Nick's FatPadTrim, Medial plica/Distal patella excision, AIR x2, LMR 3in1 Diary

[Clarkey]

21/06/16 23 Months Day 704 Post Op

Lucha, I totally agree with you that seeing as OS in the same region will agree with the diagnoses given so far of patella tendonitis. I had this at the back of my mind all along, I do not want to be travelling long distances increases my restrictive budget even more, with extra travel costs!

I have come back from my 2nd opinion consultation; the OS was really nice and forthcoming, natural and listened to my concerns carefully. I had my folder of all my knee history and previous consultations and treatment I have been through so far. This was very helpful as he had no information about my right knee history.

He also agrees with Prof Snow that it is patella tendonitis, he cannot see any other problems at this present time. He did reluctantly suggest another MRI scan but thinks again it might come back looking ok again. He is also a hip surgeon and told him the right hip is painful due to the right knee patella tendonitis. When he examined the right hip it's very tight and knotted, also he looked at my left knee that also flares up at times due to the right knee compensating for the injury. This is why I had Botox injection towards the top of my calf muscle pre-op to scope#2. It might be help once again for the hip pain?

I feel a bit stupid now, “shooting myself in the foot”, the NHS PT I cancelled on the NHS is specialised in patella tendon problems that the OS today clearly pointed out. I got agitated, frustrated and stressed out having to wait 9 weeks after being told that it could ruin my job prospects. I am doing really well as a Playworker for young people on the autistic spectrum. High praise from the leader and staff, I am now doing one to one with none verbal service users to a high standard. I will have another interview early November; I wanted to speed up the ESWT and PT sessions by going privately. If ESWT failed then surgery of 'inferior patella accessory pole excision decompression’ would be performed. 

I would then have to put my job interview on hold as If ESWT fails if surgery was finally given the all clear. The knotting feeling around the bottom of my right tibia is new; it was never there before until the last couple of weeks! Today the other OS said it perfectly normal? This is where I am feeling the sharp intense pain that’s gradually getting worse restricting my mobility

It makes no common sense that previously to scope#1 & 2 the knee pain and discomfort was minimal and went ahead with the surgeries in the hope of getting back to running at a competitive level, that’s now looking very unlikely. Back then apart from one MRI scan showing bone oedema out of several MRI’s that all came back negative. A diagnostic scope was performed pre-warned they go in and find knee perfectly ok, problems were spotted that the MRI scan missed out on.

It now not only having a negative impact on me physically it also getting to me mentally; I am now not able to go more than a mile walking as it flares up my right knee too much. Gardening I was able to do ok prior to both previous scopes, that's more of an ordeal now if I garden for too long.

My gut feelings with well over a decade of dealing with my right knee problems is that there something more than just an inflammation of the patella tendon. I feel at this stage that a diagnostic arthroscopy would be in order to take a detailed analysis inside my right knee. I am getting very self-conscious and paranoid with my slow up waking pace and limitations.   

Both Prof Snow and the OS I have seen today seem to be weary and cautious towards going ahead with ‘arthroscopic decompression for patella tendonitis’ yet the copy and pasted link from a OS in Bristol says the following.

Conclusions

I was therefore able to conclude that the initial five year review of this technique of arthroscopic decompression for patella tendonitis proved to be technically feasible, safe with as yet no significant complications, successful in the long term in 94% of patients and could be undertaken routinely as a daycase and was associated with rapid rehabilitation and return to sport.

Further this success following excision of the inferior pole of the patella and decompression of the patella tendon, without excision of the degenerative nodule supported the theory, that this condition is a result of an impingement or compression of the inferior pole upon the posterior aspect of the tendon in flexion rather than a failure in tension.

David P. Johnson MD.
Consultant Orthopaedic Surgeon
Spire Hospital Bristol,
Redland Hill, Bristol, BS6 6UT

http://www.kneeandsportsinjuryclinic.co.uk/patient-information/knee-surgery/patellar-tendonitis/

http://www.kneeandsportsinjuryclinic.co.uk/about/the-surgeon/

I was completing seeing him for another view of opinion outside the Midlands County; I then came across the newspaper article below. It could be a false accusation that has happened with Sir Cliff Richard, who had allegations of sexual abuse of a young person at a Christian concert in the States. He was cleared only last week and allegation were dropped.

http://www.dailymail.co.uk/news/article-3339287/Top-surgeon-operated-Premier-League-footballers-Wimbledon-tennis-stars-tried-bite-secretary-sat-filling-paperwork.html

Mr David Johnson could also be entirely innocent by also being falsely accused, by now he would have been struck off if he had bitten his secretaries’ arm?

Will stop now having a rant as usual, it just becomes very frustrating the whole process of trying to make headway with my never ending right knee problems. Getting told there is nothing wrong with my right knee internally. Feel like I am a hamster going around in circles or hitting my head against a brick wall right now!

