The OSTEOARTHRITIS DEPARTMENT => KNEE ARTHRITIS - Articular cartilage repair => CARTILAGE REPAIR - Osteochondral autografts and allografts (eg OATS & mosaicplasty) => Topic started by: sheppardwk on April 15, 2005, 09:31:36 PM

Title: Osteochondritis Dissecans Diagnosis
Post by: sheppardwk on April 15, 2005, 09:31:36 PM
A brief history... competitive runner - approximately 20-30 miles per week.  Began experiencing pain in my left knee in January '05.  The pain was located in the inner part just below the femur and just above the tibia.  Rested for 2 weeks, but the pain was still there.  I went to a Sports OS and had 3 X-Rays - where I was diagnosed with patella femoral chondromalacia and/or a medial meniscus tear and went through 3 weeks of PT.  The PT consisted of leg presses, lateral leg stretches with a band, balancing on a roller, and weighted leg lifts in order to strengthen my inner quads - finished up with a battery-operated medicinal pulse through my knee.  OS recommended a MRI.
I just reviewed my MRI with my Sports OS and he indicated that it appears as though I have a "bone bruise" (also mentioned that the bone may be dead) or the beginning of OCD - although nothing is loose.  It shows faintly on two sections of the MRI.  He did not indicate the size (I will follow-up with him).  He explained several options including what I now know as debridement, microfracture, and OATS.  Specifically, during scoping, he would scrape or "pick" the area to facillitate blood and the development of new cartilage.  However, he said the first goal is to try and avoid surgery; therefore, we should try to continue PT and reschedule another appointment in 4-6 weeks to see what progress I've made.  He also requested that I refrain from any activity that causes discomfort - I pushed him on this as I'm very active (softball, golf, stair walking, yard work, etc.) and he simply replied "anything" that causes discomfort.
My question is...What, if any, PT exercises can improve OCD - if that's what it really is?  Won't PT cause discomfort?  I'm concerned about the options - as I've read microfracture only last approximately 4 years!  Any thoughts would be greatly appreciated.
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: poohpoohknee on April 16, 2005, 01:16:54 AM
I have had pain in the same area of my knee for quite some time, since I was 12.  I had a medial meniscus tear repaired when I was 17 and thought that was the end of it.  I had quite a few pain free years and then when I was about 28 I started having mild discomfort in the area again.  In 2002 I saw an OS who did a scope and some abrasion to an area with no articular cartilage.  He told me it was the result of OA.  The abrasion did not work, I had synvisc injections that did help for about 8 months.  I then saw a different (better) OS who took one look at my xrays, asked the onset age of original problem and diagnosed me with OCD.  He tried a scope and did the transarticular drilling to stimulate blood supply to form fibrous cartilage in 2003.  I was NWB for 6 weeks.  Unfortunately it did not work either!  I tried a different type of sonovial fluid injection last fall, it did not help.  I am now almost a week away from my OATS procedure (4/26/05).  (My insurance made me jump through the hoops of the other procedures prior to authorizing my OATS.) 

If PT does not help you, and if you truly have OCD I don't understand how PT alone will help, I'd go for the OATS.  I am a bit bitter though after going through two procedures that did nothing for me.  I don't know everything about OCD, but from what I do understand it can never get better.  It's a matter of making you comfortable and avoiding TKR as long as possible.  It's basically a disease in which the blood supply no longer reaches the end of the femur (in my case due to a bad fall at the age of 12) and the articular cartilage slowly wears down/dies off until there are "lesions" or areas with no cartilage that cause pain. 

I hope my rambling has helped somewhat.    Diane
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: casey2291 on April 16, 2005, 05:37:48 AM
WHAT???  OCD eventually leads to a TKR???  Ok, I must have missed that in my research.  I just had microfracture for an OCD lesion and now you are stressing me out!!  Diane can you please tell me where you heard or read about OCD leading to a TKR?  Thanks.

