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Author Topic: PATELLA BAJA  (Read 14012 times)

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Offline kmack

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PATELLA BAJA
« on: January 25, 2005, 02:01:23 PM »
  I am a 28 year old male who’s occupation is an electrician, married with two sons 19 months and a 3 year old, and otherwise in good heath. November ‘03 is when my problems started when I underwent bilateral arthroscopy knee surgery.

  Prior to, certain activities would irritate my knees such as playing basketball or going up and down tall ladder at repeatedly. My knee would swell moderately and the inner portion became painful. If I were to kneel my knees would crunch. These symptoms occurred for approximately 10 years, with no past history of injury. Concerned about deteriorating my knees I sought the attention of a orthopaedist. Upon my office visit, he examed me, took x-rays and ordered a MRI. The radiologist impressions were as follows: left knee- mild degenerative arthropathy of the medial and lateral knee joint compartments. Findings suggest anterior cruciate ligament instability. Right knee- abnormal signal of the anterior cruciate ligament worrisome for partial tear and instability. No other abnormality identified. On the return visit I was told I would need to have arthroscopic knee surgery.

  In November ‘03 I had surgery and shortly after I started to have problems. The following was performed in the right knee: a major synovectomy was performed in the medial anterior and lateral compartment, a thick medial plica was removed, tear of the posterior horn attachment of the medial meniscus was removed, a loose body was removed from the posterior medical compartment, a tear of the posterior horn attachment from the lateral meniscus was removed and a chondroplasty with a Holmium laser was performed of the trochlear groove of the femur to remove fragmented articular cartilage. The following was preformed in the left knee: synovectomy was performed in the anterior, medial and lateral compartments, a thick media plica was removed, a tear of the posterior horn of the medical meniscus attachment was removed, a thick area of synovial tissue attached to the medial condyle was removed.

A day post-op my calves would get unbearable charlie horses in them when I would stand. At this time I was still on crutches. A ultra sound was ordered to rule out blood clots, which was negative. I was sent home and given muscle relaxers. A week went by and was still unable to walk without the aid of crutches or cane. I was sent to PT and in a week I able to walk with out aid. It took about two more weeks until I was no longer hunched over. I walked with a limp still. My right leg stayed bent and would not straighten out until a dinosplint was ordered. It took about 2-3 weeks for that to work I could not extend my left leg and now have great difficulty in doing so, to the point that it is impractical. I did PT for about two months until I diagnosed with neuroapraxic injury to the bilateral femoral nerves below inguinal ligaments. Neuro did not want any bending at the hip; therefore, PT said that there was not anything that they could and PT was stopped. Two months elapsed when I saw a new OS who ordered me back to PT because I was getting so weak. I checked with Neuro, which told me it was ok and that the nerves were regenerating. I have been in PT ever since.

I am still very weak, more so in my left, and unable to extend my left leg. My right knee gives me trouble, but my main focus now is to get my left equal to my right. 6/04 I had a MRI of the left knee because it was popping and having pain at the patella. My OS said the pain at the patella was condramolasa. The impression of the MRI was as follows: tear of the posterior horn of the medial meniscus without displace fragment or large flap. I was diagnosed with patella baja in11/04. The patella is 2cm lower than the right. It is believed that the pain from the patella is why I can not extend and causing the quad muscle to shut down. My present OS does not have much experience with baja and is not comfortable with operating on me. However, if he did, he would do a patella lengthening with a box wire for support. I sought a second opinion from a highly respectable OS and he would do a tibial tubercle slide.

I am not pleased with having to have another surgery, but I think I have come to the conclusion that it will be necessary in order for me to get past this. I am looking for the best possible solution for this with least invasive surgery and with the a physician with experience with baja. I know it is hard to diagnose based on what I have written to you, but I am will to travel were ever, I just want limit it to those doctors who think that can help me. I am a young man and my goal is to live a moderately active life. I would appreciate your opinion and in the mean while, I will continue PT. I have a appointment in 3/05 to see Neuro to have an EMG/ nerve conduction study to compare where I was a year ago.




