MRI scan report 'medial facet/medial trochlea disease’ + more problems!

[Clarkey]

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.

I have some idea of what wrong with my right knee, please be honest with me.

Will I be able to return back to running long distance running competitively.

Is a microfracture done when there are signs of the knee wearing out before doing PKR or TKR.

If I did have a successful knee arthroscopy in July would it be unwise to run long distance again.

Do I have to seriously consider giving up long distance running completely with the state that my right knee is at present!

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[vickster]

Nick, I don't think anyone can tell you whether you can or should run again or not.  Running seems to be the cause of your knee issues, and you need Mr Snow to give his opinion and advice as to whether running is sensible for the health of your knees.  If he suggests that you may run again, you will need his advice and your physios advice as to how best mitigate any risk. Be it shoes, gait training, orthotics, the surfaces you run on etc.  given the report says you have some varus malalignment, bow leggedness, this may explain some of the apparent medial wear. Proper orthotics may help this, I think this has been recommended before to you?

 I am valgus, knock kneed, which has likely contributed to my wear which is lateral, so I am the other way.  I cannot run, and have no desire to do so.  However, I would feel the same way if my surgeon told me to stop cycling...especially as he recently operated on my leg to deal with an injury caused when I was I knocked off my bike!

Regarding the microfracture, it's one way to help fill in small defects in the articular cartilage, it is not used where a replacement is necessary.  The arthritis primer on here is good and helps explain about the causes, treatments etc.  microfracture produces poor quality fibrocartilage and is mixed success wise

In the uk, you are unlikely to be offered a replacement until your 50s or probably 60s, at 35 that's a long time to have a painful knee, so you should try to avoid making it worse

I would say you probably shouldn't run until the scope, stick to something non impact like swimming.  You don't want to make your knee worse

All the best

[Clarkey]

Hi Vicky,

I really appreciate your help and advice and are a credit to KG and its members. I apologise if I was a bit negative on my previous posts and a bit hot and cold when members advised me by being snappy at times.

I was told before my last knee surgery pre op that due to having Asperger syndrome the knee pain was in all in my head when all along the pain was for real! This is one reason why I ignored the knee pain while running.

I certainly shown those the doubted me as I now have early signs of wear and tear in my right knee, could be the same with my left knee. Mr Snow is the 1st medical professional to take my knee problems seriously, glad I have found an understanding OS.

The main reasons I chose Mr Snow are:

•   Specialises in soft tissue injuries of the knee

•   Deals more with younger patients

•   Younger OS, I need someone younger that I can continue to see in the future for further advise and possible future treatment.

Mr Snow advised me to avoid running and should take up cycling instead that you also enjoy doing; it was bad luck your fall off the bike that has brought you to KG.

I was told for a too high knee cap TTT surgery is done to lower it; is there a procedure that can be done to do the reverse by raising the kneecap? I know PT can help raise the kneecap and not sure if there a surgical procedure that can be done to raise the kneecap?

Do not worry will not run pre op as I am physically unable to; thanks for the concern.

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[kaelyn]

I also had a bone bruise on my medial femoral condyle, they believe it was caused by the accident but irritated by a medial plica that was rubbing across it which was removed and then I had microfracture, the bone bruise had gone by my second MRI which was after my operation.

Hopefully it will be easily fixable for you, I still have pain now but it is not in the same place.

[Clarkey]

Hi Kaelyn,

That interesting to read that your medial plica was rubbing across the medial femoral condyle. I had to have mine removed in November 2009 and also had my fat pad trimmed. I was getting sharp pain and catching at the bottom of my right knee pre op that did go away post op.

Due to my low lying patella it has caused my latest problems that been speeded up by running long distance and 13 years of manual physical labour as a greenkeeper on a golf course.

I come from a large family of 6 sisters and 1 brother; they all get knee pain on and off and are slightly bowed legged so hereditary maltracking problems. Mine is more noticeable as I more active and do more hard manual labour jobs.

I have to say I did not think a microfracture would be performed as am I only 35; I wonder if I can still run as I use to competitively after a mircofracture or have to ease back! It may speed up the process of having an TKR that should be put on hold for as long as possible.

Your surgery seemed to have gone ok, are you glad that you had your surgery with no regrets; I am prone to scar tissue problems that something I have to risk as I had problems last time post op.

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[Snowy]

I have to say I did not think a microfracture would be performed as am I only 35

Microfracture isn't an age-dependent procedure the way that TKR and PKR are. I know of many people in their 20s and 30s who have had microfracture performed on cartilage defects. Microfracture is used for small cartilage defects or injuries rather than the large-scale, deeper cartilage loss that requires a total or partial knee replacement.

