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21
Thank you for the support. I agree lots of gentle movement. I did have a consult with Dr Stone but that was several months ago when my imaging was normal and he said physiotherapy. My symptoms were so awful though that I went for arthroscopy as I knew there was a chondral flap and it made sense to me that was inflaming the joint. Now, I would never have an arthroscopy for this condition.
It may be worth getting another consult with him, in light of the arthroscopy findings. I worry now that the operated knee muscles are too weak to take more surgery. Although you would assume they would come back with a strong joint.
It's good to hear that your symptoms have improved. How long did it take? I guess each knee is different. I try and do a lot of gentle movement. Short walks and swimming upper body only. Strengthening for hips/glutes/core etc. I avoid stairs and inclines amuch as possible and standing for long periods.
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Iíve also found Dr Kevin Stoneís work interesting. Heís been doing pioneering, biological/regenerative knee surgeries for a long time. He is also keen on getting patients back to sport and a fully active life. Some interesting stories about his patients with partial knee replacements running marathons etc. They do a free initial phone Ďconsultí. Worth a look maybe:
https://www.stoneclinic.com/
23
I understand it can feel like things wonít improve as Iíve been there too. After over two years of similar issues to you, things are improving with gradually increasing gentle movement, avoiding excessive stairs and hills, no running, but plenty of movement. Being still for too long and especially sitting knees bent causes me problems. Dyeís principles helped me, settling things down first, potentially over a long time before then trying to increase the envelope. He also advocates regular icing, NSAIDs and steroid injections if needed. He even discusses surgical removal of a small amount of inflamed synovial tissue I think at the extreme end. Not sure if he is still practising but he did offer video appointments for those unable to travel to SF. 

There is hope, even if if you do need to go for PFJR / TKR in future.
24
Thank you for the replies. I have been feeling desperate recently.
I am in Vancouver but would travel anywhere.
I have so many emotions about seeing surgeons and physiotherapists. They seem to think that the patient isn't trying hard enough with PT which could not be further from the truth.
When I said I had arthrogenic muscle inhibition due to anterior knee pain- they did not seem to get how difficult it is to build quads. One PT also wanted me to do weighted knee extensions. I said that the shear forces on the PFJ would be big and I thought a leg press was a better option and he said he knew what he was doing and to trust him. I didn't and I'm not sure the understanding is there.
I have read Dr Dyes papers and it makes a lot of sense to me, along with Richard Bedard/Paul Ingraham. I struggle with the envelope of function concept in my case though as I have discomfort with any movement. I am doing joint strengthening with a vertical incline plane/high rep low load movements.
Mentally, I've been floored by all this. I feel that even surgeons don't really understand the PFJ. They want to see bone on bone and major defects before doing anything. I feel that my whole joint surface is soft and not transmitting load. Definitely I have to persist with PT, especially as I am so weak after the surgery, but I would like some hope for surgeries.....
25
Hi Lucy. Sorry to hear about your knee problems. Youíre certainly not alone, so common, and youíre in the right place! I agree with Dave that the comments made by this surgeon seem strange.

Modern PFJ replacements (done by doctors with good specific experience of this) nowadays seem to be much better and longer lasting than in previous years. TKR (especially custom made and again depending on expertise) have a good track record too and overall success rate of at least 80-90% I think, so not sure where this 30% is coming from.

If you havenít yet seen the PF work by Dr Scott Dye, take a look too. You can access his research papers free online and there are vids on YT. Guru members have found his research helpful (myself included).

PF issues are a drag and can take a lots of patience and time to resolve but I hope improvements come soon for you!
26
Thanks Dave and RGB. Really helpful. Definitely agree with trying to manage for some time conservatively before anything too drastic. Giving things a chance to settle or at least extending the age at which Iíd need a revision seems sensible for now. Have you heard anything about Biopoly resurfacing? Clever materials. I think their PF trials conclude at the end of this year.
27
Lucy,

What part of Canada are in you in?
I'll see if I can come up with some recommendations.

