Patella Grade 4 Cartilage Damage - Incl. Pictures - Need advice

[reflex_nl]

Hi All,

I've been reading the forum for a while and would like to share my story and ask for help (pictures below).

My left knee patella luxated as I was tackled in a friendly game of soccer in Oct'16. The MRI indicated serious cartilage damage to the back of the knee cap. I got surgery to remove the loose bodies in my knee and they performed debridement/shaving on the grade 4 damaged area of the patella (1.2 cm^2 central in the patella) in Nov'16. All other knee items were intact.
 
I'm a healthy man, 36 years old, no issues, no medicine, no major sport fanatic. I'm mobile, and perform light physical therapy twice a week since mid dec'16, but the recovery is very slow, knee remains warm, and I have a pain during the day and more heavy pain when going down stairs, or a light 10 seconds jog. My mood is down these days... and it seems I make no more progress.

It's been 6 mths since the injury and I recently got a hyaluronic injection but that didn't help either... I have no idea what to do next :-[t. I read about Mosaicplasty, ACI, OATS, Regenexx, Chondrofiller... and Dr Scott Dye's articles, but I cannot figure out what is the best option for a Patella full thickness injury. I don't like invasive surgeries like ACI as these often have an uncertain outcome.

I will see my OS again in 3 weeks...  any tips advice , personal stories are welcome!

Thanks - Reflex

[tinydinosaur]

I know someone else here had Cartiform done, but I'm not sure if that's available for a large area defect. In my case the only option was getting an osteochondral allograft.. waiting on a transplant list. There aren't any really 'good' options for grade 4 cartilage damage - I was told transplant, kneecap removal (bad idea for knees with instability) or if i eventually got old enough a replacement.

If your defect is on one side or the other, and not right in the middle you can look at different braces that may help you, but if it's grade 4 there's basically nothing in there creating space so your bones are just rubbing on one another (that's why there's minimal physio progress, you can't rehab missing cartilage). The braces, there's an offloading brace by Ossur I believe, it basically forces the load to one side of the knee or the other to prolong the period for OA patients before replacement (haven't tried it myself), there's also the DonJoy Reaction brace which is supposed to provide tracking as well as spacing support and 'reduce the impact' on your knee during activity. I'm not very active yet myself so I can't speak to that, it's the only brace I've been able to wear for any amount of time in recent years that doesn't completely squish the kneecap (like a J-brace does).

You can also continue trying to restore homoeostasis in your knee as others here advocate, it really depends on your body whether that will work or not and will take quite a bit of time and messing around with your physio activities to find the right combination along with minimal irritation.

In my case the combination of wasted quad muscles and grade 4 damage lead my to the osteochondral allograft... I couldn't extend my leg even unweighted without severe pain - though it was a combination of lack of cartilage + a flat trochlea.

Basically does the limits your knee imposes on your life function / quality of life impact it enough to warrant surgery, is the question that it comes down to for you.

[reflex_nl]

Thanks for sharing your story. Could you share a bit more about your case?

1) location and size of the defect?
2) did you try injections?
3) did the osteochondral allograft help, how much pain do you have?
4) how has your quality of life improved?

Thanks,

Reflex

[tinydinosaur]

1. middle of the patella, i can't locate my surgery report with the specific size but i'll look around again

2. yes several times (i think three in between surgeries leading up to the transplant, i had a LR, debridement, plication, MPFL, debridement previously). they've always just made my joint feel unpleasantly full, but i also didn't have a proper groove. from what my surgeon tells me some people get shots every 4-6 months and that's all they need.

3. it helped yes, it's hard to quantify. functionally / mechanically it restored the space between my patella and my femur. my surgeon showed me the x-rays pre and post and it's noticeable how much space it puts back in the joint. i gained more muscle back after the surgery but continued to have pain and dysfunction which eventually lead to a trochleoplasty, so with those two (and the MPFL) my knee is functionally sound, it has a groove to slide in and the transplant fixed the cartilage problem so my patella is no longer scraping grooves into my femur.

to contrast my story, a guy also had the same surgery around the same time - 6 months post he was back to light sport, he was complaining that it wasn't as strong as he wanted yet and he felt like it was taking too long (meanwhile i was still having difficulty walking haha)

4. it's a lot better than it was, though functionally i'm still really far from being independent because of all the past problems i had. ie. previously i could stand for 5-10 minutes before the pain was unbearable now i can usually stand for 30-45 minutes. i still have major muscle loss that i'm working to get back which i think also contributes to a lot of difficulty as it puts more stress on the joint. this combined with the trochleoplasty really changed the way my chronic pain is, i used to get severe pain that would start in the joint and kind of seize the whole leg up and the whole leg would ache and now a majority of the time that pain is just in my joint and my muscles stay 'healthy'. my muscles also respond really well to a heat pack now, whereas before they just weren't having it.

