Arthroscopic Surgery???? Should I????

[JudyS]

I have grade IV Chondromalacia in my right knee as far as my MRI says. The pain is on up or down, squatting, that kind of thing. Walking on flat surfaces is ok. I am now a hiker as I was banned from running after the hip replacement surgery.

I have had cortizone and just finished the 5 hyalgan injections. Not much difference.
My doc told me the partial pattelo femoral replacement is not for me as I am too active, it does not have the track record of hip replacements. He also said I would not be happy with a total replacement.

He told me the next step would be arthroscopic surgery (although he told me it does not do much good to wash out and debride). The surgery would be for him to take a look, do some tissue release if it seemed like it would help and do microfracture surgery if it seemed as it would help.
The other knee hurts too , but has not been investigated by imaging.

I am tormenting myself with this decision. The microfracture depending on exactly where he does it would require no weightbearing for 6-8 weeks. Then a long rehab and back to strengthening these quad muscles (which have not regained strength yet from the hip surgery).
This is problably my only chance of getting pain free.

I am more afraid of this commitment to surgery than I was of the hip replacement (which was a shock and not at all anticipated)

So , I am asking all my friends here to give advice, experience with any of these procedures, comments. Thank you

Judy

 

[beachcomber]

Hi Judy,
Wow--- that is a tough decision. Like you, I have OA in multiple joints and wonder if I will ever be pain-free. We just have to make decisions that give us the best chance for relief, have faith in our surgeons and in our own decision-making skills. I often write out a pro/con sheet so I can see it in front of me in writing.

At least the 'scope will give a true diagnostic view of the knee--- better than an MRI or x-ray. And if you and your surgeon are on the same page for what is to be done depending on what he finds then it might be a good idea.

Have you considered being awake for the 'scope so you can actually talk to him about what he is seeing? Some people make that choice and are very happy with it. After all you have been through you are certainly knowledgeable enough to maybe be able to look at it more clinically than personally. You can always change your mind and have them give you the sleepy stuff at any time during the procedure.

I had bi-lateral chondromalacia 25 years ago. I am assuming he is talking about a lateral retinacular release when he says "tissue release"? That helps some people and might be worth a "go". I had that done. They can do quite a bit of work through those little tiny incisions. It isn't a "no sweat" surgery, but pretty far down on the scale from a replacement.

Good luck and I know you will make the right decision for you....

Beach

 

[Josephine]

Lateral release is of the retinaculum, Beach - you're quite right there.

As for the scope, well, some surgeons do prefer to do a diagnostic scoping but just as many feel they can get all the info they need from straight xrays and clinical examination. That's one issue.

The microfracture is another issue. I know there's been a resurgence of this procedure in recent years but initially it was used in young adults with chondromalacia dessicans whose growth was not yet complete. In those, I believe, the treatment was very successful. I don't know what the statistics are in older patients but I wouldn't have thought it was that great because the growth factor just isn't there.

I would agree with his statement about debridement as there is a tendency is for a surgeon to snip and polish (with a bur) a bit too much and actually end up causing the very kind of damage the arthritis was doing anyway. I would disagree about the washout, however, as I have known a many who were able to put off their TKR (in my case postpone it indefinitely!) by simply washing all the loose debris out of the joint. It's when a bit of that gets into the wrong spot that you get that excruciating, grit under the heel, sensation!

The patello-femoral replacement is, indeed, a relatively new addition to the KR armoury is therefore largely untried in terms of data. All of what he is suggesting is, to put it bluntly, a kind of bandaid approach and not a definitive treatment for the condition though I know many knee surgeons do this. But to put it bluntly, the likelihood of long term improvement is not fantastic.

The end result is this: you have an arthritic knee (dressed up, that's effectively what grade IV CM is) and any procedure you have done now will ultimately have to be revised to a TKR. The choice is, do you make do with a possible short term procedure - microfracture or a hemi of sorts - or do you cut to the chace and have the total now?

This largely depends upon two things:

How much pain and disability have you now?
How much are you prepared to require further surgery about 4-6 years down the line?

Given all that I have said above, were I in your shoes I would be more inclined to have a further heart to heart with him, asking pointed questions about the outcomes of such treatments - how many has he done, how many of those had 'good' results and how long did those good results last before they had to be converted to a TKR or whatever. What were his criteria for classifying it a 'good' outcome? You'd also like to know the age range of those successful cases because if he has included young patients (under 25yrs) then those would not be valid considerations for your situation. Lastly, what are the options if the outcome is either not good or short lived?