[email protected]

[Clarkey]

22/06/16 23 Months Day 705 Post Op

I was up until 2am thinking over what to do next, when I finally got to sleep straight in the morning thought to myself why should I be pay to have private physiotherapy! I can get it done by the Head Physiotherapist that was also praised by the OS I saw yesterday that speciality is patella tendon problems. Also had no letter or email to confirm the private physiotherapy, I made the enquiry 20 days ago hoping to speed things up more.

I sent an email to the complaints manager saying that the long wait for a PT appointment is raising my anxiety and stress levels. Having Asperger’s makes it harder for me to accept a long delay! Within half an hour of sending the email I managed to get booked in with the head physiotherapist for Thursday morning on July 7th, two weeks tomorrow.

I already sent an email to Prof Snow Secretary saying “sorry for any inconvenience caused, changing my mind again by cancelling the private PT appointment”. I have never had to wait over 3 weeks when I have had previous private PT appointments, 1 week to 2 weeks max wait usually. Maybe it has turned out for the better sticking to the same team at the NHS hospital I have been going to for a while now. 

Just goes to show if you are polite and tactful rather than ranting and raving then the hospital has a lot more respect towards you as an individual. They often get verbally abused by patients that have been waiting a while like I have.

My sister always gives me good advice working as an orthopaedic nurse that I mentioned before on my dairy. She often helps out the OS in theatre with nearly 30 years’ experience. She said Prof Snow will have more respect towards me if I do as suggested by trying out ESWT. If it doesn’t help then I have a good reason to ask him to do  'inferior patella accessory pole excision decompression surgery'?   

I have taken a photo of my right knee using a biro pen and a photo editing app to pinpoint exactly where the pain & discomfort is! Best way to describe the symptoms is when I press on the marked spot in an up & down motion with my thumb I can feel a knotting/hardened and squishy, can hear it click as I push my thumb upwards & downwards.

This is not normal as my left knee is fine around the tibia tubercle region. It's so obvious as well it's more around the 'tibia tubercle'. Patella tendinitis is higher up, which is the reason why I am sceptical about having ESWT? It may not have any benefits for my specific right knee problems. I will point this out to Head PT, hopefully he will examine it properly, yesterday the OS I saw did not really want to look at it pressing it gently and saying it is normal!

[email protected]

[MyKnee2010]

Hey Nick,
Just wondering.. did you mention bone spur to OS #2? I have totally different knee problems than you so I don't have any experience with it but it just strikes me that having the bone spur in there has to be causing some sort of problem?
Hope it all works out for you!
Phoebe

[Puffy the Knee Slayer]

Hiya just a quickie reply sorry I didn't see this before now. Am sorry you didnt get the job and that they are saying your inability to run is going to be a problem!

Sorry too the knee is taking so long to sort out and that you are having new, additional pain they're having trouble getting to the bottom of.  I hope there will be some progress I know how frustrating and demoralising it is.

[Clarkey]

23/06/16 23 Months Day 706 Post Op

Hey Nick,
Just wondering.. did you mention bone spur to OS #2? I have totally different knee problems than you so I don't have any experience with it but it just strikes me that having the bone spur in there has to be causing some sort of problem?
Hope it all works out for you!
Phoebe

I was thinking the same, it could well be the bone spur that’s causing me the pain and discomfort! It is very likely and feasible cause with the knotted/nodule hardened feeling I am getting by the 'tibia tubercle'. Paragraph from my December 2015 MRI scan report.

The MRI showed change of signal of the fat pad underneath the patella. Otherwise there were no pathological findings on it. On further evaluation of the MRI one may appreciate a slightly bigger distal pole of the patella with a bone spur which may be affecting the fat pad, however the signal of the tendon is normal. In addition Professor Snow was a little concerned about developing of patella Baja after surgery.

Says signals of the patella tendon are normal, I have a bigger distal pole of the patella which shows a bone spur! It seems to coincide with my current symptoms, I will point this out when I have my physiotherapy appointment in two weeks’ time, July 7th. I am sticking to Prof Snow, he has done what he can so far, trying all he can before doing scope #3, that he has not ruled out yet as an option to take into consideration.

Puffy the Knee Slayer, Thanks for the post and supportive words of encouragement, you understand the frustrations, as you are also battling on to finally come to a final conclusion into the right type of treatment for your on-going knee saga. We have similar problems with out fat pads, so understand how it feels to live with such a soft tissue injury.

[email protected]

[Clarkey]

07/07/16 23 Months Day 720 Post Op

After waiting patiently for over 8 weeks I finally have seen the Head Physiotherapist at the hospital. Today I had my initial assessment that took around 20 minutes asking questions about my right knee history and my current symptoms.  As I was expecting he thinks my right knee looks ok visually, he also did various basic tests to access any potential mechanical issues inside the knee.   

