Lysis of Scar Tissue Surgery (Margaret's sugery)

[wofford99]

Hi everyone-
I created this separate folder to hopefully help all of us by writing down each step in preparation for my scar tissue surgery which I think will be like Heather's.  I've had 12 knee surgeries as shown at the bottom.
  I have had severe pain/scar tissue since my last patella tendon debridement and scar tissue removal in December 2001. I was put in an immobilizer post-op for 3 weeks which only added to the scar tissue. I have been in PT for 2 years trying to break it up.
  Finally, I found a fantastic orthopedic surgeon here in NC who is going to get this scar tissue out.  He ordered an MRI which I had done last night.  He thinks I have terrible scar tissue (obvious), torn medial meniscus, and partially torn quad muscle.  I go back to see him on August 26 to talk about the surgical plan because he is going to operate thank goodness to get this scar tissue out.
  For the past 3 days, I have terrible pain in the medial meniscus area and cannot fully bend my leg. I think something has broken off because it hurts bad.  I am in pain management right now.
   I will keep everyone posted on the MRI results and the surgical plan. Margaret

[ls]

Margaret,
I had extensive debridement and closed manipulation in may and the most important thing is post op protocol. I was in a cpm machine 24 hours a day for a month and in extensive phisical therapy within days. I am currently at nearly full range of motion and my scar tissue has not regrown. Good Luck!
Laurie

[wofford99]

My drs office called this morning about my MRI. I have been so upset all day. The last MRI I had was in October 2002 and the 5 surgeons since then have said no need to do another one. Well thank goodness they did. Here is the abbreviated report.
  "Since previous MRI, there is a focal are of Grade IV chrondromalacia with subchrondral cyst formation in the small medial facet of the patella. Also an extensive Grade III chrondromalacia of lateral facet of patella."
   Has anyone ever had this? Thank you- I see my doc on Tuesday. Margaret

[Heather M.]

Margaret,

It sounds like you have damage to the cartilage on the back of your kneecap due to it being in contact with the joint (that dreaded infrapatellar contracture syndrome).  Your damage was called 'focal chondromalacia.'  That means you still have cartilage left in most places; if they had said grade III osteochondral lesions, then that would be huge.  I think you need to clarify that the correct terms are being used:

chondromalacia is softening of the articular cartilage
chondral lesion or grade III chondromalacia is fairly extensive damage to the articular cartilage, but NOT down to bone yet
osteochondral lesion would be into the bone and true arthritis.
subchondral cyst is a bone cyst, which is a sign that the joint is very unhappy and irritated.  It usually is a sign of 'arthritic change' resulting from bone on bone.  This seems to be the biggest finding, but not terribly surprising given what we know is going on in your knee.

I was told to consider chondromalacia grade III and IV like pre-arthritis, and if it gets deeper and reveals bone it would be arthritis proper.  I have grade II osteochondral lesions on the distal and lateral facets of my patella, and chondral lesions on the tibial plateau where the kneecap is hitting.  

Here's a good explanation of your situation:
http://www.steadman-hawkins.com/knee_chondral/overview.asp

Try not to worry too much until you talk to your doctor.  While the findings aren't great, they are not really surprising considering what is going on with your knee mechanics.  And it could certainly be worse, so please keep your chin up until you can discuss with your doctor.  Let us know what he says.
Heather

[wofford99]

Hi Heather-
Thank you SO much for your email. I am researching all of this extensivey. I have a lot of medical textbooks,etc. because I am applying to med school. I just can't fnd a whole lot on the internet but I am searching.
 I have a few questions that you may know the answer to.

1- What is chondral lesion? The same as Grade III Chrondromalacia Patella?  What is a lesion exactly?

2-Subchondral cyst- some resources say this is an early indicator of rheutmatoid arthriti. Others say it is caused from bone cancer. What causes it exactly other than the bone on bone contact?

3-What is the difference between osteochondral lesions and chondral lesions?

