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Author Topic: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery  (Read 2081 times)

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Offline RyanC

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #60 on: June 18, 2021, 10:20:16 AM »
Hi all,

Thought Iíd give a quick update before my weekly update as I saw a different surgeon today for a second opinion. This guy seemed pretty good, he certainly seemed a lot more interested than my other surgeon. I explained everything and he had a look at my MRIs. Before reading the summary of the MRI reports, he could see that I had damage to the cartilage on my patella. He was stepping through the MRI and showed me that on the left side, the cartilage was intact but on the right on the bottom side, it was missing/damaged. He then had a look at the MRI pre surgery and could see the same thing. He then did a physical exam and was pushing down on the spot where the chondral defect is and it was really sore. I showed him the picture of the fat pad impingement that the previous surgeon removed and he said ĎI wouldnít call that a fat pad impingementí and called it something else, I think he said plica?? He basically concluded that the pain I am getting in my knee is probably due to that cartilage damage on my patella and not the fat pad. He said that this issue is really hard to treat and recommended continuing to see how itís goes over the next 3-6 months. He did say a way to treat this is to do a microfracture operation but there is no guarantee that it will work. He said there are two ways to do it, one is through arthroscopy and the other is somehow he flips the patella and adds something else which is sometimes more effective. He said in the meantime I can try a hyaluronic acid injection to see if that helps which I think I am going to try in a couple of weeks.

So I donít really know how I feel about this new diagnosis. It sounds like my first surgeon just mis-diagnosed me and I had a surgery that I probably didnít need.

Regards
Ryan
Ryan from Adelaide, South Australia
23/11/2020 - Right knee arthroscopy: Fat pad impingement trimmed and minor chondral breakdown tidied up

Offline silver_maple

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #61 on: June 19, 2021, 04:37:29 AM »
Ryan,

This second doc appears to be closer to the mark. The fact that he is going through the MRI slices and not just the radiologist's report is a good sign. Not to mention the first doc didn't even comment on the MRI report, it was your physiotherapist who shared that. You would recall that a few messages back (June 4-5th) when you wrote you are getting 40-50 snapping sounds a day I ventured a guess it could be the plica. The second doc appears to confirm that. I had a snapping plica which went away on its own after 3-4 months.

More serious is the cartilage damage. Likely that's the source of the pain since the fissure is deep and there is subchondral edema. If it were not as deep you likely would not have pain that shoots up all the way to the glutes as well as downward because cartilage itself is aneural. But once the damage gets close to the bone - watch out. The mild synovitis that you also have should be symptomatically contained to the knee and not shoot up and down very far. With the icing you were generally taking care of the synovitis.

I have to unfortunately concur this cartilage damage is difficult to treat. Microfracture (MFX) will fill the gap but with inferior fibrocartilage. Could be acceptable for someone 65+ who is not too active but for someone like you, not yet 30, if you want to return to active sport, the fibrocartilage will not last.

Dr. Saw in Kuala Lumpur attempts to solve this problem by combining MFX with stem cells, reportedly resulting in close to hyaline cartilage. But he focuses on larger cartilage lesions and yours is small. You'd need to spend weeks in KL, it's a multi-stage fairly involved process, and there is no telling whether he'd take you on. This forum has lots of info on Dr. Saw.

You should've gotten a better grasp of what the other alternative proposed by the doc is. Maybe call and ask. It could be an allograft procedure like DeNovo, by the sound of it. I don't know much about its success rates in the patella.

The HA would do you no harm, so feel free to try it. It is highly unlikely to resolve the issue in the long-term even if you were to feel some short-term relief.

