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Author Topic: Need advice! MFC OCD even worse after arthroscopic drilling!  (Read 4221 times)

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Offline Mena

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Need advice! MFC OCD even worse after arthroscopic drilling!
« on: December 03, 2008, 06:57:28 PM »
Hello!
I am new to this forum so I hope I am putting this request in the right place!

I am a 28 years old athletic female on my 11th WEEK past an arthroscopic drilling to my left knee due to an OCD to the medial femoral condyle. I got to the surgery point because of pain I began experiencing after consistent running sessions. The orthopaedic I am currently seeing, before trying an unsuccessful 2 months of conservative treatment in which I mostly walked around on crutches, finally thought a regular drilling might have worked due to the fact that the lesion was still intact and I had no other problem to the menisci or ligaments at all.

During the 3rd week post-surgery, I started noticing a catching sensation I had never even had before the surgery, but I was told it was too early to say anything so I just kept the pain.
Now, on my 11th week (that random catching becoming even more painful), I have found out from the results of yet another MR arthrogram and MRI that the there is a "linear area of increased signal" between the OCD and the parent bone. The defect on the cartilage now is even more pronounced.

My orthopaedic has been suggesting we remove the diseased area and part of the underlying parent bone and replace it with another fragment taken from either another area of my body or from a cadaver. I thought it is a drastic move given that I still seem to have the OCD partially attached (?).

So the questions are:
1. Could the orthopaedic have scraped the scar tissue off the OCD/parental bone via arthroscopy before drilling the whole MFC to promote healing when he performed that very first surgery?
2. Is there an alternative treatment to this possible "remove everything and replace with somebody else's bone" thing?
3. Would pinning and screwing the piece back to the parent bone work in my case?

I have also been recently (last week) told by the physical therapists I am seeing twice a week that my left patella seems to be out of track now (rolling laterally toward the outside) and it is very weak. So I have been given some "heel tap" exercises where the therapist actually tapes my patella and quad to put it back in place during bending and stretching of the knee, hoping it will naturally return to its original normal movement.
The questions here are:
1. Couldn't that OCD be the reason why my patella has shifted its rotation away from the damaged area?
2. Is this taping my patella going to help or make the OCD fall off the parent bone even sooner since I do feel more pain as I do my physical therapy exercises with that part taped inward?

I hope somebody can help. This issue with my knee is making me go nuts!!!!!!
I am losing trust in docs. and my good mood since this all began. HELP.
« Last Edit: December 03, 2008, 07:09:20 PM by Mena »

Offline plantgeek58

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Re: Need advice! MFC OCD even worse after arthroscopic drilling!
« Reply #1 on: December 03, 2008, 10:57:57 PM »
Hi Mena,
when you say your OS performed 'drilling' on the OCD, do you mean 'microfracture'? This is where the OS removes the dead tissue, cleans up the rough edges, then drills a series of tiny holes through the bone into the marrow, in order to cause a clot, that contains some mesenchymal stem cells. The stem cells then form fibrocartilage, which fills in the defect.
Also, if this is indeed what he did, were you non-weightbearing following the surgery? Normally, in order to protect the delicate clot and the newly-forming cartilage, you would be told to stay off the leg for anywhere from 4-8 weeks. If you put pressure on it too soon, you risk ruining the entire procedure.

Trying to pin the piece of separated bone back onto the parent bone would not have worked, because the tissue, having been removed from its blood supply, would already have been dead. There was no possibility that it would heal back in. Your OS would have removed it before performing the microfracture.

As for the graft procedure your OS is suggesting, that sounds like OATS surgery. It's the normal second line procedure that is performed if a microfracture fails. The OS can either do an autograft, in which a plug of bone and cartilage is removed from a nonweightbearing part of your own knee, or he can do an allograft, in which the bone and cartilage come from a donor. Each has its advantages and disadvantages. With an autograft, you're creating another damaged area in the knee, albeit in a less necessary area, but you don't need to worry about tissue rejection or disease transmission. With an allograft, you have those 2 concerns, but the actual possibility of either of them happening is almost negligible. Plus, because the tissue isn't coming from your own knee, larger plugs can be used.

OATS surgery has a high degree of success, but it can't be performed arthroscopically, which means the recovery period is longer and it is initially a lot more painful. I had a failed microfracture on a MFC OCD in my right knee that was subsequently replaced by an OATS autograft. It worked very well for me and the plug is still in great shape almost 4 years on.

While this is the conventional next step and is probably your best option, you could look into the possibility of ACI or MACI. They are relatively new and are still considered experimental, so not all insurance companies are willing to cover them. Still, some people have had good success with them. These procedures involve harvesting a rice-sized piece of cartilage from your own knee arthroscopically, sending the tissue to be multiplied in a cell-culture lab, then re-implanting the cells into the defect in a second procedure, where they will hopefully continue to grow and multiply.

