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Author Topic: anything to be done? TKR? :-(  (Read 1293 times)

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Offline contraption

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anything to be done? TKR? :-(
« on: June 19, 2015, 05:45:43 AM »
New guy here.

51 YO male. Torn LK meniscus at age 18 (twisting injury - snowmobile) - scoped at ~26, again at 36 & 37 (broken dart repair). Been generally pretty good overall, flareups 1-2 times per year, but manageable. Skiing, wakeboarding, hiking generally ok, maybe a bit of soreness but nothing ice & motrin didn't fix in a day.

Major downhill slide over the last 3 months, with no warning. I now have trouble walking normally and especially quickly - pain in multiple locations - Quad tendon (occasionally), Pes Anserine area, some minor pain at medial joint line when poked.

The worst pain is mostly below patella and medial/top of tibia area. Pain is stabbing/sharp. No aching, not much swelling most days.

If I rest it and go slow for a few days, walking reasonably slowly becomes fine, almost normal.

Up and down stairs pretty much NO problem (say 98% good up and 97% good going down).

However, if I try to walk fast, I get severe stabbing pains that stop me in my tracks. Pain (not as severe) then lasts for days and goes away slowly.

NO issues with morning pain, sitting (NO MovieGoers sign), or even standing for a decently long time. This is mostly shows up as a (severe) walking problem.

Honestly trying to figure out what to do. Doc's basically say "you have a crappy knee", but I have not gotten any real diagnosis for the specific pain I'm having when walking.

Been doing side leg lifts, front leg lifts, calf and ham stretches, ball between knees, rolling ball underfoot (midfoot is stuck according to chiro). Seeing a great chiro/PT and a dedicated knee PT.

Had 1 Corti injection - not much help.

Had OrthoVisc series, finished 2 weeks ago. Nothing hugely noticeable one way or the other.

Bow-legged shins (both, but RK is fine).

Anyway, I'm stumped as to what to do next - looking for suggestions and advice.

Time for a TKR? How about a Mako partial (medial implant?, patello-femoral implant?)

PRP? Oats? Microfracture?

Here's the latest gruesome MRI read:

Quadriceps tendon normal.  Minor increased signal intensity in the    
proximal and distal aspects of an intact patellar tendon.  Cruciate and    
collateral ligaments intact.  Globular and horizontal oblique linear opacities    
in the posterior horn of the inner medial meniscus.  Abnormal signal intensity    
and subchondral cartilage particularly along the medial femoral condyle with    
complete denuding of articular cartilage at the medial tibial plateau.  Marginal    
osteophytosis with focal geographic subchondral hyperemia of the anterior medial    
femoral condyle.  Minimal early altered signal intensity of subchondral marrow    
beneath the denuded tibial cortex.  Spurring of the tibial spines.  Complex    
oblique tear, posterior horn and mid body of the lateral meniscus.  Diffuse    
altered signal intensity of subjacent articular cartilage but without    
delamination.  Early marginal osteophytosis.  Subchondral marrow remains normal.    
Superficial altered signal intensity and irregularity of the retropatellar    
cartilage with shallow fissuring along the medial facet.  Trochlear cartilage    
normal.  Small effusion with tiny incipient popliteal/synovial cyst.  No other    
juxta articular masses.  No free intra-articular loose bodies clearly depicted.     
Thin flat superomedial plica.  Bone marrow signal intensity elsewhere normal.

So, anyone willing to offer any advice to my hurting knee?

Everyone says I'm too young for a TKR...and even wondering if that is really the fix I'm looking for...

Thanks!


Offline dal_knee

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Re: anything to be done? TKR? :-(
« Reply #1 on: June 19, 2015, 04:56:10 PM »

The doctor saying you have  a crappy knee is not good enough information when you are looking for help.  Perhaps try him/her again and ask for detail....or find another opinion.   Sadly, you will probably gain a better understanding of what is going on with your knee by doing a lot of research compared to the information that your physician will share with you.

That being said, I'm not a physician but the fact that you have arthritic signs across the joint surface means you are not properly indicated for an OATS.  Stay away from Microfracture, no matter what the state of the knee is. 

PRP and or stem cells are a good idea to help reduce the arthritic inflammation and have been shown to retard the progress of cartilage thinning on the joint surfaces.   Also, PRP works very well for addressing chronic tendonitis, so if that is a confirmed issue, you may want to look into PRP.   It gets injected directly into the tendon for healing.   

