Microfracture Diary - medial femoral condyle

[surfbum]

I see a lot of people asking questions about this topic, so thought I'd share a little. I'm currently at 9 weeks post-op. I have done hours and hours of research reading RCT studies and journal articles, so thought I'd share a little. A little about me:

Microfracture on medial femoral condyle measuring 12mmx12mm. This was an isolated chondral defect in an otherwise healthy knee joint. Other surgeries done at the same time was a plica resection and very minor menisectomy (5%). I'm a 28 year old male in good shape (6'2" 195 lbs.) The biggest predictors of success are going to be adhering to rehab protocol/size of defect (1cm sq. or less is ideal)/age (35 and younger is ideal)/weight (obesity is not your friend).

My OS was Daniel Kharrazi in Los Angeles. He does ortho consult/surgery for the LA Lakers, LA Kings, etc...

Week 0-2:
CPM 6 hours a day (four 1.5 hour sessions throughout the day). Ice and NSAID's. Non-weight bearing. No exercises.

Week 2-7:
Exercise/ROM progression: CPM 6 hours a day (discontinued CPM at week 7). Simple PT exercises (7 days per week - twice per day); SLR's/clams/quad sets/stretching/patellar mobilizations. These basic exercises were done until I went full weight-bearing at week 7. Bicycle started at week 3 at 40 minutes/day; for the first week or so I just leg the good leg do the pedaling and let the bad leg go for the ride.

Weight bearing progression: At week 3 I started slowly and put about 10% weight down. At week 4 started putting more like 20%. At week 6 I put down about 20-30%; after a few days went to 50%; and was full weight-bearing at week 7. It wasn't until week 8 I had a somewhat normal gait and walked normally.

Week 8 and on:
Exercise/ROM progression: PT exercises (5 days per week - once per day) include SLR's/quad sets/clams/heel raises/double leg press (60 degress max)/stretching and patellar mobilizations/treadmill walking at 7% incline for 5 minutes perday - increase 5 minutes per week/bike 25 minutes per day (light resistance)/aqua jogging in pool 20-30 minutes per day.

Weight bearing progression: full weight bearing with normal gait.



HELPFUL TIPS/OBSERVATIONS:
1. After surgery, take off all the bandage they have on your leg when you ice it, otherwise the ice will not get through and will not be cold enough to help with inflammation. After icing, just wrap the ted stocking (if they gave you one for blood clot prevention) and the ace wrap. Also when icing, extend your leg straight and rest your heel on something. This helps with extension.

2. When on limited weight bearing status, walk heel-to-toe to simulate normal walking pattern. 

3. my swelling started to go down little by little, but when I went to full weight-bearing it came back. They say that's normal and will start to go down little by little again. The pool has helped tremendously with milking the fluid out.

4.Read up on anything written by Steadman and BJ Cole.

[surfbum]

Week 10:
Just beginning week 10. swelling is starting to really come down. they say after going FWB, swelling comes back and settles down after a few weeks. Still got a little ways to go to get all the fluid out. I went grocery shopping for the first time since the surgery and the knee handled the walking around really well. could feel it starting to fatigue, but didn't get inflamed or swollen.

Exercises/ROM: all exercises the same. Increased treadmill walking to 10 minutes on strength building days (5 per week). Treadmill walking forward/backwards.

[Saints21]

Hello!!

Does the swelling come back after fbw?? and if so, when ??ive been fbw for 3 days, and the swelling has gone down a lot.. is this maybe because my mfx is in a non bearing weight part ofthe bone??

Thanks!

[surfbum]

Hello!!

Does the swelling come back after fbw?? and if so, when ??ive been fbw for 3 days, and the swelling has gone down a lot.. is this maybe because my mfx is in a non bearing weight part ofthe bone??

Thanks!

"they" say it is normal, and for me it did come back and then started to go back down after being 3 weeks FWB. I'm 14 weeks out and I still have minor-moderate swelling, more so after a good day of PT. My OS said my knee looks great for being 3 months out.

I remember my swelling came back after a few days of being FWB and was probably at its worst a week after being FWB.

[Saints21]

Well. my problems of swelling are very little.. I will wake up feeling 100% and at night feel like 90% with slight swelling).. but I guess this is because the lack of muscle puts more stress on the joint...

I am lifting like 12 pounds on the leg and I see only slight muscle recovery ... cant wait to hit the gym!!!!