The long term plan for now is to stop the old physio exercises of calf stretching; RK wall squats and leg heal lifts. This is what I have been doing daily for a while now that’s not really giving any benefits. The new daily PT I have been given is what the Sports Physician mentioned of isometric holds.

Stand with back flat against wall, on right foot (1 foot length from wall) still plus lift left leg. Bend right knee 30 degrees, hold 45 seconds, and repeat x 3 for 31 days twice daily. Will add more excercises as the weeks go by.

The Head PT said it can take up to 6 to 9 months until I start to see any improvements.  I have been booked in for September 28th for ESWT sessions that should also prove beneficial. I am still remaining cautious and sceptical that the rest of my right knee is perfectly ok! I know they have seen patients with far worse knee problems than mine so assume my right knee is ok. They do not have to live with a knee that restricts me on a daily basis that's hindering my future employment opportunities.

The knotting that I can feel around the bottom of the tibia is just some inflammation around the patella tendon, I shouldn’t worry about it too much. Even though it the exact area where I experiencing the sharp intense pain as soon as I try to increase my walking pace by doing longer strides. With a long knee history of problems and having already been through 2 scopes my right knee cannot be ok and just dealing with patella tendonitis!

Also saying that my last MRI scan looked ok even though it mentions a ‘bone spur’ that could be the culprit and cause to my discomfort! It does not make any sense that pre-op to scope #1 & #2 when my right knee problems was no were near as bad as it is now but were quick to do surgery and not more PT sessions.

I have waited patiently for a while now, it feels as if no one is taking my right knee problem seriously by making a big deal out of nothing.  Six to nine months of  waiting to see if the PT and ESWT had been of any benefit. They do not have to live with a right knee that limits them on a daily basis that also becomes emotionally demanding.

One can now see from my post-op dairy how long the problems have been going on for. I still have a gut feeling that a diagnostic arthroscopy would be beneficial and would highlight problems that was not spotted on my MRI scans. Pre-op to scope #1 my right knee also look ok on MRI’s and physical assessment of the knee. Not sure how bad I have to be to be entitled for a look inside the kneecap.

Once again I am winging and moaning as usual, it just becomes very annoying and tedious the gradual process of what looks likely to come to surgery in the end. If I go ahead with what's been suggested waiting 9 months and my right knee not improved in anyway. I would be put on a waiting list for surgery that might bring it to July 2017, a year from now and 3 years post-op.

[email protected]

[Puffy the Knee Slayer]

I'm sorry it is still not being sorted and you're faced with waiting another 9 months to see if physio improves anything, it is very frustrating I know!

I think NHS in general do not take us that seriously as they see really severe cases, I had one NHS podiatrist say their clinic was more for people whose legs were practically falling off and I would have better luck going private, he said the same about physio.

Cos we can walk we don't get taken that seriously, fact is we are in pain and have problems doing activities of daily living as well as having employment impeded and being unable to do things we enjoy like running which is also good for health!!

Am sorry it is dragging on for you, I know the feeling.

[Scubagrl4]

Nick,
I am so sorry that you are having to wait so long. I can't even begin to understand how frustrated you must be. To be waiting as long as you have, it is really hard to believe that you will be waiting again. Grrr! I'm mad for you.

[Clarkey]

18/07/16 24 Months Day 731 Post Op

Two years ago today I went through my 2nd surgery on my right knee of AIR! Since the surgery my knee has not improved, has got worse rather than better. I have decided to insert 3 quotes to show members of KG and those that work in orthopaedics that my right knee is ok and of no great concern.

18/02/16 Posting report mentions ‘On further evaluation of the MRI one may appreciate a slightly bigger distal pole of the patella with a bone spur which may be affecting the fat pad’. This could be the cause of the anterior pain and discomfort. If the fat pad was a problem back in November 2009 that was trimmed, followed by AIR surgery in July 2014 to remove excessive scar tissue. There still could be scar tissue problems and inflammation of the fat pad. Fat pad excision has a 50/50 success rate that’s similar to medial plica excision and LR.

18/02/16 19 Months Day 582 Post Op

Already 19 months post-op and no better off than I as pre-op to scope#2, I would say my right knee feels worse with pain, discomfort and instability then any of the two previous scopes. The report was done by the Registrar on 23/12/15, seen him each time I attend the clinic.

Mr Clarke returns to clinic with flare up of his right knee. I reviewed him today in the presence of Professor Snow. He was doing very well after the previous surgery until a couple of weeks ago when he started to experience more anterior knee pain during physiotherapy. He could not return to running.

