Trochlear Groove Microfracture

[Marjan]

Hi,
Used to belong to this board years ago (or should I say many email addy's ago) when I had my first microfracture done, back in 2003. That was on the medial femoral condyle. The microfracture healed well, but the rehab was poor so other issues cropped up over the years. Fast forward to two days ago when I had a sizeable defect microfracture done on/in the trochlear groove of the same knee.

So, here I go again. The rehab protocol from the very beginning is different. Since the patella doesn't engage the trochlear groove when the knee is fully extended, I'm allowed to bear weight as tolerated as long as I'm "locked in" (and that is an adequate way to put it) to a brace that keeps my knee extended to no more than 20 degrees. I'm allowed out of the brace only to use the CPM machine and to take a careful shower.

I'd like to hear from folks who have had a trochlear groove microfracture procedure done and what the rehab was like. Did you start PT right away, (after the first week of recuperation?) Compared to the condyle type of microfracture, I seem to be feeling pretty good this time. Of course, the first one was a surprise and hit me pretty hard, especially the non weight bearing for 6 weeks. Being able to put weight on my leg this time seems to "help" my spirits.

On we go---------

marjan

[celinenj03]

Hey, welcome back. I didn't have the same surgery, but a regular old microfracture and am doing the dreaded 6 weeks on crutches. I'm coming into my 3rd week on Wednesday. 6 weeks didn't sound like a very long time, but it sure feels like it. please keep us posted of your progress. there are a lot of people here who had the same surgery. i believe nevella had trochlear groove micfracture. Again, welcome back.

[Marjan]

Thanks for the welcome, Celine. Oh, gosh, I'm sorry you're in the midst of the dreaded 6 weeks NWB. It can be hard on one's outlook, (and one's armpits ) You're more than halfway now, so it won't be too much longer. Rehab on microfractures are very long, IMO, but my first one is hanging in there, and it was a huge defect. I know the trochlear groove microfracture is a tough one to get successful since the stresses on that groove are not ideal for the technique, but I'm hoping to stave off a TKR for as many years as possible, so here I am.

It looks like you've had quite a go of it with your knee....all from an initial basketball injury? What a long road you've come. I hope this procedure will be the last one you'll need.

So far, I'm doing pretty good....overdid a little today by being in the car (not driving of course) for WAY TOO long, but I'm now happily (yea right) ensconced in my cranky and groaning CPM machine...that thing needs some oil or something. I'll be happy to get the clear plastic bandage off for it seems to be stretching my skin a lot. The swelling seems pretty minimal and I can actually make my quad (VMO) do a straight leg raise. Oh the little joys........

Have a great tuesday -

marjan

[Marjan]

It's been two weeks since my surgery and I think things are progressing well. Had my one week check-up last week and was disappointed with the surgeon's PA. I've gotten more info from this site and the web than I did from him. Very discouraged that day. However, I called my favorite physical therapist and he gave me more info on what I should/ should not be doing with this knee.
Because this is a trochlear groove mfx, I can walk on it as long as I wear a brace locked at zero degrees extension and flexion. Walking is no problem, although my hip would tell you otherwise. Sleeping is a bit difficult since the brace gets in the way, but I don't want to put any weight on the patella, so I'll muddle through.
I'm able to do straight leg raises, and my ROM is good. There is no swelling unless I spend too much time walking around WalMart! The knee does stiffen up at night but a half hour or so of heel slides and it's ok.

Not being able to drive is a b*tch, but that too will pass. Tomorrow I go back to my strength trainer to work on upper body and core work. PT said it was ok to do, as long as I do the exercises from sitting or prone positions. Should be able to get a good workout in.

I'm off all pain meds, but take some ibuprofen whenever I leave the house, just to keep the "straight leg brace/ walking" inflammation down.

marjan

[Marjan]

Strength training went well yesterday, although I felt weak as a kitten afterwards. Wow, where did my stamina go? The trainer had me do some left leg (good leg) work and today I'm paying for that.....oh my, lots of sore tissues in the quads! We did upper body work, as well as some core strengthening. I'm a bit sore today, but it felt so good to get the blood moving again. That's one of the hardest things about mfx surgery, you sit around so much!!

There's tons of stuff I should be doing around the house to get ready for winter, but most, if not all, include hauling stuff around and I'm not keen on stressing the knee with carrying awkward weight (like hauling in the patio furniture). I noticed that yesterday when we tried some hamstring work on my good leg, my operated leg, although it can handle my weight, didn't like being the sole "standing" weight. So, we'll just have to take it easy.

After some calls back and forth to PT and surgeon's office, we decided it was ok for me to sleep without the gargantuan brace. While I didn't sleep super well, I was more comfortable, didn't do anything weird to the knee, took no sleeping aid/pain med, and best of all, my flexion this morning was much less tight than it had been.