4- What would have caused all these changes since November because I can barely walk and don't exercise much?  If it continues at this rate in 2 years I will be in a wheelchair.  Could there be an underlying disease process or just inflammation that has not been treated?

5- Is surgery a fairly immediate need since there is a lesion? What happens if the lesion pops?  I am in so much pain I am having to use crutches non-weight bearing until I see him on Tuesday even with all the meds I am on.

I guess this could have been prevented had the past 5 surgeons taken me seriously.  I hope there is something they can do that will help and keep it from degenerating more.  Thank you so very much. Margaret in NC

[Heather M.]

Margaret,

I know this seems really scary, and I hope that your new doctor addresses each and every one of your questions.  I have a feeling that you are in good hands now, so please keep pushing for answers.  As for research, I've found the best place to do it is on the web--the most up to date stuff is there.  Go to the useful links thread (if there still is one) and on the very earliest page there were some medline journal links posted by various people.  That's where I did most of my research.

I'll try to answer what I can of your questions based on what I've learned, but your doctor is the one to ask, really.  I just don't want you worrying too much until you see him, so I'll give it my best shot.  Maybe the KNEEguru can weigh in as well.  Also, keep looking on the web, using keywords like chondromalacia, subchondral cyst, arthritis, etc.  To bottom line it for you, if these were my MRI results I wouldn't be jumping for joy, but I wouldn't be hitting the panic button just yet.  It definitely explains your persistent pain and mobility issues, and indicates that there is some activity in your knee that has to be addressed by a good doctor.

1- What is chondral lesion? The same as Grade III Chrondromalacia Patella?  What is a lesion exactly?  A lesion is a damaged area of the cartilage, where the tissue has changed.  Think of it like a scab or a wound.  The damage to the cartilage is graded I-IV as explained in the link I posted above--It has the best explanation of the grading system.

2-Subchondral cyst- some resources say this is an early indicator of rheutmatoid arthritis. Others say it is caused from bone cancer. What causes it exactly other than the bone on bone contact?  I can't answer this with certainty--I have only seen references on the net that subchondral cysts are the indication of arthritic change.  I would guess that's the case here, because the report says the cyst is in a focal grade IV chondral lesion--that means an area of concentrated damage, as opposed to widespread damage.  It looks like that might be the place where your bones rub together--please, please talk to your doctor about this, but don't borrow trouble worrying about cancer and RA when there's probably a very logical explanation, which is bone on bone contact due to patella baja and scar tissue.

3-What is the difference between osteochondral lesions and chondral lesions?  Chondral lesions are less severe--the damage is limited to the articular cartilage.  Osteochondral lesions are ones that go down into the bone itself and are the marker of osteoarthritis.  The web page I posted gives a good explanation.  Think of cutting your knuckle enough to make it bleed vs. cutting it down to the bone--degree of severity.

4- What would have caused all these changes since November because I can barely walk and don't exercise much?  I would imagine that the constant grinding contact isn't helping, and would accelerate arthritic change that would normally take years to show up.  Also, once you start having swelling, chondral lesions, etc...the process can spread to the extent that it becomes self-perpetuating.  So I had grade IV chondromalacia with my first surgery, and 18 months later, the doctor rated my damage as grade II osteochondral lesions.  The accelerated damage, they said, was due to continued bone on bone contact, the constant swelling, and release of bad enzymes that continued to break down the cartilage.  OA is a progressive disease that can be started by bad mechanics, but once the damage is done it can progress pretty quickly on its own.  OR, the damage can remain limited to the way it is right now.  Not a lot is understood about OA, and so it's important to have a really good doctor who's up on the latest studies and methods.

5- Is surgery a fairly immediate need since there is a lesion? What happens if the lesion pops?  I don't know if a subchondral cyst requires immediate surgery...my guess would be no.  If it pops, it we be reabsorbed by the body, like any cyst.  In fact, a cyst is your body's attempt to heal itself, it is a sign that your knee is trying to encapsulate the damaged area in some cases.  Again, I wouldn't want to borrow trouble--I don't think this is like having a tumor or anything.  I've actually had a cyst in the back of my good knee (a big one, the size of a whole walnut) for almost two years now.  No one seems to be in a hurry to take it out.  It certainly would explain your pain, though.