Bottom line is, the second doc is right in being hesitant to operate. Your damage is not that significant and the cost/benefit (not in terms of money) equation of surgical intervention is unclear. I am not keen on MFX but get the second alternative right and read up on it. And discuss with your parents.
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline vickster

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #62 on: June 19, 2021, 11:25:18 AM »
Hereís a Uk site that gives info about different cartilage repair options (itís a few years old, so maybe there are some other newer techniques), but de Novo for example isnít available here and I think itís being phased out in the US esp for the patella (where cartilage repair is much less successful due to shearing forces).
http://www.kneeclinic.info/problems_articular_cartilage.php
Thereís also a fair amount of info in the learning portfolio about articular cartilage issues and treatment options.

https://www.kneeguru.co.uk/KNEEnotes/learning-portfolio

The issue at least here with some of these techniques is either a lack of approval as deemed experimental and costs which can run easily to 15k plus if not available on the NHS (which many arenít outside trials).  The technique suggested above with Dr Saw is also expensive, USD 30k or more? and thatís a while ago, plus travel, accommodation, physio etc

Definitely try the HA, ease back on anything that puts lots of load on the kneecap like squats and lunges, ride your well set up bike, go swimming, walking. When working have your foot raised and your knee as straight as possible
« Last Edit: June 19, 2021, 11:34:40 AM by vickster »
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, Hoffaís 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 RyanC

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #63 on: June 19, 2021, 11:42:42 AM »
Hi silver_maple,

Yeah for sure, I am much more content with that diagnosis. I am certainly giving the first doc the flick.

I have heard this about micro fracture surgery and that the fibrocartilage is not as strong as normal cartilage. That is definitely something to take into consideration. But if I am not going to be able to run/play sport anyway with a chondral defect, then itís worth considering if it will improve my quality of life. I donít think going to Kuala Lumpur is an option for me at this stage, especially in the days of COVID.

Itís all things to think about in 6 months time but yeah, if I am really not seeing any improvements in my knee, and the surgery will potentially enable me to go on beach walks, live with less pain, maybe go on the occasional run, have the ability to travel etc. then Iíll definitely consider it. I am more than happy to give up competitive sport/sport in general and lots of running if that is the only option.

In terms of the injection, yes I am going to get it in a couple of weeks time, they sound quite safe. It costs $500 AUD because it isnít covered by Medicare (Our universal health care - and annoyingly cortisone injections are and only cost about $40) but I will just pay and get it done - Iíll call up on Monday. I understand that it will not fix my problem, but I am hoping it will give me some relief so that I can keep focussing on strengthening the muscles in my legs. My right quads are still significantly smaller than my left and feel like that might make some difference if I can strengthen them up.

Iíll find out that second operative option that he mentioned and get back to you. It was something like a micro fracture, but then he covers it with something to hold everything in. I donít think it is done through arthroscopy either so I imagine the recovery is a bit longer.

Iíll keep you updated

Ryan
Ryan from Adelaide, South Australia
23/11/2020 - Right knee arthroscopy: Fat pad impingement trimmed and minor chondral breakdown tidied up

Offline RyanC

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #64 on: June 19, 2021, 11:52:03 AM »
Hi vickster,

Thanks for those links, Iíll have a sus. Also thanks for the info about the costs, I certainly wonít be able to afford $30k USD unless I took out a big loan so that seems a bit out of reach at this stage.

Just randomly, itís interesting reading about patella microfracture recovery and it mentions that some weight bearing exercises should be kept within the 0 to 20 degree range. I am assuming that below this, there is a lot of load on the patella. If I try squats, I get to about the 20-30 degree range and get pain in my knee and when on the leg extension machine, I can do them from 0 to 20 degrees flexion but after that, this is when my knee really starts to hurt. Just kind of confirms that this cartilage damage has been the issue all along.

Cheers,
Ryan
Ryan from Adelaide, South Australia
23/11/2020 - Right knee arthroscopy: Fat pad impingement trimmed and minor chondral breakdown tidied up

Offline vickster

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #65 on: June 19, 2021, 11:57:41 AM »
Regarding HA injections, my surgeon and I over the years have found the course of 3 injections better, longer lasting (and less painful than the single injection options). Ask the surgeon about this (and the costs). Iíve had maybe 5 rounds over the years (a couple of the singles, and the rest course of 3).

Iíve not had microfracture on the patella, but Iíve now had it twice on the trochlea (and on each condyle recently)
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, Hoffaís 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 RyanC

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #66 on: August 21, 2021, 10:23:58 AM »
Hello All,

It's been a while since I last posted so I am going to give a bit of an update on how I am travelling.

I have stopped updating on how my recovery is going because I am now sure that the original surgeon did not treat me for what was wrong with my knee. I am now pretty sure that I have damage to the cartilage under my kneecap and I need to get that sorted.