For the tibial bone pain, look into a subchondroplasty.     I hate to sound like I recommend surgery, I do not.  It should only be a last resort.    If you have pain that feels like it's coming from within the bone....you know this right away, it is not a "vague" symptom at all.....  So if it sounds like your case, you may want to research subchondroplasty.    In your case, my biggest warning on this would be that if you are "close" to needing a knee replacement, the subchondroplasty will fail and you will then really need the final solution of knee replacement, within 1 year.   


Just one more comment, I think the fact that you can do stairs means you're not ready for partial or TKR.  Just a thought. 

2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline vickster

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Re: anything to be done? TKR? :-(
« Reply #2 on: June 19, 2015, 05:15:58 PM »
Other than the lateral meniscus tear, it reads like most of the arthritis is in the medial (outer) compartment. It might be that an unloader brace helps offload the bad bits. There are surgical options to offload worn parts of the knee, called osteotomy, usually a high tibial one for medial issues causing now leggedness. Find a surgeon who is expert in doing these, similarly if looking at a partial knee, find an expert in those :)

As above, cartilage repair techniques aren't suitable for large areas of diffuse damage.

Injections might help with inflammation and lubrication in the  joint and worth discussing (viscosupplementation works for me BUT you need to give it at lest 6 weeks to start working well., so be patient on that front

You might find a tidy up of what sounds like quite a raggedy lateral meniscus helps with pain and some smoothing of the osteophytes. Won't probably stop the inevitable but, with injections and physio, might give you a more comfortable knee until the replacement really is unavoidable

With the tendonitis jabs might help, but rest and activity modification are also key. There's no simple quick fix

Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline contraption

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Re: anything to be done? TKR? :-(
« Reply #3 on: June 20, 2015, 12:56:44 AM »

The doctor saying you have  a crappy knee is not good enough information when you are looking for help.  Perhaps try him/her again and ask for detail....or find another opinion.   Sadly, you will probably gain a better understanding of what is going on with your knee by doing a lot of research compared to the information that your physician will share with you.

That being said, I'm not a physician but the fact that you have arthritic signs across the joint surface means you are not properly indicated for an OATS.  Stay away from Microfracture, no matter what the state of the knee is. 

PRP and or stem cells are a good idea to help reduce the arthritic inflammation and have been shown to retard the progress of cartilage thinning on the joint surfaces.   Also, PRP works very well for addressing chronic tendonitis, so if that is a confirmed issue, you may want to look into PRP.   It gets injected directly into the tendon for healing.   

For the tibial bone pain, look into a subchondroplasty.     I hate to sound like I recommend surgery, I do not.  It should only be a last resort.    If you have pain that feels like it's coming from within the bone....you know this right away, it is not a "vague" symptom at all.....  So if it sounds like your case, you may want to research subchondroplasty.    In your case, my biggest warning on this would be that if you are "close" to needing a knee replacement, the subchondroplasty will fail and you will then really need the final solution of knee replacement, within 1 year.   


Just one more comment, I think the fact that you can do stairs means you're not ready for partial or TKR.  Just a thought.

Wow, I wasn't really sure anyone would respond, much less with great info. So thanks for that!

I haven not heard of subcondroplasty, so I'll research that right away. Thank you so much for the pointer. I also appreciate your comment about the stairs - that's my sense as well. Whenever I tell PT people or Docs that I can do stairs with no problem, they are flummoxed, as I'm sure that's probably the opposite of what they hear all the time.

PRP does sound like my next step for both the tendon and maybe joint too, figuring it can't hurt (much).

Thanks for your thoughts on Microfracture and OATS. I was getting tempted by microfracture, so I'll slow down there.

I did leave out a few clues, but I don't think it changes anything. While stairs are easy, SLOPES are hell. I have to go into San Francisco for work occasionally (fortunately the flatter sections) and anything that looks steeper than a handicapped ramp now strikes fear in my heart. Some days going up hurts like hell (like after 3 steps), or going down, or both. It takes me a week to recover after walking 1 block up a modest hill that I used to be able to jog up.

I also did a "Clarke Sign" test on myself (if that's even possible, I had to do it sitting obviously) for PF or ChondroPat. Nothing.

As for the tibial area pain...I honestly don't know the source. Some days it feels deep (like I imagine bone pain to be), though the Pes area is almost always tender with generally 2 distinct painful spots, right below the skin about 30-40mm south of the joint line, very much on the medial side (kind of at the "hollow" area).

Right now I'm having Patellar tendon pain above the patella, and deep, as well. That's fairly new.