Am I remembering correctly--you had a problem with bone infection, right?  That could explain a lot of the damage being seen on your MRI.  I really wish I could help you more, but to be honest I don't think anyone but your surgeon can determine if this is cause for great concern or not.  You were already planning surgery, right?  This will probably just help give you confidence that you've made the right decision, and will enable your doctor to make a 'game plan' with you before the day of the procedure.  

I really hope I've helped allay some of your fears.  I think your MRI is something to definitely discuss seriously with your doctor.  But I really hope and pray that he will reassure you that that the results were not to be unexpected and are a sign of the mechanical problems, not some underlying condition.

Heather

[Heather M.]

Margaret,

I found a good outline summary of the progression of osteoarthritis.  Read the following like a flow chart:


Most common form of arthritis
a.  Prevelance directly increases with age
b.  Age over 40 years: 70% of U.S. population
c.  Age over 65 years: 80% of U.S. population
d.  Associated functional Impairment increases with age

Pathophysiology
a.  Primary lesion resides in the articular cartilage
b.  Abnormal cartilage repair and remodeling
c.  Chondrocytes produce proteolytic enzymes
d.  Proteolytic enzymes destroy cartilage

End result
a.  Asymmetric joint cartilage loss
b.  Subchondral sclerosis (bone density increased)
c.  Subchondral cysts
d.  Marginal osteophytes

So under the pathophysiology section, it explains that a primary arthritic lesion due to bone on bone contact is point a, which CAN lead to point b, which can progress to point c, etc.  The end result shows what happens once the arthritic process (called arthritic change) is underway.  It sounds like subchondral cysts, stage c, come before osteophytes, which are bone spurs.  Like I said, everything I've read relates subchondral cysts to osteoarthritis, and I hope you are finding the same.  Again, your doctor is the one to discuss what these things mean--you and I can look up terms, but our surgeons have to put them in context for us.

I'll be thinking about you and hoping that your discussions with the doctor go well.  Keep informing yourself, it is the best thing you can do--so you can discuss things with your doctor and make the best decision for you.

Heather

[wofford99]

Hi Heather-
Thank you so so much. I really appreciate all of your help. Yes, the orthopedic chapter I studied in anatomy is slowly coming back to me!
    I wonder if it is strange that my patella cartilage is so bad but my lateral and medial joint compartments look so good? I know it is 2 different cartilages- hyaline and fibrocartilage which have different chemical components.
  It seems like to me if I had a systemic  immune problem releasing these proteolytic enzymes then all of my cartilage- compartments and kneecap would look bad.  It seems like the realignment surgery was not done right which caused this rapid degeneration due to the malalignment of the kneecap.
   I am going to delve through the medline articles tomorrow. I am in so much acute pain from the past week I wonder if this cyst has gotten very inflammed.  Thank you for listening. I feel so alone. My family has no concept of all of this and I have no siblings.  Thank you! Margaret

PS- Check out this website- it has lots of references.

http://users.erols.com/equinox/references.html

[Janet]

Margaret:

I don't have anything to add to the discussion except that I have I have no damage to any cartilege in my knee except the articular cartilege behind the patella. So it is entirely possible to have damage in only one compartment. The damage I have behind the patella is from the way the patella tracks due to my baja.

Janet

[wofford99]

Hi Janet-
Thanks so much for your reply also.  Are you on pain medication? I am just curious what your dosage and medication are and if they  help.  You are welcome to email me privately at hsmith99@aol.com; Thanks! Margaret

[parky_13]

Hi guys,
I am getting ready to go to Iowa City on Tuesday. I was able to get all of my surgery records. Some I understood and some I did not. I went through the records and looked up words to get familar with definitions. I did learn alot.

1.ruptured quadriceps tendon right knee. There was an attenuation-type tear of the extensor mechaniam. This was off the insertion of the patella. This is the one the physical therpist did.


