General info and my story of dislocations
Intro: I've broken this into sections - please scroll through to see if any bits are of interest to you. I know it's a very long entry, hopefully at least some of it will be useful.
Current Summary:
I am a 31 year old Australian female (I am ~165cm tall and weigh ~56kg). I have a long history of knee dislocations (most untreated), mostly left knee (see below). I had an operation May 2000: left knee arthroscopy, open lateral retinacular release, tibial tubercle osteotomy and transfer (14mm)- more info on surgery at the end of this submission. I dislocated my left knee 2nd January 2003, which is the first dislocation of any kind I have had since surgery. I am currently rehabing from this dislocation.
**My knee pathology - includes explanation of some terms
Ligamentus laxity (loose ligaments, ie more flexible, more movement in joints etc); very small kneecaps; significant patella alta (very high riding kneecaps); increased Q angle (angle lower leg to upper leg increased); J tracking (when bend and straighten leg my kneecap always moves in curve motion, significantly out to lateral side by full extension); legs hyper-extend (ie leg bends upwards eg if straighten legs tight my foot will rise ~5cm/2" from surface while thigh stays flat); trochlea (?) groove shallow (part that underside of kneecap should engage, has only a shallow groove, making tracking more unstable); tibial tubercle lateralization (where tendon joins onto shin bone is further across - right knee 9mm, left knee before operation 15mm, presumably now 1mm); "definite type patella lateral retinaculum" (think basically means loose kneecaps).
Pathology continued.
Also I have no awareness as far as symptoms go, but apparently have "moderately prominent osteopenia" in left knee (reduced minerals in bone); "minor degenerative damage in medial joint compartment and inferior patellar articular margin"; and think I was told I also have some osteoarthritus in my left knee. I've also had at least two blood clots in my left calf muscle secondary to immobilisation etc.
**In what circumstances my knees dislocate.
All dislocations except one (August 1999 - see end of paragraph) have occured while weight bearing and leg bent (anywhere between 10 and 90 degrees flexion), often at an odd angle (upper versus lower leg). Many dislocations on slopes, especially running down slopes (which I refuse to do as an adult). Many dislocations after falling or tripping over something or trying to manoevre around obstacles - not necessarily with speed. Some dislocations just running (especially childhood/ adolescence) and move the wrong way (from eleven years old I wore knee supports if I knew I had to run, I rarely run as an adult). Some dislocations from dancing - especially as an adolescent - not formal dancing, just impromptu dancing to radio etc. Some dislocations from slipping on slippery surfaces (including when aware is slippery and move very slowly and carefully). Couple of dislocations from walking downstairs. One dislocation from pivoting (but very severe, so I avoid pivoting type movements, or wear knee supports if I know I will have to pivot). Dislocation exception. August 1999 I was standing, on slippery surface (but didn't realize), just changed weight from right foot to left (without bending legs or moving feet), weight on ball of my foot, foot shot forward, left leg bent in air, left knee dislocate in air - ie movement causing dislocation was not precipitated by my leg being bent or fully weight bearing.
**In what circumstances my knees don't dislocate.
I have never dislocated my knees from direct impact to that knee. I have never dislocated my knees while sleeping. I have never dislocated my knees while wearing knee supports (usually tubi-grip). I have never dislocated my knees from a squat or a kneeling position.
**The way most people's knees dislocate.
The usual way for a knee to dislocate is for the kneecap to move across, towards the outside of the leg, more severe the further it goes. Rarely the kneecap can dislocate to the inside of the leg, but usually is a result of over compensatory surgery. (Also can dislocate so the kneecap jolts back into the leg and lower leg juts forward, but I know little about this kind of dislocation.) The movement in dislocating can strain or tear various ligaments, more severe if ligaments are torn. Subluxation is a partial dislocation where the kneecap doesn't track properly or moves around / slips but not enough to be classified as a full dislocation. Some people's kneecaps will spontaneously reposition themselves to the correct position. Some people will reposition it themselves - either by quickly straightening the leg, or by physically pushing the kneecap back into place with the hand. Putting the kneecap back into its proper position is called reducing or reduction. Sometimes bits of bone can break off after dislocations, so usually an x-ray will be done to rule this out.