I doubt the patellar tilt you're experiencing has anything to do with the OCD. It's more likely due to your VMO being weak from the surgery. If you work on exercises to strengthen that, it will eventually pull your patella back into alignment. Taping shouldn't impact the OCD, but neither should it hurt. If it continues to bother you, you should let your therapist know and maybe discontinue using it.
Terre
RK 7/04 part. m. menisc., plica resect., MF
    3/05 part. m. menisc., open OATS
    1/07 part l. menisc., MF, patellar chondroplasty
    9/08 MF
LK 11/04 & 8/06 part m. menisc.
     7/07 LR, patellar tendon debrid., part m. menisc.

Offline Mena

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Re: Need advice! MFC OCD even worse after arthroscopic drilling!
« Reply #2 on: December 06, 2008, 10:49:24 AM »
Hi Terre,
Thank you for responding. No I did not mean microfracture. My OS literally performed a knee scope with anterograde drilling. He did not remove any dead tissue or clean up anything (this is the first fact that made me wonder). He just drilled 8 holes from the front of the knee while the OCD lesion was still intact. Now I have bony edemas where the drilling was performed and the OCD defect seems to be more pronounced than before. As far as the OATS, yes you are right, I believe that is what the OS is thinking of doing. However, being that the lesion is still intact and not detached from the parent bone, does that sound like the best course of action?
This is why I don't get it.

Am I making sense?

Offline plantgeek58

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Re: Need advice! MFC OCD even worse after arthroscopic drilling!
« Reply #3 on: December 07, 2008, 05:11:14 AM »
Hi Mena,
I had to look up antegrade drilling, because I'd never heard of that method of treating an OCD. Now I think I understand a bit better. I learned that this is a pretty common way of treating a stable lesion in young patients, but it seems not to have worked for you.

As far as what to do next, I would advise making another appointment with your OS to talk more about the OATS procedure. This is a big decision and you'll want to get all the facts before making it. Express your concerns, ask about other options and have him explain to you why he thinks this is your best option. I think it's a reasonable next step, but only you can decide if it's worth going through the long, painful recovery. I can tell you that you'll be nonweightbearing for at least 4 weeks, you'll probably end up with a scar at least 5 inches long down the center of your knee and formal PT will probably last a minimum of 4 months. You have to seriously commit to the rehab protocol in order to get the best result and you'll need to baby your knee for at least a year. If you can handle all that, there's a good probability that the procedure will succeed and give you pain-free function again.

Still, it's a lot to think about. Take your time and weigh all the pros and cons before you make the commitment. If you have any more questions about it, feel free to ask and I'll try to help. Good luck.
Terre
RK 7/04 part. m. menisc., plica resect., MF
    3/05 part. m. menisc., open OATS
    1/07 part l. menisc., MF, patellar chondroplasty
    9/08 MF
LK 11/04 & 8/06 part m. menisc.
     7/07 LR, patellar tendon debrid., part m. menisc.

Offline Mena

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Re: Need advice! MFC OCD even worse after arthroscopic drilling!
« Reply #4 on: December 07, 2008, 11:23:54 AM »
Hi Terre,
Thanks again for taking the time to give me some advice. I do have a follow up appointment with my OS on the 19th of this month to discuss the results of the last MRI (results which, like I previously mentioned, do not seem to be that comforting). However, many questions still remain unanswered. I still don't understand why pinning is not a good fix. I have read cases where pinning was a good solution for adults with OCDs in my same state (not too stable but still not that unstable to cause damage to the cartilage).
I found that info at this link:
http://www.kneeandshoulder.md/print/print_osteo.html

When I asked my OS if performing that surgery was a possibility though, the answer was:
"Actually, you cannot pin a fragment that is still stable." Why is that if it has already been done successfully by somebody else? Why do I need to get the whole thing removed and substituted when trying to reattach my own piece in its proper spot is a possibility?

Then I have the physical therapist (which I have been seeing 3 times a week since September  this year) who tries to reassure me that everything is "not to worry about" because it might actually take more than a year to heal from my drilling surgery, when results (and my knee pain and catching) tell me otherwise (in 1 year, the fragment might be broken apart inside the knee in pieces which then will have to be removed for sure, because that is how OCDs degenerate if left untreated right?).

This is why I am thinking that these people might be either incompetent or maybe think I am completely illiterate about the subject. Either that or they are just plain liars!
My problem is that, being in the military, I do not seem to have much of a choice. Maybe I should just tell them I refuse to get anything  I am not convinced of done by them, no matter what the consequences are…This is what’s killing me. Why do they do this to people?















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