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Author Topic: Partial Synovectomy and Patellar Release 6.5 months After Mosaicplasty  (Read 464 times)

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Offline jgardner

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Intro: I am a 56-year-old (ex-)ultramarathoner who hopes dreams of returning to running. The main lesion that I've been dealing with since 2018 is a full thickness cartilage defect of the right lateral trochlea. I was able to PT my way around it for a while, but things came apart in 2020 with some additional medial knee pain. On 7 December 2020, I had mosaicplasty for the lateral trochlear lesion and a smaller medial condyle lesion and also a partial meniscectomy for a small degenerative medial meniscus tear. (It was not clear which (if either) of these medial injuries was causing my medial knee pain). Additional details and background can be found on my blog at https://kneed4speed.blogspot.com/.

The Problem: My recovery from the mosaicplasty was troubled from the start. Lots of bleeding, swelling, numbness all the way down to my right foot, and a flared up Baker's cyst had me off to a slow start. My OS had prescribed 30 days of meloxicam after the surgery and towards the end of that first month my  inflammation cleared enough to get more aggressive with PT and start cycling. I probably overdid things, but the effective anti-inflammatory medication fooled me into thinking I was getting away with it. I definitely cycled a bit too much. During the 2nd month of recovery, I started to get severe stiffness in the knee and just above and below it. Sometimes this was accompanied by a slight burning sensation, faint redness, and a warm knee joint. A follow-up MRI showed severe scarring of Hoffa's fat pad and synovitis. 6 months into PT, I was getting stronger, but the stiffness and other synovitis symptoms were not improving. My kneecap mobility was poor and not improving even though I was working on patella mobility every day.

The Surgery: Yesterday, I underwent an arthroscopic procedure to "clean up" the inflamed mess created by the double mosaicplasty and partial meniscectomy that I underwent last December. Here is a recap of the surgery summarized from the surgical notes:
  • The medial patella facet, the lateral patellar facet, and the trochlea were all grade 2 and loose areas of cartilage were debrided to a stable rim.
  • The osteochondral grafts in the medical femoral condyle (from the previous surgery) were intact.
  • The graft donor sites on the lateral femoral condyle were intact. There was slight cartilage overgrowth on one that was debrided using a shaver.
  • Significantly scarred Hoffa fat pad was resected.
  • Parapatellar tendon releases were performed.
  • Synovitic inflamed tissues in the medial gutter, lateral gutter, and suprapatellar pouch were removed.
The procedure lasted less than an hour and I woke up from the sedation (with spinal anesthesia) quickly. My pain wasn't too severe, but drifted higher and so I received a single 5 mg dose of oxycodone in the recovery room. After another 30 minutes or so, my pain decreased a bit and I was released from the hospital. I did not take any pain meds the rest of the day, but did take a few acetaminophen tablets before going to bed.

Day 1: I feel pretty good for the first day post-surgery. I took my meloxicam (30-day prescription) and a baby aspirin (7-day prescription) with my breakfast. I iced for 30 minutes twice early in the day using a Game Ready cryotherapy machine that I have rented for two weeks. I did my first home PT session (quad set, SLRs, knee ROM, gentle patellar mobility, stretching) and did okay. Pain free knee ROM was well past 90 degrees. I needed 2 crutches to walk yesterday after the surgery, but have been getting by with a single crutch today.

Hopefully this is a new beginning for me in recovering to full activity. It has been a frustrating 6+ months with limited progress. I've learned a lot of things from this forum that I wish I had known before my first surgery. I'm posting here to "pay it forward" and hopefully help other learn from my failures, and hopefully soon, my successes.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Day 2: After I wrote yesterday's entry saying I was down to using only 1 crutch...I went back to two crutches as I experienced a lot of swelling and some pain late in the day. It seems like the icing was a bit much for me yesterday as my knee seemed to worsen after a 30-min on, 30-min off, 30-min on sequence. I cut the intervals to 20 minutes today and elevated the temperature a bit and that seemed to work better. Had my first PT visit this afternoon. My ROM was 113 degrees. The therapist added calf stretching and strengthening to my routine.