**Way my knees usually dislocate.
Up until 1999 my kneecaps never dislocated by going out to the side. Typically my knees (usually my left knee), would dislocate by my kneecap turning in a clockwise direction, then returning to its normal position by going the same distance counter clockwise. The kneecap would not go around the knee or leg, it stayed at the front of my knee, roughly where its meant to be, and would turn so the orientation would change, like moving on its axis in one spot. The amount it rotated varied. Sometimes a quarter turn and back, sometimes a half turn and back, sometimes a full (365 degree) turn and back. Once (when eleven) my left knee did two full revolutions clockwise and two full revolutions counterclockwise. This was when I could not use my other leg to brace myself (usually as soon as I feel one knee start to rotate I put my other leg out to stabilise and take the weight off the leg that's started to dislocate), but on this occasion I was playing hopscotch, balancing on my left leg, bending down to my right to pick up a stone with my right hand, both my legs were bent, had full weight on my left leg, body infront and to the right side and couldn't get my right leg down to stabilise quickly enough. Many medical practioners will say it is not physically possible to dislocate the knee rotationally like this at all. They may give rationale it is impossible because the kneecap is embedded in the tendon joining the thigh bone to the shin bone, the ligaments wouldn't allow such movement etc. However my kneecaps do (or at least did) move in that way. Once, as a teenager, I even grabbed at my knee while it was dislocating, it had rotated clockwise (think half turn), and I grabbed at my knee held it for about half a minute (while I plucked up courage to let it go - painful rotating back into position as well as going out), then let go and watched my kneecap rotate back into place.
**Way my kneecap dislocated August 1999.
This is when I'd just changed weight from my right to my left foot (see above). My left kneecap went out, toward the outside of my leg and downwards. I don't know exactly how far it got, but when I landed on the ground it was at the top of my calf muscle at the back of my leg. That is it travelled at least 18cm or more than 7 inches. My leg was still bent at about a 70 degree angle. I say I don't know exactly how far because I thought that it may have gone back in, I had felt my kneecap go out and keep going out, then felt it move back, but obviously not to where it should be. My kneecap was at the top of my calf muscle at the back of my leg, and because to that point my kneecap had always returned to its correct position more or less spontaneously, I didn't know how to get it back in place. It was literally whacked back into place about 45 minutes after the injury, by a senior male nurse in accident and emergency, who implied to me that he was a doctor. Although the hospital report said my knee was reduced under analgesia, I can assure you it was not. [And yes it was excruciatingly painful and I let out a blood curdling scream which my husband heard from the waiting room area.] I was given two panadeine tablets a few minutes sfter he had whacked it. I had been given some pain killing drug by inhalation by the ambulance officers when they arrived on the scene, but this had well and truly worn off by the time my kneecap was repositioned (and just to give credit where credit is due - both ambulance officers were fantastic). My point being ambulance personel and medical staff saw where my kneecap was, and it was after this dislocation that orthopaedic doctors/ surgeons first discussed preventive surgery with me. Also the first time they asked me about my whole history, did a CT scan,identified most of my knee pathology; and I got an inkling that some of these people began to believe me (or at least not outrightly dismiss me).
**Way my kneecap has dislocated recently.
In the dislocation I'm currently recovering from, my kneecap moved how most people's move. That is, out to the outer side. May have been a little downwards aswell. I did not see the position, I felt it went as far across as about the width of the kneecap, so the inner edge of the kneecap is where the outer edge would normally be.
**History of my dislocations.
First time my knee ever dislocated I was 4 or 5 years old, was my left knee. I tripped over a broom in the kitchen at home. I was not seen medically or treated because my knee did not swell up significantly, and there was no injury to be seen. My assertion that my knee had "twisted" must have seemed implausible.
History continued
Second time I dislocated my knee I was 7 years old, again my left knee, this time at school, I fell over, can't recall the details, maybe manoevring around the wood pile. Again there were no obvious signs of injury, so I wasn't seen or treated.
