Patella Cartilage damage - what is next? (MRI Pictures - page 2)

[reflex_nl]

Hi all,

I already suffer for 10 mths from grade 4 patella cartilage damage. They have done a scope to remove the loose fragments and shave the cartilage. In the last couple of months I visited four OS's with a lot of cartilage experience in the region since I'm not improving on my knee.

Status today:
No pain at night, mild pain during the day, getting worse if more active during the day. I can walk and cycle but not intense. I can stand for 2 hours but not pain free. I cannot do any (light) sports. The knee has a bit of swelling and is sometimes a bit warmer after exercise (details: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=68466.0)

Recommendations:

• OS 1 (Falke - NL): Grade 4 damage, no mall alignment: do nothing, wait and see, let it "heal" and light PT, let's see later for new options
• OS 2 (Claes - BE): Grade 4 damage, mall alignment: do micro fracturing on patella and a lateral release
• OS 3 (Lagast - BE): Grade 4 damage, some mall alignment: need new MRI, maybe bio implant, but low successrate on patella
• OS 4 (Mortele - BE): Grade 4 damage, no mall alignment: OATS needed asap (Osteochondral Autograft Transplantation Surgery) required, if not condition will worsen significantly over the next year.

I'm a but clueless now... they are not in alignment on the issue and I worry the condition of my knee can worsen. In my country or in Germany/Belgium, they don't offer Denovo NT or (M)ACI and I don't believe in micro facturing or MACI for the patella (read a lot of articles on this).

I'm also hesitated to go the OATS route...  even though the OS gives it a good chance of success. I read good stories on Denovo on the patella, but it is far way any really expensive...

Any advice/help welcome!

[Vickster]

Have you read this diary? There's a surgeon in Kent, UK doing some new treatment for cartilage repair. Just a short hop across the Channel

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=69426.0

Might be worth a private consultation

[reflex_nl]

Thanks - I will give this a try as well....

[Brandon123]

It is frustrating that there is no standardized proven treatment for patella cartilage damage, and everything depends so much on your specific case, and the opinions of different OS. Just wanted to add that I have received the same recommendations as your OS 1 and 2. And my "OS 1" said DO NOT go the "OS 2 route", as micro fracturing and lateral release according to him is old school thinking. So you should probably avoid that one at least!

My OS 1 also says that it is critical what type of cartilage damage we are talking about. In my case, for example, the damage it is quite evenly spread under the patella, kind of like arthritis and hence difficult to fix with any of the above mentioned procedures. If I recall correctly, however, wasn't your damage more localized at one spot? 

[reflex_nl]

yes it is.... knee problems are already complicated and now even the OS's are not in alignment. Indeed I will skip MF and LR, but still need to get rid of pain. Some pro NBA's did OATS, which some success.

My damage is indeed "focal" one spot, but fairly large...

For your issue I would try PRP or stemcells.

[Brandon123]

Yes, I have actually been thinking of PRP and stem cells, but it is very expensive (at least stem cells) and there seems to be very limited scientific evidence for these procedures regarding chondromalacia/arthritis. On the other hand, I am getting desperate, so let's see:)

In your case, the options seem to be OS 1 route or OS 4 route. Do you see any improvement at all? If so, I would probably try to be patient and give it some more time. If there is no improvement whatsoever, I think you should check if there are any studies on the success rate of OATS for patella cartilage damage. As we know, the patella cartilage is always difficult to fix:/ Also, before considering actually doing an OATS, I think you should get at least one more OS (old or new) to support that procedure in your case.

Denovo is difficult and expensive of course, but maybe your very very last option?     

[SuspectDevice]

I agree with Brandon

Re OS 4 - why will the condition worsen significantly?  I'd suggest that with the right amount of gentle movement and rest, it may actually improve?  Though perhaps there are things you have to do which are unavoidable (e.g. work activities) which is why OS4 says it will worsen.

[email protected] you want to avoid like the plague - I got told that lateral release crap too, even though my kneecaps were pretty well aligned.  Those blokes should be booted out of the profession, charged with medical negligence.

The problem might be that they have already done the dreaded patella shave (which I believe has been shown to be worthless, or in fact make things worse), so maybe you have a long time of really careful activity needed to let the cartilage heal....and there is plenty of evidence patella cartilage can heal, but it needs time and patience (years?)

