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Author Topic: is there any hope for those of us with patellar lesions?  (Read 1374 times)

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Offline twobadpatellas

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is there any hope for those of us with patellar lesions?
« on: December 22, 2010, 03:25:11 PM »
Hi all,

This is my first post here, but I've been reading for 6 months now.  I'm a 30 year old male and was formerly very active (running, biking, triathlon, crossfit, etc).  I am about 3 months out from a microfracture and lateral release to address a nickle-sized (~3.5 cm^2) grade IV lesion on the lateral facet of the patella of my left knee.  I know it's still early, but my symptoms are not improved.  My OS is beginning to believe that the procedure failed, but he wants me to give it more time.  Meanwhile, my right ("good") knee is now painful during extension, going up and down stairs, and has started clicking.  These were the same symptoms I had in the left knee.  Although I haven't had any imaging done, I strongly suspect that I have a severe cartilage lesion on that patella as well.

I know the next steps are either OATS or ACI, but my insurance considers both of them "experimental" for patellar lesions.  I have a high q-angle and a j sign, so I may benefit from a Fulkerson procedure, but I'm not sure how much it would help in isolation if I can't address the cartilage defect.  We might be able to win an appeal, but it seems unlikely.  I have been reading good things about partial knee replacement for the patellofemoral joint, but my OS told me yesterday that it would be borderline malpractice to do a replacement for someone my age.  It's beginning to look like I have few options except to suffer through a progressively more disabling chronic condition for the next 20-30 years until I'm finally old enough for a replacement.

I guess I'm looking for success stories.  Even assuming I could get the ACI, has it actually led to long-term success for anyone with patella defects?  It's been extremely hard to deal with going from carefree and athletic to functionally disabled in just one year.  I have an 18 month old and I'm wondering if I will ever be able to play sports with her or chase her around the yard.

I'm not doing too well emotionally with this.  I can't understand why we even evolved patellas to begin with.  They only give us about 15% more leg strength.  In exchange, we got this extremely complex mechanical joint that is subjected to thousands of pounds of shear forces during daily activities and whose alignment must be meticulously maintained.  Wouldn't it have been easier to just evolve quads that are 15% stronger?  You can gain that much strength in about 1 month in the gym.

I need to hear that there is hope.  At this point, I'm no longer hopeful about the future -- all I see is increasing disability, limitation, and misery.

Sorry to be such a downer, but this is where I'm at.
10/2010   L knee LR + mfx 3.5cm2 lesion patella lateral facet
2/2011  Followup MRI shows complete defect fill and resolution of subchondral edema -- but still have symptoms

Offline Lottiefox

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Re: is there any hope for those of us with patellar lesions?
« Reply #1 on: December 22, 2010, 04:43:04 PM »
Hey,

Sounds like you're in a similar place to me 12 months ago, although I haven't been through the surgery side. I have lateral and medial patella lesions (Grade3-4 but pretty much Grade 4 and pretty much not leaving much of my patella covered in the shiny stuff any longer!). I have always had crunchy knees but last year, after a summer of more impact activity (Boot camps, running, boxercise etc) and a strenuous workout program my left knee started to hurt. A lot. MRI scans showed the damage plus I have a lesion on my femur too, which I know happened during 90 shuttle sprints on uneven ground one summer day....and my right knee also has the same issues to a lesser degree.

I saw three separate surgeons. The first said OATS on the femur and ACI on Patella. I spent 10 days in shock, crying quietly into my duvet/husband/cat. I then saw a second OS who said Chondroplasty of the patella, microfracture on femur. I still didn't commit to doing anything. I then saw a surgeon who is pionerring a new repair technqiue called Cartifill - this combines a MFX basis with a collagen substance on the top. It hardens immediately and is going to help patella lesions as clearly the kneecap is under shearing forces all the time, making ACI etc tricky. He sent me for in depth scans, tracking, CT etc. He then recommended Cartifill and a lateral release. I have lateral patella tilt but I track pretty much OK and my tibial tubercle distances etc are all OK. However, I do have underlying rotational issues, and I was not wholly convinced about shifting the dynamic of one bit of the knee with the other issues staying the same. SO - I decided to commit 120% to conservative measures and see what happened. I found a physio who took me back to basics. I cut out any impact activity for sports. I still cycled, weight trained (no squats!), cross trainer, simple circuits etc. I then had a course of Celebrex and then a Euflexxa injection. 12 months on I can now cycle 30km on the indoor bike 3 times a week. I can walk as much as I want. I have cleared our drive of snow this week, when last year I couldn't carry shopping in from the car. Are my knees perfect? No way. I still have to think about twisting movements, I can't run (not anymore than over the road), But I can kneel, squat, exercise, and generally not think of my knee(s) every minute of the day. Perhaps I have been lucky. But I do know that desperate feeling when the rest of the world has seemingly good knees and when your fomerly active life suddenly disappears down the toilet. I recall crying at my mum's house this time last year with a bag of peas on my knees. Had someone given me a gun I'd have done the deed! (on my knees probably!).