I'm having some trouble with range of motion exercises. The muscles and tendons behind my knee (bottom of hamstrings and top of calf) are "grabbing" after I flex my knee through its full range of motion. It is starting to get sore back there. The PT wants me to do ROM around 5 times per day, so this could become a problem. This happened after the last surgery as well and it took me quite a while to get past it.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Days 3 and 4: Day 3 was uneventful. I did 3 sessions of PT on my own. The problem with the grabbing (or "spasming") tendons behind my knee is making ROM exercises painful. On Day 4 I had another PT visit. The PT noticed that I had some bruising behind my right knee...perhaps contributing to the tendon grabbing I've been experiencing. He had no mercy on my tendon problem during the session...improving range of motion is the most important goal early on in my rehab. I have to keep doing as much as I can tolerate. I'm doing a mix of different ROM exercises, lying down, sitting on the edge of table and using my good leg to assist my injured leg, and putting my right foot on a step and leaning forward (thus flexing the knee). The PT measured my ROM at over 120 degrees...a good place to be on my 4th day after surgery.

To my surprise, the PT asked me to warm up on a stationary bike before my session yesterday. He wants me to do this at home as well. I have a road bike on a trainer at home...I'm going to switch from my clipless pedals to standard pedals today so that I don't have to "snap in." I'm very wary of cycling right now...I was clearly a bit overzealous with cycling while rehabbing from my previous mosaicplasty and it may have caused or at least contributed to my synovitis. I'm going to try to comply with my PT, but with extreme caution. I have a currently inactivated Zwift account. To avoid the temptation of getting "sucked in" and following or chasing after virtual riders, I'm not going to reactivate my account any time soon.

I continue to not experience very much pain. Last night I woke up with my knee hurting a bit and took acetaminophen. This is only the second time I've taken a pain drug since coming home from the surgery. I am experiencing some pain, but I'm experiencing it as just a slight burning sensation over the entire front of the knee from my patellar tendon (near my resected fat pad) to the thigh just above my knee joint. Most of the time I'd rate the pain a "1" on a 10-point scale, and never more than a "2" so far. I'm surprised that so much synovial tissue can be removed without experiencing more pain.

I'm continuing to ice around 5 to 6 times per day, 20 minutes at a time. I do this with my leg elevated (by a stack of pillows) and I'm applying gentle compression with the game ready ice machine. This seems to be working well. I'm not using the coldest setting on the machine (34 degrees Fahrenheit), but I'm up just a tick from that (36 degrees). I still have considerable swelling, but it is much less than I experienced during the previous surgery recovery.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Days 5-7: No major changes on Days 5 to 7. It was a holiday weekend here in the US, so I didn't have to work and there were no PT visits. I was able to sleep in (which I think is really helpful...sleep is "king" when it comes to recovery), ice frequently, and go through 3 PT sessions per day at an easy pace. Pain is about the same (occasional feelings of a mild burning sensation in the front of the knee). I sometimes get a slight cold sensation in my right shin, but it is not persistent. My assisted range of motion is improving, but passively there is still lots of stiffness. I still swell very easily when I am upright and particularly when I am standing. I think I am in an okay place for being only 7 days out from my 2nd surgery in less than 7 months. I'm very tired of crutches, icing, PT, swelling, etc., but I'll just keeping "zooming in" on the next planned session (of icing or PT) and execute that. Hopefully, when I "zoom out" again in a week or two, I will notice real progress.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Week 2: Pretty routine 2nd week after surgery. PT three times per day. Lots of 20-minute icing/compression sessions (still using the cryotherapy machine)...and rest (took this week off from work). Also lots of time sitting in NYC traffic (I travel from NJ to NYC for my PT sessions). By the way, my wife is a saint for driving me to all these appointments.

I've been feeling a bit more vague burning pain from the patellar tendon area to just above the knee. Sometimes I get kind of a cold, irritated feeling instead. Not very painful...but I worry that inflammation is creeping back. I've not taken any meds for breakthrough pain since my last entry, but continue to take meloxicam daily. I had two circular adhesive bandages covering each of the arthroscopy "portals" and have now removed one. It stuck to the stitched area a bit and there was some bleeding, so I left the 2nd one in place for now. I will remove it today or tomorrow.

My assisted ROM is now about 130 degrees. Still a lot of stiffness to work through, so that ROM has not translated to easy walking just yet. Nonetheless, today I've not used crutches at all for the first time since the surgery. My knee still swells very quickly when I'm standing. I'm still waiting for the PT success to translate to functional improvement.
« Last Edit: July 14, 2021, 05:20:51 PM by jgardner »
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Week 3 - 3.5: Progress has been slow and I've had days where the stiffness seemed to worsen a bit. When I'm fully stretched out, my assisted range of motion in my right (injured) knee is not far behind that of my "control" (left) knee. However, the stiffness I have to push through to get that nearly full flexion prevents free and easy use of the right leg. I'm walking with a limp (...although I'm trying not to limp per instructions from my PT). I feel I've stagnated a bit on my recovery, but my PT seems to think I'm still on course and my kneecap mobility has improved a little.