Had to re-correct the red highlighted lettering as I have never really seen improvements since the surgery and have never done really well! I will point this mistake out when I next attend clinic.
 
On examination he has full range of motion, no knee effusion. He points out pain in the patella region.

The MRI showed change of signal of the fat pad underneath the patella. Otherwise there were no pathological findings on it. On further evaluation of the MRI one may appreciate a slightly bigger distal pole of the patella with a bone spur which may be affecting the fat pad; however the signal of the tendon is normal. In addition Professor Snow was a little concerned about developing of patella Baja after surgery.

Professor Snow explained all the problems and symptoms to Mr Clarke. There is not much we can address surgically at this point as Mr Clarke’s rotational CT showed normal alignment and the MRI scan did not show an obvious pathology. Therefore Professor Snow injected Mr Clarke’s right knee with Kenolog and Marcaine and hopefully this will give him pain relief. We will see Mr Clarke back in clinic in 3 months’ time.

Yours sincerely, 

Mr  *** ****

Senior Clinical Fellow to Professor M Snow

Have already explained in my last post what I think should happen next when I am next in clinic on Wednesday morning March 16th. It is now hindering me on my daily lifestyle, being restricted in what I can and cannot do! With spring around the corner with longer warmer days will become agitated if I cannot go for regular long distance walks etc.

I will decline a 4th cortisone injection that I doubt will be offered to me again! It is obvious now that it’s not really working and of great benefit in resolving the knee pain and discomfort. Extracorporeal shock wave therapy (ESWT) is another none invasive treatment, it’s a cheaper/safer option to go for? It might not work, the last option would be surgery! I doubt rest will solve the patella tendonitis that now looks more chronic rather than an acute condition. 

Scuba, I am glad to find an understanding PT that knows how to go about getting my knee right again unlike the one I saw shortly after pre-op. He made me do too much PT; this made my right knee even worse! I am now paying the price for it!

[email protected]

18/09/15 Posting report mentions ‘I discussed possible treatments with rotational osteotomy, I explained all the pros and cons of the surgery, however I would like Professor Snow to consult the patient before listing him for further surgeries. I asked him to come back in four weeks’ time and we can decide about his further treatment’. This was what the Registrar recommended, he is the only person so far that has managed to pinpoint the exact intense pain anterior knee pain. Both Prof Snow and the other OS I saw for a 2nd opinion ruled out doing an osteotomy. Why mention it in the first place if it's a borderline case for a knee realignment surgery.

18/09/15 14 Months Day 427 Post Op

14 months post-op after AIR surgery and hope I am 3rd time lucky in 5 days when I finally get to see Prof Snow. Lucha, you are right that it a good that the hospital are making sure I am seeing the best! My right knee problems has not been a straight forward fix as originally planned.

It will be a big stress and release finally knowing what going to be happening next and no longer trying to guess? I am not going to let a bigger surgery than the previous two get me down after googling 'rotational osteotomy' kids under the age of 9 have had this procedure done think mainly because they have ’rotational deformity!

I will type out the report and as far as I can see and from what the Registrar told me that my CT scan came back looking ok but he was under time pressure!

Dear Dr ****

I have reviewed this gentleman in clinic today, with the results of the CT scan. His TT-TG on both sides is 13mm and there is approximately 37 degrees of external rotation of the distal tibia with respect to the proximal tibia on the right, and 42 degrees on the left.

I discussed possible treatments with rotational osteotomy, I explained all the pros and cons of the surgery, however I would like Professor Snow to consult the patient before listing him for further surgeries. I asked him to come back in four weeks’ time and we can decide about his further treatment.

Yours sincerely

Mr *** **** 

I do know that 13mm is within normal range and nothing to worry about. What I am not so sure about is the 37 degrees of external rotation of the distal tibia with respect to the proximal tibia on the right, and 42 degrees on the left is something to look at as it matches with the term ‘rotational osteotomy’

Could the wrong angles cause excessive maltracking problems to such an extent that the a knee realignment surgery of rotational osteotomy is required! PT has not helped my PFS is at a chronic level that it now having a daily impact in my daily activities.

I am not a expert as I am only guessing what could be wrong! I would think an exploratory scope or a lateral release surgery would be a less drastic form of surgery that often not a successful surgery! I will not say anything or suggest to something else. I will leave it to the capable hands of experts to decide what happens next. Why did he say surgeries in his report that could well be a grammar error! It could be for hardware removal if the procedure in the report was to go ahead.

[email protected]

20/03/14 Posting report mentions ‘It is always difficult to know exactly why people develop medial facet or medial trochlea disease as usually it is the lateral compartment of the patellofermoral joint which suffers from maltraking’. Once you have ‘medial trochlea disease’ the knee will never be right again slowly deteriorating! Prof Snow did mention microfracture surgery as a likely outcome. Once he looked inside it was scar tissue causing the unusual type of bone bruising.