edit: if i can answer any more questions for you i'll do my best. my decision to have surgery wasn't hard because there was no functionality of quality of life i was giving up. ie. they really couldn't make it any worse and i was getting no where with physio (8 years of it at that point)

[Brandon123]

Hi Reflex,

I also struggle with cartilage damage under my knee cap, but in my case it is probably more evenly distributed/spread out (hence, more difficult to fix with the above discussed procedures). You can read more about my story in the end of the following thread: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=67307.0

Anyways, can I just ask you what type of hyaluronic injection you did? Synvisc One? Also, I'm not an expert in any way, but since your injury and surgery were quite recent I think (and hope) you can still make great progress naturally with time. I remember I read Dr Scott Dye saying that it is not unusual for a traumatized (injury and/or surgery) and inflamed knee to take many many months to calm down.

I remember I took me a long long time to recover from my first injury and cartilage debridement/shaving, but I got back to pain free and almost normal function eventually. Then the knee broke down again many years later, but that is another story:)

My knee also gets warm/hot/red almost every day, but I have noticed that it makes a surprisingly big difference if I ice the knee 20 min in the morning and 20 min in the evening. A 20 min icing at lunch helps the situation even more. Besides braces and stuff as tinydinosaur mentioned, maybe McConnell taping could be worth looking into? Haven't tried it myself, but I have understood it sometimes can help by pulling the knee cap away from an irritated area, calming down inflammation/irritation.

Best,
Brandon
 

[Aly0108]

Hi Reflex,

I also struggle with cartilage damage under my knee cap, but in my case it is probably more evenly distributed/spread out (hence, more difficult to fix with the above discussed procedures). You can read more about my story in the end of the following thread: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=67307.0

Anyways, can I just ask you what type of hyaluronic injection you did? Synvisc One? Also, I'm not an expert in any way, but since your injury and surgery were quite recent I think (and hope) you can still make great progress naturally with time. I remember I read Dr Scott Dye saying that it is not unusual for a traumatized (injury and/or surgery) and inflamed knee to take many many months to calm down.

I remember I took me a long long time to recover from my first injury and cartilage debridement/shaving, but I got back to pain free and almost normal function eventually. Then the knee broke down again many years later, but that is another story:)

My knee also gets warm/hot/red almost every day, but I have noticed that it makes a surprisingly big difference if I ice the knee 20 min in the morning and 20 min in the evening. A 20 min icing at lunch helps the situation even more. Besides braces and stuff as tinydinosaur mentioned, maybe McConnell taping could be worth looking into? Haven't tried it myself, but I have understood it sometimes can help by pulling the knee cap away from an irritated area, calming down inflammation/irritation.

Best,
Brandon

I live with the same issue for 2 years. My last MRI in November 2016 looks good, no cartilage damage  in both knees, but I am sure that I have cartilage damage in of my knees. I dont find a solution for my knees, only I do every day exercises and I take supplement Krill, Oil and Same.
Brandon, after your story, I dont want any surgery, I say surgery will not help my knee caps.

[Brandon123]

Hi Aly0108,

If the MRI in November 2016 didn't show any cartilage damage, at least you shouldn't have any serious damage I guess, which is good news! Be careful so you don't exercise too much, it is easy to push an already irritated knee over the edge with exercise. I have been forced to cut back on physical therapy several times, in order to get better. Lastly, I think the long recovery I had from surgery was simple because the OS didn't real fix the damaged cartilage, only kind of polished it. So after the surgery I had still damaged cartilage (although a bit more smooth/even surface) but now also the inflammation/irritation from the surgery that needed time to calm down. However, when the knee eventually had calmed down from surgery, it did feel much better than before, although not perfect. But as you say, in your case, I don't think there is any need for surgery (unless you have some other injury not mentioned here).

[Aly0108]

Hi Aly0108,

If the MRI in November 2016 didn't show any cartilage damage, at least you shouldn't have any serious damage I guess, which is good news! Be careful so you don't exercise too much, it is easy to push an already irritated knee over the edge with exercise. I have been forced to cut back on physical therapy several times, in order to get better. Lastly, I think the long recovery I had from surgery was simple because the OS didn't real fix the damaged cartilage, only kind of polished it. So after the surgery I had still damaged cartilage (although a bit more smooth/even surface) but now also the inflammation/irritation from the surgery that needed time to calm down. However, when the knee eventually had calmed down from surgery, it did feel much better than before, although not perfect. But as you say, in your case, I don't think there is any need for surgery (unless you have some other injury not mentioned here).

