knee damage - long term problems

[Mabs]

Hi all, I'm really hoping for some advice/ opinions on a very long term issue. 36 year old female.

I feel in April 2016 and banged my knee cap VERY hard. Long (med neg) story but there was a long delay in treatment despite an MRI showing a large retro patella flap.

Operation in Dec 2016 - removed 1x1.5 cm of cartilage from upper  medial retro patella. Was told at the time that it was partial thickness, but two more MRIs later (one in June 2017, one in April 2018) and it's being described as full thickness. See attached for cartilage damage on April 2018 image. I even paid to see the surgeon who operated and he is now saying full thickness (!).

Pain greatly alleviated by the op in 2016 (I was seriously convinced I'd fracture knee cap for the 6 months before). But I'm having a lot of issues (soft tissue) still- should note here I had a lot of muscle wastage by Dec 2016 – was trying to do physio exercises but getting lots of swelling and generally used crutches for 6 months.   

The operating surgeon is saying I shouldn't be - got a second opinion and that guy said it's no wonder I'm having soft tissue issues, the knee cap won't be tracking right, there is pressure on bare bone and I probably need a partial replacement/ plug type thing on back of patella. He doesn't do it but did write to my GP for a referral to an NHS guy who does.
Any opinions on what the above two guys have said?

My current issues are fat pad becoming immobile and swollen (although apparently it's not impinged, synovitis type symptoms and catching down each side of the knee – possibly to do with my synovial tissue as apparently my meniscus look perfect. I struggle to keep knee bent (so restricted to <30mins driving) and have recently realised if I don’t do knee bending exercises to build quad I can walk a lot further (so can now walk 1 hour, it’s hurts but I can do it, when I was trying to do physio exercises in morning I was getting swelling after 10-20mins walking later in the day. Up until 6 months ago it was swelling a lot, although now the swelling is more intermittent – I think that might be related to the fact I have managed to build up leg muscle a bit more- albeit slowly and painfully.

Basically I used to be a super fit tri/ cyclist/  runner with zero issues and now I’m living like a pensioner and really struggling to get Drs to talk me seriously (which had been an issue since I had the accident – I have made a formal complaint about initial treatment). I’ve given up on sport again really but I would like to be able to go on holiday/ travel and stuff like I used to. It’s making things like that hard work and pretty unenjoyable.
Awaiting NHS appointment in a few weeks, it will be my 2nd referral. 

I want to know if the above cartilage damage could be causing these issues. Or whether that could be a red herring – i.e. is it related to the synovitis (I’ve been reading about plica syndrome). Also, can stuff go wrong in these ops? I wasn’t getting all the patella fat pad issues before op, now the soft tissue pain on inside extending towards MCL.

Thanks, sorry for the massive post, really getting desperate.

[Vickster]

Where in the U.K. are you? There’s an excellent Physio expert in kneecap issues in SW London. Private only but might be worth a consult for a non surgical opinion

Have you seen a sports Physio with patella expertise? Have you had the kneecap taped as a diagnostic to see if there is a tracking issue? If there is, a cartilage transplant may not do much good as it’ll just wear due to the shearing forces in the knee

Good luck

[Mabs]

I'm in Yorkshire, have been seeing a pretty good physio all this time and have tried taping, doesn't make a huge amount of difference tbh. Perhaps when walking a bit more but certainly not with bent knee stuff.

I've already spent £1000's on this, it's got to the point where I'm a bit broke because of it. Meant to be seeing patella expert end of month (NHS consultant), i'm just trying to go ready with some thoughts. I've a feeling they don't want to go down replacment route becasue I'm 36 but it's really effecting my life a lot. I've been really diligent with physio but it's getting to the point where I've been doing it for two years now and it's seems to be making it worse.