Have you tried to run underwater.. I guess thats the next logical step into recovery at like 3.5 moths post-op...!!

[surfbum]

Dude, you're golden and it sounds like you're own your way. What protocol are you following? 12 pounds sounds crazy! Lol, I was only doing 2-3 pounds. I was aiming for muscle exhaustion around 20 reps. In the Steadman/Hawkins protocol, until you reach 16 weeks, your workouts should only be focusing on building an endurance base, not a fast-twitch muscle base. 

I'm following the Stead/Hawkins protocol. I'm actually hitting the gym (16th week) for the first time tonight. I still have swelling, but no pain. Can go up and down stairs without any pain or trouble, can bend down in a squatting position with no pain, etc... From my first surgery, I remember having swelling until hitting the gym. That muscle contraction milks the fluid out and the muscle base takes pressure off the joint.

I do go to the pool 2-3 times a week. I just do aqua jogging with the buoyant pool belt. Last week I started using 3 pound weights on my ankles in the pool when aqua jogging. My regimen for rehab was 2 days on 2 days off. Now that I'm starting the gym, it will be 3 days/week.

[Saints21]

haha I know about the 12 pounds but I was trying to maintain little muscle I had left... I obviously doing it with no pain whatsoever..!

I have no problems going up down stairs etc.. today I have a slight discomfort and pain like 1/10 squatting but Ive always had knee pain when it rains and its very humid and it has poured all morning!.. also could be the kneecap re-aligning itself... well see!!

need to get one of those floaters to aquajog!! im doing bike 5 times a week 25 minutes.. today 27 .. with 0 discomfort.. well see what happens!!!

Godd luck on your rehab as well!

[surfbum]

I'm currently at 6 months. Starting month 4, I started doing strength training in the gym (per steadman&Hawkins protocol). I use the squat type machines, outer quad and inner quad machines, and hamstring machines. I ride the stationary bike everyday for 25-35 minutes. On rest days, there is zero tension on bike, but during stregth days, I increase resistance to 11 out 20. Still using the treadmill (during strength days) at an incline of 7% at 3.5 mph for about 15 minutes.

In the last 2 weeks, I have decreased the strength days to 2x week since I'm lifting more normal amount of weight during gym sessions and my body needs more time to recover.

Good news...The Dr. did an MRI last week and the defect has filled in!! The MRI report and the Dr. saw no signs of chondral damage or wear. I'm feel a pinching sensation/ache occasionally, so this should proof for many that even though the MFX was a success, you'll still feel pain but it should be resolved by 18 months.

I think my success was a combination of non-weight bearing to partial weight bearing for a full 7 weeks (steadman recommends 6-8 weeks), riding the bike EVERYDAY for 25-40 minutes, and taking the rehab process slowly like Steadman recommends.

[poikiloid]

Can you tell me about how many RPMs you usually bike? I guess it would be different when you do no resistance versus 11 resistance?  None of the Steadman papers suggest how fast to pedal...
My PT said the more cycles, the more synovial fluid getting pumped in and out, but I wonder if going too fast might cause excessive shearing fluid pressures or something. If you know how fast you usually did it, and had your good result, that would be a possible guideline for others.

[AndrewH]

Good news...The Dr. did an MRI last week and the defect has filled in!! The MRI report and the Dr. saw no signs of chondral damage or wear. I'm feel a pinching sensation/ache occasionally, so this should proof for many that even though the MFX was a success, you'll still feel pain but it should be resolved by 18 months.

My defect filled in completely as well (confirmed by my OS after I woke up after my recent mosaicplasty on the same spot). However the pain I felt in that spot never really went away. Most of the time it felt exactly the same as pre surgery.

I think they key to success is a decent amount of hyaline cartilage forming rather than just all fibrocartilage, which is what appears to have been the case with myself.

Good to read about your recovery.

On a side note, I noticed this week that the England cricketer Andrew Flintoff this week announced his retirement after undergoing microfracture in September last year. He was hopeful of making a comeback but has finally admitted defeat. Proof again that microfracture might not be good enoiugh to get people back to full sporting activities.

[AndrewH]

Can you tell me about how many RPMs you usually bike? I guess it would be different when you do no resistance versus 11 resistance?  None of the Steadman papers suggest how fast to pedal...
My PT said the more cycles, the more synovial fluid getting pumped in and out, but I wonder if going too fast might cause excessive shearing fluid pressures or something. If you know how fast you usually did it, and had your good result, that would be a possible guideline for others.

