Microfracture breakdown?

[crumblingknee]

Hi everybody,
I had a microfracture. It was healing well and now it is suddenly falling apart.
I have had a menisectomy, chondroplasty, and microfracture with chondroplasty (focal point of the trochlea) on the left knee over the past 4 years.  I had the microfracture in August 2006.  According to the OS it was a microfracture of a full thickness trochlear chondral defect 20 x 18 mm.

I saw a top-notch consultant in January 2007 for a second opinion.  He ordered a very detailed MRI in February 2007.  He said the left knee was healing well and the defect was filled in with new tissue.  He saw the knee again in September 2007 & described the motion of the knee as smooth.  In November 2007 I was considering returning to jumping rope and volleyball. I saw the consultant in early November 2007 & he said I had a “normal knee.”

The weekend after I saw the consultant the weather turned cold and my knee started to become painful. Later that month the outdoor temperature continued to drop and my pain level continued to rise.  I went to see the OS. He ordered another MRI, detailed but not quite as thorough as the consultant’s MRI. The MRI was performed in January 2008 and I just got the results back. I was flabbergasted to learn that I have a full thickness defect “along the trochlear surface of the distal femur.” The treatment plan offered by the OS is Synvisc shots & my losing weight. What happened? What do I do?
Thanks,
Neil.

[Nettan]

Did you ever return to jump rope and volleyball ?
Just curious. Is there a possibility that the MRI from November can be compared with the MRI you just had ?
Sounds like either the MRI in November wasn't read as should or that you had a very fast breakdown.
Is this the exact same are where the microfracture was performed or a new area ?

[crumblingknee]

Hi Nettan,
Thanks for your reply.  I never returned to volleyball or jumping rope - the consultant had said not to   . My OS looked at the 2008 MRI - I am not sure if the OS looked at the 2007 images again. I am not sure  if the exact same area is at issue. Just to clarify, the first MRI of knee was performed in February of 2007 and the second MRI was was performed in January 2008. It sounds you like recommend a second opinion? Also I have a full thickness defect - that means I have bone rubbing on bone? How concerned should I be about this knee's future?

Did you ever return to jump rope and volleyball ?
Just curious. Is there a possibility that the MRI from November can be compared with the MRI you just had ?
Sounds like either the MRI in November wasn't read as should or that you had a very fast breakdown.
Is this the exact same are where the microfracture was performed or a new area ?

[laura_utah]

Wow, I agree with Nettan that your failure seemed to be very fast (<11 months).  I had a similar situation except in my case the breakdown occurred over ten months starting with intact, original hyaline cartilage (sob).

I think that it is imperative that you understand as much as possible about why your repair broke down so quickly.  If you try for another repair, you will want to make sure that whatever mad this one fail doesn't affect the next one too.  Bear in mind that, if the causes were alignment-related, they could affect the function of even an endoprosthesis (artificial knee).

As far as Synvisc and weight loss go, they're good temporary measures to keep the damage minimized while you determine the best way to restore your knee.  Do NOT consider living the rest of your life with patellofemoral arthritis.  You use your patellofemoral joint for EVERYTHING!  You need it to walk, swim, bicycle, do yoga and pilates, dance, drive a car, work in the garden....see the point?  The tibio-femoral joint can be effectively unloaded by just not weight bearing, so, folks with arthritis in those compartments can get by with simply switching to swimming and cycling instead of running and hiking, etc.  WE CAN'T!!!

Additionally, have you ever tried to lose weight without using your legs?  Good luck!

If I were you, I'd start researching everything I could about patellofemoral alignment and chondral repairs and why they succeed and fail.  Become a "knee warrior" and save you patellofemoral joints with education!  This website is a great place to start learning about the basics of patella tracking, positioning, and loading principles.  There are also good overviews of the various chondral repair techniques available worldwide.

