Knee manipulation with existing blood clot

I had patella realignment surgery on 12/21, open knee rather than scope.  Developed large blisters on knee as a result of alergic (allergic) reaction to Benzoin about 10 days post op.  Was withheld from therapy for an additional 2 weeks to allow blistering and suture site to heal.  Began therapy about 3.5 weeks post op and managed to get to about a 35degree bend (with assistance) but was told it would be another 2-3 weeks before they assisted me in actually putting weight on a bending knee - for now just walk with the brace at the locked straight position.  Went for my follow up at 5.5 weeks and they found a blood clot in the calf.  Was put in the hospital for a week to regulate the blood thinners and was black-balled from therapy AGAIN until vascular doctor released me.  I was warned that my leg would likely go stiff during this time and we may need to consider manipulation treatment once the vascular doctor was okay.  I'm now 2+ mths post op and have not been allowed to return to any sort of physical therapy.  I've been told by my vascular doctor to keep my leg elevated above my heart the majority of the day as I have swelling all through the lower part of my leg.  To further this, I'm unable to put on compression stockings as I also had a hammer toe correction done at the same time of knee surgery - that coupled with the fact that I can't manipulate the stockings on.  I've been instructed to put an ace bandage on the leg the majority of the day -kind of a simplistic compression stocking.   Vascular doctor sent me a copy of my medical records and the ultra-sound scan notes indicate the inability to view some of my veins due to swelling; however, the clot has not changed in size.  I have another 2 weeks of this extreme elevation and they'll re-evaluate for consideration to allow me to proceed with therapy.  That will be at the 3 month mark that my leg will have set in this stiff position.  The ortho doctor indicates it will be unlikely I'll be able to bend it and wanted to go ahead and do the manipulation procedure...he says clot is so small it can't do much harm.  Vascular doctor would not agree to it until I'm off the blood thinners.  Hemotologist will not take me off blood thinners until I'm more mobile.  Its a viscious cycle that I can't seem to jump off of.   Vascular doctor said they may consider the manipulation IF the doctor agrees to put a filter in.  Hemotologist warns me now that there could be complications with the filter and that I may be on blood thinners for life.  Ortho doctor says he'd do the manipulation and release me to go home within a few hours.  Hemotologist sais I would be in the hospital for a day or two.  UGGGHHH.  I can't find any record of someone having the manipulation under anesthesia WHILE also having an active blood clot in their calf.  The scary thing to me is that my surgeon is gung ho to get this knee fixed all the while disregarding the bomb in my leg that TWO other doctors are obvioulsy concerned with.  Is there a precendence to this?  What was the outcome?  I just want to go back to walking my 1-2 miles every other day again!!!

[S. Kaul, MD]

Hi there!

Wo! That’s a long n round story to go! Well, Let’s look at the key facts here; we have a clot, that the vascular and the haematology doctors are concerned about and I would agree with them. Unless we get rid of the clot, a manipulation would be risky but is still required if we aim at a functional knee. Also prolonged immobility is another risk factor for clot formation. Now this clot would either need to be dissolved or extracted or prevented from reaching vital organs. Filter is an option but since the haematologist is apprehensive about it, clot extraction can be tried followed by blood thinners to prevent further formation; following which the orthopedician can take over. I would suggest talking to the vascular surgeon regarding the possible option.
Hope this helps.

Take care!

[jls5151]

Thank you for the response.  My plot thickens.  I am now 3 months and 8 days post op.  I've been back to PT for 2 weeks to try to gain ROM of my knee in lieu of MUA.  I started at 35 degrees, progressed and have now reached a plataeu at 55 degrees.  I started having intense throbbing cramps in my calf area where the DVT was spotted, went back for a follow up scan with Vascular Dr to rule out growth of DVT.  Two techs had to scan me because they werent sure they were seeing right.  It was determined I had extreme swelling in the calf area and they are unable to see my venous system or the clot.  The techs wrote down that I had sufficient flow above and below the swelling (although I heard them question it when they were viewing and discussing), so vascular dr is indicating it appears clot is gripping tight (where they can't see) and is not growing (where they can't see) and I'm in the chronic stage of this clot now....that may or may not still be there.  

They are reaching out to ortho dr to allow him to proceed with manipulation under anesthesia and will discuss with hematologist about allowing me to stay on Coumadin (vs. bridging with levanox) while I have the MUA done.  The ortho agrees that I may have some bleeding in the knee but that even while on Coumadin it shouldnt be significant and he doesn't intend to do this via arthroscopic methods....so closed only, no incisions.  What happens if I do have bleeding in the knee while on Coumadin?

No one has given me any sort of options about clot extraction, although all my non medical friends have asked if I could just get it 'sucked' out.  

I don't understand why my calf is swelling so much if I don't still have a DVT.
I'm trying to get a second opinion with a vascular surgeon but am striking zero due to their schedules are soo booked up!!

I feel like I'm being forced into the MUA regardless if this DVT is there or not with no regards just so the surgeon can get the unresolved knee surgery off his books.