Thanks Brandon,

Your the MRI didn't show cartilage damage of knee caps. My knee caps irritate my fat pad laterally, and that cause me pain and swelling. I calmed down my swelling a year ago, but now my right knee is painful because I moved in another home, and I stand a long time on my foot. I use every day Same 400mg and Krill Oil 4000. I do exercises only isomeric, my knees dont tolerated PT exercises, and I decided to do only my exercises home. I dont have another injury, only this problem of knee caps.
I think that is a problem of cartilage, usually laterally. 

[reflex_nl]

thanks for the answers this helps...

1. middle of patella defects are tough to heal as I learned, due to the sheering forces
2. I read a lot about injections and still not sure if they help - did you do stemcells?
3. Good to hear that it did help... but it is a risky surgery with a long recovery time
4. Quality of life is the final measurement...  I feel an irritating pain the whole day, I have good days and bad days, and it it difficult to correlate them with PT or physical activity. Since the injury is 6 mths ago...  I'm not sure if it does improve and I wonder what is causing it.

1. middle of the patella, i can't locate my surgery report with the specific size but i'll look around again

2. yes several times (i think three in between surgeries leading up to the transplant, i had a LR, debridement, plication, MPFL, debridement previously). they've always just made my joint feel unpleasantly full, but i also didn't have a proper groove. from what my surgeon tells me some people get shots every 4-6 months and that's all they need.

3. it helped yes, it's hard to quantify. functionally / mechanically it restored the space between my patella and my femur. my surgeon showed me the x-rays pre and post and it's noticeable how much space it puts back in the joint. i gained more muscle back after the surgery but continued to have pain and dysfunction which eventually lead to a trochleoplasty, so with those two (and the MPFL) my knee is functionally sound, it has a groove to slide in and the transplant fixed the cartilage problem so my patella is no longer scraping grooves into my femur.

to contrast my story, a guy also had the same surgery around the same time - 6 months post he was back to light sport, he was complaining that it wasn't as strong as he wanted yet and he felt like it was taking too long (meanwhile i was still having difficulty walking haha)

4. it's a lot better than it was, though functionally i'm still really far from being independent because of all the past problems i had. ie. previously i could stand for 5-10 minutes before the pain was unbearable now i can usually stand for 30-45 minutes. i still have major muscle loss that i'm working to get back which i think also contributes to a lot of difficulty as it puts more stress on the joint. this combined with the trochleoplasty really changed the way my chronic pain is, i used to get severe pain that would start in the joint and kind of seize the whole leg up and the whole leg would ache and now a majority of the time that pain is just in my joint and my muscles stay 'healthy'. my muscles also respond really well to a heat pack now, whereas before they just weren't having it.

edit: if i can answer any more questions for you i'll do my best. my decision to have surgery wasn't hard because there was no functionality of quality of life i was giving up. ie. they really couldn't make it any worse and i was getting no where with physio (8 years of it at that point)

[reflex_nl]

Hi Brando,

Thanks for your story. My injection was an Ostenil plus, pretty similiar to Synvisc. Like you I also did recovery from my first ~grade 2 injury on the Patella. It took about 5 years. This time I lost all my cartilage (focal) defect and I feel my knee is in a far worse shape than the previous time.

I tried taping and braces... it helps a bit but not much; I appreciate your positive words that it may still improve since it is a "recent" injury. Dr Dye talks a lot about people who have pain w/o a specific trauma and considers rest/light activity/ice as the way forward. I truly believe this for minor concerns, but when you have large cartilage loss to the bone, I guess this keeps irritating the knee joint. hence, I was looking in to "fillers" in the UK they have "Cartifill" and in Germany "Chondrofiller".

I have no rush into trying these yet - I'll wait for another 6 mths but would love to hear if people with focal patella defects did recover.

Brandon, since your damange is more evenly spread, did you check into stem cells (e.g. regenexx)?

Hi Reflex,

I also struggle with cartilage damage under my knee cap, but in my case it is probably more evenly distributed/spread out (hence, more difficult to fix with the above discussed procedures). You can read more about my story in the end of the following thread: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=67307.0

Anyways, can I just ask you what type of hyaluronic injection you did? Synvisc One? Also, I'm not an expert in any way, but since your injury and surgery were quite recent I think (and hope) you can still make great progress naturally with time. I remember I read Dr Scott Dye saying that it is not unusual for a traumatized (injury and/or surgery) and inflamed knee to take many many months to calm down.

