Chondromalacia Patella + Patellar Tendinosis

[papasmurf1978]

I would've never known that I have cartilage softening if I didn't get lateral pain cause I would not have done MRI. I'm looking into anything available since if there will be something available one day to fix the soft cartilage defect then I will do it. Of course this would be my last resoft. Right now I'm focused on physiotherapy. What is strange is that one knee has some crepitul in it and other don't. I will look into the acid injections you mentioned. Might be good idea to lubricate them as a precaution. By the way, are you still 100% mobile or have limitations?

[vickster]

Pretty mobile, not necessarily pain free but all complicated by the injury to my shin in February on the same leg as my knee and then trying to train too soon for a 100 mile bike event which annoyed my back and LCL/ITB...not clear cut

In the last 2 weeks I have cycled over 200 miles (including 52 on Sunday) and been to the gym half a dozen times (mainly rowing, recumbent cycle, resistance work and stretching)

My main limitations are that I can't kneel comfortably nor sit back on my heels - partly due to flexibility which is improving but also due to the 1.5cm2 hole in the cartilage on my femur...which has now been there for nearly 5 years.  Doesn't really get better or worse, the injections every 18 months seem to help as my surgeon reckons I'd be much worse off without them.  I also have two meniscus tears, but pretty full ROM

Try to just get on with it, two arthroscopies, really don't want more.  There are risks, it hurts after, means time off work, off life, off the bike, leaves swelling and scars

The limitations don't specifically limit, I can't jog or run but have no need nor want to.  Get a bit stiff sitting for long times, can get twinges and niggles but nothing unmanageable.  Try not to think to much about it if I can.  I've stopped formal physio for now as my insurers won't pay for any more, just doing the gym, stretching, limiting cycling to some degree (I had to pull out of my ride on the strong advice of the specialist as training adequately would have caused me worse issues)

[papasmurf1978]

I also got used to the pain which at worse would be 6 or 7 at times but usually it's at 3 or 4. When I wake up, the first couple of minutes are painless and then the pain kicks in. It's like my system knows when to let me know that pain will be there. I try not to take any pain killers, would on occasions.

[vickster]

I sent you a message

[papasmurf1978]

Here's the english version of my MRI done last week:

[papasmurf1978]

MRI RIGHT KNEE
Clinical information :

Femoropatellar syndrome. Chondromalacia.

Protocol :

The examination was done utilizing the routine knee protocol.

Findings:

1. Cartilages (Outerbridge classification) :

The patellar cartilage is mildly heterogeneous centrally compatible with a mild chondromalacia (grade I/IV) with a normal thickness. The cartilage of the trochlear groove is within normal limits. No femorotibial cartilaginous abnormality.

2. Menisci : Normal. No tear identified.

3. Cruciate and collateral ligaments : Intact.

4. Tendons and patellar retinaculum: Normal.

5. Osseous structures : Normal, without contusions, fractures or other lesions.

6. Other : No joint effusion. No popliteal cyst present.

Opinion:

Mild patellar chondromalacia.




MRI LEFT KNEE

Protocol :

The examination was done utilizing the routine knee protocol.

Findings:

1. Cartilages (Outerbridge classification) :

Mild patellar cartilage heterogeneity medially consistent with mild signs of chondromalacia (grade I/IV). The patellar cartilage maintains a normal thickness. The trochlear cartilage is normal. As for the right knee, the trochlear groove has a normal morphology without dysplasia. There is no patella alta. No sequela of an old patellar subluxation. The femorotibial cartilage is normal.

2. Menisci : Normal. No tear identified.

3. Cruciate and collateral ligaments : Intact.

4. Tendons and patellar retinaculum:

Mild heterogeneity and discreet thickening of the distal patellar tendon at its attachment at the anterior tibial tuberosity. The other tendons are normal. The patellar retinaculum is normal.

