Partial Synovectomy and Patellar Release 6.5 months After OATS/Mosaicplasty

[jgardner]

Month 8+: I'm now over 8 months past surgery (and 15 months past the original mosaicplasty and OATS surgery). I'm still making progress. I don't know the full extent of how much function will return and how my return to running will go...but I'm in a pretty good place now. This might be my last entry in this diary (although I'll be checking in to answer any questions and maybe do a longer term update or two).

I've been doing 20+ minute continuous runs every other day for the past month. Today was my longest so far, I ran for 29 minutes and covered 2.77 miles. There has been no major swelling or reactivity due to running. I don't think I could do this every day (yet), but running every other day feels sustainable. On the days between runs, I do 20-25 minutes of indoor cycling and sometimes some strength/weight work. I still do some "band" work and stretching and other PT exercises.

I'm functional enough to drive and occasionally go in to work. I'm lucky I've been able to work from home as much as I want since the first surgery, but now I'm trying to visit the office once a week or so. My first major travel (a week in Seattle, a 6-hour flight from my US East Coast home) is scheduled for early April...that will be a big test. (Perhaps if it is a disaster, I'll return to the forum to complain.)

I still rely on my left leg to get me up and down stairs, but frankly I don't care much about being able to do stairs properly...I'm getting by without doing that, so why do that and risk causing irritation to my right knee? (I guess my opinion could change if I find myself needing to get up and down stairs more.)

I also still get some swelling if I'm on my feet for a long time, but it is manageable. I wear a knee sleeve for much of the day to apply some compression to help with the swelling.

That's it for now. Let me know if you have any questions. I have tried to be transparent here about what worked and what didn't and the mistakes I made along the way. If I have done too much and my knee blows up and I need surgery #3, I'll be back again to share my journey.

[willp]

I don't know if you'll read this, but I just wanted to wish you the very best of luck from one runner to another.

I'm currently struggling with knee issues that were brought on by an unnecessary surgery in NYC in 2005 and which required a second 'salvage' surgery. They're very different to your issues, but I have noticed that it can be hard to find people who really understand runners' desire to return to their sport on here.

Keep going with the rehab, and I really hope you're able to return to racing!

[jgardner]

Thanks so much willp! Nice to hear from someone who gets it (...and doesn't yell at me to give it up and try cycling or swimming, etc.). I'm sorry to read that you are experiencing a flare up. I hope your situation improves and you can get back to doing what you love.

I'll do a full one-year follow-up post soon. The topline is that I am still improving. It is very slowly coming along. I can run for a little over an hour now. I'm going to throw out my old personal records and start tracking new post-surgery personal records (PSPRs). I am still keen to figure out what I can do...with what I have left.

[gaoshanfelix]

@jgardner
It would be cool if you could write a bit more about BFR training - did you start this alone or with a PT? I just stumbled over BFR 2 days ago in a medical paper where it was presented as best tool for training strength after cartilage surgeries/with cartilage problems.

I think I want to start it too - but besides googling I do not know where to start. So if you could share pages/instructions that helped you - that would be really cool. I right now think BFR is the only/best way to train your weak leg/side without loading the surgery site too much. BFR seems like the solution in that usually it's impossible to get to the same strength as your other leg before being fully pain free - but needing the muscle at the same power to help healing and to protect the surgery site itself.

Is Vald (Saga/Airbands) shipping the replacement for free? I guess they aren't 1 year old and you don't live in Australia. I kinda cannot find any company having some decent BFR bands available in Europe - smartcuffs is US and VALD is Australia - those two seem to be the main brands. I think I will take the plunge and order from Saga - with import taxes they aren't cheap (the website is horrible as they do not tell you about import taxes at all - even selling in € - but surely they will add up and they do not do a pre clearance of them).

[jgardner]

Hi @gaoshanfelix
I've been keeping up with your posts with interest. I've learned some things from your explorations of the scientific/medical literature on cartilage repair and recover. I hope you are successful in returning to the activity level you desire.

Good question on BFR. I think the topline is that BFR has been very helpful in restoring strength to my right leg and accelerating my return to running. The rationale for this training makes sense...you can get a better muscular workout without using heavy mechanical loads that would be too much for your recovering cartilage and other supporting structures.