I'm still icing frequently (app. 6 times per day, 20 minutes each time), but I've returned the rented cryotherapy machine and am using a compression wrap that contains 3 reusable ice packs. It closes with Velcro and is a bit stretchy...perfect for creating a moderate level of compression. It does not get super cold and starts loses it coldness after 10-15 minutes, but it seems to get the job done. Swelling goes down and redness and heat sensation disappear. I actually have 2 of these cheap compression wraps that I alternate. It takes a while in the freezer for them to get cold enough to be effective.

My twice-weekly PT sessions in NYC have started to include a little more strength work in addition to the kneecap manipulation/massage and ROM work. I've done some band walking and even a set of chair squats. I'm going to add sideways band walking to my daily home routine, but my PT wants to hold off a bit longer before adding squats and other strength moves on a regular basis. (It seems he is testing the waters a bit on what I can tolerate and what my knee still overreacts to.) At home, I'm still doing the basics like quad sets and straight leg raises in addition to ROM exercises and kneecap mobilization. I'm doing some easy cycling (5 to 12 minutes) once or twice per day as a warmup for a PT session.

I'm still taking meloxicam, but that prescription will run out after 5 more daily doses. After my last surgery I rebounded a bit after withdrawing from NSAIDs and my knee inflammation worsened. I also suffered from frequent migraine headaches for a few weeks after stopping medication. I'm already bracing myself for withdrawal in the coming weeks.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Re: Partial Synovectomy and Patellar Release 6.5 months After Mosaicplasty
« Reply #6 on: August 06, 2021, 06:16:50 AM »
Week 4-5: Another 2 weeks of slow progress. My right knee assisted ROM has improved to 140+ degrees...almost as good as my left knee. Kneecap mobility has improved a little as well. However, I'm still not able to tap into that ROM to improve functional movements. Lots of stiffness. Swelling is a major issue...I can't stand upright for more than a few minutes without starting to swell. I'm walking a little better, but still far from normal.

The withdrawal from meloxicam has gone better than after the previous surgery. I was a little "headachy" at times and felt some fatigue and inflammation, but nothing like the frequent migraines I had last time. I'm 8 days out from my last dose now, so I should be past the worst of it.

My physical therapy is mostly the same as previously reported. I'm doing a few more exercises with a band above my knees (I've added band "clocks" to the sideways walking I mentioned earlier.) My therapist has introduced some leg presses and chair squats...but just to test the waters and see if I can tolerate more strength work. I expect an increase in strength work over the coming weeks.

My biggest worry now is about the swelling. Since the first surgery last December, it has been a constant problem. It is keeping me from driving and going to work. I would be willing to use a crutch as necessary to get out more and go to work...but I can't really get out since I can't be upright for more than a few minutes without swelling and pain. Icing, compression, and elevation has been working well to relieve the swelling, but I'm wondering if I am doing too much of this. Is this slowing my healing? I'm thinking of going longer periods without ice and not elevating my knee as much...but having lots of fluid around the knee is not a good thing. This is tough to solve.

« Last Edit: August 17, 2021, 04:27:28 PM by jgardner »
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Re: Partial Synovectomy and Patellar Release 6.5 months After Mosaicplasty
« Reply #7 on: August 17, 2021, 10:36:33 PM »
Week 6-7: Another 2 weeks and another report of some...but not too much progress. Assisted ROM is very close to "normal". Kneecap mobility is staying about the same: better than after the first surgery, but not normal. Perhaps when the swelling and inflammation subside some more, I will see further improvement in mobility. There is still considerable right knee stiffness (especially in the "fat pad" region around the patellar tendon). Swelling is still a big problem. Walking continues to improve, but very slowly.

My PT has added blood-flow restricted exercises to my routine, so I am starting a "strengthening" phase of rehabilitation. The exercises (unweighted leg extensions and straightening the knee against a resistance band) went okay, but my knee swelled enormously during the effort.

I think a large contributor to the swelling I experience as soon as I stand up is some sort of venous insufficiency. When I stand my right foot turns red. It is clear blood is getting down there easily, but the return trip is hindered. I'm getting some small brown spots and faint discoloration of the calf. These could be hints of venous insufficiency. Maybe a vein somehow got obstructed or a valve(s) inside a vein was damaged during the first surgery. If there is a bad valve, it is my understanding that not too much can be done other than using a compression stocking and trying to keep my leg elevated when possible.

