Three options...but which one?

[teresa.uk]

I have not been on the board for while...got fed up with not being able to say that my bilateral arthroscopies and semi-open lateral releases for patella O/A(diagnosed 10 years ago) were a resounding success.My right knee pain is bearable,and I can now squat,albeit gingerly.However,my left knee is worse,I cant kneel.squat and stairs are a problem,and I walk with a limp due to weight bearing being horrible!The pain is tolerable with Vioxx 50mg,and Dihydrocodeine 60gs at night.I would take more during the day,but I wouldnt function.I have had to give up nursing,as I am unsafe.

I am due to see my Surgeon next week.I have being seeing him 3 monthly,but we have held out from any action until one year post op.He has given me 3 options that we will discuss.A patellectomy,a Fulkersons or a partial knee replacement.Here in the UK,the surgeons are just as reticent about early TKR(I am 46),and I have to say,I agree that a TKR is the last resort.

Has anyone else been given choices like these for OA?He is going to refer me to another OS for a 2nd opinion,with these options.I am at the end of my tether,and he cannot explain why one knee should work,and the other be made worse.

Any bright ideas from you experts?I would appreciate it,as I have posted a few times,with only occasional replies.

Thankyou for listening.
teresax

[Linds]

Hey Teresa, Wow , I am sorry to hear that your one knee is so bumbed out..but good to hear that the other one seems to have had some improvement.

I wish I could make some suggestions to you on what to do for your surgeries..however, I personally havne't had that much experience. I have only had a LR, and at 23 years old..the options open to me are alot more limited. I have been researching Patellectomy though, and have yet to hear a positive result from this surgery. You could see the responses to my post under Know eachother just want to chat...topic is Hands up. Wish I could be of more help...
I hope that you get the information that you need...and that someone who knows about this stuff responds to you.
Take care, HUGS and HOPE and Lot's of luck
Linds

[teresa.uk]

:DThanks for you reply Linds,
I looked on the post,and I have read that patellectomy seems a drastic course of action. I think my Surgeon is looking at this to be the less likely of the 3...he did say that it woud get rid of the pain(no kneecap,no pain..sounds so simple,doesnt it!)but it does weaken the joint.

You made me feel better just talking to someone else..those who suffer pain constantly,with whatever ails them,do tend to suffer in silence for our loved ones,but its so nice to know others understand....

Hugs

Teresax

[KM]

Hi Theresa,
good luck with your decision.
I have now had Fulkerson's done on both knees, the 2nd one in December. It is a long road, but fortunately my 1st one was a big success, and I can only hope that this one will be too. I would think that would be a preferable alternative to TKR, if possible...
please say the word if you have more questions+
Take care

[melody]

Theresa,

My OS has given me a similar choice which has my head spinning. He suggests either a Maquet procedure or a patellectomy. He told me that other procedures will not work because I have no cartilage left on the kneecap and a TKR is not warranted at my age (53). At least I am too young for something! I really do not like the sounds of the patellectomy and am going to another OS for a second opinion. I don't want to say "I wish I had..." after whatever I choose to do. Good luck to you; I wish I had an answer for both of us.

Melody

[teresa.uk]

Thanks for the support you guys!

I dont think I like the sound of the patellectomy, so unless either of my surgeons can promise me the moon,I dont think I will go for it!!It is nice being too young for something,isnt it!!!!!I am due to see my surgeon on the 28th of Jan,and I assume I will have to wait a bit to see the 2nd Surgeon,so I will keep you posted of any other brainwaves they come up with.My Surgeon did say,that whatever he plans,he will do an thorough arthroscopy before he proceeds with anything on the table,so if he feels that the planned procedure will not be of any benefit,he will not proceed,so we will have to see.

Thanks for the support all of you

teresaxx

[Heather_M.]

Teresa and Melody,

I actually know of several people younger than both of you who have had wonderfully successful knee replacements. These days, a doctor won't let a few years of age win out over quality of life. That being said, if you can avoid the TKR with other surgeries, or at least put it off for a few years, I definitely would.

