Help! I'm really conflicted: Meniscus transplant + oats + microfracture Vs. PKR

[cm100]

Hi Everyone! english is not my native lenguage, so I'm sorry for any typo.

I'm 38 years old, and in 2010 i had a bad accident, which basically caused severe damage to my knee, torn ACL, lateral meniscus destroyed, femoral condyle fracture, cartilage damage and other things. In the surgery they only repaired my ACL and removed the meniscus.

Since that moment, my knee was over. Basically I can't give ANY impact to the knee, for example, only one small jump will cause the knee to get swollen with fluid, delayed burning pain and hobble for a weeks. I can't run in an emergency situation, etc.

Now, this year, I'm conflicted with 2 different opinions.

First doctor opinion: cartilage defects are "focal", in the tibial plateau, above and below the missing meniscus (MRI report says 4th degree). OATS should be performed in 1 chondral defect, and for the rest of the cartilage damage the only possible attemp is microfracture. Also by placing a meniscus the situation will improve, he says, so he will perform a meniscus transplant. He is the most experienced doctor in meniscus transplants in my country. 

Second doctors opinion: The damage is not focalised, and its way too extended over the cartilage to attempt a procedure like first doctors suggestion. He says he needs to perform an arthroscopy to really evaluate the knee and the real cartilage damage. He needs to see, feel and touch the cartilage, to see if maybe I could benefit from "Chondrocyte implantation" , but I would say he was way more inclined to PKR, but he wasn't specific. He also mentions that he can't completely correlate my level of damage with being SO disabled. He means I SHOULD be in pain and doing bad, but no AS bad as I'm doing, but mentions that everybody is different. He says that most people with this level of damage just have to quit sports completely, and some pain here and there, so he says "perhaps" there's something else in my knee that we don't know, that's also why he needs to do the arthroscopy, to be 100% sure that what he's going to offer is what must be done. When I asked him about the first doctor opinion, he says it's not a good idea, to treat the chondral defects and meniscus transplant in the same surgery "that's what gives the worse results", "but also this won't solve the situation" and that the "chondral defects of the tibial plateau are the most difficult to treat, if not impossible". When asked about his experience in meniscus transplant, he said he has performed 11 cases, but he is not offering it to me, up until now.  He is one of the most experienced surgeons in knee replacement in my country.

PD: FIsrt doctor gave me some "minor strikes" to the knee to test the area of pain, and my knee reacted bad (as a delayed effect) and it's burning and I'm hobbling. After 2 months I was finally feeling a bit better from this, when another doctor did a weird extention of my knee, in an unhealthy angle, with my tibia bended to one side, I felt pressure on my knee, and I'm in a burning pain again. I'm a bit angry with them.

[AndrewC]

Hi, sorry to hear this. It really sucks to injure yourself at a young (ish) age, I have been there and done it.

I would carefully consider both doctors. Often I found meniscus transplant experts are very keen to do a transplant, to show their skills and try and help. Even if it fails.

But if it was me I would go with Dr one if they are both of equal skill and respect, but you need to bear in mind, if that doesn't work out, will doctor 2 still be happy to do a PKR?

I know someone a bit older 55 who had a PKR and has since got back to a lot of activities pain free, not running but cycling, golf etc/

Hope this helps a bit

[cm100]

Hi, sorry to hear this. It really sucks to injure yourself at a young (ish) age, I have been there and done it.

I would carefully consider both doctors. Often I found meniscus transplant experts are very keen to do a transplant, to show their skills and try and help. Even if it fails.

But if it was me I would go with Dr one if they are both of equal skill and respect, but you need to bear in mind, if that doesn't work out, will doctor 2 still be happy to do a PKR?

I know someone a bit older 55 who had a PKR and has since got back to a lot of activities pain free, not running but cycling, golf etc/

Hope this helps a bit

Now a third doctor believes an osteotomy is the way to go, he said I've lost the aligment of the bad knee due to the injury and that I'm loading the lateral comparment (the bad compartment), when it should be the opposite. He says we should bring the knee back to the original position, but he said he need to futher study the case.
I'm going crazy with the different opinions!!

[vickster]

Did you ask about unloader braces? Personally, I’d try one of osteotomy is being considered especially if you have pain weight bearing (walking)

[cm100]

Did you ask about unloader braces? Personally, I’d try one of osteotomy is being considered especially if you have pain weight bearing (walking)

I'm going to ask him about it in the next appointment.

Another very respected doctor I saw many months ago said that what's happening to me is due to the missing meniscus.
I can't "stomp" or jump, just ONE stomp or small jump will cause the knee to get swollen and  then burning pain later. I wonder if is this a post menisectomy symptom? I haven't read anyone else describing this exact same condition.

[vickster]

I’ve had meniscus trims in both knees but don’t have such a reaction although my left knee is always swollen. How much meniscus was removed? Lateral or medial or both?
The meniscus is a shock absorbers to protect the bones. If you also have damage to the articular cartilage and especially to the bone and marrow beneath you could get pain (do scans show deep damage and bone marrow oedema?)
If now misaligned even more force will go through the area. It would be best to avoid stomping and jumping especially on a hard surface.

In addition to the brace, perhaps see a podiatrist/orthotist to get your gait and feet assessed. If you’ve not done so. Custom orthotics may also help to offload if you’re putting pressure uneven through your knees

There’s good meniscus info in the learning portfolio to read

[cm100]

I’ve had meniscus trims in both knees but don’t have such a reaction although my left knee is always swollen. How much meniscus was removed? Lateral or medial or both?
The meniscus is a shock absorbers to protect the bones. If you also have damage to the articular cartilage and especially to the bone and marrow beneath you could get pain (do scans show deep damage and bone marrow oedema?)
If now misaligned even more force will go through the area. It would be best to avoid stomping and jumping especially on a hard surface.

In addition to the brace, perhaps see a podiatrist/orthotist to get your gait and feet assessed. If you’ve not done so. Custom orthotics may also help to offload if you’re putting pressure uneven through your knees

There’s good meniscus info in the learning portfolio to read

No, I don't jump or stomp, I can't, it just that it limits my daily life and makes me feel insecure, for example I can't run in an emergency situation, as I feel that every stomp is destroying / damaging  the knee.
Lateral meniscus was completely removed. I do have cartilage damage, 4th degree, but the same symptoms were there even before the MRI showed this generalized cartilage damage , back from 2010 when I had the exact same symptoms (after the injury). At the beggining there was only a small  subchondral defect as far as I understand, but doctors said that it can't be treated with surgery and that it would resolve after the rehab, which never happened.
This facts + considering the different opinions makes me doubt what the real problem is, and what's really going on.

[vickster]

I think in your situation, given the complete lack of meniscus and full thickness damage to the cartilage, I would try bracing and any other conservative methods and then if those don’t work and the pain is unmanageable/unliveable, the osteotomy or PKR (do you need any correction of the alignment with the PKR?).

The likelihood with both though is you’ll need a TKR in the future.

As there are different treatment options it seems in your case, and surgeons have different specialism and expertise, you’ll get different recommendations.

Good luck