I actually did a few months of BFR training between surgeries #1 and #2 with my local PT. He used a thigh blood pressure cuff...so it was kind of crude, but I think it was effective. He didn't share with me how he calibrated it (he likely did not want the liability of me trying it on my own at home and hurting myself). He told me we were shooting for 80% blood flow restriction. We did primarily leg extensions and SLRs and added in some single-leg isometric squat "holds" later in the process. I always aimed to do 4 sets of each exercise to total failure (or close to it) with 30 reps in the first set and then 3 more sets of 15 reps each.

After surgery #2, I did my PT at HSS in NYC. My OS very much advocated for BFR training and my PT there started me on BFR a few months after surgery. At first I did all my BFR there. They had very nice equipment there...self calibrating cuffs that constantly adjusted pressure as you exercise. The main exercises were SLRs and leg extensions, both using light ankle weights. I eventually added in leg presses on a machine and terminal knee extensions (TKEs) with a heavy band. I again used the same 30-15-15-15 pattern of repetitions to failure. (So...sometimes I wouldn't get to 15 reps on that last set.) I rest only 30 seconds between sets, but I deflate the cuff(s) and wait at least one minute (usually closer to 2 minutes) between exercises.

As I improved (and demonstrated that I was really serious about keeping up with my home PT program), I started to go to PT in NYC less frequently and my therapist suggested purchasing BFR cuffs to use at home. This way I could do the baseline strength work at home and have time for more specialized work at their facility. I purchased the Airbands cuffs from VALD. Expensive...I paid US $389 for them (shipped) back in Sept 2021. I see they are still the same price at https://airbandsbfr.com/.

I have kind of a love/hate relationship with these bands. When they work...they really work well. You calibrate them and use them with a phone app. They are completely wireless, which makes exercises like squats or using a machine much easier than when tethered to a pump. I developed a five exercise routine with them. I did SLRs, leg extensions, and TKEs with one cuff on my injured leg. I then did glute bridges and chair squats with cuffs on both legs. This worked fantastically for a while. My strength really improved. On a test at HSS, my (injured) right quad was measured at 91% of the strength of my left. I "graduated" from HSS physical therapy at that point and have been working on my own at home since.

In early January of this year one of the cuffs started to leak air. (For about 30 seconds I thought I had made a dramatic leap forward in strength...until I saw the deflated cuff.) Vald was responsive when I asked to have the cuff fixed or replaced, but they asked me to first return both cuffs...not just the one that went bad. I probably should have insisted on keeping the functioning cuff until I received a replacement, but I thought a short break from BFR would be fine and I returned both cuffs as they requested. Unfortunately weeks went by and I did not receive the replacements. They said they were out of stock. Eventually I got my PT involved. I'm sure HSS is a big account for Vald, and I finally got some action and received the replacement cuffs in early March...two months after my initial complaint. They shipped the replacements for free.

In early May...it happened again. One of the cuffs deflated while in use and I can no longer calibrate it. Another slow leak. I haven't complained about this yet. After Vald's service was so slow the last time, I decided for now to just switch to doing right-leg-only exercises with the one working cuff. I will revisit this if that one fails.

I find it difficult to recommend the Airbands BFR cuffs due to the customer service issue and the quality issue I experienced (and they are expensive!). I think the optimal route to BFR training is to convince your PT to order BFR equipment so you can get the benefits and not have to deal with the service/cost/maintenance issues. The cost of a few sets of these BFR cuffs is cheap for a PT practice to purchase relative to some of the other specialized equipment they need to buy...and it gives them another capability they can advertise.

Well...that is my full BFR story. (Probably a bit more than you asked for, but that gave me the opportunity to "vent" a bit.) From following your posts I think BFR would work well for you. It is not for everybody. Going to muscle failure and at the same time having your muscles run out of oxygen creates a special kind of pain. You are an athlete and I'm sure you know how to push yourself to get the most out of BFR training.

[gaoshanfelix]

Thanks for the detailed information. Wow that makes it even harder to decide. If I lived in Australia or US I would know what to order. I may rather go for smartcuffs then, and hope they are more reliable.

91 % is really a great result.

[jgardner]

One Year Follow Up:

As promised a few posts ago, I'm back with a one-year follow up. The topline is that I'm still improving...I'm running longer, back at work a few days per week, and I'm starting to make some progress on stairs finally. A full year after my 2nd surgery (and over 1.5 years since the "big" cartilage surgery) and I'm still not close to "normal", but I'm grateful to be still moving in the right direction.