My pains come from at least 2-3 different places depending on the day and the motion involved, though it is almost 100% related to knee extension motions.

I'd say all of them are of a "pinching"/stabbing kind of sensation (Level 10 kind of pain) rather than a more diffuse ache or soreness.

Anyone know anything about Fat Pad Impingement? wondering if that might be part of it.

Here's a summary of the MRI findings that I forgot to copy last time, FWIW:

IMPRESSION:     
1.  Globular and horizontal oblique linear signal abnormality in the remnant    
posterior horn of the medial meniscus.  Changes may represent reinjury/recurrent    
tear versus postsurgical morphology.    
2.  Complex tear and maceration, posterior horn and mid body, lateral meniscus.    
3.  Advanced chondromalacia of the medial compartment and mild early    
chondromalacia patella.    
4.  Minor patellar tendinosis    
5.  Joint effusion with tiny incipient popliteal cyst.

Thanks again for your thoughts!









Offline contraption

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Re: anything to be done? TKR? :-(
« Reply #4 on: June 20, 2015, 01:10:15 AM »
Other than the lateral meniscus tear, it reads like most of the arthritis is in the medial (outer) compartment. It might be that an unloader brace helps offload the bad bits. There are surgical options to offload worn parts of the knee, called osteotomy, usually a high tibial one for medial issues causing now leggedness. Find a surgeon who is expert in doing these, similarly if looking at a partial knee, find an expert in those :)

As above, cartilage repair techniques aren't suitable for large areas of diffuse damage.

Injections might help with inflammation and lubrication in the  joint and worth discussing (viscosupplementation works for me BUT you need to give it at lest 6 weeks to start working well., so be patient on that front

You might find a tidy up of what sounds like quite a raggedy lateral meniscus helps with pain and some smoothing of the osteophytes. Won't probably stop the inevitable but, with injections and physio, might give you a more comfortable knee until the replacement really is unavoidable

With the tendonitis jabs might help, but rest and activity modification are also key. There's no simple quick fix

Again, thank you SO much for responding!

Unloader brace - good thought. I've seen those words but have not researched that. Do they work? That might be what I need to keep from re-injuring this daily and give it a chance to heal.

Osteotomy sounds terrifying, I think I know the basics of that and it sounds gruesome, but still preferable to a TKR if I can avoid it. That said, having an Osteo fail followed by a TKR is unappealing.

I assume TKR can be done after an Osteo?

Thanks a lot for the Visco comment. The Doc did say to wait 6 weeks, but my assumption was that it would be a noticeable quick fix (like days or a week) if it worked, and they would only call failure after 6 weeks of it not working. Good to know that there really might be some hope that it will work, given enough time. I don't understand why that would be the case, but good to know that it might be.

I'm new to this whole world of osteoarthritis - is that kind of pain the "jabbing/stabbing" kind, or more of constant dull ache?

FWIW, I can stand on my bad knee LOCKED with zero pain.

Again, my pain comes with walking quickly or going up/down slopes. I don't know anything medical (but I'm a mechanical engineer), but that does not seem to be what i would expect from Osteoarthritis, but I'm really just guessing.

I'm hoping that maybe my current issues are soft-tissue related and not really joint surface degradation, yet, anyway. I sure would like to get another 10-15 years out of this hardware before TKR, which I know is inevitable given the crap-condition of the meniscus.






Offline mmrocker13

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Re: anything to be done? TKR? :-(
« Reply #5 on: June 30, 2015, 12:03:19 PM »
Depending on how expansive the lateral tear is...and I'd guess if you have tears in the horn and mid body, as well as substantial fraying, it's probably fairly large and possibly chronic. That would be a huge complicating factor for an HTO. I'd get a few surgical consults and really explore your options.
89: Pat. dislocation, lat. meniscus tear, femoral OCD lesion
89: debridement, chondroplasty, lateral partial menisectomy
02: partial lat. menisc., debride
02: mfx
09: subtotal menisc., debride, c'plasty
10: scope/debride
10: varus DFO
13: HWR
15: total menisc., debride, c'plasty, notchplasty

Offline contraption

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Re: anything to be done? TKR? :-(
« Reply #6 on: July 01, 2015, 05:23:29 AM »
Thanks. I've seen some improvement, but every day is a new adventure - some days it's marginally ok, other days/minutes I feel like I'm being stabbed in the knee with a steak knife.

I'm trying to figure out who to talk to - if anyone knows any excellent replacement/Mako/subchondro surgeons in the San Francisco Bay Area, I'd love to hear of them.















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