5. Osseous structures : Normal without contusions, fractures or other lesions.

6. Other : No joint effusion. No popliteal cyst present. Small mediopatellar plica.

Opinion:

Signs compatible with a mild patellar chondromalacia.
Mild distal patellar tendinosis. To correlate with clinical findings.

[papasmurf1978]

I was looking into PRP treatments and got this info from India's Orthopedic Surgeon:


Patient needs arthroscopic coblation condroplasty with PRP injection both knees



Stay in hospital 2 days

Stay in India 7 days

Can anyone comment on the PRP procedure. What is the success rate of getting cartilage regenerated?

[MDAL]

Papasmurf:

We need to go slow with these kind of things. I had both those procedures separately (different points in time).

Chondroplasty means the surgeon will shave off cartilage that is breaking apart smoothing edges and so on. This is simply a clean up that is done in order to remove the inflammated part that is signalling the trouble as well as smoothing the rough edges in order to allow better mechanical motion.

This is highly controversial to do because:

1) Cartilage won't grow back, degeneration will continue where the doctor stopped.

2) You may trigger and inflammatory reaction with surgery that will lead your own immune system to "eat" the cartilage further.

3) There is no guarantees that the mechanical properties that are left will be useful (for instance if some zones are left too thin, the mechanical forces might lead them to break down faster leaving it bone on bone in a short time.

4) There are always risks of infection, formation of scar tissue etc.


This is the part without PRP, now with PRP:

PRP is great, I had 12 shots of it so far this year alone and I couldn't be more happy. Yet this was not related the previous procedure but far after it.

PRP as you described is highly unlikely to grow you any cartilage especially if it's just a few shots.

Properties of PRP are (take this with a grain of salt because nothing is written on stone):

- Anti-inflammatory properties that contribute to symptomatic relief.

- Healing of the superficial damaged layer that is signalling trouble, which leads to synovial inflammation and all the symptomatic mess.

- Eventually and without any proof, it may lead to regeneration if applied for long term with large number of injections.

In the context of the procedure you mentioned that is offered in India (7 days), all I see is the use of PRP post-surgery in order to heal the superficial layer and help you deal with inflammation post surgery. It's a good idea, that in my opinion should actually be standard with any knee surgery, but that is not a procedure designed to grow anything back unless you stay there for months taking shots and even so there is no scientific evidence that it will. I have a good experience with it though.

If I understand correctly you are in US and traveling to India for this? If so this may be a rush move since you may have hundreds of options at home with lower costs.

I have compared many options of traveling to India, and most turn out to be more expensive than doing them at home in Europe.

[papasmurf1978]

Hi MDAL,

I live in Canada. Thanks for your very thorough explanation. I'm interested in getting a treatment that will grow back the layer of cartilage they will shave off.

I looked into couple of options:

1. Chondrofiller (already in use in Europe) producing hyaline-like cartilage
2. Agili-C (currently in clinical trials) producing hyaline cartilage according to studies

Do you have any info on one or both if any?

[vickster]

Right now, once it's gone it's gone...only cartilage transplantation like ACI really.  Maybe in 15-20 years according to my OS

[papasmurf1978]

Hi Vickster,

no disrespect to your OS but mine said the same thing. He didn't even know there are procedures available already to treat cartilage damage. Oh well, I guess mine was a bozo.

[vickster]

Mine certainly does, it's one of his areas of interest, involved with ICRS, trials etc.  the UK system makes things less accessible if there's no trial. Canada sounds similar.  If no private insurance here, some stuff is just not available, and even then, they often refuse to cover if experimental as they follow NHS guidance.  We aren't used to paying large sums out of pocket

[MDAL]

Hi MDAL,

I live in Canada. Thanks for your very thorough explanation. I'm interested in getting a treatment that will grow back the layer of cartilage they will shave off.

I looked into couple of options:

1. Chondrofiller (already in use in Europe) producing hyaline-like cartilage
2. Agili-C (currently in clinical trials) producing hyaline cartilage according to studies

Do you have any info on one or both if any?