And finally, get a second and a third opinion and see if their assessments marry up with his.

 

[JudyS]

Thanks Skeet and Jo,

I have to write down all the pros and cons. I know for one Jo, I would rather have a total knee 4 years down the road than now. In less of course he finds the mri was not accurate on the other sections of the knee.
I am very knock kneed on the right side and will ask him if the release will help with some staightening. I can't see being so knock kneed to be a good thing.

I do plan on the heart to heart talk as you suggested. I can only see a total as the next step. He did say that the microfracture on my hip was not successful although fibrocartilage had started growing. I will also ask if this scope can make the situation worse. Of course it will in one way as walking on the flat is fine . After my muscles have been dormant for 6-8 weeks it wil be starting from scratch again!!

Thank-you so much both of you for your input. I do not like decisions!!! If I am already at stage 4 in the kneecap, I can't see continuing what I am doing to cause more damage.
Any thoughts on that???

Thanks again
Judy

 

[Josephine]

Well, nothing in this life is ever for certain. If a life in medicine has only taught me that much it was a good lesson learned. My surgeon had me on the waiting list for TKR ASAP. I was in a lot of pain. He had intially suggested a unicompartmental but then reneged on that when he did the scoping. However, after that - no debridement just a look and a washout - I was very much improved. Then, have to admit it for I know many of you are active Christians, I started having prayer and laying on of hands, also annointing. Each time it seemed to work a little. Occasionally I had acute episodes that made me think "oh NO!!!"

but it would subside and all would be well again. Since the last time I had prayer (from a member of the Lakeland Outpouring Team about a month ago) all symptoms seem to have disappeared. Suffice it to say I have been able to undertake quite a bit of gym work!

And there was the man I met at the RNOH last summer. Much against the professor's advice, he was resolutely refusing to have a TKR, instead opting for a scope/washout every 6-10 months according to his symptoms. He'd been putting off the inevitable that way for almost three years.

I think you have to go with what your gut tells you. After all, you're the one that has to live with the consequences. If you're prepared to accept the (possible) consequence of early conversion to TKR then go for it. After all, it might be a whole lot longer than six years!

As for will it cause any more damage - well, the end stage is the degeneration proceeds and you get bone on bone which could end up with a extremely painful locked knee. My sister got to that stage and ended up having to use a wheel chair if she wanted to go out of the house. Not fun! She's in that stage again now with a bad hip. It's all a matter of risk and odds. Will you be lucky, won't you? Only time tells in the end, of course.

Finally, has your surgeon identified exactly the cause of your knock-kneed-ness? Is it an anatomical deformity you've had a while or collapse of the bone that has only recently occurred? Makes a difference to my answer.

 

[JudyS]

Jo you are so wonderful. Thank-you so much for all of your input. Over the last few years, I have seen the power of my prayers work .
I am glad your knee is behaving.

The question about the knock-kneed-ness: I with my extremely horrible memory do not remember if I have had it forever. I would guess that I have. When I ride the bike at the gym my leg hits the bar on each rotation. I think I would have noticed if that was new (maybe)
I have been in pt a lot over the last 6 years. I do remember at one place where they were working on a lot of me that they were doing some movement of the kneecap. It has always been out of line.
My surgeon commented on it after the hip replacement when he was watching me walk. I do have orthotics for overpronation. He had them adjusted a little and I wear them most of the time.

I do feel I have a good foundation for our discussion in 11 days. The only outcome will be a scope or nothing at this time.
If i thought I would have the scope and be back to normal activity in a few weeks, I would just go for it. The possibility of 6-8 weeks off, then rehab, and about 4 months till back to normal is the scarey part!!!!

Before that I have to deal with my back!!!!! Thoracic spine still hurts!!!!!

I am still very lucky and should not complain!!!!!

Thanks again
Judy

 

[AlaskanTKR]

Judy -

I have no experience with the microfracture - my doc never recommended that. I am a TKR as a result - or better yet - at the end of.. - 5 (i think) scopes to clean up chondromalcia and meniscal tears. the scopes kept me going for 7 years, but when there is nothing left to clean up - then the big decision had to be made. After my last scope 2 years ago life was absolutely awesome. I lost a ton of weisght and learned to ski and got back to a bunch of wonderful sports I had avoided for a long time - always thinking it was the weight. interstingly enough my knee deteriorated even more rapidly after loosing the weight - probably because i "played" so much harder. i wouldn't go back and trade any of the scopes. each of them provided a window of relief which let me get back to life after only about 3 weeks of "uncomfy" feelings - swelling, etc. rehab was a breeze and by the last 2 scopes not necessary since I knew the drill. The TKR has been a tad bit more challenging. Microfracture and its rehab sounds way tougher than any scope. My guess is that if you are going to return to being "tough" on your knees and enjoying life than the scope might be faster and get you back out and enjoying life. Your statement about having a heart to heart with the OS is perfect - lay it on the line - decide what "YOU" want as a result. I think you and are are in reverse of each other!