[reflex_nl]

Hi Guys,

Thanks for the replies. Indeed I first await my new MRI and find at least other supporters before heading into surgery. The patella remains a difficult item to treat and what if it fails...  no clue what options I have left. MF and LR are no options.... and my do more damage.

To be honest, they had to remove the loose bodies in my knee and shave it a bit, otherwise other cartilage can break off and get stuck in your knee. I hope they didn't remove too much...

The other risk I foresee is being in pain and inactive for x year and than still go into surgery. I'm not sure if it will worsen over time by just doing daily life stuff; have you heard or read this before?

[SuspectDevice]

Hi Guys,

Thanks for the replies. Indeed I first await my new MRI and find at least other supporters before heading into surgery. The patella remains a difficult item to treat and what if it fails...  no clue what options I have left. MF and LR are no options.... and my do more damage.

To be honest, they had to remove the loose bodies in my knee and shave it a bit, otherwise other cartilage can break off and get stuck in your knee. I hope they didn't remove too much...

The other risk I foresee is being in pain and inactive for x year and than still go into surgery. I'm not sure if it will worsen over time by just doing daily life stuff; have you heard or read this before?

Yes, mine definitely got worse with daily life stuff.  We had a large treed garden that took lots of regular maintenance.  We sold that house and got a smaller block with an easy care garden + a ride-on mower to take the strain of my knees. Also, I could not squat or crouch for about 4yrs. I also tried to avoid stairs (not always possible) and other things which aggravated including most of my sporting activities (triathlon, cycling, running, leg weights, kicking while swimming).  It was some serious activity modification, though nothing like Richard Bedard and even all that was not enough - I needed the Celebrex to take me into the real recovery zone. 5 yrs it took me, but I made 90% of the gains in the last 4-5mths on Celebrex.  That reduced my pain levels enough to start doing some real leg strengthening, which took the load off my knees and hence into a more positive spiral.

[Geronimo]

this sounds weird but walking and hiking actually helps and i feel myself much better when i do that a lot. light cycling helps too. i've forgotten about sports since my issues kicked in and am just happy to be able to move in this world without huge amounts of pain. the only thing which made me much worse is full squat I did yesterday while trying to fix my boat. immediately got worse 3 times that's what I forget: as soon as you get better you should still remember to avoid activities which put you back. staying at home and doing nothing doesn't help at all.

i've been doing some heavy lifting trying to move my inflatable boat here and there and despite my expectations to flare up right away I actually felt better, but I tried to bend my knees as less as possible.

i'm now waiting what happens after my surgery when I'm fully healed (5 weeks post op and still have soft tissue pain which is almost gone though) and then will look into carticel option as this seem to be the best way to restore cartilage this days.

[Brandon123]

The other risk I foresee is being in pain and inactive for x year and than still go into surgery.

I'm also a bit afraid of this as I can see how my muscles, general health, and everything are slowly getting worse by this inactive lifestyle. The thing keeping me from having a surgery is of course that there are no really good surgical options for me. I would love if they could just go in and easily "fix" this bad cartilage

When will you have your new MRI? Please let us know what it said. I'm also considering doing a new one in a few months, it was over 2 years ago I had my last one done.

[Geronimo]

you have to find activities which don't aggravate your condition and stick to them, otherwise things will get worse. i tried rest 10 times already and it never made me feel better. now I try to walk as much as possible, use exercise bike with lowest setting at home, hike, boating etc. no running, basketball and all the stuff i used to like so much of course but looking at other scenarios i'm pretty happy i can walk without pain at all.

[reflex_nl]

I believe that if you don't use it you lose it... but indeed becarefull not to overdo. The question is what state would you consider surgery or other more invasive procedures... hard to get a answer on this.

Still awating my new mri report

[Geronimo]

if you are in lots of pain there is not much to lose in my opinion. as said before, cartiflex seems to be the only option after arthroscopy has failed. you can continue with PT but honestly for me it only made things worse.

[reflex_nl]

Thanks for the help. Pain is a 2 out of 10 in daily life and gets to a 4 or 5 after being active...
Do you mean cartifill? on what basis do you believe in this procedure?