In answer to the question on repair techniques. I think you are right to be concerned that a re alignment may not solve the problems. It will depend on how the pressure moves in relation to your damaged areas. A member on here had a TTT with lateral lesions and has done very well. Doublemom is her name. There are success stories on with patella ACI but they often also involve a re alignment in combination. There is a current diary on here of someone with patella ACI and a TTT of some variant. Check out the Diaries section. There are also new techniques developing - the Cartifill is one such technique (google Anan Shetty for the pioneer) and also the De Novo graft has been used with some sucess on patella lesions I think. People on here have had the PF joint replaced too, with good results but I think they were older than 30 (although probably only 40 or so). I think unless you've got damage on both the patella and trochlear groove then a PF replacement is probably not the first line of action.

Do you have a good surgeon? Where are you based? With complex issues like mechanical alignment problems and a patella lesion (which has happened for a reason - probably your alignment if its happening on the other knee) you need a patello-femoral specialist. You might need several opinions. I would also say that 3 months post LR and MFX isn't *that* long. It feels like it I know. But things may well improve. With inflammation still ongoing in the knee after surgery the symptoms will still be problematic. You may well find that in another 3 months things have improved. Use that time to research different options. But don't rush into anything - patella issues are horrible but desperation makes you do desperate things.

I really hope things improve. I feel your frustration, I really do. I often dream of someone giving me new kneecaps - and straighter legs so I can do a lunge again without wanting to faint! Don't give up hope. You can make things better, hang in there.  :)

Lottie  :)
Bilateral patella OA since 2009, no surgeries.
Euflexxa working well x3 to current
Right forefoot CRPS post fusion surgery 2011
Refusing to let the ailing parts stop me....

Offline Lottiefox

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Re: is there any hope for those of us with patellar lesions?
« Reply #2 on: December 22, 2010, 04:48:59 PM »
I knew I'd see a recent patella ACI/TTT Diary:

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=53410.0

Really detailed and a good read.  :)

Good luck!

Lottie
Bilateral patella OA since 2009, no surgeries.
Euflexxa working well x3 to current
Right forefoot CRPS post fusion surgery 2011
Refusing to let the ailing parts stop me....

Offline twobadpatellas

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Re: is there any hope for those of us with patellar lesions?
« Reply #3 on: December 22, 2010, 05:22:40 PM »
Thanks for much for the reply.  It helps a lot.

I have a good OS, or at least I thought I did.  He's fixed a whole bunch of knees for people in my area and everyone raves about him.  I even work with someone who also had an mfx and LR from him, and she's doing very well now. I went to another OS for a second opinion, who was actually one of Dr. Fulkerson's students, and he told me that the first OS is great and that he wouldn't hesitate to go to him or send a family member to him.

I've been on what seems to be a very aggressive rehab.  I didn't have any sort of brace to limit flexion and I didn't have a CPM machine.  I was in a straight leg brace for three days.  After that I was told to limit pressure but to move it a lot, which I did.  I've had a couple of complications.  My knee slipped off of the balance ball while doing PT homework on day 14 which led to a severe hemearthrosis with massive swelling and pain.  I had to go to the ER to get it drained and it was a big setback.  Last week I was carrying my daughter down the stairs, going down one step at a time (as I have done since the surgery) when I slipped and nearly fell.  I had to push very hard off the left knee to keep from falling, and I could swear to you that I felt something under my kneecap get crushed when this happened.  It didn't hurt much, though, and it didn't swell much afterward, so I don't know what to think.  It does feel like I have more crepitus in the joint now than I did before this incident.

It's frustrating because both of these docs have not displayed much curiousity the root cause of my problem.  They haven't taken any measurements.  The first doc recommended mfx and either LR or Fulkerson on the basis of a physical exam and an MRI.  No CT, no xray.  The second doc took x-rays, including the Merchant view, which looked totally normal.  My patella did not display any tilt.  I questioned why I would benefit from a LR if I don't have tilt, and I was told that I could still have abnormal lateral pressure caused by a tight LR without visible tilt.  I had a severe IT band injury in the left knee after running a half marathon about a year ago, and I figured the LR might have tightened up after that injury.  But now that the right side is doing the same thing, this explanation seems unlikely.