Hang in there! Think and research and talk with the OS. find out what a long term plan looks like - i have to admit - my OS was always up front - once we started pulling out piece after piece of torn cartilage we knew we were looking at a tkr - the big question was when. Stay strong!

Marianne

 

[Josephine]

Ah - well, if it is long-standing, I doubt the lat release will do much for it. But see what he says. I hope all this has helped you come to a decision.

 

[Simon]

Judy

The knock knee and the chondromalcia sounds a bit like me and the problem was patella malalignment (I had a very significant Q angle). Early on lateral releases helped some, then I had a tibial osteomy to lift the patella tendon to take some of the pressure off the knee cap. On the other side, he was not able to do the tibial osteomy so he just removed the medial facet of the patella which had the major part of the chondromalacia. This and some scopes all gave some relief for varying amounts of time but in the end it all got up with me. Like Marianne, I also lost a whole bunch of weight and by the next year the knees were really bad. I also think activity had to do with that as I bought a log cabin at that time and because the knees were not hurting as much I did alot more standing and walking around as well as stairs. The BTKR has been great still trying to get all the ROM in the right knee but it was much worse than the left as I had torn the menisci a few years before and the knee was swollen for 2 years.

The decision to be awake during the scope is a good one. I did that with all but the first 2 surgeries and it was helpful as I could move the knee so they could get a better idea of the tracking. I was even awake through the BTKR and watched the computer as it drew the knee so they could see how the implant would fit.

Sounds like you have a good relation with your surgeon which is good and I think you will come up with the best solution. If the chronomalacia is in one spot and hopeful at the edge removing that part of the knee cap could be a temp. answer.

Simon

 

[JudyS]

Thanks Everyone

Simon , Marianne and Jo you have all been helped temporarily by scopes. That is very positive. What I really have to discuss with him is the possible microfracture (which requires a periiod of no weight bearing) and or the lateral release.
I will definately ask about being awake.

Simon, are you awake enough to make a decision given options at that time?

Jo I would definately not go for the total at this time. Buying time without a lot of down time is what I am after.

Of course all of this will change if I end up needing thoracic spinal fusion!!!
Thanks again
Judy

 

[exjock]

Microfracture surgery is a long recovery. I had this procedure done on my left knee in 1990 and my right knee in 1992. Left knee has been great ever since. Right knee it never helped and I hade 2 scopes and eventually a TKR this summer on the right knee. Based on xrays the left will eventually have to be replaced but it still feels pretty good after 18 years. It is a tough decision. If you think you will need a TKR in the future I don't know if the down time for the microfracture surgery is worth it since there is no guarantee. When I had mine done I was in my early thirties so it was worth the chance.

 

[JudyS]

Thanks Exjock

The long recovery is the part that worries me. My doc initially did microfracture on my hip, although when he got in there (arthroscopic) I was found to have severe arthritis.
When he did the replacement 4 months later, he did say that fibrocartilage had grown in.

I guess I will have to get the details from him on different scenerios.

Glad you have been helped in one knee. That is positive!!
Judy

 

[Simon]

Hi Judy

I was totally awake and breathing on my own as I did not use any sedation at all, just the epidural. I had some long conversations with the surgeon during surgery (the ones before the BTKR). During the BTKR I could tell something was up but the surgeon did not say anything at that time, I think he was too busy trying to get the surgery finished.

I had no problem other than getting a bit cold but the anesthesiologist would just bring me another warm blanket.

Hope this helps.

Simon

 

[JudyS]

Let me just say that you are very brave. I think I would want to have some mild sedation

I think my fear comes from the one time I asked to be totally awake. Very dumb of me , but it was for an upper endoscopy. When the doc asked me to close my eyes as she was inserting the gargantuan tube down my throat, I knew I was in trouble. Only wish i had a signal to knock me out as I would have used it.

I think I am going to have the scope, but I still have another week before I see that doc.
Thanks again
Judy