I remember I took me a long long time to recover from my first injury and cartilage debridement/shaving, but I got back to pain free and almost normal function eventually. Then the knee broke down again many years later, but that is another story:)

My knee also gets warm/hot/red almost every day, but I have noticed that it makes a surprisingly big difference if I ice the knee 20 min in the morning and 20 min in the evening. A 20 min icing at lunch helps the situation even more. Besides braces and stuff as tinydinosaur mentioned, maybe McConnell taping could be worth looking into? Haven't tried it myself, but I have understood it sometimes can help by pulling the knee cap away from an irritated area, calming down inflammation/irritation.

Best,
Brandon

[tinydinosaur]

1. middle of patella defects are tough to heal as I learned, due to the sheering forces
2. I read a lot about injections and still not sure if they help - did you do stemcells?
3. Good to hear that it did help... but it is a risky surgery with a long recovery time
4. Quality of life is the final measurement...  I feel an irritating pain the whole day, I have good days and bad days, and it it difficult to correlate them with PT or physical activity. Since the injury is 6 mths ago...  I'm not sure if it does improve and I wonder what is causing it.

2. not yet, my surgeon briefly mentioned PRP but didn't really get into it, the last time my knee was looked at on the inside my graft was still nice healthy cartilage. going to have a look again inside and go from there.
3. if you're looking at these options don't be afraid to seek second, third, etc opinions - if you haven't already try to get referred to a surgeon who specializes in patella issues. for the graft i was told the main risk is in the first 6 weeks of it rejecting it and not healing together. there are other less severe options but i'm not sure if they are for large areas.
4. if you have cartilage damage you are probably more susceptible to arthritis type pain changes with the changes of the pressure/weather. it affects the fluid in your joint.

they will probably tell you to give it another six months, sounds like a pretty big injury so your body is just getting to the stage of full healing (they say that the tissues heal in about 6 weeks but the body doesn't fully recover until 6 months - 1 year.)

[Brandon123]

Hi Reflex,

Thanks for the info. Well, I have thought of PRP as well as stem cells, but there seems to be limited scientific evidence that it works (especially stem cells). These procedures are also really expensive and not that easy for me to access (I live in Europe). But I guess it would probably be worth taking a serious look into before having another surgery of some sort...

Could such procedures be of any help in your case, or does your type of cartilage damage require some kind of "filler"?

[reflex_nl]

indeed evidence on stemcells is low and the cost is high. I'm not sure if fillers work.... hence, I would love to hear from fellow board members if they had success.

BTW: how long did your recovery take until you reached a "stable" state?

reflex

[Brandon123]

There seems to be few success stories with stem cells around this forum, maybe simply because few have tried it (e.g. because of cost), I don't know. But I found this thread that raised the issue over three years ago: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=61573.0

Regarding recovery and reaching a "stable" state, I would say after my first surgery 2009, it took me around 2 years before the knee felt somewhat "normal", without any limitations in everyday life. It never felt completely normal, but very good. So good that I almost forgot about these knee issues and during 2015 took up (careful) running again. Then soon after all went downhill (stiffness, pain, red/warm), and I have not recovered yet...I guess the patella cartilage couldn't take the running and broke down further or something.

My dilemma is that quads are much wasted in the problematic knee by now, but the cartilage/joint cannot take almost any strengthening exercise without getting all flared up, painful, stiff, warm, red swollen etc. And wasted quads then only makes the problem worse, and so forth. OS and PT just wants me to exercise "within my limits". But within those limits, quads are not getting strengthened sufficiently. Hence, my hope for some treatment that could fix the underlying cartilage damage/inflammation/irritation.

I don't know if this helps, but my big "break through" in my recovery from the surgery 2009 came when I stopped doing all the PT exercises that were painful. This is not the official recommendation, however, my OS and PT said explicitly "no pain, no gain", but I got so tired of the pain and constant setbacks, so I just gave up on everything the made the knee feel worse. Instead, I did the few exercises that felt good and then tried to do as much normal stuff as possible, like walking, standing etc. In hindsight, without knowing anything about it, I think I kind of applied Dr Dyes "envelope of function" logic, and got better.

Are you doing a lot of PT and exercises?
     

[reflex_nl]

indeed, it is indeed costly and regenexx does a lot of nice marketing. I will discuss it with my OS.

Your quads are indeed important as they relieve the knee joint of stress, but it is hard to train them without serious activity. 

Normally in a week I do:
- light PT for 2x 30 min
- cycle for 1.5 hours
- swim for 1 hour
- static leg lifting to strengthen leg muscles/quads for 15 min each day

However the only time I'm not in pain is early in the morning when I wake-up. Knee feels ok, but after 20 min walking around in the house/stairs... it is over.

I would describe it as a constant / irritating / annoying pain in the whole joint (pain level 2 out of 10), knee heats up, gets warm. Often I cannot correlated it to my activity level...

How would you describe yours?

BTW: Iceing does help to bring the pain down during the day.