My right knee pain is pretty minimal right now. There is some occasional discomfort when I move in certain ways and I have a lot of stiffness still when I get to 100+ degrees of flexion. There is much less swelling now, but if I'm on my feet for hours I still experience some. I wear a gently compressive knee sleeve for most of the day when I'm up and around and that seems to minimize the swelling. I'm running with a knee sleeve as well (not sure I need to...but I'm making progress so I'll keep doin' what I'm doin'). I don't notice any swelling after running and only a little bit after BFR and strength training to total muscle failure.

I have continued to run every other day (until today...see below) and continued to very gradually nudge the duration of my runs up. About 6 weeks ago, on a day following a rest day with no running or weightlifting, I awakened with a flare up of pain in my right knee. I have no idea why. The day before I had only cycled a little and did some PT exercises including bands and balance practice. I decided to shut down the PT exercises and took a few extra days off of running. When I started running again...I kept it much slower. This seemed to work. The pain gradually disappeared and I was able to resume running every other day and weightlifting every fourth day. I have not gone back to some of the PT-type work I was doing, but I have started working on going up and down stairs a bit.

Today I ran for the 2nd day in a row. This is my first week attempting a 4-days-per-week running pattern (with 2 days of strength/BFR and one total rest day). It went very well and I was able to run 6.5 miles (~10.5K) after doing a short run (2.5 miles) yesterday. I've also started to do one treadmill workout per week where I do some 30-second intervals at faster speeds. Well...not very fast right now, but you have to start somewhere. I didn't push anywhere near the outer limits of what my knee can do and I held good form.

Well, that's it for now. I'm going to continued to very, very gradually nudge my activity levels upward and see just how far I can go (literally and figuratively). I'll back off a bit if I experience an increase in pain or stiffness or decrease in ROM or mobility.

[gaoshanfelix]

I guess at some point you decide to just start running/training even though there is pain as long as it doesn't cause inflammation or too much inflammation? I somehow hope my knee becomes fully normal again - that I can run without any pain and I think I will wait for 1 year after cartilage surgery before just deciding to run into the pain.

At what point is the healing process over/so far that not doing the sport you like outweighs the movement/muscle building/happy hormones you get from it?

Reading studies it seems kinda 99% of people will still report 1-2 out of 10 pain anytime after surgery. Many more. Clearly whenever you start something new after surgery you have to go through some pain to adapt. At the beginning of this process - you know this pain is actually needed and part of your recovery (studies backing up that faster weightbearing is better or at least equal to using your crutches for longer). But then with running (and all sports requiring running) the studies become very hard to interpret.  Looking back it is always easier to see progress than at the current state.

For me it's hard to understand that you run while you still have problems with stairs - but then your surgery is well over a year ago so I guess further keeping it safe and not running will not profit you. I really have to look to get BFR training going - my left leg muscle is so strange - around the knee it's 90% back in size - same around my butt. But in the midsection the muscle is kinda missing - it's like the muscles from my butt extend down 5-6cm further on my healthy leg. I guess this has to do with the ROM in which I have pain. Are your muscles just tiny bit smaller or different in shape too?

I kinda guess if you start with higher impact sports too late - you run into risk of implant overgrowth with cartilage surgeries - well not likely on OATS as you have bone/cartilage full piece replacement. Oats usually has the fastest recovery of any cartilage surgeries. Seeing that you damage was rather small - you were quite unlucky I guess that recovery takes so long. I think without BFR training you would be way more behind.

[jgardner]

Hi @gaoshanfelix,

Sorry about the delayed response. (Busy week.) You ask some great questions. I'll try to answer as best I can below.

I guess at some point you decide to just start running/training even though there is pain as long as it doesn't cause inflammation or too much inflammation?

From the time of the first surgery, my orthopedic surgeon and physical therapist had aggressive timelines sketched out for a return to running. They thought that some light running might be possible about 6 months after surgery. (They have successfully returned professional basketball players to action in a similar timeline, despite the tremendous impact and shearing forces you get from basketball.) The hard part of the first surgery (the autografts and the allograft) seemed to go well...there were signs from a 3-month follow-up MRI that the bone of the implants was integrating nicely with the surrounding bone in my knee. Of course I had a bad inflammatory reaction to the first surgery and had the second surgery 6.5 months after the first to remove inflamed tissues. After that surgery the surgeon told me my grafts looked "great".