Between the age of 7 and 11 I dislocated my knees about a dozen times, mostly the left, but sometimes the right. I could tell how far it had twisted. I became a very strong hopper, and could hop great lengths on my right leg if I needed to. After each dislocation, I would usually mainly hop for the rest of the day or few days. I could put weight on the leg soon after dislocating, but it would hurt and I was scared of it re-dislocating, so I was very reluctant to put any weight through my injured leg for several days after each dislocation (sometimes I had to, including if I had dislocated both legs within a short time frame).
History continued
My first major dislocation was when I was 11 years old, first time medically assessed as patella (kneecap) dislocation with torn ligaments. Mostly described above, the time it twisted two full revolutions and two revolutions back. This time my knee immediately swelled to huge proportions. I was given ice at school and kept ice on it until home time. I hopped to get around. I continued to ice it when I got home (assume I was driven home from school). The swelling did not subside at all, I was kept home from school the following two days and kept it iced virtually the whole time. When the swelling still didn't subside I was taken to hospital (children's hospital). They gave me crutches and put my left leg in a backslab of plaster (not full plaster because the swelling was too great). I can't remember how long I had the crutches or plaster that time (felt like a very long time, but I was eleven, everything seems like a long time to an eleven year old), maybe four months? I had physiotherapy (PT) for a long time after that, and that physio didn't believe me either. When the plaster came off I wore tubi-grip (cylindrical elastic bandage) on my knee for some time. Tubi-grip became my best friend, and I wore it the vast majority of the time I played any sport or had any phys ed, at least on my left knee, sometimes both. And whenever I dislocated my knees I would wear it until my leg felt strong again.
**History continued - include aspiration
From eleven years to sixteen years I dislocated both knees frequently, especially the left. In March 1987 I dislocated my left knee in a typical way for me, think half turn. I was at a school beach carnival, in a bucket race, running down the slope on the sand to the water's edge. Because it was at the beach I didn't have the tubi-grip on (knew was high risk activity for my knees to dislocate - running down slope of unstable surface, but because at the beach, and I didn't know I was going to be told to do running on sand, I didn't bring the tubi-grip). As far as I was aware at the time, it felt like it always felt after dislocating, and I hobbled up the steps on the bus, and hopped. However, my knee swelled up, and refused to go down, and was still up the next day, so I was taken to hospital. This time I was given a rigid brace, and crutches. I used the brace and crutches for about twelve weeks. This was also the first time I had my knee aspirated. Aspiration is where they reduce swelling by sucking it out. To aspirate they give you a local anaethetic by needle into your knee, then put a needle-like instrument in your knee, which is open at the top. Then they put a closed syringe into the opening, and pull the syringe open so it fills with fluid from your knee. If there's more fluid left they keep putting syringes in until they can't get any more fluid out, and may push down on your knee to squeeze that last bit out. In my case they got 240mL of bloody fluid out (which is a lot considering you are meant to have about 1mL in your knee). The experience was very painful, and despite taking anti-inflammatories, compression bandaging and high elevation, my swelling came back, about the same amount, overnight. I have since been told, by a physio I trust immensely and has a lot of expertise with knees etc, that, unless the swelling itself is the cause of the pain, you shouldn't aspirate until about ten days after the trauma, preferably after the swelling begins to go down by itself. The person who does the aspiration makes a huge difference too, I've had it done twice, and I would recommend getting it done by someone who has lots of experience doing them, such as a GP who specialises in sports injuries. The difference is huge. Applying cold packs and elevating before and after helps too. My advice would be only get it done if you have to - and if the only reason they can give you is to reduce pain, my advice is to say no emphatically, the procedure itself is painful, and you will be in additional pain because of the reduced cushioning for at least a couple of days.
History continued
From 16 to 19 years both my knees continued to dislocate, mostly the left, as previously (without needing medical intervention). November 1990, age 19, I dislocated my left knee, it was only a quarter turn and quarter turn back, and at time of injury I thought it would be okay. I was at work, and even though I could initially put weight on it (painfully), and I iced it immediately, it got progressively worse as the day progressed. I had to keep working, this job was not physically strenuous, but I had to move around, stand etc, I rested it as much as I could, but couldn't keep it elevated, and because of the heat generated by my knee the chemical cold packs would completely lose all cold within about five minutes, so I couldn't effectively cool it. My knee swelled up huge amount, by the end of the day I couldn't hop, hobble or anything else (I was wheeled out on a furniture trolley to the carpark and driven to hospital). The doctors really wanted to aspirate my knee but I wouldn't let them (see paragraph above this one). I was given the same sort of rigid brace, crutches, anti-inflammatories, pain killers etc. Again verdict was dislocated patella and torn ligaments. This time I was only on crutches two or three weeks, but the brace for twelve weeks, and physio for about six months (felt like forever).
