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Author Topic: my story and a Chondral defect 1cm^2  (Read 1445 times)

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Offline seawolf_1234

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my story and a Chondral defect 1cm^2
« on: September 15, 2016, 04:14:58 PM »
I'm a generally healthy 33 year old male from NYC. For the last 7 years, after getting knocked off a bike by a car, I have been experiencing problems with my right knee. The accident resulted in a large medial meniscus tear. I had a meniscus repair and it partially failed. The same surgeon who performed the repair went back in and trimmed a small portion of unhealed medial meniscus, but left most of the repair hardware(sutures, anchors) in the knee. In retrospect I now know the repair hardware continued to cause me problems. Unfortunately I was misdiagnosed and after 1.5 years of pain and irritation on the medial side,  after consulting with 7 ("top" surgeons in NYC(HSS and NYU) I opted for HTO. My symptoms went away for another 1.5 years. Then the hardware, which drove me to HTO, started to move around. I had 5 procedures to remove the suture anchors that were travelling through the tissue. It was like having pebbles in your shoe, only for me it was in the knee! Once that was cleared out I had two really good years. No pain, no swelling...until 6 months ago(4.5 years post HTO) when I got up from a couch and felt very sharp pain in the lateral side. I had another scope which confirmed a small lateral meniscus tear and a chondral defect on the femur of roughly the size of a penny. Right now my knee is swollen and walking more than 20 steps doesn't feel good. Anything besides a soft foot landing causes sharp pain on the lateral side of the knee where the cartilage is worn away. Carrying groceries or a heavy backpack also causes pain. I'm taking Aleve for pain daily. I'm convinced this problem is a direct result of the HTO I had in 9/2011 that loaded the lateral side. The surgeon suggested OATS to plug the hole. He didn't think my alignment was that bad. Going to try an unloader brace next week for pain relief. I'm nervous about committing to another invasive procedure after such terrible experiences, but the alternative of pain, swelling and continued degeneration is even scarrier... Right now I'm inclined to give a green light for OATS if things don't improve in the next 4-6 weeks. anybody have any advice, encouragement, or experience with OATS they can share? thank you
« Last Edit: September 15, 2016, 04:25:50 PM by seawolf_1234 »

Offline dal_knee

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Re: my story and a Chondral defect 1cm^2
« Reply #1 on: September 15, 2016, 09:33:46 PM »

Sorry but the only sensible thing after HTO (with today's ORTHO technology ) would be a total knee replacement. The OATS will not hold very long due to increased mechanical pressure on the lateral side which happens with HTO.  Not sure what to say, you are 33 and too young for TKR. Perhaps consult with regennex but off hand not sure if they can help.
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 seawolf_1234

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Re: my story and a Chondral defect 1cm^2
« Reply #2 on: September 15, 2016, 10:28:30 PM »
not even thinking about TKR. did i paint that bleak of a picture?!

first of all, my knee was perfect just over 5 months ago and still in a good state minus the small defect. i can squat, go up and down stairs, have full flexion, been doing 25 mile bike rides outdoors, etc. second, there are other options before TKR like makoplasty. my plan is to try the unloading brace ASAP next week. if the brace does the job i can do OATS to relieve myself of pain/swelling and the brace will maintain neutral alignment. my medial side is in good shape, patella is perfect.

Offline Vickster

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Re: my story and a Chondral defect 1cm^2
« Reply #3 on: September 15, 2016, 10:34:29 PM »
What's the state of the rest of the cartilage in the joint? Is it all fairly worn (hence the HTO) or do you just have the 1cm2 defect?

If that's the case, a TKR seems pretty extreme (that said its not clear from your post why you had the HTO in the first place? You said you had a meniscus tear? Why was the HTO indicated, seems a massive op for a tear? Did you end up severely bow legged as a result?

I have a weight bearing defect on the lateral condyle,1.5cm2,  grade 4, but filled with fibrocartilage in response to the trauma. Now been there 7 years, wasn't eligible for MACi due to (mild) knock knees and kissing defect, I keep my knee happy with hyaluronic acid injections every couple of years :) have some other softening, couple of mostly asymptomatic meniscus tears

Worth exploring conservative options first and newer cartilage repair techniques if the rest of the cartilage is intact
« Last Edit: September 15, 2016, 10:39:32 PM by Vickster »
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline seawolf_1234

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Re: my story and a Chondral defect 1cm^2
« Reply #4 on: September 15, 2016, 11:10:14 PM »
prior to HTO i had a 6 degree varus(bow legged) alignment on my right knee. HTO was only done because i was misdiagnosed. the pain and irritation on the medial side 5 years ago was from pledgets and sutures left behind after a meniscus repair. i didn't need the HTO. it was a gross mistake. in fact i asked these so called "top" surgeons about the possibility of suture anchors causing my symptoms. all of them said it almost never happens. nobody bothered to do a sonogram which i had to subsequently multiple times to locate these foreign bodies. in fact one of them admitted years later when i came to see him to get the pledgets removed that the HTO was a mistake.

the rest of the cartilage surfaces are healthy, with normal wear for my age. i was still very active until recently. now the pain really hits me with impact like going down a staircase a little too hard. the momentary pain can be so intense my knee almost gives out. the defect also causes pain when i sit. everything i'm feeling is localized to the lateral area of the knee where the defect is located.