My 2014 MRI Scan Feedback on my right knee:

20/03/14

Diagnoses: Anterior knee pain right knee previous Botox injection facia lata.

This gentleman returns to clinic. He has not really had significant relief following Botox injections and IT band stretching and as such we went onto perform and MRI scan of the knee. This has shown medial femoral condyle bone oedema which I think probably represents cartilage degeneration.

He also has an abnormal signal within the fat pad but this is probably representative of his previous arthroscopy and scarring because he did suffer with stiffness.

It is always difficult to know exactly why people develop medial facet or medial trochlea disease as usually it is the lateral compartment of the patellofermoral joint which suffers from maltraking.

He does have a low TT-TG distance which may explain this and he is slightly varus. His IT band is still tender today but exquisitely painful and his popliteal angles were very good.

I think the only step forward I could go would be to undertake an arthroscopy to assess the medial trochlea, potentially there is scar tissue or band which is rubbing on this area which could explain the oedema but similarly it could well be a control lesion.

If it is small we could treat this at the same time with a microfracture but if it is larger we may need to return to use a different technique. He is fully aware of this.

Nicholas states that his pain is now impinging on his daily life and would like to consider intervention. I have listed him for a knee arthroscopy and will see him in due course.

There not much else I can do; I will leave it in the expert hands of Mr Snow that I have 100% confidence.

Mr Snow is there to help me that I fully appreciate, I will try best to remain positive Pre Op; it is just unfortunate that I have maltracking, bowed legged and a low lying patella that has started to wear the knee out, I may have to think wisely is it sensible to do run distance running in the future post op?

Mr Snow suggested cycling instead of running; I can see his point of view as it is the closest you can get to running with minimal impact on the knees.

It just hard to get use to the idea at the age of 35 that I may never run competitively again long distance that was something I was rather good at.

I can only blame myself as I ignored the knee pain while running and also ran at a too quick pace and now I am paying the consequences for my actions. 9 miles in just under an hour I have proof of, that is of some credit.

Also have an even better reason to help and support children with special needs instead of manual labour jobs like gardening and greenkeeping. It will just make my knees worse; doing a complete career change is a wise move and my dream job.

Bad things happen in life for a reason!

[email protected]

With all my past right knee problems and surgical procedures there could well other problems inside the knee, I cannot see it only being chronic patella tendonitis! MRI scans are not 100% accurate, which can easily miss things out. Too many OS’s religiously seem to go by what comes up on the MRI scan, not on the patient’s knee history and present symptoms.

What concerns me the most that Lucha is also going through, employers not wanting to take you on or warning you that you could lose your job if you continue having time off with on-going knee problems. I feel restricted in my volunteering with autistic young people, not being able to run is a big concern for my future as a potential employed Playworker.

Need to be physically active in the job description, the manager has already told me I could be a liability and safeguarding issue. If I young person has a meltdown and runs out of the building or even worse runs onto the main road while out in public I cannot give chase!     

[email protected]

[Clarkey]

01/08/16 24 Months Day 746 Post Op

I saw the Head PT once again and the isometric leg holds have improved the muscle density slightly, I can squat more easily without wobbling too much as I squat down. He has now given me some wall squats and leg side leg raises on top of my isometric leg holds. I have been booked in to see him again in a months’ time 01/09/16. I then will have 3 sessions of ESWT starting from 28/09/16, I have been told it slow progress! I still feel that I past the stage of conservative methods of treatment.

I know there is a patella tendonitis specialist OS down in Bristol, It is only an hour drive to the clinic from where I live in Droitwich Spa of around 60 miles. Mr David Johnson has a worldwide reputation for patella decompression surgery. The same surgical procedure has been suggested by Prof Snow if conservative treatments fail. I do have a lot of respect with the Prof Snow who's dealing with a tricky knee condition, he is more than capable to do the surgery.

http://www.bristol-knee-clinic.co.uk/boc/patients/patella_tendonitis.asp

It sometimes beneficial to see an OS that has specialist knowledge and expertise in chronic cases of patella tendonitis. I need to be fit for when I have an interview to hopefully become a play worker for an autistic organisation for young people on the autistic spectrum.

Mr Johnson surgical technique for chronic PT seems to tick all the boxes for my present RN condition. 

http://www.bristol-knee-clinic.co.uk/boc/patients/patella_tendonitis_surgery.

Prior to Surgery

Scrub nurse Prior to surgery and post operatively it is important to strengthen the muscles of the leg and to reduce the stiffness. Regular exercises should be undertaken to do this. Static quadriceps exercises consist of tensing the muscle on the front of the thigh whilst the knee is straight. Hold the contraction for 5 to 10 seconds, rest for 5 or 10 seconds and begin again. This should be repeated 10-50 times. Whilst lying on your back the straight leg should be lifted into the air and held for 5 to 10 seconds, then lowered rested for 5 to 10 seconds and repeated 10 to 50 times. If possible these exercises should be undertaken against weight or resistance or in a gym using exercise equipment.