One thing that happened last mfx surgery also, and that is that my patella tendon gets really, really tight. Last time, I don't think it ever came back and the surgeon this time did note that there was real scarring in that area. Not sure whether he "released" some of that scarring, but this time, although tight, I'm really working on keeping that patella tendon more flexible. Guess the advantage in a way is that this time around I'm not so freaked out by the tightness, the aches and pains that come with mfx. I know the patella tendon is just that, it's not part of the healing area, so it gets a pretty good massage a couple of times a day.

All in all, mfx surgery is one of those surgeries where you have no idea whether it will work (the clot will adhere and become pseudo cartilage) or whether that one movement you made messed up the whole thing. It pays to be careful, but yet, you have to keep moving so the knee doesn't freeze up with scar tissue from what I think is the bleeding the doc induced. Such fun.........

marjan

[Marjan]

Well, here it is several weeks later and I'm bored out of my mind! LOL

I think things are going well, but those initial six weeks after mfx are just never ending it seems. I'm so glad that I can do weight bearing this time, but wearing that brace, putting it on/off is really becoming annoying.

Next thursday, the 12th, I'll be going in for my 6 week check-up and hope that we can start opening this brace up a little bit, because walking with my leg extended, if not hyper-extended, doesn't do much for the IT band, and other muscles. I've noticed my quads are looking totally anemic, although I am able to do SLRs with 5 pound weights. Since week four, I've been riding my stationary bike (no resistance, of course) to keep the knee flexible and the fluid moving in there. It has helped tremendously and some, if not most, of the tightness that's so common in mfx is starting to fade.

I know I'll have my hands full rehabbing the quads. It never ceases to amaze me how they just "disappear" seemingly overnight. When I first came home from the surgery, I remember thinking that my quad looked decent, and my quad sets seemed strong, but as I stopped using the leg for things like stairs and normal weigh bearing, those quads have taken a hike! Back to one skinny leg, one muscular leg.....yuck!

Pain wise I feel good. Twinges every once in a while, but nothing earth shattering. Sleeping was a problem for awhile because that knee sure is tender when you try to "curl up" in bed! I'll take a couple of Tylenols to help me sleep sometimes.

I'm very anxious to get started with PT. I've been in contact with him and have done the exercises that I'm limited to, but I'm itching to start using the knee again. I know, I know.....it's going to take time, lots of time, but unlike my first mfx, I am in much better spirits this time around and anxious to get on with my life.

One thing about mfx....one surely has time to re-evaluate one's priorities. Pretty soon the election will be over here in the US......THEN what will I do with my time! LOL!

marjan

[ghost]

It was so good to find your post. I'm scheduled for mfx surgery on the trochlear groove on 12/2 and I've been trying to find out what to expect. This will be my 3rd knee surgery in a little less than a year so I'm getting tired of limping around. The first was a medial meniscus, 3 weeks later I fell and re-tore the medial and tore part of the quad tendon as well as destroying the back of my knee cap leaving me with a grade 3-4 trochear lesion. Anything you can tell me about what to expect would be appreciated. I've been told I will be able to walk but in a brace locked at 0-20 degrees. Beyond that I've picked up some basic info by surfing the net.

Thanks,

Ghost

[Marjan]

Hey Ghost,

Good luck on 12/2. The procedure is fairly simple, deceivingly so, but the rehab is pretty long (and boring). Being able to ambulate, even at 0-20 degree flexion is a real bonus, versus the mfx done on weight bearing surfaces that need no weight bearing for a minimum of 6-8 weeks. If possible, find a good PT before your surgery and find out what you can/can't do (per your OS's orders) once you get home.
I started on a CPM machine the day of my surgery, and did a lot of heel slides to keep the knee from stiffening up. One thing that I've noticed with mfx surgery is that the knee seems to feel like it's in a vise for awhile. Really tights, stiff and inflamed feeling. I venture to guess that it's because when they pick/drill the holes and make it bleed, your body reacts by sending "all it's troops" to the knee, hence the heat, stiffness from swelling, and vise like feeling.
The other thing I'm noticing is that as time has gone on, even though I'm walking, my quads have gone bye bye. I do a lot of straight leg raises, and I can initiate a quad contraction, but it's pitiful. That in turn is going to put pressure on your knee when you move it around without the brace (showers, sleeping, sitting on the sofa, etc) so be careful when you move the knee around while flexed (obviously non weight bearing). This phenomenon got worse the longer after surgery. I'm at almost 6 weeks now and it seems like the knee is operating out there without any muscle structure (which it probably is!!) I can't wait to get the ok to start doing some more work.
Bottom line, this process is LONG, and tedious. Filled with ups and downs (but then you probably know that from your other surgeries). The whole idea is to protect the clot, it takes months for it to form a strong matrix, so no heroics when you're rehabbing!!