Offline Vickster

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Re: my story and a Chondral defect 1cm^2
« Reply #5 on: September 15, 2016, 11:19:46 PM »
Ah ok, that's rubbish

At 33 you shouldn't really have much cartilage wear unless you've engaged in extreme or serious high impact sport, so not sure what you mean by normal?

Perhaps try to seek out a doctor who can offer cartiform, seems to be superior to other older techniques like Oats, de novo, especially microfracture

I'd be trying injections and physio first to reduce inflammation and optimise muscle balance before more major surgery
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline dal_knee

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Re: my story and a Chondral defect 1cm^2
« Reply #6 on: September 15, 2016, 11:54:17 PM »

After you have an HTO (with normal alignment prior to the HTO), things like "cartilage repair" surgeries don't work anymore due to excess compression on the lateral side.   That's why cartilage repair is tried PRIOR to HTO, always.    You'll just re-develop the same articular cartilage defect.....does that make sense?  Do you want to go through another surgery, rehab etc, for it to last a couple of years or so??

Regarding the unloader brace, my thought is that the HTO probably "fixates" the angle of alignment, and the brace couldn't possibly do much to modify that.

I revise my assessment and do agree that a PKR can be tried prior to TKR.  Normally with HTO, the medial side is thinned down due to OA and then post HTO, the lateral side becomes thinned down.  So that's why they recommend TKR and that's the reason I wrote that.   Yours is a different case, I can't believe they missed the suture issue and recommeded an HTO.  Oh wait, I can believe it.....just keep reading stories on here.

Btw, hope I don't sound like I'm definitely recommending a pursuit of knee replacement, I'm not.  I'm just telling you what most surgeons will say:   post HTO, with continued pain/dysfunction/high demand patient, the only thing left in the arsenal is a prosthetic.

That's great that you can do all those things you listed, I wish I could do those.     However, the basics that you are having issues with (groceries/ carrying heavy weight), sitting, etc are pretty alarming from my perspective and consistent with cartilage defect issues.    These are every day simple tasks and they may not be easily recovered with conservative treatments.   Is a bone edema mentioned in your MRI report??
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 seawolf_1234

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Re: my story and a Chondral defect 1cm^2
« Reply #7 on: September 16, 2016, 12:21:24 AM »
Last mri was 5 months ago and it showed nothing of note besides "continued cartilage wear" compared to an mri of 2.5 years prior. None of my tears ever showed up either on the dozen or so MRIs

Offline seawolf_1234

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Re: my story and a Chondral defect 1cm^2
« Reply #8 on: September 16, 2016, 12:26:54 AM »
Right now the knee is a few degrees valgus. Maybe two to four degrees. If the brace can neutralize the alignment why wouldn't OATS work for me?

Offline dal_knee

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Re: my story and a Chondral defect 1cm^2
« Reply #9 on: September 16, 2016, 12:51:44 AM »

Theoretically, IF the brace can undo the effect of the HTO (I've ever heard of such an application) and the OATS is a 15-year success (or fill-in-the-blank here.....whatever number of years you would call a success), than you could get relief.     I don't think it's possible to "live" with the brace on all the time.  That's not its purpose.

Also, you will get different opinions on success rates for OATS, probably depending on whether that surgeon offers it or not.   I consulted with a surgeon who offered it to me and said the 2-year result look good but the 5-year mark is unacceptable.  It's a gamble. 
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 bradyj7

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Re: my story and a Chondral defect 1cm^2
« Reply #10 on: September 16, 2016, 09:32:03 AM »
Hi seawolf,

I had oats im doing ok, see here - http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=67286.0

If you have any questions ask away. I read your story, id probably try it if your in a lot of pain, why not.

Offline seawolf_1234

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Re: my story and a Chondral defect 1cm^2
« Reply #11 on: September 16, 2016, 03:12:48 PM »
Thank Vickster. The surgeon I have now seems like a competent doctor at least as far as the surgical part of the job. Unfortunately in my area surgeons in hospitals get paid per service so they are incentivized  to do complex procedures. That makes it hard to fully trust them. He did show me the pictures from surgery which show him poking the femoral condyle and a depression made by the instrument in the area where i have pain. So basically that spot is worn through. Getting inflamation down is definitely key. I have been doing a lot of PT on my own religiously without success.  Paying $4k for stem cells and $700 for PRP just to say I did it doesn't sound appealing. It may come down to that option... I had 5 cortisone injections in the past when there were other problems(meniscus tears, foreign bodies). Cortisone didn't help at all in those situations with pain or swelling.

Offline seawolf_1234

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Re: my story and a Chondral defect 1cm^2
« Reply #12 on: September 19, 2016, 06:38:16 PM »
Just received my 2nd opinion from a different surgeon. He told me not to even think about another surgery for 6 months until I strengthen my leg. He said every time you have a surgery it's rolling the dice and I had a lot of them already. I'm going to take his advice and put all efforts into rehab. He was optimistic that I can improve my knee without an invasive procedure like OATS. Hopefully tomorrow I'll get the unloading brace and will continue the rehab.

Offline bradyj7

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Re: my story and a Chondral defect 1cm^2
« Reply #13 on: September 20, 2016, 11:21:28 PM »
That sounds like a good approach.