39 yrs old: PF Arthroplasty?

[sinequanonsarah]

It's been quite some time since I last posted (last was during my recovery from tibial osteotomy in my left knee in 2006). Now I'm here about my right knee. (MODS, please feel free to move to the most appropriate board!)

Some background: hypermobility leading to recurrent dislocations from 11 years old. lateral release, medial reefing at 13. Then tibial tubercle osteotomy on my right at 16 (left was at 24). NO knee dislocations since before the osteotomy/ies.

DESCRIPTION OF PAIN & MANAGEMENT
Over the past 7 years or so, I've been dealing with increasing pain that isn't well treated with what I've tried: cortisone, synvisc (HA) injections. I stopped both in 2015. Both seemed to be mildly helpful at first, wore off quickly, then had little effect when "fresh," so I stopped. Pain is primarily in the front of my knee (under kneecap) and I am to the point of being woken up regularly from pain and going down stairs one at a time with my left. Activity levels have plummeted (I used to walk a lot and hike) and I have gained weight since. In additional to painful achyness, I have sharp pains with certain motions (kneeling and squatting aren't possible). I also avoid plenty of other things due to the pain of OA, such as going to the movies (even pre-COVID). I'm at the point of forcing myself through walks a few times a week (typically 1 - 2 miles; I'm typically at around 4,000 steps daily, 8,000 if I walk). I force myself through this because even though I am sore afterward, the "during" the walk part actually feels quite good. If I'm going to be in pain anyways, I might as well be in pain and have gone for a walk to keep them moving. To deal with pain, I'm currently icing frequently, using topical Voltaren, and typically ibuprofen 1 - 2 times a day (I try to minimize as much as I can to save my stomach but often need it when I wake up from pain).

NEXT STEPS:
about 2 -3 weeks ago I visited a new OS who specializes in replacement, as I'm at the point where I feel like it's my last option (based on what previous Dr's have said; I've since moved for work). Was initially frustrated with his PA, who said joint space on X-rays looks good and gave me a flyer with brace options that I could purchase from Amazon (note: space in medial and lateral compartments does look pretty good with medial being a bit worse than lateral, but PF compartment not as good). The surgeon was much better when he came in and essentially said that he doesn't love the idea of any sort of replacement for someone my age, but doesn't see any viable options outside of a partial replacement of the patellofemoral compartment. He warned me that I will need a revision at some point. He suggested that I do PT for 6 weeks (to see if strengthening deals with very immediate concerns , then decide if I want to move forward. If I do, I will get a fresh MRI for him to review pre-surgery (my last was about 7 years ago). That appointment, set for beginning of October, will be to seriously discuss moving forward.

I'm at a point where I can't see PT fixing this. While I've gained decent strength in the past 3 weeks, I'm still not close to trusting my knee enough to go down the stairs, for example, and I'm still regularly waking up at night in pain. I need to make a decision about going for the MRI in another 3 - 4 weeks.

My surgeon did mention other therapies such as stem cell injections (and at least one other I can't remember now); the issue is that these aren't covered by most insurances here in the US (including mine). The are prohibitively expensive.

Soooo...  What would you do? I know this is a huge leap and while the OS's initial approach in our conversation was one of "this should not be done on young people," he was also telling me about successes of somewhat younger (but older than me) patients who were able to do things like go hiking afterward. it made me hopeful for the first time in awhile. FWIW in this discussion, I know he does "minimally invasive" (I honestly don't really know what that means, technically speaking) and uses MAKO.

What things should I be thinking about here? I appreciate any and all advice.

[Brandon123]

Hi there,

You've struggled a lot with your knees I can see. Have you looked into or discussed allografts with any of your docs? It was recently discussed in this thread:

https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=79121.0

Here a nice article about Patellar Allograft Resurfacing:

https://www.sciencedirect.com/science/article/pii/S2212628718300495

If an allograft is not an option, I guess PFJR is your only option (surgery-wise) at this point.

This thread by Dave33 and RGB is really valuable for anyone considering PFJR:

https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=74611.0

Maybe you should also considering getting a second opinion before deciding on a PFJR? As you mention, it is quite a big step to take. Anyways, keep us updated!