Regards,
Keith :'(
« Last Edit: January 28, 2005, 01:53:16 AM by kmack »

shadehawk

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Re: Do not know what to do or what Docs to see!!!!
« Reply #1 on: January 25, 2005, 04:05:29 PM »
Hi Keith, sorry about your knee problems. Since you have been diagnosed with patella baja you should talk to Heather M., Callie 'bajalady' & Janet. They all have this condition. They have a lot of experience with this condition and will have some info that could help.

If you do a search on the first page of this site on patella baja alot of the posts should come up for you.

There are a lot of others here also that have this condition, sorry I am unfamilar with all their names. Look through the posts on Patella Baja and Google search this condition for more information.

I think you should hit your modify button and recall this patella baja.
« Last Edit: January 25, 2005, 11:43:19 PM by shadehawk »

Offline Janet

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Re: PATELLA BAJA
« Reply #2 on: January 28, 2005, 07:26:21 PM »
Dear Keith:

I'm sorry more of us hadn't answered you yet. I have been away from the boad because my son is in the hospital. But I'll try to fire off a quick response and move this back up to the top.

If you have patella baja, you have a problem with fibrosis (scar tissue). Patella baja happens when the patella and/or patella tendon gets scarred down and can't move. Eventually, the patella tendon itself thickens and shortens, pulling the patella lower. There is also a correlation between weak quads that are not strong enough to pull the patella up. But once the patella tendon changes, it is a permanent change unless you can address the scar tissue that is holding everything down. There is a fairly short window of time to do this. I think Heather M. says it is 6 months.

Then, because the patella is in the wrong position, it is easy to develop lesions in the articular cartilege on the back of the patella. If the patella isn't in the right place, it obviously rubbing in areas where it shouldn't. The first signs of this are the chondromalacia....a softening of the articular cartilege. This is graded, with I being the least serious and IV being worn all the way through. Did they give you a grade?

Anyway, you need to see an arthrofibrosis specialist. I would NOT let anyone do ANY surgery on your knee unless they had some specialized training. Unfortunately, these specialists are not that common. Where do you live? We can point you to some surgeons that others on this board have found helpful.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline Janet

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Re: PATELLA BAJA
« Reply #3 on: January 28, 2005, 07:34:04 PM »
(continued)

I developed patella baja following a quad tendon rupture and open repair. I won't go into all the details. Just suffice it to say that it wasn't caught early, and eventually I found another doctor. I had more surgery, but the scar tissue came back. I was extremely limited functionally and had a lot of pain. No one could understand why my quads would not respond. I worked extremely hard in PT with a biomechanical expert for nine months, with little result. Eventually my OS threw up her hands in defeat, but referred me for a second opinion to an arthrofibrosis specialist. He knew right away the scar tissue had returned. I had further surgery and very specialized PT. That was 19 months ago. My quads have responded, and I am stronger than before (but not up to normal....probably never will be). I function better. But I will always have limitations and pain. I have a grade III defect on the patella, which will only continue to get worse.

PT for an arthrofibrosis patient is different than for a normal healer. There are special protocols to keep the knee less traumatized so the scar tissue doesn't return. This is another reason to find an arthrofibrosis specialist. Many have their own PT departments that follow their protocols exactly.

Please let us know where you live.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline kmack

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Re: PATELLA BAJA
« Reply #4 on: January 30, 2005, 09:36:48 PM »
Janet,

Sorry to hear about your son, I hope everything is ok.  I live in New Orleans but willing to go anywhere to fix this knee.


Thanks
Keith

Offline Heather M.

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Re: PATELLA BAJA
« Reply #5 on: January 30, 2005, 10:17:40 PM »
keith,

Your case is very complex, and I would suggest that you get all your information together and go see *several* specialists who have had success dealing with patella baja. That's because each of them will likely have a different plan for treating your knee; your job is to do your homework and select the doctor whose plan best fits within your comfort zone and your expectations for the future.

I'm afraid you will have to travel, though. We haven't really found any doctors in the South through our research--the closest one would be in Columbus, GA (Hughston Clinic, I think it's called--talk to STgiles). Also, there is supposed to be an absolutely fantastic orthopedist at the Health South hospital in Birmingham (or is it Huntsville?) Alabama. He is the physician for the US Olympic Gymnastics team. I don't know if this doctor has experience with patella baja, but he has worked on some incredibly complex cases. You'd have to do research on the Gymnastics team to find the doctor, or do some google searches and see what you come up with. This doctor was featured on Discovery Health Channel, which indicated he worked at the Health South rehab center in AL--you might be able to search on the Discovery web page.