History continued.
I continued to have dislocations, mainly left leg, that did not require intervention, from 19 to 28 years (November 1990 to August 1999), but they were much less frequent. Dislocation at 28 is described in "way my knee dislocated in August 1999". This time I had the same brace again for about twelve weeks, and crutches about three weeks (I think). I also had physio - but had someone recommended to me and he has been brilliant - (used him again after surgery and again in current rehab), and hydrotherapy for first time. Hydrotherapy is great, I recommend it, as long as you know what exercises are going to be beneficial and what to avoid, I had a routine of exercises designed for my requirements worked out by a physio (PT), was shown how to do them, was watched to make sure I did them right, and then could practise on my own whenever I could organise access to a pool. I returned to work (physically strenuous) about March 2000.
**Surgery
I had surgery in May 2000, idea being to prevent knee dislocation occurrences. Operation was Arthroscopy, open lateral retinacular release, tibial tubercle osteotomy and transfer (14mm). Arthroscopy - putting camera in through key hole surgery to look around inside the joint - but I think some doctors use term to include other stuff they do through key hole surgery like removing foreign bodies and some biopsies and stuff. Open lateral retinacular release - cutting particular tissues on outside of knee to free up movement, so it's less likely to pull the kneecap out to the outer side. Tibial tubercle osteotomy and transfer - move tendon (which kneecap is embedded in, joins thigh bone and shin bone) toward inside of knee, to help kneecap track better, hold tighter; then anchor tendon into top of shin bone. In my case they moved it 14mm and fixed in with two stainless steel screws. This part of the procedure necessitates a large scar - can be vertical or horizontal, mine horizontal. Different sorts of screws can be used, and they can be removed at a later operation if necessary. I still have my screws in. You have a drip and drain, and the procedure of course is done under general anaesthetic. I had no major complications. I had to put as much weight through my leg as quickly as I could because of blood clots. I had skin reaction to the tape where my skin blistered, but it healed fine. For a long time I had no sensitivity to heat or cold for part of my knee and top of my shin, towards the outside of my leg. This was from nerve disruption, which also caused a corresponding area to feel different sort of super sensitive but numb simultaneously, which lasted for a very long time, even now the sensation of touch is different to before the operation. I also couldn't kneel at all because of discomfort for a long time; still hurts to kneel, can do on a soft surface like a mattress, but still hurts. You can physically put your hand over the screw heads and feel them, particularly one. Can be tender over the screws, and sometimes feel like they react especially to cold, but mostly they're fine. I probably won't choose to have them removed unless they become more problematic or I am having that knee operated on for another procedure and they can take the screws out at the same time.
Update: I had no dislocations of any sort from the operation in May 2000 to my current dislocation in January 2003 (more info above) when it was again put in rigid brace, back on crutches etc. Despite the operation, it did dislocate, and to the left, the kneecap felt tighter going out and coming back, but it still dislocated. I hope it is not indicative of things to come... At this point I'm not 100% sure about future operations. I know of two that may be considered. I don't know all the details, but as I understand, one involves pulling down the tendon which pulls down the kneecap to restrict kneecap movement; the other involves cutting a small wedge out of the shin bone to line up the shin and thigh better. Currently I am completely off work, out of the rigid brace, recently off crutches, wear a small brace that allows movement or bandage, continuing physiotherapy ("PT"), just begun hydrotherapy. Not sure when I will be cleared to return to work.
Overall I guess I've had about 90 or so dislocations, mostly to my left knee. I have been dependent on crutches, had my left leg immobilised, been rehabilitated etc six times (five times for dislocations, once post operatively).
Feel free to contact me. My email is shflaf@ca.com.au We may change email addresses soon, if so, I'll post a very brief note to this site with the new address.
From:
shflaf@ca.com.au