About 2 months ago now I had a hyaluronic acid injection in my knee. It did seem to give me some relief but I feel like the benefits have all but gone. I am now left with the same knee pain I have had all this time. It has now been 9 months since the surgery and its safe to say it did absolutely nothing and was a complete waste of time and money and I am pretty disappointed in the surgeon. If anything it just weakened my muscles and made my knee worse. I certainly don't recommend Dr Roger Patterson out of SportsMed in Adelaide, SA.

As mentioned in previous posts, I saw another surgeon and he recommended microfracture on the defect. He said there is two types he can do, one is keyhole and the other is where he'll have to flip my knee cap, do thee microfracture and cover it with a gel that holds everything in.

I have booked myself in with a third surgeon to get another opinion as I certainly don't want to go under the knife again for the wrong thing. That appointment is on the 21st of September 2021. After that, I will make a decision on what I will do. My concerns with the microfracture is that it can potentially only last a few years and then needs to be done again, which I certainly don't want to do. I want to get something done that will give me some lasting results.

Anyway, I will update on how the appointment with the third surgeon goes and will go from there.

Ryan
 
Ryan from Adelaide, South Australia
23/11/2020 - Right knee arthroscopy: Fat pad impingement trimmed and minor chondral breakdown tidied up

Offline RyanC

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #67 on: September 22, 2021, 08:42:57 AM »
Hi all,

I am not reporting on how my recovery is going anymore but I will update on what has happened as I have seen a new surgeon now for some second opinion (of the second opinion).

As mentioned in the previous post, I saw a surgeon and he recommended microfracture on the defect on my patella. I had an appointment with a third surgeon yesterday just to get another opinion before I went under the knife again. Basically this third surgeon agreed that the damage was on the lower right hand side of my right leg's patella and he essentially said there was nothing he could do and that damage to the patella can rarely be fixed and that I am stuck with it. I kept asking him questions and he finally said what he could do, which didn't have a high chance of working is a lateral release. I'll attach another photo of my MRI but he said it is tilting a bit to the side where it is getting irritated. He said I could try the microfracture plus the lateral release but has was basically saying that it has a low chance of working.

I am not really sure what I am going to do now. My knee has been OK recently but it still flares up and then takes 2-3 weeks to settle. I still cant jog and just live a pretty sedentary life.

What I am leaning towards is having another hyaluronic acid injection, as I did see some relief after that and to really spend this summer going hard (but not overdoing) the rehab, really trying to strengthen my hips, glutes and quads - I have been doing this but I also get lazy and just don't do it sometimes.

Then, in about 4-5 months, if its really something that I feel like is worth the risk of another surgery, I will go ahead with it. I am still not really sure and still thinking about it. If anyone has any input, please let me know :)

Ryan
Ryan from Adelaide, South Australia
23/11/2020 - Right knee arthroscopy: Fat pad impingement trimmed and minor chondral breakdown tidied up

Offline silver_maple

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #68 on: September 22, 2021, 02:39:57 PM »
Ryan, frankly I am leery of microfracture plus lateral release. The doc himself says there is a low chance of working. Not sure if he mentioned there is a good chance of you actually being worse post-op. Further, traditional microfracture, like the one proposed, results in a fibrocartilagenous fill (lower quality, lower durability) and in that place you need hyaline.

Please look into stem cell mixes, esp. adipose-based. You are young and bone marrow could also has some effect. No guarantee of a fill but at least there is no downside risk (other than money spent) and the procedure is repeatable, if needed. The patellar defect does not appear to be big enough to look at grafting although that could come under consideration down the line (years) if nothing else has worked.

Now, if you have pronounced patellar maltracking that needs lateral release to get fixed that's another matter. I haven't re-read your entire thread but from memory you did not have severe maltracking. So a lateral release could well over-correct any minor maltracking that might exist.

You could inject HA or PRP over the next few months as you continue to research. Try to find some physical activity that minimizes flares - being sedentary is not good for systemic health. I have found swimming to be quite nice for my creaky knees.
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline Chris H

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #69 on: September 25, 2021, 03:05:44 AM »
Hi Ryan.
My name's Chris, I also live in Adelaide and had the same surgery as you back in July 2020. Currently I'm frantically searching the web for fat pad solutions and came across your story. I'm going through exactly what you are. I'm finding no success with anything and I believe my surgery has made things worse. I would love to grab your information so we can keep in touch to chat privately and discuss. Maybe work together to try and find a solution?