PapaSmurf:

I may need to sound a bit negative regarding these Chondrofillers and Agili-Cs...

So what are they? They are the "new kids in the block" from something that has been in market for over 20 years, and for which I have came across more than 20 brands of it, which are rarely used in clinical practice because they don't have much acceptance between surgeons (and with plenty of valid reasons). Among those reasons I can state one, because there is better in the market, with enough clinical practice and expertise built on it, namely ACIs, where they collect a tiny sample of your own cartilage, multiply it in lab, re-create cartilage that is hyaline alike, and re-implant. Since there are real cells on it, it is far more than scaffold structure, it is already cartilage.

The difference is that those products you mention are just scaffold materials, with a lot of limitations, for which in real practice obtain a huge failure rate and very low durability, independently of all the great things that are mentioned in the box, which are never demonstrated in long term studies with decent design.

The actual results are way beyond success rates of ACIs, and success rate is something important, if someone is going to cut your patella, flip it upside down and then reconnect all the structures. It will never be the same again mechanically, so at least it's better to use the effort on something with more reliability.

Implants and scaffolds aside, if you want to achieve some level of regeneration without having your knee disassembled to parts and attached back together, you have some options in Canada:

One a controversial doctor (but who does seem to get the job done): Anthony Galea
http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=62143.msg618123#msg618123

And for a probably more affordable cost there is a doctor in Utah who is very well regarded in the articular cartilage repair forums using stem cells as well. Docere clinics, you can read a lot about it there.

Note that there are no magic treatments for cartilage repair. I have had stem cells from fat plus PRP and I am doing really good...

[papasmurf1978]

So when you had PRP injections, did they need to shave off part of your patella cartilage? So the purpose of PRP is to control inflammation and pain or rather that and help cartilage regeneration? I'm in Canada and there's not much available here yet. Europe and Israel seem to be dominating the market on cartilage regeneration.

[MDAL]

Nope. Debridment and PRP are not related in any way. In fact this is the first time I ever heard of it being used together.

PRP simply consists of extracting blood, spin it in a centrifuge to remove red blood cells which is most of the blood and something you don't really want in the joint, and concentrate the platelets and the growth factors (hormones), contained in the blood. Note that cartilage does not regenerate on it's own (or at least rarely successfully), because it has no blood supply to it. The theory is that if you supply the blood good stuff there is a potential for healing similar to any other body part which is vascularized. Several hormones in it, such as IGF and TGF-B1 have been show to help regenerate cartilage by multiplying cells, capturing stem cells, transforming them and induce collagen formation.

This is no magic wand though, evidence is limited, and most studies usually focus on very few shots. So what can be reliably said at this point is that it does have a demonstrated anti-inflammatory properties with symptomatic relief but there is no proof that regeneration is achieved. Note that cartilage is constituted by less that 5% cells, the rest is collagen (inorganic), collagen production is very slow and can take months or years to take proper effect. Results evaluation by MRI for example, are very faulty, it is only able to see large defects, often even big defects skipping MRI analysis being found later by surgery.

So given this slow regeneration and poor methodology, no study has been conducted to really measure it. Most studies are based in simply asking questionnaires to patients to see how they are going, conducted by single doctors or small centers... there is no big pharma or big money involved in this, because any doctor can choose between hundreds of kits and centrifuges in market to do so. Patents are useless in this field.

All together, it is a possibility, but no one has firm evidence. Same with stem cell treatments. There is mounting evidence of very positive effect and individual cases (anecdotal evidence, well such as mine).

It's not true at all that Europe or Israel are leading the way. Most research and early clinical application are being done in the US, Europe has been mostly importing methods and equipment for it, although there are some studies going on in Europe which are based on US developed methods. Other zones of heavy research are Asia, (China, South Korea, Malaysia and even Vietnam) mostly because they don't have the same legal limitations or time stalling bureaucracy that conducting studies in the west have.