You might want to read about so-called patello-femoral joint replacement, or PFJR--it involves what is basically a partial knee replacement, in that it calls for resurfacing of the patella and trochlear groove. You use up much less bone this way, so it's an option for younger patients.

I would strongly recommend against patellectomy. It's a very short term fix, and sometimes causes many more problems than it fixes. What's more, if you have OA you know that sometime in the future you'll have to have a TKR. This is made much more difficult if you've had a patellectomy. As in, much lower success rates.

The PFJR is a good option if you have damage isolated in the patella or trochlear groove. If you have signs of lateral or medial compartment arthritis, or if you have bad tracking, then the PFJR is not a good option. I've heard of some people have a TTT and then the PFJR, but again the success rates are somewhat lower.

My doctor has advised me to hold out for a few more years, that orthopedics is just perfecting ways to address patellofemoral arthritis. It can't come soon enough for me.

Heather

[Jennifer]

Teresa~~~~

These are nearly exactly the choices I was given prior to my latest surgery. I was told patellectomy, TTT (the OSs are now calling them T3s), or a partial knee replacement (pat/fem component).
I went with the T3 as it was what I was most familiar with and because it could be undone...sort of a stop along the way if it doesn't work.
However, if I need to consider another option down the road (although I am hopeful and starting to be confident about this procedure's positive outcome) I would be willing to consider either of the other options.
Patellectomy is a hard choice, but I have two friends that have had it done and have done very well for a long period of time (one woman had hers done in '76 after a failed T3 and has done wonderfully...raised children, been active even sporty, worked full time...the other woman had hers done in '82 and she is also doing very well although she is less active than the other woman...by choice). The right surgeon can make the patellectomy work and it can be a long term solution. I have told my OS that this is the next option for me if it comes to that.
Partials are okay, however the pat/fem has some issues that the other partials do not and I don't think there is enough of a long term track record for me to comment firmly on it and frankly I only know people who have had partial lateral components done with great success.
Amazingly enough because of my trochlear dysplasia there has also been some talk of trochlearplasy...and all of the research said that was a mess of a procedure in terms of outcome yet it seems to be coming back in vogue...go figure.
The biggest key to your success is to find the right surgeon...then listen to him and follow his every instruction.

Good luck with a tough decision.

Jennifer

[teresa.uk]

:DThankyou all for your replies!

My OA is mainly behind and on the patella surface.The LR was a long shot for the knees, but my right kneecap was moved to a reasonably minimally affected area,and therefore has been reasonably successful,but my OS tells me that the left kneecap was moved to a much more affected area,which may be why it has made things worse.Wonder why he did it then!!!

I think a partial knee replacement may be the answer listening to you guys,but I will see the 2nd OS,who has a wonderful reputation for rebuilding hips as well as knees,and see what he thinks.I will keep you posted!

Hugs and thanks

Teresaxx

[laura_utah]

Hmmm......If the problem is cartilage damage (ie. OA) on the backside of the patella, why isn't anyone trying some sort of biological resurfacing? There's abrasion, microfracture for big, diffuse, arthritic lesions. There's paste graft, OATS, mosaicplasty, and ACI for circumscribed lesions. Hey, that's a LOT of things to try. Any one of which would FIX THE PROBLEM without the need for drastic, not to say expensive and invasive things like osteotomies, TKR, and (heaven forbid) patellaectomies.

If you can't find a local surgeon interested in at least trying some cartilage re-growth, send your films to someone abroad and pay for a consultation. Dr. Stone and Steadman in the US, and Dr. Toft in Germany are all experts at these techniques and offer some sort of film review for a reasonable price ($100 US or less).

Whatever you do, make sure your pain is under control when you make your decision - don't do anything out of fear or panic because of severe pain as it is almost always the wrong decision in the long run. Good luck.

[Heather_M.]