Finally, here is a list of doctors and their locations. These surgeons have all done extensive work and published in peer-reviewed journals about their work with arthrofibrosis and patella baja. They are listed roughly from West to East in the US. I've only had surgical experience with one (Dr. Steadman), and have seen two others (Paulos and Noyes) for consults. Most people posting in this section have seen either Drs. Steadman or Sterret, Dr. Eakin, Dr. Hughston (I think), Dr. Noyes, Dr. Lindenfeld, or Dr. Millet for surgery. Others are waiting for surgery with Dr. Wickiewicz or Dr. Shelbourne.

Dr. Colin Eakin -- Palo Alto, California
Dr. Lonnie Paulos -- Salt Lake City, Utah
Dr. J. Richard Steadman -- Vail, Colorado
Dr. William Sterret -- Vail, Colorado
Dr. Randy Viola -- Vail, Colorado
Dr. Jason Folk -- Vail, Colorado
Dr. Donald Shelbourne -- Indianapolis, Indiana
Dr. Frank Noyes -- Cincinnati, Ohio
Dr. Thomas Lindenfeld -- Cincinnati, Ohio
Dr. Thomas L. Wickiewicz -- New York, NY
Dr. Russell F. Warren -- New York, NY
Dr. Peter Millet -- Boston, Massachussetts
?? at Hughston Clinic-- Columbus, Georgia



Please keep in mind that surgery is only half the battle--the physical therapy and supportive care post-op is also critical. Dr. Steadman told me it is the real factor for success or failure, which is why he's developed (apparently along with some other doctors like Noyes and Paulos) a very specific post-op regimen for lysis of adhesions patients. Dr. Steadman also uses a procedure called an insufflation to deal with early adhesions that try to come back after surgery. This is done *instead* of the more traumatic MUA or manipulation. So as you can see these doctors are still working on innovative new treatments for the arthrofibrosis patient. I'm sure other doctors besides Steadman have these procedures, but I can only speak about the doctor I had surgery with....

Heather
« Last Edit: January 31, 2005, 03:04:53 AM by Heather M. »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline bajalady

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Re: PATELLA BAJA
« Reply #6 on: January 31, 2005, 12:55:07 AM »
Hello,

Contact David Aiken MD in New Orleans if he's still there. Just have a consult if you can. Talk to his nurse first and make sure he is the one I remember. I don't know if he is considered a "fibrosis specialist." I also don't know anything about him, but I read an article once, a case history about a baja patient he helped. He does the tubercle proximilization procedure. I am almost certain that is his name. Took me a while to remember.

There are no easy answers to your problem. The big surgeries they usually do to try and correct the baja if it's "true baja" on the x-ray (the base of your patella is way under Blumenstats line) sets you up for bad scarring due to the complexity of the procedures, so it's on the scar tissue merry-go-round you go again.

If you can find a scar tissue specialist and work out your insurance etc. (the list above) who also does the complex open procedures, you should be ahead of the game before it starts. Good luck to you. I am sorry you are in this position or I'm sorry your kneecap is in this position. Oops, forgive me geek humor. Let the board know how things go.

Callie
« Last Edit: January 31, 2005, 03:44:59 PM by bajalady »
Lft-- 1 open, mutiple scopes, combo Fulkerson- TTT and modified Maquet, more scopes.
RT--multiple scopes, one open
Baja, patella infra/contracture, DJD--Fibrosis

Offline kmack

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Re: PATELLA BAJA
« Reply #7 on: January 31, 2005, 01:50:38 AM »
I guess I am on the right track.  I am going to see Dr. Flandry at the Hughston Clinic on 2/10 and a Dr. Dugas at Healthsouth on the 2/9.  I wanted to see Dr. Andrews at Healthsouth, but he referred me to his associate Dr. Dugas.  I am waiting for my appointment with Dr. Steadman.  I was thinking about seeing Dr. Noyes, but now I think I will wait.  In the meanwhile, I will check out the doc for the gymnastic team and Dr. Aiken in N.O. Ya'll are great help.  I hope things go better for you.