I read an article recently about forces on the patella during cycling. Apparently the forces are greater, the greater the resistance or gear and also when cycling more slowly. Also, there are less forces if your seat is high.

Cycling with a high seat, moderate resistance and a high cadence (90-100 rpms) is ideal.

[surfbum]

good info. Yes, a high seat is a definite. I read in all of the rehab protocols that the seat level should be at height where there is only a slight bend in your knee. I pretty much just raised it until my leg was stright, then lowered it one notch to where my knee slightly. I ride the bike at a rate of about 75 rpm, seemed like a good speed to me. Definitely agree that at lower speeds, you can feel a greater amount of pressure on the joint. On the other hand, with a fragile surgery like this, I wouldn't feel comfortable wacking away at 100 rpm either.

Did anyone else still need to ice their knee through out the day even at 6 months? My OS said it just means the joint is still healing which is good. It feels like the site magically healed within the last few weeks because I don't feel any pinching/ pain/ aching any more, and the warmth and need to ice is starting to decrease.

[Caerwyn]

Hi Surfbum5412! Very interesting posts! Nice to get a rough idea of how others in a similar situation are getting on! I'm also a 28 yr old (young!) male and weigh 70kg (around 154lbs). I'm in good shape and am a semi-pro football (soccer player) here in wales, uk. I'm 3 weeks post-op and had a osteochondral defect measuring roughly 10mm on the lateral aspect of the medial femoral condyle in my left knee, which was treated by microfracture. I had no other problems with the knee and the lesion is apparently not directly on the weight-bearing surface according to my OS. He's also a reputable surgeon over here having operated on Manchester United FC soccer players in the past. My protocol is as follows :-

0-3 days - CPM machine 6-8hrs daily. Touch WB 10-15kgs (22-33 pounds) with crutches. Static quads, gluts, stretching and the usual circulatory exs, ice, NSAIDS etc.

3 days - week 4 - passive movements through range and regain full extension via mobs. No active Quads or hamstrings through range.

Week 4 - week 6 - Partial weight bearing (1/2 body weight). Active movement at knee closed chain that doesn't engage the lesion and all previous exercises.

Week 6 - week 8 - Full weight bearing if tolerated. No limit to active movement and open kinetic chain exercises. Resistance to be added as tolerated. Then week 8 - light jogging added on sprung surface then week 12 - twisting, turning etc added, then week 14-16 return to sport.

The protocol appears to be very similar to yours. My current concerns keeping in mind i'm only on week 3 is intermittent clicking and aching sensation in the knee whilst on the CPM always on about 30 - 40 degrees of flexion, which then settles. I've also noticed pronounced wasting in my calf muscles despite regular ankle pumps with theraband.
Just wondered if you had also felt clicking or an uncomfortable ache on passive movement?
Were your calfs wasted? Did you do any strengthening work at my phase on them and what?
Are you involved with a particular sport?
Sorry about all the questions there, it's just the more info on common problems etc the better.
It sounds as though your managing your case very well and i wish you all the best in completing your recovery successfully!
I wouldn't worry about the heat aspect of things by the way, it's obviously just your body working away at that healing the affected area. I'm a physical therapist myself and have known patients with varying injuries/ops to experience heat etc up to 2 yrs post injury/op. Guess there are so many variants in all of this that it's mostly a case of symptom management later on down the line with the trusted ice. All i would add is that from my reading also on the subject, the more gradual the return to more vigorous activity the better, as we both know it's fibrocartilage that's hopefully in there not the original stuff. The biggest mistake we can make is ignoring symptoms later on after all the hard work.
I'll look forward to hearing from you and keep up the good work!!

[poikiloid]

I started stationary biking at about 2 (or was it 3?) weeks. You can start as early at 1 week, depending on lesion size, or as late as 4 weeks for large lesion. My quads had inhibition and were already noticeably small by then. At a certain ROM while extending knee (an active activity, obviously, so not quite the same as w/ your cpm), I'd get a "catching" unless I pointed my heel forward, instead of my toes forward. Basically, weak quads often cause the patella to track (move) incorrectly, so I had to compensate by changing my foot angle a bit to avoid the catching. As the quads slowly returned (6 months and still not 100%), the tracking corrected, and now I rarely have catching. See this site (click "How do I do exercises for patellar tracking disorder?") for good knee exercises and stretches (both very important): http://www.webmd.com/a-to-z-guides/exercises-for-patellar-tracking-disorder I also had a "fuzzy" feeling in the knee for a good while that's gone away in the last couple months. I think it was from inflamed synovial membrane postop that has resolved now.