One great thing you have on your side is the sure knowledge that you CAN grow repair cartilage.  Now, you need to understand how to keep it in place while it matures.  I'd consider looking at things like anterior interval scarring which create an artificial case of "patella baja" and huge, abnormal pressures in the patellofemoral joint (Google Steadman's papers on the subject).  If this was your problem, it could easily explain why you lost your repair so fast.  Heck, the best hyaline cartilage can't take twice the loads it was designed for.

Also remember that you've only tried the most primitive of the cartilage restoration techniques.  If you need it, there's always autogelous chondrocyte implantation and the matrix-version thereof, osteochondral allografting, and shell allografting.  All three of these techniques have been proven to work well in the patellofemoral joint IF DONE PROPERLY.  DO NO GIVE UP!!!!!

Folks I would consider consulting with:  Ron Grelsammer (patellofemoral guru), Tom Minas (one of world's best for ACI retropatella and trochlear repairs), Richard Steadman (founder of microfracture and concept of anterior interval scarring), William Bugbee (world expert in osteochondral shell grafting).  Over the next two months, I will be going to consult with all of these folks my patellofemoral knee problems

If you'd like, please feel free to email me at laura.wurth @atk.com (work email).  Our situations seems so similar that we should share knowledge.

[crumblingknee]

Hi Laura,
Thanks very much for your thoughtful reply. It is really helpful & I will follow-up. I wish to add that you made a very good point regarding knee cap alignment. My OS was talking about doing an osteotomy prior to the receipt of the latest MRI. Hopefully, it will not come to that.
Best,
Neil.

Wow, I agree with Nettan that your failure seemed to be very fast (<11 months).  I had a similar situation except in my case the breakdown occurred over ten months starting with intact, original hyaline cartilage (sob).

I think that it is imperative that you understand as much as possible about why your repair broke down so quickly.  If you try for another repair, you will want to make sure that whatever mad this one fail doesn't affect the next one too.  Bear in mind that, if the causes were alignment-related, they could affect the function of even an endoprosthesis (artificial knee).

As far as Synvisc and weight loss go, they're good temporary measures to keep the damage minimized while you determine the best way to restore your knee.  Do NOT consider living the rest of your life with patellofemoral arthritis.  You use your patellofemoral joint for EVERYTHING!  You need it to walk, swim, bicycle, do yoga and pilates, dance, drive a car, work in the garden....see the point?  The tibio-femoral joint can be effectively unloaded by just not weight bearing, so, folks with arthritis in those compartments can get by with simply switching to swimming and cycling instead of running and hiking, etc.  WE CAN'T!!!

Additionally, have you ever tried to lose weight without using your legs?  Good luck!

If I were you, I'd start researching everything I could about patellofemoral alignment and chondral repairs and why they succeed and fail.  Become a "knee warrior" and save you patellofemoral joints with education!  This website is a great place to start learning about the basics of patella tracking, positioning, and loading principles.  There are also good overviews of the various chondral repair techniques available worldwide.

One great thing you have on your side is the sure knowledge that you CAN grow repair cartilage.  Now, you need to understand how to keep it in place while it matures.  I'd consider looking at things like anterior interval scarring which create an artificial case of "patella baja" and huge, abnormal pressures in the patellofemoral joint (Google Steadman's papers on the subject).  If this was your problem, it could easily explain why you lost your repair so fast.  Heck, the best hyaline cartilage can't take twice the loads it was designed for.

Also remember that you've only tried the most primitive of the cartilage restoration techniques.  If you need it, there's always autogelous chondrocyte implantation and the matrix-version thereof, osteochondral allografting, and shell allografting.  All three of these techniques have been proven to work well in the patellofemoral joint IF DONE PROPERLY.  DO NO GIVE UP!!!!!

Folks I would consider consulting with:  Ron Grelsammer (patellofemoral guru), Tom Minas (one of world's best for ACI retropatella and trochlear repairs), Richard Steadman (founder of microfracture and concept of anterior interval scarring), William Bugbee (world expert in osteochondral shell grafting).  Over the next two months, I will be going to consult with all of these folks my patellofemoral knee problems

If you'd like, please feel free to email me at laura.wurth @atk.com (work email).  Our situations seems so similar that we should share knowledge.