When you have a TKR, part of the bone is cut away to allow the mechanical components to be placed in the knee. Because these mechanical parts have a finite lifespan and there's only so much bone that can be cut away, TKRs (and to a slightly lesser extent PKRs) tend to be done later in life. This way doctors can be more certain that the person's lifespan won't drastically exceed the life of one or two sets of replacement knee components.

Microfracture doesn't involve cutting away bone or the use of mechanical parts, so it's a very different kind of procedure. With microfracture, the doctor makes tiny holes in the bone that release cells which form a new layer of fibrocartilage to fill in the damaged area. Microfractures have to be very carefully protected while they heal to ensure the cartilage doesn't get damaged; it's extremely important to follow any instructions about weight bearing and activities to avoid if you do have this done.

As to whether you'll be able to run again once it heals, that's really impossible for any of us to say. It depends on exactly what the damage is (your OS doesn't sound like he will be certain of this until he does the scope and can see inside the knee), where it is, and how successful any procedure to fix it will be. Certainly I know of folk who've had excellent comebacks after microfracture, but each individual case is very different. Your OS will be able to give you the best idea at this point of what may and may not be possible in the future, but even he may not be able to give you clear guidance until after the scope.

[vickster]

Nick, if you are cleared to start running again, some of the info here, and other places on the site might be helpful

http://www.knee-pain-explained.com/knee-pain-from-running.html

[Clarkey]

Hi All,

Thank you Vicky and  Snowy for your replies and now can see that it a common procedure to be having a mircofracture surgery procedure done at the age of 35.

Mr Snow runs The Cartilage Clinic and read about how a microfracture is performed, that Snowy  has explained well. I know it is still early days as I have not even yet had the exploratory scope done on my right knee. It may just be a simple repair of a torn cartilage with no microfracture required; this would be an ideal scenario with no mircofracture needed.

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.

I have spoken to my sister who an orthopaedic nurse, she often assists in knee surgery and said that the next stage if the wear is larger than it should be may do a PKR by fitting in a mental plate. This only done if you are an older patient in the UK.

There are other methods according to Mr Snow's website other then a mircofracture. Some members may be more familier with what could be performed rather then doing a PKR for younger patients.

Autologous Chondrocyte Implantation & Mosaic-plasty

I do not think this will apply to me the most drastic surgery that still fairly minor is would be a mircofracture surgery. What is annoying as I am not the type to keep still and like to be active is none weight bearing for 6 to 10 weeks after the mircofracture. They say if you do not follow instructions given could ruin the new growth of new cartilage cell growth!

Worse case scenario Mr Snow has to do a 3rd scope; would he perform a Autologous Chondrocyte Implantation & Mosaic-plasty to see if they work.

http://www.thecartilageclinic.co.uk/surgeons.html

http://www.thecartilageclinic.co.uk/Treatments.html

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[vickster]

Nick, i think for any sort of advanced cartilage repair to be done, i.e. Funded on the nhs, other more straightforward repairs need to have been tried and failed, i.e. Microfracture.  Aci costs over £10,000 and is actually two operations!

There are few centres doing aci on the NHS, a long running trial was happeneing, now finished recruiting.  I dont know if birmingham is one

The arthritis primer in the information hub has good info generally about this stuff

Also, the patella and trochlea tend to respind less well to repairs due to the shearing forces exerted when the knee is used, bent

Before the op, talk to Mr Snow about what will be done, he may microfrature there and then rather than operating again, if he thinks thats right, but you need to consent, so talk to him

[Clarkey]

Hi Vicky,

According to Mr. Snow's website he does do procedures like Aci at The Birmingham Royal Orthpaedic Hospital and have coped and pasted the last paragraph on his website.

Mr. Snow has a major interest in Cartilage and Sporting Injuries of the knee. He treats all aspects of cartilage injuries using the full spectrum of cartilage regeneration techniques. He regularly attends The International Cartilage Repair Society meetings where the latest developments and technologies from around the world are discussed. Mr. Snow is currently involved in exciting research at The Royal Orthopaedic Hospital. In combination with a group in Belgium he is attempting to regenerate cartilage by using patients own stem cells.

http://www.thecartilageclinic.co.uk/surgeons.html

I am not sure if I would be allegeable for such a procedure or not with the high costs and 2 surgeries rather than just the 1 with mircofracture procedure. I have had to tell the Director of an Autism Charity for Children with Autism that I am not in the position to become a team leader to lead a team of adult Asperger syndrome gardeners during the summer months, due to my knee surgery in July.