Anti-inflammatory tablets (Indomethacin, Voltarol, Brufen, Naprosyn etc) should be stopped 2 days before surgery. On the morning of surgery patients should fast from midnight and arrive at the hospital at 7.20 am. For afternoon surgery you will be fasted after 8 a.m. Prior to the operation any tablets or medications you take, or allergies you may have to medications, should be brought to the attention of the surgeon. Please notify your surgeon and anaesthetist in advance if you are taking any anti-coagulants (blood thinners), hormone replacement tablets, the Pill or suffer from diabetes or any other significant medical condition.

The anaesthetist and Mr. Johnson will see you before surgery. The operation is performed under spinal or general anaesthesia. There will be one or two small incisions in the front of the knee either side of the patellar tendon. These may be closed with a steri-strip or single suture. Following the operation patients usually wake up with a brace on the leg and a continuous passive motion machine that is designed to gently move the knee even while you are asleep. This is used to maintain a range of mobility in the joint to speed your recovery. A removable knee splint may be used to support the knee during the recovery period.

What I like about Mr Johnson surgical technique is using a CPM straight after surgery to avoid swelling and build up of excessive scar tissue.

Surgical Technique

A general anaesthetic is generally used. Sometimes a spinal injection is preferred. A tourniquet is usually used and routine prophylactic antibiotics are administered.

Through small 5 cm incisions either side of the patellar tendon below the patella. The arthroscope (telescope) is inserted into the knee for a thorough inspection of the knee. Through the other arthroscopic portal a mechanised shaver of approximately 5 mm in diameter is inserted.

Mr Johnson performing surgery

This is used to elevate the fat pad from the non articular inferior pole of the patella. Then the inferior pole and the overlying tendon can be identified. Using a small mechanised burr the inferior 5 mm tip of the patella is excised thus decompressing the affected area of the tendon on the deep posterior aspect of the tendon. Irrigation of the knee is undertaken to remove the debris from the knee. The wounds are closed with a simple steri-strip or single sutures and a wool and crepe bandage is applied.

Patients can generally mobilise full weight bearing, can be discharged as a day case procedure. Full weight bearing can be allowed without crutches, splint or plaster cast. The patient can usually return to office type work in 3-5 days and driving soon afterwards for short distances.

For the first 3 weeks very little formal physiotherapy is necessary. Patients should gently move the knee so as not to get stiff but should otherwise rest as far as possible. Anti-inflammatory medication should be continued during this time. Regular icing of the knee should be undertaken to reduce any swelling of the knee. After the 3-week period clinical review is undertaken by Mr. Johnson. After three weeks active flexion and extension exercises and static quadriceps exercises can be started. However resisted through range extension exercises are to be avoided at this stage. Light work and more manual activity can be undertaken at this time.

After 6 weeks it is usual to return to static cycling, gentle swimming and non-impact gym exercises. Resisted knee extension exercises should be avoided until 6 weeks following surgery. Jogging on the flat surfaces may be restarted after 9-12 weeks depending upon the rate of recovery. Analgesics and anti-inflammatory medication are usually necessary for between 3 and 6 weeks following surgery and are helpful when returning to exercise or sports.

The results reported by Mr. Johnson show that 94% of patients have been improved following this sort of surgery such that sporting activities can be resumed.

I have had fat pad issues previously that was highlighted in my last MRI scan in December 2015 as well as a bone spur! If the PT and ESWT doesn't work, would it be ok to suggest the above procedure to Prof Snow. Would it be rude and disrespectful to suggest such surgery? I feel it could be beneficial for me with the use of the CPM after surgery. Too costly to pay privately by having the surgery done by Mr Johnson, Prof Snow can do the surgery to a high standard just as good as Mr Johnson.

[email protected]

[Clarkey]

18/08/16 25 Months Day 763 Post Op

I have been keeping on top of my recommended PT, it has  has helped ease the pain slightly. I can still feel intense pain and discomfort still as soon as I try to speed up my walking pace, or do larger strides. I still feel as I have done all along that it will not get better with just PT and ESWT sessions. I have had many years of knee pain and discomfort, this time round my right knee is a lot more restrictive than it was pre-op to scope #1 & 2.

I will of course do what I have been told do for now, it is now getting towards the end of any further conservative methods of treatment. If PT and ESWT sessions make no difference then I would have patellar decompression surgery as the next option that has already been mentioned. I would accept the knee it is if I was not keen to return back to long running again. My future job as a care support playworker for young people with autism, I need to be more physically fit.

