Grade 4 Chondromalacia Patella- suggested scope abrasion

[chrisd]

I've been suffering with left knee pain for the better part of two years now that came on just after I ran my first full marathon which I failed to fully and properly train for due to other issues. It was misdiagnosed last year as quad tendonitis without the insight of an MRI so I chose to live with it. I gave up running earlier this year in hopes of finally conquering the lingering pain, but it hasn't let up despite the rest, so I asked for and got an MRI done at the end of December. I went for review of the results and was told that I do not have tendonitis, but grade 4 chondromalacia of the medial patella. He said that there was a round area of cartilage that was just missing and asked if I had a trauma to my knee. Outside of the stresses of running mileage, I have not. He suggested an arthroscopic procedure in which he would go in and clean out the damaged/ loose cartilage and spur the growth of scar tissue to take its place. There was no discussion of non-surgical options like PT or injections.
My pain is with me all day every day, but is not severe or limiting to my daily routine. It's liveable. I'm wondering if the more conservative treatments might be worth a try before the scope since nothing that's been done in the past was done for this condition? Thoughts?

[Lottiefox]

Just a quick reply - I have identical Grade 4 damage to medial and also to lateral aspects of patella. Caused by running (not marathons!) with poor gait and weak muscles. I resisted surgery. I have returned to good function and pretty much zero knee pain using a strong course of Celebrex which seemed to settle the inflammation I had, then focused PT that worked on my glutes, hamstrings and quads in a way that didn't aggravate the kneecap - lengthy but I can now leg press 90kgs and hamstring curl 40kgs...3 years ago I couldn't walk down a slope. I also have Euflexxa injections on a 12 monthly basis with a surgeon in London. I pay for these but they have worked really well for me.

Problem with a scope on Grade 4 is they can only seal the edges and possibly do microfracture which I think is what your OS is alluding to when he says try and spur on scar cartilage. MFX on the patella is not great as the blood supply is low, and also it gets such a lot of shearing force when we walk it tends to struggle to ever bed in. Not saying it can't help but it isn't guaranteed.

Personally, having done it this way, I'd seek some conservative but intensive measures and see how you respond. But that is me, and others may feel differently. I certainly have learned there is no need to hurry into surgery. I took 12-14 months to return to good function with the right programme of stuff and I'll be off for my jabs again soon! Scopes can help, they can do nothing or they *can* make matters more irritated and the knee takes ages to settle down. No way of knowing what your outcome will be. If you have severe limitations then often a scope seems sensible; if like me you kind of live with it but would like to improve it, have a hunt around for options. Mine are not the only ones but they worked for me. I don't run now, but I spin, hike, weight train. Not sure how my knees will be in 10 years but hey - carpe diem.

Good luck

Lottie

[Brambledog]

Hi,

I had grade 3/4 OA in my patella femoral compartment before an arthroscopy 18 months ago. I had debridement done and it is not always a walk in the park. I developed a nerve condition after mine, which is rare (not surgeon's fault) and has affected my recovery, but I would definitely recommend you explore conservative treatment like physio before you go the surgical route.

If your knee still functions and you can live fairly normally, I would request a course of PT and work really hard at all the exercises, as Lottie says!! Keep the scalpel away as long as you can....but that's just my view. Lots of arthroscopies are fine, but there are also some folk who wonder how much good debridement actually does anyway, as any scar tissue formed after debridement (I'm not talking microfracture here) is not the same as your original cartilage.

Good luck, whatever you decide

Brams

[chrisd]

Thanks, Lottie and Brams for your detailed responses!

I've emailed the surgeon's office to see if he can answer a few questions I had about alternate avenues of attack and will post updates as I get a response and determine what course of action to take.

[chrisd]

So, I've done some more reading and thinking and wonder why I wouldn't want to go straight to a partial knee replacement for the patella rather than a scope or PT? I've got grade 4 chondro so there's no fixing it and there's nothing else wrong with the joint. By replacing it I might be able to get back to running after rehab. Am I thinking wrong?

[chrisd]

duplicate- oops.

[vickster]

How old are you? What country are you in? Do you have free and straightforward access to healthcare?