[Vickster]

There's some good info in the learning portfolio, e.g.

http://www.kneeguru.co.uk/KNEEnotes/primers/patella

How are the other bones? A cm2 defect sounds like there should be repair options although the kneecap is especially tricky, especially if there's maltracking which presumably could exacerbate a central defect. Often some realignment is needed, surgically if physio hasn't helped

If physio is making things worse, then it may simply be time to stop for a bit and simply rest especially if you've developed inflammatory PFS (do meds help?) A visco injection might help lubricate the knee, but I don't think they are usually available on the NHS, but worth asking the new surgeon

[Mabs]

Hi, thanks for the link and replies

I've pretty much been resting for a month now - and even before that I wasn't doing a huge amount, 3/4 times a week doing a few set exercises in the gym. I'm kinda worried if I keep on like this my leg is going to waste away again (and actually it's starts aching in a different way once the muscle starts going downhill, that probably is an increase in maltracking).

I should also say when I first had the accident I also partially tore my quads tendon. It's healed but I've always has issues over the medial condyle area - I did have a visco injection ~3 months after the accident and it did help for about a month. It's like the weird slight  ache I had there has spread over much of the medial area of my knee and in the last few months I'm getting issues on the outside and fat pad. It is generally like a burning on top of dull stabs and really is related to when I bend my knee more than 90degs and with more repetitive things (even swimming isn't awesome).

 I'm just wondering if the cartiledge hole is a bit of a red herring and I actually did something else which hasn't healed well. Or, as I mentioned, plica syndrome, but there are lots of articles out there which say it isn't a real thing. When I had the op the "rest of the knee was perfect", consultants aren't keen to discuss what is on MRI reports and keep saying things aren't of importance but I did see I had an MCL sprain which had healed. No idea how I did this given I've really been doing pretty "safe" exercises in the gym and that sprain is wiithin last months.

Thank you again.

[PwordsB]

Have you had an x-rays on this?  As mentioned in the other replies, the alignment of the limb needs to be correct for any surgical options to be worthwhile.  I'm only a 'self-made expert' in my specific knee problems that I've been having for 2.5 years, which aren't the same as yours, but my guess would be that some x-rays to assess patella tracking as well as lower limb alignment would be a great tool in deciding what to do next.  Of course, as you have noticed, the NHS doesn't tend to go the way you need it to go.

[Mabs]

Hi,

Thanks, I've had a couple of xrays. but yes, everything is a bit hap hazard :-( ?I'll mention it on next appointment.

Wishing you luck with your knee.

M.

[reflex_nl]

Hi Mabs,

Very similar type of cartilage damage, MPFL avulsion and light bone bruising as I had with my knee. Please check my story and MRI's and x-rays on this forum.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=69981.0

I went to dr. Shetty in the UK after visiting > 10 OS'es. He operated me in dec'17. Still recovering, but slowing getting better and having less pain.

Reflex

[Mabs]

Thanks Reflex, can I ask how long it was between you accident and having the first scoop? And we’re you in the UK?

Cheers for the info.  Glad to hear your getting reduced pain now.

M.

[Vickster]

He’s from the Netherlands I believe but paid to see Shetty privately (in Kent). He may also still have an NHS practice and team though

[reflex_nl]

Yes, I'm Dutch . My accident was in Oct'16, 1st surgery/scope in Nov'16 in NL, no improvement, 2e surgery in Dec'17 in UK. I paid all out-of pocket... no coverage.

[Mabs]

My surgery was 7 months after the accident, so leg had wasted away a fair bit. I paid eventually but wish I had done sooner - just everyone kept saying I should be okay with physio, it turns out it was pretty misdiagnosed. I largely think the issues I'm having are related to how long it was left for and muscle wastage.

Thank for the advice -I'm seeing new OS in a couple of weeks so will see what he says.

[PuneKnee]

Yes, I'm Dutch . My accident was in Oct'16, 1st surgery/scope in Nov'16 in NL, no improvement, 2e surgery in Dec'17 in UK. I paid all out-of pocket... no coverage.

Hi, how much did it cost in total?

[Mabs]

Mine cost about £4.5K in all, including follow up appointment and fees for anaesthetist etc. That was at Yorkshire knee clinic.

Physio afterward was on top of that.

[Slavnov]

 almost 7 months passed since surgery after bike accident but I still have pain in tibia platue area, especially after walking for 10 or 15 minutes. My new Orthopedist orderedCAT scan and I just gotscary results. Do I need another surgery to fix broken screws? What do you think? Can this problem cause permanent damage?