Casey  :)
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: sheppardwk on April 17, 2005, 09:06:55 PM
That's certainly not something I want to her or entertain either.  I just heard about OCD four days ago and now we're talking about TKR.  My OS indicated our first priority is to avoid surgery with PT, re-evaluate in 4-6 weeks and see where we've progressed.  I'm hopeful I can avoid any procedure much less think about TKR.
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: brattkids2 on April 18, 2005, 08:51:03 PM
OCD can lead to TKR as none of the proceedures to repair or replace the damaged cartilage are permanent. Eventually all the cartilage will wear away (but this could take years and years) and there will be bone on bone and extensive damage leading to TKR.

My information came from three different OS including one listed on the surgeons on this board.

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: casey2291 on April 18, 2005, 09:00:55 PM
Hi Paulette,

Thanks for the information!!  Not what I wanted to hear, but I do appreciate you posting what you had heard.  I guess that means I might be a lifetime member of this board    :-\

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: Jakem on April 19, 2005, 01:13:26 AM
Hi Shep,

You are not going to like what you are about to read, but you might as well be hit with reality right from the beginning as I wish I was so I wouldn't have had all the false hopes everyone on this message board has gone through.

When you damage the articular cartilige, you are basically screwed.  Rest will not help it and PT won't help it.  My doctor wasted a year of my life with rest/PT.

You have 3 options and all of them are lousy and none do what they are advertised to do.

Microfracture - They drill into the bone so it bleeds and it produces fibrocartilige (scar tissue cartilige) where the normal hyaline cartilige used to be.  Any doctor can and will perform this surgery on you.  It has an official success rate of 75%.  In reality the success rate is about 15%.  Success does not mean jogging and recreational sports again.  Success means you can walk to the refrigerator with only minor discomfort.  85% of the people who have had microfracture wish they could do that.  Not only that, in the rare successful cases, the success lasts only a few years as scar tissue cartilige will wear out.  For defects greater than 2 cm x 2 cm the success rate is basically 0%.  Worse still, the surgery and recovery is extremely painful and even more painful when your false hopes are dashed and it doesn't work.  You are non-weight bearing for 6-8 weeks followed by months of rehab all for nothing in most cases.  There are a couple of rare but well know exceptions, the Asian guy in California who returned to marathons and he has his famous Woo Hoo Microfracture site.  Also Jason Kidd came back to Pro Basketball after a 1 CM2 non weight bearning microfracture.  I can name 6 other NBA guys who failed to ever make it back and scores of NFL guys such as Terrel Davis who was treated by Steadman.

OATs/Allographs -  This procedure takes a plug from your non- weight bearning part of your knee (OATS) or from a cadaver (allograph) and fills in the injured site.  For OATS you are robbing Peter to Pay Paul.  The official success rate of this procedure is 85%.  The actual success rate is closer to 50%.  It can only successfully be used for 1 cm2 (OATs) or 2 cm x 2 cm (Allographs).  This is also long recovery even if successful.  Even if successful, you will limited in future activities.  Worse still, most insurance companies will make the doctor try a microfracture first, or the doctor will insist on his own that you try microfracture first.  Basically you will lose 2 years of your life in rehab and pain for nothing if you have a microfracture then an Oats/Allograhph.

ACI - This is the mother of all operations and rehab.  It takes two procedures and over a year in rehab.  Many insurance companies won't cover it and few doctors can do it.  This has an official success rate of 88%.  The actual success rate is close to the official success rate.  However, it doesn't do what it is advertised to do.  Yes it does produce hyaline cartilige that upon inspection "looks great".  However the "successes", while having significantly reduced pain and improved functionality, cannot return to to anything other than a very low level of recreactional activity.  See Allan Cormier's excellent web site on this procedure.  His was a typical "success".  He put off TKR for many year, reduced the pain, increased the funtionality, but can't jog, can't play a pick-up game of basketball and will experiance pain and swelling after a long hike or bike ride.

Most people on this group have gone from surgery to surgery with disappointment after disappointment for many years.  We are all hoping the next surgery will be the one that works or if we follow the perfect reahab we will be alright.  In reality, most have been recovering from or planning for another surgery or are in perpetual rehab for years and years and will be for the rest of our lives or until we are old enough to have a TKR at age 55.

I hate to be downtrodden, because I am an optimistic person in general, but the reality is that when injure your articular cartilige, you are in for hell.  You will be going from surgery to rehab to surgery to rehab and in most cases getting worse and worse.