I also had Osgood-Schaltter as a teenager.  As a result, I have HUGE tibial tuberosities.  A Fulkerson would make them even higher.  I already have trouble kneeling, I'm not sure if I'd be able to do it at all after a Fulkerson.

My pre-surgery symtom was that my patella would catch on extension as I entered about 20 degrees of flexion.  Then it would snap with a sudden release and pain.  Basically from 10-25 degrees of flexion it was sore and prone to catch.  I could get through that arc if I used momentum or if I could unload the patella a little bit as I passed through that arc.  I could go downstairs by basically "falling" onto my right foot each time to avoid the controlled eccentric contraction through the painful flexion arc.

My OS told me that my patella was getting caught on my femur at the initiation of flexion.  My surgical notes say that this was corrected after performing the LR.

I really wish I could find a doc who would sit down and give me a COMPLETE evaluation, with measurements, to try to get to the bottom of why this happened.  I would greatly appreciate a doctor who would show some curiosity about why this happened.  I don't know how to find one, though.  I've been to the two highest rated patellofemoral guys in my area.

Obviously, I'm very frustrated.  I've been reading lots of post-op threads.  The problem is, people seem to stop updating after a few months.  It makes it really hard to see how they are doing a few years after the procedure.

I can really relate to what you are saying about the emotions of all this.  I'm not much of a crier but I've been shedding a lot of tears since all this began.  The last two weeks, where it has really started to look like the mfx didn't work, have been really difficult.  I've been really worried that my daughter will have this condition too and I've been feeling a lot of guilt about that and also about the father-daughter experiences that we will miss because of my limitations.  I've even been wondering if we should have any more children because I'm afraid of passing this on, and I definitely wouldn't wish it on anyone.
10/2010   L knee LR + mfx 3.5cm2 lesion patella lateral facet
2/2011  Followup MRI shows complete defect fill and resolution of subchondral edema -- but still have symptoms

Offline Lottiefox

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Re: is there any hope for those of us with patellar lesions?
« Reply #4 on: December 22, 2010, 07:24:06 PM »
Hey

You have been through it. That "event" with the balance ball won't have helped at all in terms of general healing. It will have set you back so try and be patient and hang with it. The nearly fall down the stairs probably just caught some of the damaged areas. I don't think you'd have done anything major - I know I've banged my kneecaps and stuff and felt like I have heard something fly off inside but they've always settled down. The ITB and running and the LR are all interlinked from what I've read. Running with slightly skewed biomechanics places us at higher risk of things like ITB injuries and problems, and then the knee starts to hurt, and the ITB tightens more...etc etc......and bingo you've got a patella that isn't happy. I can relate to the catching at that certain point. I am the same with stair descents, kind of fall down them at times although since my PT kicked in I do have more control. I noticed the other day I can actually extend my leg when putting it onto the leg press at the gym rather than a kind of "flinging it up and on" motion I used to do. Progress is slow!

I think in terms of getting to the bottom you need a doctor who will look at alignment and rotational issues. Femoral and tibial torsion can impact on the patella and when those measurements are known you'll kind of know if correcting something with a TTT is a good idea or just adding one problem to add an underlying issue. Not saying you want to be going into derotation surgery, but if you get the full picture and explanation then you'll be able to make a proper choice. I found knowledge was my biggest factor in starting to feel more positive.

Please don't worry about missing out on the father-daughter experiences - you sound like a fine Dad to me. To be worried about it means you won't let it happen. You will be running around with her (perhaps not in half marathons!) in the future. My Dad had bad joint issues, as do both of his sisters. And he was as myopic as anything. I inherited both delightful traits! But he was also smart, funny, had a hot temper, loved animals, and was loyal. I *hope* I may have got some of those traits to along with my bum knees and batlike vision. So, please don't feel guilty about your daughter. She is what she is, and you are what you are. Knees don't take that away. They just make the journey along a bit more challenging at times.

I think people do stop posting here - usually because they recover and get on just fine! At least thats what I hope.

Hang in there. There may be someone along who has some more practical suggestions. What PT are you able to do now? is it still aggressive? Oh and surgeons are surgeons - they may be great but they do see a surgical fix for things!

Take care

Lottie  :)
Bilateral patella OA since 2009, no surgeries.
Euflexxa working well x3 to current
Right forefoot CRPS post fusion surgery 2011
Refusing to let the ailing parts stop me....