I often wish I had obtained a physical therapy license.  I've had so many orthopedic surgeries that I feel no one is a better qualified PT than a patient who has lived through the recovery process.
28
GENERAL KNEE QUESTIONS and comments (good for new threads) / Re: PFJR post op activity
« Last post by RGB on August 06, 2022, 10:05:39 AM »
Hi all. I think I'm going to regret getting into this discussion but I'm unable to restrain myself. To be clear, I'm not a medical professional so nothing I say beyond my own personal experience should be acted upon without your own research. Also, I did all my reading/research on patellofemoral cartilage damage more than 5 years ago before I had my PFJR. I haven't read anything much since apart from the occasional discussion on this forum. I'm not going to restate my history - I'm sure it's somewhere on this forum for those interested.

First let me venture that I think PFPS and pain due to patellofemoral cartilage damage are not necessarily the same thing. PFPS can be present without obvious cartilage damage and so it's not always clear what's causing patellofemoral pain. I never researched this further because I had clear extensive cartilage damage but, without such damage, my first port of call to address resistant PFPS would be something along the lines suggested by SuspectDevice - a 6 month course of Celebrex, a cessation of aggravating activity and a very gradual reintroduction of strengthening/activity. That's probably what I'd do with minor cartilage damage as well - only because the alternatives are not great and, if it works then the time and effort will be well worth it.

With extensive patellofemoral cartilage damage, the options are not great. Chondroplasty has nothing going for it. If I was older (I was late 40s when my damage became apparent) I would not bother with microfracture (even with stem cells a la Dr Saw), PRP or stem cell injections (fat, blood or bone marrow derived). I researched those, believed some of the hype, invested a good deal of effort and money and, for me, they were a waste of time. The research supporting them is patchy at best and the simple fact is that, if they worked reliably, everybody would be doing it and there wouldn't be any discussion on this forum. There will always some early adopters (both doctors and patients) but until there are good widespread results the chances of you or me picking the one technique that solves what is a very hard problem are small. Some of the techniques might work better for younger ages but that wasn't my position so I didn't pay much attention to this. Also, these comments are very much restricted to damage to the patella or trochlea groove. The stats are better for damage elsewhere. At the time I did my research, MACI results weren't that great for patellofemoral damage. The surgeons that I consulted that offered MACI refused to do it for me because of this and I agreed with them.

All of this leads to PFJR as a solution. My PFJR is 5.5. years old. Is it perfect? No and there's not a day goes by that I don't wish I had a 'normal' knee so I could do a wider range of activities (climbing and trail running mostly). Is it better than before? Absolutely. Previously I could climb and descend one flight of stairs a day without pain. Biking, skiing and extensive walking, especially on hills were completely out of question. Now, I've learned to mountain bike and, in a few years, I've gone from beginner to riding Grade 5/6 trails which give more than enough adrenalin for most of us. Uphill is more of a problem than downhill. I can do around 2 hours of really steep uphill a week. Any more and the knee swells. I can ski but not as far or fast as I'd like. 4 hours a day, every second day is about my limit. Does it feel natural? No and I try not to load it beyond around 90 degrees of flexion. But it's pretty good. Is it deteriorating over time? Maybe - I'm not sure. I'm getting older (60 this year) which makes it hard to tell what's the knee and what's the rest of my body. My plan is to give it another 5 years or so and then think about a TKR. A word of warning though - there's a good recent paper that shows that the revision rate of TKRs after PFJRs is much higher than the revision rate after just a TKR. So part of me wonders if I should just have gone for a TKR. However, I think I would have been worried about my mountain biking with a TKR - I've had some pretty spectacular falls and I could well have damaged a TKR prosthesis. So my TKR will be reserved for when I stop mountain biking.

That's it. Feel free to disagree with the views I've expressed - they're really those of an amateur reading technical papers, supported by an evidence base of one knee. So certainly subject to challenge. Regards to all.
29
MACI has some amazing outcomes even in PFJ.

Surgeons are often careless and aggressive and that turns a simple chondroplasty into a recovery nightmare.

If any surgeon offers me a chondroplasty again, I'll ask why we aren't trying to regrow cartilage as well.
30
Interesting article. I didn't have microfracture, just minimal chondroplasty that has weakened my joint considerably and wasted the leg muscles. It's heartening to hear you did recover. I would never recommend anyone has a chondroplasty.
The OATS may be something for me to consider. It just seems that in the harsh environment of the PFJ, the success is not great (less than the TFJ). If anything, I feel like I would ask for a PFJR.
This site is a wealth of information.
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