Laura,

I am patient of Dr. Steadman's and asked if he would do microfracture on my grade II osteochondral lesions. He would not, for the following reasons: the patella does not respond well to any of the cartilage restoration techniques. The success rate in his estimation was significantly less than 50% overall, whereas for other areas it was up in the 80%s or better. Also, he will not replace the cartilage until they are positive that the tracking has been sufficiently altered to prevent the new fibrocartilage from getting chewed up as well. His point was that often if you can fix the tracking to unload the damaged areas, it wasn't necessary to repair the cartilage because not every lesion every person has hurts....he called it one of the mysteries of arthritis. So his approach would be to fix the tracking (but he doesn't do open surgeries like the TTT :-/) and then examine cartilage restoration options, but with the knowledge they they are less successful on the patella.

Anyway, just wanted you to know that these have been my experiences trying to get someone to fix my patellar lesions. According to everyone I've talked to and the med-line research I've done, the options are much less happy for cartilage restoration techniques on patellar lesions than for those with damage in other areas.

That's not to say no one out there does patellar work--there are a few people who have had ACI and OATS on patellar and trochlear lesions. I hear Dr. Toft will take on some patellar lesions. But many of the doctors I've talked to won't touch my knee--first they recommend a TTT or alignment surgery to deal with tracking, making it a multi-year process. Now, it could just be that my knee is supremely crappy and has gone beyond many of these techniques (grade II osteochonrdal lesions which advanced from grade IV chondromalacia in less than 2 years). Maybe for less damaged areas (meaning the alignment isn't so bad) there are better options? I'd sure love to hear about them.....

Heather

PS I agree with you completely about not making a decision while in pain! Pain management has helped me take stock, fly around and visit doctors, and not take the easy out 'exploratory arthroscopy' option which got me into trouble in the first place.

PPS I have a question in to Dr. Toft about whether he deals with patella baja, which is the problem I have that's grinding away my patellar cartilage.

[laura_utah]

Excellent points Heather! Unfortunately, many of the "mainline" cartilage restoration techniques are not as successful on the patella as on, say, the femoral condyles. However, this does not mean that they do not work - especially if rigorous post-op protocols are followed. I also agree with the alignment issues - don't just start grinding away the new stuff just like you did the old - Dr. Toft is definitely in agreement with Dr. Steadman on this point! Perhaps these difficult alignment issues contribute heavily to the lowered success of cartilage restoration on the patella?

I got the impression that theresa's main problem was a big lesion (like, grade IV) or just complete abscence of patella cartilage and that the re-alignment surgeries were not successful because there just was not enough cartilage left to work with.

I suppose it all comes down to really understanding where the pain generators are, and, unfortunately, the PF joint is nearly as complex as the spine in this respect.

[teresa.uk]

Thanks Heather and Laura,

You have certainly given me food for thought!I think my Surgeon has had the right idea,by being the one who wants a second opinion from a very experienced colleague,who I have actually worked with. I will certainly talk to him about other avenues.My pain is constant when walking,stairs,getting up from chairs, agony to kneel and squat,so it is a load bearing problem.I have always worked on my ROM,and have full range with minimal discomfort.My surgeon does not know why my knee has got worse,whereas the other one has responded reasonably well,although still painful.He is at a loss, because my OA is not severe,although extensive over the patella and surface of the femur.He did do a surface debridement at the time.
Anyway,thanks you guys.More to think about!

Teresax

[Heather_M.]

Laura,

In light of the discussion on cartilage restoration, here's an interesting and very technical update from the medical literature. It doesn't address patellar lesions, just the efficacy of various techniques. It's very dense, but worthwhile reading:

http://www.cartilagerestoration.org/news/news3.html

Heather

[laura_utah]

Thanks, I've read this some time ago. You might also want to look at Dr. Toft's latest study (on his website). Of particular interest to me was the histologic data where the repair fibrocartilage appeared to densify and become more and more "hyaline like" with passing years. This seems to contradict the theory that fibrocartilage never lasts more than a year or two.

Until prosthetics designers can get the plastic out of knee prosthetics, we are very dependent on these biological solutions if we want to pursue active lifestyles safely. Thanks for encouraging me to continue to "do my homework" - it will pay off in the long run.