I'll try to follow up on the potential vascular issue at some point. My OS and PT don't seem particularly interested in following this path at the moment. I may have to go it alone on this. My OS and PT seem to think that it is worth checking to see if I might have an inflammatory or autoimmune disorder of some kind that is contributing to my inflamed knee and slow healing (...I do have some relevant family history and some other non-knee symptoms and history that support such an exploration). I expect to hear from them soon on this.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Re: Partial Synovectomy and Patellar Release 6.5 months After Mosaicplasty
« Reply #8 on: September 05, 2021, 09:45:58 PM »
Week 8-9: I felt like I made some real progress over the last few weeks, but just in the last few days, I've experienced an increase in mild and vague burning pain around and above the kneecap. I guess I just did a little too much. Over the past few weeks, I had been doing a little bit of walking and had less swelling than usual. Hopefully the mild burning pain is just a small step back and I can get back on track this week.

1.5 weeks ago I had my 8-week post-surgery follow-up visit with my orthopedic surgeon. He was reasonably pleased with my progress. He said he would give my knee a "B" grade at this point (a little more kneecap mobility and a little less stiffness would have qualified me for an "A"). I was expecting that we might be launching an exploration into the source(s) of my continued swelling (rheumatic/autoimmune? vascular?), but for the time being, it is status quo.

I had a good visit to my PT last Monday where some body-weight chair squats were added to my routine...as a test. (I think I passed the test, I didn't overreact or swell too much after.) I was supposed to try some BFR exercises last Thursday. However, I couldn't get to NYC since the remnants of Hurricane Ida (including tornadoes, hours of torrential rain, and severe flooding) submerged and/or destroyed so many roads surrounding my town.

I'm hoping the mild burning pain will respond quickly to rest, so I can resume doing more walking and quad strength exercises, and reduce the time spent icing/elevating my knee.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Re: Partial Synovectomy and Patellar Release 6.5 months After Mosaicplasty
« Reply #9 on: September 17, 2021, 02:09:41 AM »
Week 10-11: The burning pain I reported last time did resolve after a few days and my improvement resumed. My walking is getting closer to normal. I'm going outside for a walk around my street every other day (that takes 6 to 7 minutes, but I'm intending to gradually increase the length and the frequency). I continue to do an easy 20-minute indoor cycling session every day and I've seen improvement in my cadence...it reaches into the low 80s now. My pre-surgery cadence was typically in the high 80s. My PT will allow me to add more resistance once my cadence gets back to the pre-surgery level.

I'm doing more blood-flow restricted exercises (knee extensions, SLRs, bridging) as I'm beginning to work on strength. My assisted ROM is now about the same as in my non-injured knee. My kneecap is moving better, but it still is not as loose as the non-injured one.

In terms of symptoms, I seem to be doing better. My swelling isn't as rapid. I can tolerate longer periods of sitting upright and even walking about the house. I may be able to return to work in the not-too-distant future. I have started to wear a compressive knee sleeve during outings or when I have visitors. This helps me control the swelling for a longer period without having to ice/elevate. I haven't started driving yet...but I've been cleared to give that a try. I still have stiffness and occasional pain in the area of my patellar tendon/fat pad. I'm a long way from "normal", but I'm becoming more functional.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection

Offline jgardner

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Re: Partial Synovectomy and Patellar Release 6.5 months After Mosaicplasty
« Reply #10 on: October 02, 2021, 12:50:43 AM »
Week 12-13: I've had some ups and downs over the past few weeks, but zooming out, I think I'm still trending in the right direction. I've continued to go out for a walk every other day. I'm up to 10 minutes now. My PT gave me the green light to increase the resistance (only 1 gear) on my bike. Still only doing 20-minute cycling sessions.

I've continued with the blood-flow restricted (BFR) therapy and today for the first time I did BFR at home. I purchased a wireless Bluetooth pair of cuffs that calibrates and inflates via an app on my phone. It worked well today. I'm starting with just SLRs and leg extensions (with a 1-lb ankle weight). More exercises will be added if I can tolerate and recover from these two exercises.

I still have considerable right knee stiffness and some sporadic swelling. A few times when I overdid the exercise (e.g., strength training and walking on the same day) I experienced a day or two of mild, but nearly constant burning pain in the knee. Overall I feel like I'm improving, but need to be cautious about not getting too excited and doing too much.
12/2018: MRI: Rt Knee Lateral Trochlear Chondral Defect
1/2019: PT and continued running (100-mile race in 6/2019)
11/2020: MRI: Rt Med. Meniscus tear; small chondral defect on med. condyle
12/2020: Mosaicplasty and Partial Meniscectomy
6/2021: Partial Synovectomy, Patella Release, Fat pad resection