Since none of the 3 surgeries do as advertised, you may want to strongly consider doing nothing if you can bear the pain.    If I could have done it all over again, I would have done nothing and just limited my activities, taken glucosime/Condroitin and taken Celebrex or Viox and I would have saved myself lots of false hopes, deadended rehab, extreme pain and disappointment.  Many on this group would have been better off also, but Hope Springs Eternal so they won't admit it and doctors are always willing to do more surgeries which is their bread and butter.
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: poohpoohknee on April 19, 2005, 02:19:32 AM
My OS is has been very honest about my OCD from the start.  It has always been a matter of my comfort over anything.  The way he put it we are trying to avoid TKR for as long as possible.  However since I am allergic to ibuprofen and many other NSAIDs, surgery, vicodin and living with pain have been my only hopes.  Last fall I decided to try to live with the pain, wearing a knee brace for support.  I went to a party in February, and there was dancing.  I hurt so bad for the next week I decided I had to try something else.  I am 36 years old but after that weekend I felt 80.  So my OS is going to do OATS.  I am keeping my hopes up that I can get a good result!  Hey even a few months painfree seems like a good result to me right now.  Besides, it's a 6 week minumum vacation from work!  (Thank God for short term disability!!)

Sorry to burst any bubbles, Diane
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: casey2291 on April 19, 2005, 04:19:04 AM
Well, now I'm depressed  :(

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: sheppardwk on April 19, 2005, 09:26:27 PM
Depression is certainly starting to settle in for me as well.  I've now read and heard everything from "simple procedure" to TKR.  Just a little on the W-I-D-E  R-A-N-G-E side of things, don't you think.

I've contacted my OS and asked several questions.  As a result, he has asked that I come in to talk with him - and no PT until we meet.  I'm scheduled to meet with him tomorrow afternoon (4/20)  Any questions that anybody can suggest that I ask?  Any that you would like asked or wish you had asked?

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: brattkids2 on April 19, 2005, 10:54:13 PM

That was the best thing you could do!! Ask your OS lots of questions about different proceedures. If it is just a bone bruise that you have it will just take TIME to heal. If its OCD ask your OS what you can and cannot do as far as activities. I know activity is based on size, location, and grade of lesion. If microfracture would benefit you? If it fail what then? Your OS should help ease your anxiety about your knee!!

Please keep me posted as to what the OS said!!

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: JG on April 21, 2005, 12:11:17 AM

I struggle with something very similar to you, bone bruises that may or may not be necrotic.  I have one on my patella (seems to have finally gone away), one on my tibia and one on my medial femoral chondyle.  I struggle with the MFC one the most.  Last year, it was really bad so he recommended going on crutches for 6 weeks to allow the bone time to heal or go into a unloader brace which is what I did.  This really helped.  Many times they can't really tell via xray if the bone bruise is dying or getting better. 

The TKR talk for you seems a bit...well rediculous.  However, the progression of a spot going from "maybe necrotic" to "necrotic" to OCD is the problem to address.   I agree with the posters about OCD not getting better with PT, it won't.  However, you don't have OCD (definitively), just "maybe necrotic" bone.  I agree with Paulette, these take time to heal...lots of time.  I would ask about being NWB for a stretch.  See if that helps.  If not, there are lots of options before TKR.  My knee is really bad (grade IV arthritis in all compartments, yada yada yada) and I don't even consider TKR an option.   When I had my big mosaicplasty two years ago, there was a patient before me who had mosaicplasty for a huge OCD.  He was back up and running in 8 months or so (granted he was 18 at the time).

Good luck
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: sheppardwk on April 21, 2005, 02:55:15 AM
Well, I met with my OS today as a follow-up and essentially indicated that I had done quite a bit of research since meeting with him last Thursday and had lots of questions.  (Thanks to this board as well - especially Casey, Pooh, Jakem, Brattkids, and JG)  I specifically asked whether I had a bone bruise or OCD and whether PT was something that should be done to alleviate my problem.  He seemed impressed with my questions and general knowledge of OCD, debridement, Microfractue, OATS, etc.  (Again, thanks to this board) I continued to press him on the "picking" of the bone and "fluffing" of the articular cartilage and the resultant rehabilitation of these procedures.  Bottom line - he believes it's a bone bruise on the medial femoral chondyle (non-weight bearing) and for me to forget I ever heard him mention OCD.