Good luck, let me know how it goes!

marjan

[ghost]

Marjan,

Thanks so much for the info. I have a really good PT whom I trust immensely. With three surgeries in less than a year he has been my life preserver. One of the problems I had was that the surgeon who did the first two surgeries basically told me that I would have to live with the pain for a few more years and then he would replace both of my knees. Needless to say I wasn't thrilled at the prospect. My PT recommended that I see a surgeon in Boston, Ma., Dr. Gill, the PT used to work with him and he specializes in joint preservation as well as being the team physician for the Boston Red Sox. Hopefully the mfx will do the trick. I'm getting tired of only sitting in chairs that have arms and going up and down stairs one leg at a time.

I've been really working on the quads for the past month kind of hoping that I can overbuild the muscle to a degree so that there will be something left when I'm finally out of the brace. I've been told 8 weeks in the brace locked to 20 degree max and then another month with some gradual increase in the degrees until I can get some extension. This should be interesting I am not the world's most patient person.

Thanks for your help. Good luck with the rehab and keep me posted.

Sue/Ghost

[Marjan]

Hello Sue (I think Ghost is a neat handle) -

Sounds like you are in good hands (both surgeon and PT wise). My surgeon was/is excellent, his PA is PAthetic. It was him I saw yesterday for my 6 week checkup. I've been through MFX before (femoral condyle) and know how important PT is. Like you, I have this great, life saving PT guy. Well, the doc's PA told me, "all looks good, you're free to go".....HUH? No more brace (nope), no PT (nope), I can do stairs (yep).....Ok, at that point, I turned to him ,said, thanks, goodbye. I'm considering writing a letter to the surgeon, for I think his PA sucks (pardon the french).

Anyway, enter my PT ...saw him today, for I'll be darned if I'm not going to have professional help with this. (I did make the doc's PA write me a script for PT....pretty much a generic one). So, the PT is familiar with trochlear groove MFX and hid his dismay well when I related my visit to the PA(professionalism, I assume). I told him that I'd learned alot about protocols (like opening the brace slowly to help the healing area), etc. and he agreed that we should take things pretty much according to Steadman's protocol.....SO, I'm wearing the brace with it set at 30 degrees max until I see him next Monday. Wow, what a difference 30 degrees make! My brace was set for zero before (I probably did 20 degrees when I walked to the shower without it!). My knee is tired tonight, but almost a "good" tired.

As far as strengthening your quads are concerned....by all means get them as strong as possible, but don't despair if you lose some, or most, of their strength after mfx. No problem though, strength can and will be regained. My calves have also suffered, but interestingly enough, my hip flexors and ab/adductors are still "with the program"....go figure....guess I'll be walking sideways! LOL

Another good thing to work on prior to your surgery is proprioception. Balance on the surgical leg (on a BOSU ball, or something equally wobbly) That type of balancing will help you as you start to walk without the brace (eventually).

Ah, just recognizing that you're not a patient person will help, I think. I'm not patient either and it's been hard at times, but the mantra of a successful MFX is time, quality healing, and no pushing..... the last being the hardest for me. You know....if 10 reps is good, 100 is better???? Nope...

Stay in touch,

marjan

[ghost]

Hi Marjan,

It must have been the week for unorthodox DR's visits. I had a scheduled follow-up with the OS who did my first two surgeries. I told him I'd been to Boston for a second opinion and he looked at the photos from my last surgery in June and counseled against doing the MFX and suggested I wait longer for the last surgery to heal. He couldn't offer any suggestions as to what was causing the pain or how to fix it, but still felt waiting was the way to go along with doing a bone scan. Since I've had a tough time accepting doing a third surgery to begin with I was close to tears. He is a good OS and truly cares about his patients. The problem is that if the pain hasn't improved in 10 1/2 months what are the chances that another 60 or 90 days will make a difference.

As you said, enter my trusty PT. He spent more than an hour just talking with me. He has been the one person who has been hands on for the past 4 months. (I mean that literally as most of the pt was spent physically breaking adhesions from what my pt feels was a partial quad tendon tear). After talking with him and the reality check of stomping my foot when the dog was lolligagging outside (which on the pain scale landed my on Mars for about 20 minutes) I've decided, with reservations to go ahead with the surgery. I still have a tough time with stairs, especially descending, I always sit in a chair with arms so it's easier to get up and stomping my foot or catching my foot on something is always a new experience in pain. Doing something has to be better than running a holding pattern.

We're about the same age. I'm a few months shy of 50, life is too short for this crap. I don't want to catch for the red sox but it would be nice to be able to get into my kayak, something I can't do at the moment.

Speaking of crap - write a letter about the PA, sounds to me like he needs a lesson in patient relations.

Good luck with the rehab and keep me posted.