My mum will have a left TKR in October, her surgeon said it might make it worse rather than better, it is a risk and gamble if it s success or not. I think all OS's have to show they are sceptical about doing surgery to cover themselves from being sued. This is why Prof Snow is reluctant for now to do any surgery, he is concerned that I could be worse off being more prone to scarring.

I have read up online that Mr Johnson in Bristol put his patients on a CPM machine straight after surgery, I have seen it on Dr Noyes website for AF surgery, he also recommends that a CPM machine is used after patellar decompression surgery. I would feel better if it did come to surgery, that I am given this type of treatment option. I do not want to pay privately for surgery down in Bristol. I am sure Prof Snow and the Birmingham Royal Orthopaedic Hospital must have plenty of CMP machines available.

[email protected]

[Clarkey]

01/09/16 25 Months Day 777 Post Op

I had 3rd scheduled physio appointment this morning with the Head PT of the hospital Physiotherapy Department. He is happy so far with my progress, I have now gone to the next phase of my PT schedule. I am always going to be weary and unconvinced, saying it take time to get over chronic patella tendonitis! Two months of PT is still early stages, need to give it more time to build up the muscles and loosen the tensed up muscles.

I can see I am can now squat easier without struggling, the leg muscle are a lot stronger from doing the right legged isometric holds. I am now going to try out 2x20 sets twice a day 1 & 2 legged squats without the aid of a wall as I did previously. I have more respect towards NHS PT’s after saying negative things about NHS PT's in my previous posts.

My next PT appointment is on the same day as my ESWT session 1 out of 3, 28/09/16 in the late afternoon early evening. I just have an incline with so many years’ experience with my right knee problems that it not only patella tendonitis.

On further evaluation of the MRI one may appreciate a slightly bigger distal pole of the patella with a bone spur which may be affecting the fat pad’. This could be the cause of the anterior pain and discomfort, not just inflammation of the patella tendon.

The PT has been helpful as I am not limping as much as I use to, I am able to walk longer distances than before the PT sessions. The knee pain feels like it did pre-op to scope#2 the anterior pain is a lot more intense this time round. An exploratory arthroscopy and wash out of the knee as well as doing patella decompression surgery might prove successful 3rd time round.

My mum is having a left TKR on 30/09/16 after having her left hip replaced in May, her OS is down to earth with a good sense of humour. Despite having a good sense of humour he pre warned my mum a TKR might make her left knee worse rather than better.

I been told by my sister that assists OS in theatre that they always have to say the worst case scenario to cover themselves fully. If an OS said the surgery will be a great success and goes the opposite way, they are likely to get stuck off and sued.  She told my mum that the majority of TKR's are successful. 

Prof Snow and the one I saw for a 2nd opinion both told me that patella decompression surgery is risky! I could be worse off post-op than I was pre-op! Mr Johnson says that the surgery has a 94% success rate, PT sessions will not cure patella tendonitis if it gone to the chronic stages and have had the condition for a prolonged time period.

http://www.bristol-knee-clinic.co.uk/boc/patients/patella_tendonitis_recovery.asp#rc

Assuming I am right and PT and ESWT fails to improve my patella tendonitis, is it ok to suggest Mr Johnson surgical technique to treat prolong patella tendonitis. I think sometimes making a polite suggestion is ok. We now have access on the web to research our specific knee problems, if there a good report back from another OS it will be benefit other OS's to try out Mr Johnson technique.

Microfracture surgery is a good example of one OS research and success that’s now a common knee surgery before having a TKR for young patients.

[email protected]

[Clarkey]

18/09/16 26 Months Day 794 Post Op

I am carrying on doing the physio exercises of 20 x2 one and two legged squats. I can feel at times right knee making a cracking sound while doing 1 legged squats, I think 20 is enough rather than 40. Also what I have noticed and is that since the autumnal weather is setting in with damper and cooler conditions that the right knee is more painful again. Before it was not too bad and thought maybe the PT has actually worked.

My mum is due for a left TKR at the end of this month even she said her knee pain felt ok and was having 2nd thoughts to go ahead with the surgery. Now it gone cooler and more damp her knee pain returned. I still think I am right that my right knee will not really improve with PT and ESWT sessions in 10 days time. I will do what has been suggested and then if the knee not improving I have a good reason to say that my knee does not feel right, please go ahead now with a diagnostic arthroscopy.

I do still miss not being able to do long distance running, when I see others out there doing what I could do to a competitive level. I still have think the bone spur is the main cause of the pain and discomfort rather than just patella tendonitis.

[email protected]

[Puffy the Knee Slayer]

I really hope your mum's op is successful and wish her all the best for a good recovery.