He suggested I begin/continue with PT in an effort to strenghten the muscles around the knee and attempt to create a better tracking for the knee.  However, he did caution not to perform any exercises that causes pain.  We want to identify and improve the problem not compund it.  I asked about the articular cartilage damage and he mentioned that on a scale it was toward the minimal damage, at this point, and that we want to keep it there.  He agreed that it will be a permanent factor and that I need to accept it - at 38 - this is not uncommon.  I mentioned that I want to be able to resume my activities - running, sports, etc., and he suggested keeping active and seemed to think that I may be able to resume my hobbies.

He also addressed necrosis very similar to the way JG relates it - "maybe" to "necrotic" to OCD.  His recommedation is to PT for 3-4 weeks, return to him and decide how to proceed.  Any known PT or therapies to alleviate bone bruising?

Thanks for all of your comments.

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: stgiles16 on April 21, 2005, 02:25:48 PM
I am not a dr but I am now confused. How can a bruise on the MFC NOT be in a weight bearing spot? I may be wrong but I thought that the whole MFC was a weight bearing spot.

anyone know for sure?

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: casey2291 on April 21, 2005, 03:16:44 PM

I was also confused about the MFC being a non wieght bearing area.  I am also confused as to why your doctor mentioned OCD and talked about doing microfracture and then dismissed the idea the second time that you saw him.  Have you considered a second opinion just to be on the safe side?

Casey  :)
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: sheppardwk on April 22, 2005, 01:15:57 PM
Here is what I found:

Page 3, 2nd paragraph under Epidemiology:

The incidence of OCD in the general population is estimated to be 15 to 30 cases per 100,000 persons.1,5 Although rare, it is recognized as an important cause of joint pain in active adolescents. OCD has typically been known to affect males between 10 and 20 years of age. One study noted that boys are three to four times as likely to be affected as girls.3 The incidence appears to be increasing in women2 and in younger children,1 perhaps because of increasing involvement in organized sports.

The most commonly affected areas include, in decreasing order of frequency, the femoral condyles, talar dome and capitellum of the humerus.6 The knee is involved about 75 percent of the time.3 Classically, the non­weight-bearing medial femoral condyle is the location in 85 percent of cases of OCD of the knee.7 OCD must be ruled out in the contralateral joint, because 20 to 30 percent of cases are bilateral.3

I'm not a Dr. either, all I know about condyles is from what I've read - the make up of the knee consists of the medial femoral condyle and the lateral femoral condyle.  Each condyle has an anterior aspect and a lateral aspect.  Hopefully someone else can shed some insight as well.
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: brattkids2 on April 22, 2005, 07:02:16 PM

Here is another article that explains that there arenon weight bearing portions to the chondyles.

Hope everyone is doing well today!!

Title: Re: Osteochondritis Dissecans Diagnosis
Post by: kathleenj on April 22, 2005, 08:23:07 PM
Wow this is interesting.  I was just reading something this was from an International Cartilage Repair Symposium attended by Minas, Boland and others.  Granted it was from 1998 it stated at one point that 'there is no truly non-weight bearing portion of the articular surface".
I was under the impression that there was infact non-weight bearing portions of the knee, gosh, thats where my plugs were apparently taken from. lol  Who knows now. 

Its an interesting read if your interested in cartilage regeneration techniques, but like I said its from 1998. The area that mentions the weight bearing issue in on page 2 or maybe 3 under the Oats/Mosaicplasty section.
Title: Re: Osteochondritis Dissecans Diagnosis
Post by: sheppardwk on April 22, 2005, 09:25:08 PM
I'm not really sure, but apparently 85% of OCD lesions are located on the lateral side of the medial femoral chondyle (MFC).  In layman's terms, I suppose that would be the inner portion of your knee where the femur forms the chondyles.  On my left knee for example, it would be the left-most (lateral) portion of the inner chondryle or the MFC.