Offline RGB

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #70 on: September 25, 2021, 11:10:04 AM »
Hi guys. I have no medical training and I'm much older than either of you. So you should take what follows with several grains of salt. What I do have is experience with a similar problem starting 12/13 years ago at the age of 47. I started with a focal lesion on the trochlea and later developed a matching lesion on the patella. Believe me - I understand how debilitating patellofemoral cartilage defects are. One flight of stairs a day was the max without pain and swelling. No cycling. So all I could do with my legs was walk on the flat. I went through the full range of treatments - normal microfracture, debridement, PRP injections, adipose derived stem cell injections and, finally, Dr Saw's microfracture + lateral release + blood derived stem cell injections, staying a few months in Malaysia and then returning for injections every 6 months for 2 years. None of it worked and the operations all made things worse. My only way out in the end was a PFJR - with which I am very happy. However, at your age I'm not sure that's a good option. I understand the argument that treatments may have moved on since I underwent them but I do keep up my reading and I don't think they really have. Or I may have just been unlucky, or too old. However, what I would now tell my 30 year old self with those problems is:

"Find a way to conquer your psychological demons and find a way to live with the problem. Find a form of exercise you can tolerate and use that as your physical outlet - there are a few - swimming, sea kayaking, etc. If there's a quantum leap in treatment then by all means check it out but don't go searching for the rare doctor who'll promise he can make your condition better when most of the others say there's nothing they can do. If it really was that certain, everyone would be doing it. Once you get old enough, you can get a joint replacement."

I'm not saying all this applies to you both (especially the 'psychological demons'!) but there may be bits of it that are helpful. There are other threads that discuss my journey in more detail.

Good luck to you both.

Offline silver_maple

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #71 on: September 25, 2021, 03:06:18 PM »
I second what RGB is saying. For Ryan in particular the option of doing nothing should probably be #1. Occasional HA or PRP can control inflammation if it gets out of hand. Neither will solve the underlying issue. I'd be really careful with lateral release for minor maltracking. I think it is next to impossible to do the release in such a way or to such an extent that the maltracking is perfectly offset and the knee functions like that of a newborn. Some of the more heart wrenching stories on this board have been from people who desperately want a lateral release reversed and for that the options are severely limited.
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline vickster

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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, Hoffaís 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 RyanC

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Re: Arthroscopy with Fat Pad Impingement Trimming Surgery & Recovery
« Reply #73 on: September 26, 2021, 11:12:04 AM »
Hi all,

Thank you for all your replies, it has given me a lot to think about.

I tend to agree, I think going in for another surgery really is not a good idea at this stage, especially for the lateral release. Also, I really haven't regained my strength I had pre surgery, and I think if I have another surgery, I will end up with a very very weak right leg. In saying that, I have been in contact with a number of people on Reddit who have had microfracture on their patella and have had good (but not perfect) results.

I think what I am going to do now is really try and strengthen up my bad leg (plus my good one). I have signed up for a program online called 'Knees over toes'. It seems a bit 'cult-y' but does have good reviews. Basically a program with heaps of stretching and strengthening exercises, all of which help the knee. I am going to combine this with my strengthening of my hips, glutes and quads. I am also going to get another hyaluronic injection (will try and get my doctor to do a series of them), and I am also looking into PRP and stem cell treatmets. There seems to be a good place in Adelaide that does PRP and stem cell treatment at the same place. The side effects and risks of these seem to be low, the only thing is they are very expensive. HA injections are $500AUD a pop and PRP are $350. I am not too sure how much stem cell treatment is but I am sure it is expensive. And yeah that is pretty much my plan for the next 6 months. I am still not ruling out microfracture surgery, but I agree it is not the time to do it and I would like to gain more strength in my legs before doing so.

Ill keep everyone updated!

Ryan

Ryan from Adelaide, South Australia
23/11/2020 - Right knee arthroscopy: Fat pad impingement trimmed and minor chondral breakdown tidied up