[sinequanonsarah]

Much appreciated @Brandon123
I found the threads from @RBG and @Dave33 incredibly helpful. Like Dave33, I found my HTOs to be incredibly painful and difficult to recover from, and it's somewhat relieving to learn that this could be an easier experience. Based on what they report of their post-op, it certainly sounds that way.

Re: allografts, this was discussed a few years ago, but the surgeon ultimately felt that patellar malalignment meant that I wouldn't be a good candidate as it wouldn't last long enough. And re: second opinion, my last Dr (before I moved) believed this was my last option, as well, so I feel fairly confident in that.

I've now completed 4 weeks of PT and am still not close to going down a stair on that right knee. The strengthening I'm getting can only be helpful, though. The more I go through PT without serious progress, the more resigned I become to moving forward. My next appointment is 10/12/21 and I have half a mind to see if I can move it up. If I'm going to do this surgery, I'd like to do it before year's end for insurance purposes (not to mention hoping the COVID Delta variant doesn't make scheduling difficult).

You've struggled a lot with your knees I can see. Have you looked into or discussed allografts with any of your docs? It was recently discussed in this thread:

https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=79121.0

Here a nice article about Patellar Allograft Resurfacing:

https://www.sciencedirect.com/science/article/pii/S2212628718300495

If an allograft is not an option, I guess PFJR is your only option (surgery-wise) at this point.

This thread by Dave33 and RGB is really valuable for anyone considering PFJR:

https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=74611.0

Maybe you should also considering getting a second opinion before deciding on a PFJR? As you mention, it is quite a big step to take. Anyways, keep us updated!

[Brandon123]

If you decide to go ahead with PFJR and have any questions I'm sure you can jump into @RBG and @Dave33's thread and they will help you. Good luck!

[Dave33]

Heh, I just got a surgery date for my 2nd pfjr, so double the fun, so to speak.

Yeah, it certainly seems like you got some decisions to make. Definitely not going to talk you into a joint replacement, but if you've any questions, like Brandon mentions, I'd be happy to share my experiences (which are pretty interchangeable with RGB, heck, we have the same implant)

best of luck

[sinequanonsarah]

Update: got the MRI results back yesterday. Have folllow up with the surgeon on Wednesday next week but would love any insights /thoughts you all might have in the meantime. I don’t have the images, just the report. I continue to have not much progress at PT; while I’m stronger, pain and function are the same.


Study Result
Impression
1. The patella is subluxed and tilted laterally with degenerative arthritic changes involving the medial and lateral patellar facets. There is an associated area of edematous change within the superior lateral aspect of Hoffa's fat pad compatible with patellar tendon lateral femoral condyle friction syndrome.
2. Susceptibility artifact related to internal fixation screws within the proximal tibia.
3. Small osteophytes arise from the medial and lateral femoral tibial compartment secondary to mild degenerative change with the tibia mildly subluxed laterally with respect to the femur.


CLINICAL HISTORY: Chronic pain. History of lateral release of patella and tibial osteotomy.

COMPARISON: Radiographs 7/12/2021.

TECHNIQUE: MRI KNEE RT WO CONTRAST

FINDINGS: Anterior and posterior cruciate ligaments are intact. Medial and lateral collateral ligaments are intact. No meniscal tear is identified. There is magnetic susceptibility artifact within the proximal tibia secondary to 2 internal fixation screws extending through the region of the tibial tuberosity into the proximal tibia. There is a normal volume of fluid in the knee joint. Distal quadriceps tendon and patellar tendon are intact. Small osteophytes arise from the medial and lateral femoral tibial compartment secondary to mild degenerative change with the tibia mildly subluxed laterally with respect to the femur. The patella is subluxed and tilted laterally with degenerative changes involving the medial and lateral patellar facets where there are areas of cartilaginous thinning, complete cartilaginous loss and chondromalacia. No retinacular tear is identified. There is a focus of edematous change within the lateral aspect of Hoffa's fat pad compatible with patellar tendon lateral femoral condyle friction syndrome.

[Brandon123]

As it doesn't seem to be mentioned in the MRI report, I think you should ask the OS about the severity/grade (and size) of the arthritic changes. I guess it could determine whether a PFJR makes sense or not.