I strongly recommend you (or someone) go to the nearest university with medical journals and print and ready everything by Steadman on the topic. Or try to get copies through interlibrary loans. Maybe you can get them emailed to you.

According to Steadman, you should be doing stationary biking by now for such a small lesion. It gets nutrients into (and waste out of) your knee so repair tissue is better quality.  Read Steadman, and show to your therapist. Probably want to start daily biking very soon. (If you have a choice, a recumbent bike would be easier to get on and off of, and the back support is nice.)

[surfbum]

Thought I'd check in and give an update...

8 Months:
Intense Strength training day (1 day/week) squats (currently up to about 200lbs.), hip adduction/hip abduction machine (currently at 140lbs.), Calf machine.
Moderate Strength training (1 day/week) moderate resistance on bicycle, 20 minutes of walking at 7% incline, approximately 60 Step ups with 30 lb. weights
I'm also riding the bicycle with very light resistance about 3 times per week.

Obviously by now, my rehab training is more tailored to my fitness and rehab, but thought I'd share. I saw my OS last week and he says about 90% of the swelling is gone which he says he is more evidence that the surgery was a success. I still have to ice my knee early in the morning and before bed. Also, after the intense strength training day, my knee aches, but nothing too bad. My OS suggested a Synvisc injection to help with the aching until complete healing which takes 1 1/2 - 2 years post-op.

Side note: beware of portal incision scar tissue. I had a very bothersome lump of scar tissue underneath the lateral incision that was forcing my knee cap out of alignment. This caused a popping sensation when extending my leg and I'm thinking this caused the pain and inflammation I was having. The OS injected cortisone into the scar tissue area and my knee feels looser (kneecap glides normally now) and my knee feels better and better as every day passes.

[surfbum]

The protocol appears to be very similar to yours. My current concerns keeping in mind i'm only on week 3 is intermittent clicking and aching sensation in the knee whilst on the CPM always on about 30 - 40 degrees of flexion, which then settles. I've also noticed pronounced wasting in my calf muscles despite regular ankle pumps with theraband.
Just wondered if you had also felt clicking or an uncomfortable ache on passive movement?
Were your calfs wasted? Did you do any strengthening work at my phase on them and what?
Are you involved with a particular sport?
Sorry about all the questions there, it's just the more info on common problems etc the better.
It sounds as though your managing your case very well and i wish you all the best in completing your recovery successfully!
I wouldn't worry about the heat aspect of things by the way, it's obviously just your body working away at that healing the affected area. I'm a physical therapist myself and have known patients with varying injuries/ops to experience heat etc up to 2 yrs post injury/op. Guess there are so many variants in all of this that it's mostly a case of symptom management later on down the line with the trusted ice. All i would add is that from my reading also on the subject, the more gradual the return to more vigorous activity the better, as we both know it's fibrocartilage that's hopefully in there not the original stuff. The biggest mistake we can make is ignoring symptoms later on after all the hard work.
I'll look forward to hearing from you and keep up the good work!!

I had clicking too. Definitely felt it during heel slides and when I'd extend my leg out while sitting in a chair. My clicking never went away though, and in the end found out it was due to some scar tissue that slowly built up at the lateral portal site. I've received a cortisone injection into the scar tissue (about 2 weeks ago) and I religiously massage it. Since the injection, the clicking has gone away by about 80%. OS said I would need to come back for 1-2 more injections.

My calfs totally wasted. They started coming back after I started a walking program on the treadmill and even more so when I got into the gym at 4 months. Honestly though, my muscles are still smaller than my good leg, and they're slowly getting bigger. Only thing I can say is that it takes time. Also, For me those little at home exercises didn't much other than slightly minimize complete muscle wasting. Real strengthening for me happened when I started walking and getting in the gym.

I'm a avid skydiver with 700 jumps and I surf as well. I busted my knee on a high speed high-performance landing Super funny to see the video of the surgery...ok here we have a healthy knee and....OH MY GOD....a massive hole in the articular cartilage that goes through to China.