The Director told me he had a microfracture done on his knee and that I am not allowed put out any weight onto my knee for 6 to 10 week after a mircofracture. This would drive me insane as I am very hyper as I need to be on the move a lot; I will become grumpy for a couple of weeks by not being as active as I am use to being.

The Director also told me the Ex England cricketer Freddie Flintoff had to have a microfracture surgery. I know he had a lot of knee problems throughout his England and Lancashire cricketing career, the Director had his knee done the same time as Freddie Flintoff

Just the waiting game now, not much else I can do for now!

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[kaelyn]

I was able to weight bear immediately after micro fracture surgery as it was performed on a non-weight bearing part of my knee so don't lose hope. Don't over research things and jump to the worst conclusions, it won't help with stress levels and stress delays healing.

[vickster]

Hi Nick,

As above, until you talk to Mr Snow you won't know what to expect.  The trochlea isn't weight bearing from my understanding, however it is subject to shearing forces as you bend your knee.  It maybe that you can walk but perhaps Mr Snow may have you in a locked knee brace to stop bending.  That is pure speculation though!  Braces are commonly used to protect a cartilage graft after transplantation too.  I developed fibrocartilage on a traumatic weight bearing femoral defect without any protection at all, although this is quite unusual I think (4+ years on it's still intact I believe).

I wouldn't make any assumptions or worry about what happens until you talk to Mr Snow (which will presumably on the day of the scope now).  Ask him questions, probably write them down as you'll likely be a bit nervous and muddle headed before the op!

If he's not mentioned cartilage transplant yet, it is highly unlikely he'll even start that process as it is extremely costly and only available for limited numbers of patients.  In the UK too, it seem surgeons are quite unwilling to patch up around the patella as success rates are lower due to the shearing forces

This gives some good background on cartilage repair (although it is a little old now and won't cover all the really new fangled stuff with stem cells etc)

http://www.kneeclinic.info/problems_articular_cartilage.php

[Clarkey]

Hi Vicky,

Not knowing that is making it difficult to accept! If Mr Snow knew what he needed to do purely on just looking at my right knee MRI scan before surgery I would not be asking so many questions for some reassurance.

I do now admit I did overdo it while running long distance by showing off my speed for several miles while the majority of long distance runners that I see go at a nice steady speed; they do not pound each step as I did before reinjuring my right knee through heavy impact and force.

13 years of manual labour on a golf course plus did lots of heavy lifting and gardening during childhood and adolescent years; back then had the odd pain and discomfort, so there is no great surprise the stage I am finding myself in right now.

Thanks for your link and advice once again.

I was able to weight bear immediately after micro fracture surgery as it was performed on a non-weight bearing part of my knee so don't lose hope. Don't over research things and jump to the worst conclusions, it won't help with stress levels and stress delays healing.

Kaelyn I in total agreement with you and best not to over analyse what could happen and maybe part of my autism and asperger’s to go through the same thing over and over again; could say also have OCD as I like to check and reassure myself.

Also tend not to listen to others peoples advice and guidance as I was pre-warned by my Sports PT, GP and my Mum to ease back on my running! I thought I knew better than them and ignored their advice; I am now paying for my actions, I did not think at the time it would would happen to me that I am wearing out my knees.

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[vickster]

Perhaps you could email Mr Snow and ask him about the post op rehab depending on what he finds / does.  He's got a while to answer so shouldn't feel pressured to respond immediately . He presumably knows your overall situation so will understand. Just explain you want to be prepared and reassured

You will need to be ready to follow his instructions if he does do microfracture or it may not work and you could be worse off, so best be prepared beforehand if you are going to need to be on crutches and so on

[Clarkey]

Thanks once again Vicky.

I could contact Mr Snow's Secretary to ask Mr Snow that I need some added reassurance before my knee scope, he is well aware I have AS that are in the last notes when I had my surgery on my right knee in 2009. Says I have Asperger’s and do not like a mask put over my face until I am actually knocked out.

This was mentioned briefly when I had my Botox injection last year as there is always an anaesthetist on standby; this is routine while doing CT guided injections. That day was bad enough and was only a minor procedure, I was freaked out then, so may ask for some pre sedative meds to make me feel calmer before going into theatre.

As you have mentioned there is plenty of time still to ask Mr Snow about post rehab after a microfracture, or any other types of procedures that Mr Snow decides to perform.

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