It's really frustrating seeing other people get on with their running etc. One of my colleagues does triathlon, she is superfit and full of runner's high.

I think once you have done all they've asked of you and you're still having problems you are within your rights to ask for surgery, or what do they expect, to go on doing endless physio forever!!! I've been doing physio daily since 2013!!

[Clarkey]

29/09/16 26 Months Day 805 Post Op

Yesterday I saw my physio and sports physician that went as expected to carry on doing my PT exercises. I have now been told to add some weights when squatting to help build up the quads even stronger.  I saw my physio at 15:20 that only took 10 minutes. I would have to wait for another 2 hours until I have my 1st ESWT session with the sports physician. I spent some time around Northfiled high street just down the road from the ROH Birmingham to pass the time quicker.

I did not see the sports physician that suggested ESWT who was absent, I saw another member of his team. Before I had my 1st shockwave probe I was asked if I am taking any meds that I am not at present. I was asked where I am feeling the pain, I told him experiencing anterior knee pain by the tibia in my right knee. Once the pain had been pointed out I sat upright on a raised couch where gel was applied to the bottom of my right knee.

The ESWT machine was turned on with the probe against my kneecap, when it was turned on it felt like someone was tapping lightly against my kneecap with a small hammer. There was some pain and discomfort as the pulses went through my kneecap that went red. It took about 6 minutes of ESWT. I was asked towards the end that I may feel lightheaded after turning of the machine. I felt slightly dazed that soon subsided while sitting up for a few minutes.

It is too early to say if it will be beneficial or not after three 0S’said how affective ESWT is for patella tendonitis. At least now I am doing what has been suggested, if it does not make any difference then all conservative methods of treatment have been exhausted. The only option left would be surgery that is a big risk and gamble, with a 50/50 chance of success. I am willing to take a risk and a gamble!

I have not been around lately on KG Bulletin Board; I have been busy taking part in a Criminal Responsibility Workshop with ERC Voices Project at UAI Galway as a Storyteller working together with a Respondent from Nottingham University who teaches criminology as a lecturer. We are working on a chapter on autism awareness and criminal responsibility within the justice system that lack empathy and understanding into wrongful convictions for adults and young people on the autistic spectrum. Hoping if all goes well in October 2018 our chapter will be published with a university book publisher based on my own personal battles with late diagnoses of Asperger syndrome during a breakdown period.

I am happy to share what I went through to help spread awareness as I am not ashamed to admit to having a criminal record unfairly held against me.  I was wrongfully convicted for minor criminal damage and actual bodily harm when restrained incorrectly at a hostel back in May 2005. For cracking a window panel and pinching and scratching staff had to spend 2 nights in a police cell, then 3 weeks on remand in prison. Taking into account my Dad had terminal cancer with regularly verbal abuse and physically threats by the support workers with an incident when the hostel manager got a service user to punch me in the face for refusing to get out of bed to go into work. 

I was on 7 different types of antipsychotics and antidepressants; I was self-medicating, none of the hostel support staff took control of what I was responsibility for my meds. This caused personality changes causing aggressive outburst! This is completely out of character as I have never had any history of aggression or violence before and after my breakdown period.

Now you know why I am not able to get full time employment helping and supporting young people with autism and other additional needs as it kept on record till your 100 Birthday under the present law in the UK. I have tried to appeal against my convictions but without success as I have been told it unlikely to be overturned at the Supreme Court as I have already guilty.

https://ercvoices.com/2016/09/14/meet-the-storyteller-nicholas-clarke/

https://ercvoices.com/2016/09/15/meet-the-respondent-nell-munro/

https://mobile.twitter.com/nickwclarke1978

I am of course never going to give up hope, by the end of this year might get discretion from an autistic young people’s organisation that know I am not a danger to children and was treated poorly by the authorities where I have been volunteering at for 18 months. Ideally like to overturn my criminal record that I am working on doing as I was not a criminal, I was a victim of abuse and neglect during my breakdown, I should never have been the culprit. 

Puffy Thanks for wishing my mum good luck for tomorrows left TKR surgery; it will be worth going through as she will be more mobile by spring 2017. You are right I am really miss running long distances and enjoy supporting young people with additional needs that are both a battle to achieve right now.

Will end on a positive note by sharing an email from a leader I helped out at during the summer playgroup scheme.

Nick,

I would like to thank you for your help over the 4 days you were at ****! You not only thought on your feet at times, but worked so hard alongside the rest of the team to ensure that all of the young people had a fantastic week, you coped seamlessly with all tasks requested and support the staff team well. There was not one young person I did not see you working with at some point, and I know that one young person in particular really enjoyed playing with you as he talked with me several times about this!

Also, on behalf of all the young people who will be using the wii in the future I would like to thank you once again for your kind donation of the maraccas and mat.

[email protected]