[cbalotro]

Week 8 and on:
Exercise/ROM progression: PT exercises (5 days per week - once per day) include SLR's/quad sets/clams/heel raises/double leg press (60 degress max)/stretching and patellar mobilizations/treadmill walking at 7% incline for 5 minutes perday - increase 5 minutes per week/bike 25 minutes per day (light resistance)/aqua jogging in pool 20-30 minutes per day.

Weight bearing progression: full weight bearing with normal gait.



HELPFUL TIPS/OBSERVATIONS:
1. After surgery, take off all the bandage they have on your leg when you ice it, otherwise the ice will not get through and will not be cold enough to help with inflammation. After icing, just wrap the ted stocking (if they gave you one for blood clot prevention) and the ace wrap. Also when icing, extend your leg straight and rest your heel on something. This helps with extension.

2. When on limited weight bearing status, walk heel-to-toe to simulate normal walking pattern. 

3. my swelling started to go down little by little, but when I went to full weight-bearing it came back. They say that's normal and will start to go down little by little again. The pool has helped tremendously with milking the fluid out.

4.Read up on anything written by Steadman and BJ Cole.

Congratulations! It is great to hear that the microfracture treatment worked well for you! How are you and your knee doing now in the New Year! I hope all is well.
Anyways, I am 8 weeks post op and just had a post op appointment with my OS. He said that the swelling has died down but there is still some fluid in there. He didn't refer me to any PT so I'm doing all my PT with research online. I came upon your post and was very happy to see someone put up their post-op rehab.
For your exercises you did in week 8, how many reps and sets did you do for each exercise?
How much weight did you do for the leg press?
And Can you describe the aqua jogging that you did? thank you!

[surfbum]

Knee is continually getting better. It's been exactly one year, and although not 100%, it gets better and better with strength training and time. Scar tissue takes 2 years to fully remodel, so time is our friend. Lol, don't you hate that phrase by now..."just give it time."

I still have a little fluid in there. I see a huge difference every month, so I'm assuming the cartilage is maturing and quad strength is getting better.

As far as strength training in the 8th week and on, I kept reading everywhere that 20 reps is the gold standard. After reading Steadman and other protocols derived from randomized-control studies, the only thing you should be doing is building an endurance base for your muscles.  Steadman protocol recommends to NOT hit the gym and begin using weight machines until the 16th week (4 months). The idea is that you should slowly transition into heavier weight because your muscles have atrophied and the cartilage is still maturing.

When I was still using PT, they had a leg press type machine that used tension cables and I performed single leg presses. It was probably at most 20-30lbs. When I got into the gym, I started at around 60lbs and increased 10 lbs. every 10 days (per Steadman protocol). For awhile, I sort of plateaued at around 130-140 lbs, but I'm currently doing double leg squats (letting my injured leg do most of the work) and I'm at 200 lbs. I do strength training for my leg 2 days per week. I'm also at the gym 3 other days a week working out my upper body. So I'm in the gym 5 days a week. As a result, I also ride the bike for cardio (20 minutes) and stretch my quads, etc... for a total of 5 days a week.

For aqua jogging, I just bought one of the buoyant waist things and warmed up by doing aqua cycling for 20 minutes,  then progressed into aqua jogging for another 20 minutes. Basically, to aqua jog, just pretend your running. The water creates resistance and it's quite the workout.

[surfbum]

So here I am 15 months post-op and the Microfracture was a failure. Knee swelling never went down all the way and constantly had a moderate amount along with warmness and redness starting in April. Also, felt an aching feeling at medical femoral condyle site.

Went to a new cartilage specialists in LA (Dr. Bert Mandelbaum). He said that after microfracture, a 1/3 do really well and return to sports, a 1/3 do "OK", and a 1/3 don't heal at all. It's funny to hear the real world success findings compared to Steadman's (which is totally bogus). Dr. told me that microfracture is like rolling dice.

Happy to report though that the next option is DENOVO NT which he always recommends now...especially after failed microfracture. His theory on why not to go on to ACI is because if your cartilage cells can proliferate properly to heal a microfracture site, why would use the same cartilage cells with ACI? He's seen much better and faster healing times with DENOVO NT, so that was his choice and my choice (my choice even before I walked through the door into his office).

My view is why would anyone get anything other than DENOVO NT, like ACI or OATS? DENOVO NT is one surgery while preserving other cartilage sites in your knee. Plus, younger ANYTHING have higher cellular activity and will heal faster with better quality.