2.there was a rent in the retinaculum extending at the superolateral border of the patella extra-articular extending appox 5 inches proximal. Also the removal of a small ossicle superior to the femoral component. This was on the left knee


3. Removal of retained hardware rt knee and manipulation of the rt. knee under anesthesia.


4. Arthroscopic synovectomy rt. knee The patella was very tight clinically so he went in a loosen the scar tissue.

5. rupture of biceps tendon rt. knee and partial rupture of quadriceps tendon. A transverse rupture of the quad tendon extending from the vastus interomedialis laterally. He also put in place a restore patch.

I am stuck now at 65 degree's he wants to manipulate again in hopes of gaining 10 degree's. He is pushing for a new replacement  he believes this is the only way I will be able to function.

I still have a tear in the left quad tendon to deal with.

Does any of this make sense?  Thanks Parky

[Janet]

Dear Margaret:

The issue of pain management is a timely topic right now. Having had surgery 8 weeks ago, I find that the pain from the surgery is gone. However, I still have more pain than before surgery, especially when (trying to) walk, and going to PT five days a week makes me very sore. When I no longer needed the Vicodin, I was on Ultram (Tramadol) for several weeks, but the OS would not renew the prescription. So I am back on the Celebrex (200 mg 1-2 times per day) which I was taking before the surgery. It keeps things barely tolerable as long as I'm careful to stay off my feet as much as possible, and I even sit at my desk at work with my leg elevated. If the Celebrex had been enough, I wouldn't have gone through the surgery in the first place! I feel like they're not taking my pain seriously. My OS is a "big name" knee surgeon and I've been happy with his care up to this point. It's not like I want to be on a lot of medications, but just don't think that being in a lot of pain is helping my recovery. I'm not in agony, but in more pain than I'd like to be on a daily basis. I've actually made an appointment to talk with my family doctor about this, as she is the one who prescribed the Celebrex in the first place.

Janet

[wofford99]

     I saw my orthopedic surgeon today to talk about the MRI report.  As suspected, my cartilage degeneration has now progressed and is now considered degenerative joint disease.  He said they have come out with a patellofemoral replacement but he told me to wait a few years until they perfected it.
   He said he hasn't had much luck with a patellectomy.  So, he is going to do arthroscopic to clean out scar tissue, clean up the cartilage, and look at and take out this cyst. He said he can't guarantee that it will help the pain a lot but my kneecap is just grinding terribly. He wants to get a closer look too at the knee.
  He said he can do surgery with a femoral nerve block and IV medication. I had this done when I was 13 with my third knee surgery and I woke up in the middle and it was awful. Has anyone else had a femoral nerve block and do they give you any sedation pre-op because I just don't want to feel much putting the nerve block in. Also, during the surgery I just don't want to feel much and I have a very strong pain medication tolerance so I hope I am comfortable.    
   If they can start the IV beforehand and give me some kind of sedation so I don't have to walk into the operating room, I would be very happy.  I would appreciate any feedback on the femoral nerve block.  Thank you! Margaret

[Janet]

Margaret:

I have always chosen to have the general anesthesia, so can't give you any advice about the femoral block. But I believe they do give you IV sedation and you really won't remember much.

It sounds like you're doing the right thing by having a scope, although every surgery can compound problems and irritate the knee even more. But I know my OS said there just isn't any way good way to really find out what's going on inside the knee without going in and looking. That's why so many times people come out of knee surgery having had a different procedure than they thought they would. When is your surgery? Good luck!

Janet

[wofford99]

Thanks so much for your email. My surgery is on my 27h birthday which is Septmber 17. Happy birthday to me! I am really nervous about this anesthesia option of the femoral nerve block because I have such a high toleance for pain meds. Also, I get so anxious about surgery and even seeing them remotely messing with my knee and even feeling pressure might send me over the edge!
 I know I sound like a head case but you all I am sure can understand. When you have had 12 surgeries, you just don't wat to feel anything and put yourself through anytning else. Thanks for listening! Margaret