Sue

[Marjan]

Hello Sue,
I'm sorry to read about your OS experiences... I know that orthopedics is not a straight forward field, most diagnostic tools offer only a partial look into the problem, hence every one of those docs has a different interpretation. All three docs I have seen have said that the scope is the best way to see what's going on in the joint. My doc went in thinking my first mfx had deteriorated and that he might end up collecting cells for a Carticel procedure. When he got in there, the original defect looked ok, but the trochlear groove was shot....something that wasn't clear at all on the MRI. The lateral meniscus that the radiologist said was torn, was actually a discoid meniscus (rather than horse shoe shaped, it was a complete disk ....bonus, I guess). Anyway, all that to say, if you've discussed all possibilities with your OS (the one in Boston) then sometimes just getting in there can tell him a lot. Maybe you are looking at scar tissue, not a trochlear groove problem at all. Who knows?
From what you are saying, it sounds like you are in pretty much constant pain, unless you sit on the sofa and eat bonbons! Yeah, that's a real fun life! I decided to go to a third OS because number 2 (forget about number 1....male chauvinist who DID want me to sit on the sofa!) well, number 2 said there was nothing he could do, and to live with it til a TKR. Since I'm pretty much assured that a TKR is in my future, and since, thank goodness, I have adequate insurance coverage, why not try to make it better for a couple more years? I will exhaust all my options before I get that TKR.
Your PT guy sounds like mine......one of the good guys! I still think there should be a medical field for ortho guys who are not surgeons, but MDs with true rehab knowledge and experience. I think my PT would be good for that.
I'm doing ok today....think I overdid yesterday and today my knee feels cranky, painful and a little, well, scary....but then I remember this from before, agonizing over whether the surgery worked or not....hopefully this too shall pass.
BTW - I'm a kayaker also. Fortunate enough to live on a lake, unfortunate enough not to be able to get IN my kayak! Next spring, I hope, hope, hope. My passive flexion is only about 3 degrees less than my good leg, PT was thrilled with that...so maybe I'll be able to haul my butt in that kayak come springtime. I have a Necky 17 foot sea kayak.....just perfect for our waters here. How about you??

Marjan

[ghost]

Hi Marjan,

We live less than a mile form a lake so it is really convenient. Kayaking started as a family activity until one day when we decided to kayak up river into an ocean bay called Great Bay. We started out and my then 16 year old daughter stopped, folded her arms and said "What intelligent family would buy four boats with no motors." After I stopped laughing I grabbed her kayak just before she crashed into the trestle of an old train bridge. We now have 2 nine foot Perceptions and last summer we traded the other two for a tandem 17' Necky. Not that we got to use it. I couldn't bend my leg enough with weight on it to get in and my husband had surgery for a shoulder injury in September so he couldn't paddle. I too am hopeful about next spring. I used to ski but at this point my knees are shot and the upcoming surgery will be my fifth so there's no point pushing that issue.

Be careful not to overdo it. I would have to guess that those muscles need to be retrained and that isn't going to happen overnight.

From the pain scale it's not as bad as it sounds. If I'm not putting weight on it while it's bent it really doesn't cause any pain at all, bending it without weight is no problem. From a range of motion I can get to 125 degrees with a straight unweighted bend. As the pt found out if you change the angle of my foot I can fly off that table as if I were born with wings. PT has done wonders with that, when I started with PT the rectis femorus muscle was like a steal band and was adhered to the bone. Needless so say, since the muscle wasn't working for me simply sitting down was a trick. Now sitting and standing is much better but stairs are still not great. I'm pretty sure that is a function of the angle of the knee and the location of the defect. That is the main reason that I'm going thru with the surgery.

Keep plugging - like you I'll do anything short of a TKR.

Sue

[Marjan]

Hi Sue,

Well I'm properly terrified! The knee pain got steadily worse after posting yesterday, I could not get rid of the pain last night, even after 1.5 percocets (which for me is HUGE). The pain is there even when I'm sitting with my leg elevated. It's hot to touch (I'm icing a lot and have taken anti inflams) but the whole knee cap feels like it is raw. Yea, I'm scared. I'm seeing my PT today, hopefully he'll talk me off the ledge. Hitting the Advil is helping a little bit, but I've gone back to "straight legging" it, since bending while walking seems to aggrevate it. Oh boy........ a little nerved out here -

marjan

[ghost]

Good Morning,

Hopefully today is better for you. I would have freaked out too. I'm not much on meds either. I took one oxycodone after each of my last two surgeries and that was it. Any news on the pt front. If your pt is like mine he/she will have a very calming effect.

As the time gets closer my nerves are getting to be more on edge. I've never doubted whether I wanted to have surgery done until this one. If you had the choice would you do it again?

Keep me posted on the progress.

Sue