There are more advanced cartilage repair techniques available and it is always best to try to keep your own bits intact if you can. It may be that you need some sort of realignment surgery for these to work but this is fairly commonly done

There are people on this forum who have had luck with ACI, people in the US who have undergone de Novo and others who have had successful treatment with stem cells - there is a specific section on this forum where these procedures and people's experiences are discussed. You may be able to return to sport, but realistically the rehab for these procedures is at least 12 months and more likely 24+.

As Lottie says, with 12 months of rehab you could be back to full strength - work with a physio, make sure your gait is sport on, take it slow etc. Consider another sport such as cycling, much less hard on the knees than running

I have had tidying done of grade III of my lateral patella, which was very successful. Not done as a single procedure, but when I had a bit of meniscus removed (I didn't even know there was patella damage going into the op)

Do you know how big (or small) the hole is - this will also affect what can be done and the possible success of the outcome. They don't usually even consider replacement parts if there is a small, single defect and certainly not if there is no limit on function These are major open procedures with much cutting and slicing, not like an arthroscopy (and even these take 3-6 months to recover from fully).

I would do the physio, maybe get a second opinion from a cartilage specialist

Good luck

[chrisd]

Hi Vickster, I'm 42 in the US and pay for health insurance that gives me limited access to procedures based upon approval of referrals from doctors. I was told it was grade 4, but not necessarily how big the defect was. I'm still waiting for the OS to get back to me about the possibility of non-surgical options in his mind. Depending on what that answer is, I may seek alternate opinions.

[Lottiefox]

I agree with Vicks, you definitely need to establish how big the defect is and also, probably more critically - WHY it has happened. For example, do you have issues with the alignment of your knee, the placement of your patella, the rotation of your bones. A PFJR (partial patella replacement) is a BIG undertaking and is also relatively new in terms of procedures. Bear in mind they don't last forever and they are the same as any replacement - they remove part of your bones to fit in the new parts. No going back. Any issue with alignment also needs to be corrected or you'll have new parts running in exactly the same wrong method as your own knee does but that will be a) painful and b) probably highly restrictive. If I didn't have many restrictions on function I'd not be looking for a PFJR. No one can say you'll run again after you've had one done. It is definitely an option worth reading about and discussing. Many people on here have the, diaries by snorunner outline hers (she has had them on both), FMRCathlete, Lea50 have both had them but with some complications.

Keep researching, you're doing the right thing.

Lottie

[Brambledog]

Hi again chrisd,

I looked into PFJRs myself at one point, and although some folk here have had them and got good results, they are no easy option, and there seemed to be a growing opinion (from what i read, and my own surgeon) that they just don't last as long as the surgical community originally hoped, in many cases not much more than 3-7 years. In a Patella Femoral Joint Replacement (PFJR) they replace the back of your patella with a plastic button, but most importantly, they remove and replace with metal the trochlear groove on the end of your femur that your patella moves through as your knee flexes. It's not as big an op as a TKR, but it's big enough, and as Lottie says, there's no going back. When the PFJR needs replacement (which depends on many factors, including your activity level) you have to go straight to a TKR. More bone gone. It doesn't sound like the sort of route that is going to give you a better future in terms of running marathons....but keep reading and there might be some folk who've had it done have been able to do this.

Many surgical procedures are offered to the patient as a means of sorting things out and giving them their life back, but it's not always that simple. KGs is full of people who have had to go on to have other procedures on top of the original one, to correct things, fix other bits that went wrong, sort out infections, etc etc. And too many people have now got a life that involves limitations. Now KGs is a place for people who haven't had the best time of things so of course you are seeing a skewed picture here, with more negative experiences - after all, if it's all gone swimmingly you don't need to keep posting! However I think it is a salutary lesson in what can go wrong sometimes, and if you read through a few threads you'll see the 'signatures' of people at the bottom of their posts detailing their history. I'm not trying to frighten you off and say surgery is BAD, but it is always a risk and well worth weighing up the pros and cons thoroughly. Just keep researching (as you are!) and make your own decision.

It's a mad old game, but you are on top of this and doing everything you should be in terms of gaining knowledge. That's more valuable than anything!

Getting another opinion is a great idea if you can do it. Good luck with your OS this week and I hope he can come up with some ideas for you.

Brams

[Louisamith]

Lottiefox, did you ever get back to running ?