After the second surgery (late June 2021), it was my PT who decided when it was time to try some running. In November 2021 he had me run a few 4-minute intervals on an Alter G treadmill at 60% of my body weight. Shortly after that my PT allowed me to insert a few 15-second jogs into the walks I was doing every other day. There was quite a bit of pain initially...but things improved during workouts and from workout to workout.

The criteria my PT used to determine my readiness to run was that he thought I had sufficient right leg strength from the BFR training and that my knee wasn't reacting/swelling very much after walking and other exercise. He did not want me to do full bodyweight sustained running until I had achieved 80% right leg strength in his testing.

So...the answer to your question is "yes." I started doing a little running starting about 10.5 months after cartilage surgery, but didn't reach intervals of 2 minutes of steady running at fully body weight until a year after surgery. My first continuous run of 20 minutes with no walking was in February of this year (14 months after cartilage surgery).

I think your idea to wait for a year to start running is smart. I think I might have waited a bit longer if I was younger. I'm 57 years old now. At 54, I still felt young and was running about as well as when I was 35. During that first year after surgery when I was mostly lying on my sofa with ice on my leg...I felt like I did a lot of aging. I experienced weight gain, higher blood pressure, worsening of my blood lipid profile, more hair loss, a growing prostate, etc. If you want to minimize the effects of aging...keep moving!

At what point is the healing process over/so far that not doing the sport you like outweighs the movement/muscle building/happy hormones you get from it?

That's the big question! I don't know the answer for me (or anyone else). Do too much too soon...that is clearly a problem. However, if you don't keep working that injured knee, your leg muscles atrophy, you can lose range of motion, and you lose the benefits and anti-inflammatory effects of regular exercise. So there is risk in doing too little.

For me it's hard to understand that you run while you still have problems with stairs...

I don't entirely get it either. (…and my coworkers are dumbfounded as well.) I would say I've gotten better at exactly the motions I practice the most. Nothing has come back easily. If I want my leg to move easily in a certain way, I've got to spend time moving my leg that way. I've been incorporating more stair work recently and I'm improving. My PT was okay with getting me going on the running before I could do stairs. Getting that eccentric muscle control to slowly lower my full body weight with my injured right leg has been one of the slower things to come back.

...my left leg muscle is so strange - around the knee it's 90% back in size - same around my butt. But in the midsection the muscle is kinda missing - it's like the muscles from my butt extend down 5-6cm further on my healthy leg. I guess this has to do with the ROM in which I have pain. Are your muscles just tiny bit smaller or different in shape too?

Yes, I think my right quad is still a little smaller and definitely lacks some of the definition in my left. When I did my final PT session at HSS, my PT told me that despite the 91% test, I clearly needed more strength in my right quad. I agree with your comment about pain. I feel that if I stopped doing the strength work on my right side, I would experience atrophy.

[gaoshanfelix]

Three days ago I hit a rock while kitesurfing, and split open my ball on the good leg. I'm walking really badly now as I'm not supposed to weight my good leg to let the cut heal (6cm long and it was nearly 1cm deep - needed 8 stitches).
So now I cannot even ride my bike. What a mess due to my stupidity forgetting about those rocks (I know their location more or less)? And that right when I felt my kitesurfing became a good excercise for my left leg and my coordination slowly returned, starting with pops and my left leg clearly slowly regaining some speed and sensitivity (though not power).

It's a constant struggle after that surgery. But yeah I will stick to my principle of starting early on those sports I really love and going slow on running (will see if in August 9 months past surgery I can instead start trailrunning before I start running in the flat. Somehow both uphill and downhill running (couple of steps, like 5 seconds) feels was bettet than 5 seconds running in the flat.
Likely also muscle related.

One thing I am good at is keeping a very strict diet. So I lost weight when immobile because I lost muscle weight and kepts my body fat constant around my feel good optimum of 10% (my look good optimum is of course lower at 7-8% but that's so damn hard to keep for me)

[jgardner]

Hey @gaoshanfelix,

Sorry to hear about your injury! Don't beat yourself up over this accident...stuff happens. I hope you heal quickly and can get back to your rehab.