Thanks
keith   

Offline stgiles16

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Re: PATELLA BAJA
« Reply #8 on: January 31, 2005, 02:21:07 AM »
Keith, I hope you like Dr Flandry as much as I do,,,,,,,, he is great. Just for general information, Dr Jack Hughston passed away this past fall. I saw his name listed in this thread and thought everyone should know. Good luck

missy
2 ligament recons right ankle
2 arthroscopic,
5 open knee procedures
2 Plica removals
bone spur removal
2 microfractures
4 debridements
2 open LOAs all on left knee
Arthritis,both knees, ankles, shoulders, elbows, hands,spine
Fibromyalgia
Arthrofibrosis
LOA & PKR 2/15/06
RA
in pain mgmt
TKR JAN 2012

Offline Sharon

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Re: PATELLA BAJA
« Reply #9 on: January 31, 2005, 04:20:58 AM »
Hi,

I'm seeing Dr. Thomas Wickiewicz at the Hospital for Special Surgery in NY City for my patella baja. He has recommended a surgery for me that he has done several times in the past for this problem and claims that his patients have had siginificant improvement as a result of. Basically, he's doing a patellar tendon replacement with an allograft. He would replace a piece of my tibia, my entire tendon and the very top surface of my patella with this. I'm still hesitant about going through with it because it's something I haven't found too much info on yet and I'm still looking into getting a second opinion but I'm not sure with who. I most likely won't have to make any decisions on the surgery for awhile though because even though they do have me on the list to get an allograft it's going to take awhile. They have to find a tendon from someone with a similar tendon length to me and as I'm really small they have told me that it's going to be really hard to get me one. Good luck and let us know how your appts turn out!

Sharon
Left knee:
LR-5/99 & 9/01
Distal realignment and LR 7/02
TTT revision 6/03
screw removal/MUA 10/03
d/x with severe patella baja
7/05 patellar tendon replacement w/piece of quad tendon
4/07 OATS

Offline kmack

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Re: PATELLA BAJA
« Reply #10 on: February 14, 2005, 11:59:20 PM »
I saw two doctors this past week,  Dr. Dugas of Health South, a.k.a. Dr. Andrews clinic in Birmingham, Al. and Dr. Flandry of Hughston Clinic in Colombus, Ga..  Dr. Dugas told me he would do a lengthening of the patella or  if possible live with it and try to beat it with aggressive PT.   Dr. Flandry told me that the patella was scared down, the fat pad was fibrous, scar tissue was in the joint itself and that scar tissue was pulling down the patella.  I would need to have an open procedure to remove the scar tissue, because he can not get to every place he needs to get with a scope.  I would have to stay up there 2-4 weeks and have aggressive PT for 6 months to a year.  Dr. Dugas did not sound like an arthrofibrosis specialist to me but Dr. Flandry did.  He told me that he sees my condition about 20Xs a day whereas a regular OS sees it 1-2Xs a year.  I go see Dr. S 3/15 to see what he thinks.  Could you all give me some feed back on what you all think on the open surgery.




Thanks,
Keith

Offline Nick_Knack

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Re: PATELLA BAJA
« Reply #11 on: February 15, 2005, 03:33:36 AM »
Hey Keith,

I had an open arthrolysis and posterior capsulotomy this past summer.  I went from about 10 degrees extension loss to 2 degrees or from 3 1/2 inches difference from other leg lying with legs off edge of bed to 1/2-1 inch.  It sounds scary because it's open but it's nothing compared to the crap you have been through thus far.

Anything to restore normal biomechanics.

Good Luck,

Nick
Age: 35
1989 rt ACL (+25 degrees ext loss)
1994 rt ACL resection (+ 10 deg)
2001 rt ACL revision (+ 10 deg)
2003 rt med meniscus repair (+10 deg)
2004 rt LOA and post capsulotmy (zero degrees)
2005 rt LOA and tib bone plug removal (even w/ other leg)
2006 rt Fulkerson TTT & ACI Carticel

Offline bajalady

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Re: PATELLA BAJA
« Reply #12 on: February 15, 2005, 03:56:07 AM »
Hi,

The open surgery has a chance of getting to all the scar tissue. Scopes don't get it all when your knee hits a certain point in the fibrosis cycle. Depends on how severe the scarring is and where it is. I had a big open one, but mine was done with a Fulikerson/ Modified Maquet. I was so low and the fibrosis was so deep and my soft tissue was shot through with the scar tissue that even a large open LOA was not going to be enough to "raise" my patella.

