fighting the odds…

Thanks so much, KNEEguru.

I understand that more severe fractures = more ROM issues.

But why? What is the mechanism? Is there some other factor besides fibrosis causing the ROM deficit in these cases? Why does a more severe fracture cause more ROM loss? As I say, my MRI shows nothing out of the ordinary currently, so where does the cause lie exactly, of the ROM loss in these cases?

I feel like I am missing something.

[The_KNEEguru]

I recently had a four-part fracture of my left shoulder, which is not the same of course and I did not have an open reduction (ORIF), but I too have some ROM loss and would love to see a 3-D model of exactly where all the bits ended up...just so that I know what I can expect in term of reaching my final ROM.

I imagine in your situation there is no single answer - imaging of the joint may seem normal now, but there may be subtle displacements of the individual bone fragments, patellar tendon, cruciate ligament, etc. not showing up in imaging - as well as any tightness of the capsule, which is I know what you are worrying about. The bottom part of Dr Noyes' paper here - https://www.kneeguru.co.uk/KNEEnotes/ar ... ue-release - will be of interest to you, although he is not talking about TPF specifically.

[vickster]

I’ve had SPECT CT scans on my feet and ankle, the amount of detail is astonishing if you can get a referral for one.
A normal CT is not too shabby either for seeing much more detail than an MRI
There can be some reticence around doing them though because of the radiation (although far less than flying I believe!)

[The_KNEEguru]

I guess for a fracture you would need to compare any SPECT with the good side...

[vickster]

Yes the scan covered both my feet and ankles I think, the detailed reporting on the injured side

[Douglas_Firs]

I recently had a four-part fracture of my left shoulder, which is not the same of course and I did not have an open reduction (ORIF), but I too have some ROM loss and would love to see a 3-D model of exactly where all the bits ended up...just so that I know what I can expect in term of reaching my final ROM

Oh no. I empathize. I had 'frozen shoulder' 10 years ago with a lot of ROM loss that lingered for 2 years. It was extremely challenging. Even raising my arms overhead to wash my hair was impossible. I'll be hoping you get a good recovery for your final ROM.

I imagine in your situation there is no single answer - imaging of the joint may seem normal now, but there may be subtle displacements of the individual bone fragments, patellar tendon, cruciate ligament, etc. not showing up in imaging - as well as any tightness of the capsule, which is I know what you are worrying about. The bottom part of Dr Noyes' paper here - https://www.kneeguru.co.uk/KNEEnotes/ar ... ue-release - will be of interest to you, although he is not talking about TPF specifically.

This is very interesting. None of my 4 orthopedists has ever raised the possibility that my ROM deficit could be some kind of anatomical 'new normal', that the subtle irregularities of the repaired joint, as you say, could be the thing preventing me from getting full ROM. But it seems obviously possible.

I am wondering now if it is even safe to continue trying to 'stretch' the joint into further extension with the JAS brace, PT overpressure, etc? If the issue is anatomical/mechanical, am I forcing a joint that does not want to be forced? Endangering it? My OSs all endorsed continuing to try to get more extension with Time Under Tension and overpressure. But now I wonder.

[The_KNEEguru]

I will see if I can get Physiotherapist Sebastiano Nutarelli to jump into this thread and answer your last question...

[The_KNEEguru]

Sebastiano felt he could not advise without seeing imaging…