Offline Kimberly 77

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Re: is there any hope for those of us with patellar lesions?
« Reply #5 on: December 22, 2010, 08:10:57 PM »
I don't have much advice for your medical problems but as far as the way you are feeling as a dad I can totally relate and I can also tell you it is a foolish way to feel.( I mean that in a nice way) I am a right leg amputee and have been my whole life. I have 3 kids, 12 & 7 year old boys and a 3 year old daughter. My kids are my life, I get up and move everyday because of them. I have never been like other moms but have always made the best of it. Being a parent isn't all about playing basketball, or running in the backyard. It is about love and being there for your kids. Even if being there means sitting in a chair on the sidelines, all our kids see is us being there. I have had many times where I felt I was not doing all that other moms do but I always remember I am doing everything I can do. I am not the mom who plays sports or runs with her kids, I am the mom that shows up at all the games to cheer them on. To me that is what is really important. Last April I injured my only knee, since then I have had surgery and it failed, I am mostly wheelchair bound now. Which is a shock to me I have always walked with crutches so nothing new there but this wheelchair thing is hard and hard to accept. I find myself feeling like you alot, and I pull my head up and remember what life is really all about! Take heart in the wonderful things around you and don't fret about the things you cannot change about yourself! Your daughter will always remember the way dad was there.
Right leg amputee.
Osteoarthritis in left knee.
Medial femoral condyle defect, arthoscopy 8-2-10
Grade 3 defects, patella, medial femoral condyle, tibia scoped1-12-2011
Physical theraphy and awaiting microfrature 2-1-12

cdubb

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Re: is there any hope for those of us with patellar lesions?
« Reply #6 on: December 22, 2010, 08:24:33 PM »
Hi twobadpatellas,
Totally sucks having 2 bad kneecaps!  I'm a 31 year old female with a young 4 year old, active little boy, so I know what you mean about wanting to be active with your kid.   It's my thread that Lottie provided a link to.  Thanks Lottiefox! I'm only 7 weeks today, so can't really give you a read yet on success of the procedure.  If it's good though, I'll probably look at doing the other knee in a year or so (it was scoped the same day as my left knee patella ACI/AMZ).  

I had concerns about insurance approving the ACI; however, my insurance turned it around in under 2 weeks from submission.  In conversations with my Dr.'s PA after my biopsy scope, she told me that in her 6 or so years of working with my Dr., they have only experienced 2 final denials.  They often have to go to an appeal and then a peer to peer, and generally at a peer to peer, they'll approve it because the peer to peer becomes more education in nature since many orthos are not educated in cartilage restoration.  I tihnk the Dr. you are with makes a difference with insurance companies on approving things.

I would have the Fulkerson discussion with your Dr because from what I recall from my Dr. telling me during my biospy scope (I stayed awake for it because it could have been a microfracture/AMZ or just a biopsy and I didn't want to not know what I'd wake up to).  Anway...my MRI showed a lateral defect; however, it ended up being central when he was in the knee.  He told me during the surgey that since mine was central and not lateral,  I needed ACI with it, as an isolated AMZ (fulkerson) only would have a 50% success rate, but with ACI it would be 80% or more.  A lateral defect would have greater success with an isolated AMZ or AMZ with microfracture.  Essentially, with a patella lesion, correcting any malalignment is important.

Feel free to let me know if you have any questions about my recovery.  You can read through my diary also that Lottie provided the link to. I try to bold the header line on recovery updates if you want to try and do a quick read since there is also a lot of small talk going on through the thread.  You can PM me also with any questions.  If you don't have enough posting yet, let me know and I'll PM you my e-mail.


Offline twobadpatellas

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Re: is there any hope for those of us with patellar lesions?
« Reply #7 on: February 04, 2011, 04:06:23 AM »
I know it has been a while, but I'd really like to offer a deep and heartfelt thanks to everyone who replied to me.  I really was in the pit of despair, and truthfully I didn't have a good Christmas, but recently I've been taking a hard look at my life and realizing that I have so much to be grateful for.  I'm excited about all the new cartilage repair technologies that are coming out, and I have hope that I will one day be able to fix these knees and go back to my active lifestyle.  In reality, I have it so much better than many others with knee issues -- I am still mobile, and I don't experience chronic pain unless I attempt movements that I can mostly avoid in daily living -- that I feel almost ashamed of my despair.  My main limitation is going down stairs, particularly if I need to carry something that prevents me from carrying some of the weight with my arms. I carry my daughter down the stairs via the butt-slide, and she thinks it's fun that way.   ;D

Thanks again.  I can't express how much you have helped set me straight.
10/2010   L knee LR + mfx 3.5cm2 lesion patella lateral facet
2/2011  Followup MRI shows complete defect fill and resolution of subchondral edema -- but still have symptoms















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