At a certain point, no scope and no open LOA will raise your patella----it may loosen it up some but it will not change the height. You probably are not to this point yet or Flandry would have told you. That is good. I also had a smaller open after the Maquet to free up the tendon----no big deal to me. In spite of all I've had done, this knee is still baja, but not nearly like it was before.

Missy has had the Flandry surgery by him and she is pretty happy with it. Tendon lengthening is "huge and risky" and if Flandry thinks he can get your patella loose with just an open LOA and fatpad surgery that is great.

I see you are seeing Steadman too. Ask him how many surgeries he thinks you will need. Georgia (Flandry) is closer and cheaper than Vail by far although Steadman is a really really good surgeon and fibrosis OS.

Read Jennifer123 and Jaci's threads on soft tissue. They are Steadmans patients and they have had more than one surgery in Vail. And they are not done yet. They have to stay up there for each procedure (rent a condo etc) and for some time after for the initial rehab. Can you afford that? Even in off season? Big consideration I would think. But you could end up having more than one surgery by Flandry too. Hope not but hard to tell. There are so many uncertains with scar tissue.

Good luck to you. Baja is just awful; sorry you have to join the "club."
Callie
« Last Edit: February 15, 2005, 05:46:44 PM by bajalady »
Lft-- 1 open, mutiple scopes, combo Fulkerson- TTT and modified Maquet, more scopes.
RT--multiple scopes, one open
Baja, patella infra/contracture, DJD--Fibrosis

Offline scarlit_sky

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Re: PATELLA BAJA
« Reply #13 on: February 22, 2005, 02:33:23 AM »
I know I am a little late in replying, I am from Hammond, but my OS's office is in Slidell. He is really great, Dr. Timothy Devraj, he is at oschner. If you haven't found another OS yet I would reccomend you to fo see him.

Kayla
18 y/o
LR 1/05 TTT + MPFL Recon.-- 6/05- R
LR + MPFL recon 12/05 TTT-- 4/06  IND-- 6/06- IND & screw removal-- 7/06 IND 10/06 Exploration 10/06, 12/06, & 2/07-- all left
Chronic Osteomyelitis- Currently facing amputation

Offline MelP

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Re: PATELLA BAJA
« Reply #14 on: March 05, 2005, 03:41:38 PM »
Two weeks ago, I got a second opinion at Duke Sports Med. that I have a serious problem - patella baja.  As you know, the news has been devastating.  I have always been super healthy and active and have a three year-old and one year-old. 

Thank you so much, Janet, Heather, Missy and Callie for your resposes to Keith's questions.  It has given me so much hope to know that there are others out there going thru the same thing I am and that I am on the right track - I have an appt. with Dr. Noyes in two weeks.  I think he may be the surgeon for me because my mother lives in Cincinnati, so I could just live with her post surgery (I live in Charlotte, NC). 

Would you recommend seeing another arthrofibrosis specialist in addition to Noyes?

And, what is a MUA? (is it a manipulation?).  Is surgery used to treat patella baja referred to as a arthrofibrosis surgery? 

I got in this predicament because of a benign cyst in my knee.  When my first surgeon removed the cyst, he noticed damage to the pateallar tendon (that didn't appear on the MRI?) and repaired it.  I think he just locked down my knee for too long - 6 weeks with  no range of motion and after that, I could only do 40 degrees because he installed a wire around my patella.  My first surgery was Nov. 5th and the surgery to remove the wire was Jan. 24th. 

It seems like I've caught this somewhat early (under 6 mos.), so I hope that will help me.

thanks,
Melissa :)

Diagnoses: patella baja, arthrofibrosis, severe atrophy of quadricepts muscle. Dr. Frank Noyes performed 6 surgeries to restore function to my knee. Surgeries included lateral releases, Z-lengthening, scar tissue removal, and complete reconstruction of my patellar tendon.















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