Meniscus, OA, Osteotomy, Transplant?

[Meniscus]

Hello and thank you for reading this.

TLDR: had meniscus surgery 30 years ago. I’m 46, in good shape, male. Recently had an event. Knee is worse. Not sure what to do. I will be getting scoped to remove the last of my meniscus but doctor is suggesting an unloader brace as a long term solution. I just can’t do it. I am slightly off alignment so osteotomy might work. He says I can’t have a transplant because of OA and little cartilage. I’m bone on bone but it doesn’t hurt just rubs.

30 years ago I had a majority of my lateral meniscus removed from my right knee. I felt fine until a few months ago while training in the gym. Felt a click. A couple days later I had swelling and had to get it drained. There was blood in the fluid. It swelled a couple more times over the next few weeks but haven’t had an issue in the last three months. I’m walking much better now other than the occasional catching which causes shocking pain when I extend the knee. It comes and goes.

I have seen several doctors and I received a range of opinions. From letting it be to an osteotomy and meniscus transplant. I would like to delay knee replacement as long as possible. I was given an unloader knee brace but to be honest I can’t see myself wearing that for 20 more years.

I have two questions.
1. What would you do in regards to surgery or treatment? I was told by some given the arthritis I can’t do a transplant. I have also read about a new gel meniscus that has been approved in Europe. I’m not saying money isn’t an issue but I am willing to pay for a solution. I currently have an HMO.

2. I have read that an osteotomy will really take a while to recover. Could I get scoped now, get an injection (like synvisc) and enjoy the spring and summer and then get the osteotomy during the winter? Where I live the weather has some serious seasons so I don’t mind being stuck at home during the winter. Will an extra 8-10 month delay on the osteotomy really cause my knee to seriously deteriorate?

I would be so very grateful for any advice or guidance. It’s really difficult to determine what to do.

Thank you.

 

[JDinCT]

In my very untrained medical opinion, the unloader brace is not a very good long term solution. I have been using one since October 2018 and it does not give me much relief and it is cumbersome to wear to say the least. It you have a bone on bone condition, it will only get worse over time.

I would recommend getting several "second" OS opinions and do some research on your known. I'm sure you will get some additional advice from this here on BS that at much more knowledgeable than I.... all the best!

 

[Celle]

Hello @Meniscus - and

I will be getting scoped to remove the last of my meniscus but doctor is suggesting an unloader brace as a long term solution. I just can’t do it. I am slightly off alignment so osteotomy might work. He says I can’t have a transplant because of OA and little cartilage. I’m bone on bone but it doesn’t hurt just rubs.

From letting it be to an osteotomy and meniscus transplant.
I would like to delay knee replacement as long as possible.
I was given an unloader knee brace but to be honest I can’t see myself wearing that for 20 more years.

I think you need to look for yet another second opinion. Your current surgeon is not giving you good advice.
He wants to remove the last of your meniscus, which will only make things worse, and then condemn you to using an unloader brace for ages.

Another surgeon has mentioned an osteotomy, and you've also had a meniscus transplant suggested.

I'm sorry, but what you really need - and what will fix your knee much more successfully long-term - is a total knee replacement (TKR). You're not too young for that, as many people in their forties, and even in their thirties, have had successful knee replacements. And a TKR can last for 30+ years.
You need to find a surgeon who will look first at the state of your knee before he looks at your age.

Frankly, the other suggestions are only short-term solutions. An osteotomy is very painful and the recovery is difficult. It seems to be a harder recovery than the recovery after a knee replacement.
A meniscus transplant is only likely to succeed if a very small portion of the meniscus is affected - yours is too far gone for that.

The only real solution for your knee, since you have OA and your knee is already bone-on-bone, is to have it replaced.

I would certainly not consider any other operative alternatives, because they are likely to be only a temporary fix.

I'm also going to ask @Josephine , our Nurse Director, to give you her opinion.

 

[Celle]

PS: What is "TLDR"? I had to look it up. I can only find that it might stand for "too long; didn't read" or that it means a summary.

On BoneSmart, we prefer people to only use the abbreviation in this article:
abbreviations and acronyms

 

[rosieNZ]

Hi
I am a 67 year old female. I put off my TKR for as long as possible due to all the reasons you state. My xray indicated bone on bone several years ago but it wasnt THAT painful so I lived with it.
Suddenly last August when on holiday my knee buckled and a large effusion (swelling) developed. Its been very painful since and my TKR is scheduled for this month. I have been taking analgesia ever since and am close to not being able to walk due to pain, knee locking and instability/falling. Using a brace helped me to get by but wasn't a long term option. I still had constant pain, couldn't walk far, started falling due to instability and struggled to work due to pain, lack of sleep etc. Who knew it could be like this!
So this is what I think :
1. Get second opinions. It helps to weigh up the options and make a decision.
2. Look at the impact on your life. For me, when looking back, I realise how my knee has impacted my life. Its been stupid to allow this to happen.

Quality of life is what it comes down to when considering a surgery like a TKR. There is no easy answer. Even with a knee replacement your life will be impacted.

If it was me, I would sit with a blank sheet of paper and make some columns, write my potential limitations and potential gains for each option.

You only have 1 life and today is just as important as the future.
Make the best decision you can and embrace it. If you postpone surgery it can be revisited.
If you have surgery and your new knee wears out, C'est la vie. There are options.
If pain is intolerable, your life is being changed to live within restrictions. A replacement knee is not as good as a perfect natural knee but its not as painful.
Good luck with your decision. Remember a conservative decision now does not preclude making a differant decision later.
Rosie

 

[Celle]

If it was me, I would sit with a blank sheet of paper and make some columns, write my potential limitations and potential gains for each option.

This score chart may help you to assess how much your bad knee is affecting your life:
Score Chart: How bad is my arthritic knee?

 

[Josephine]

I am slightly off alignment so osteotomy might work.

I would never recommend anyone to have a High Tibial Osteotomy (HTO). It's a butcherous procedure and the recovery is protracted.

He says I can’t have a transplant because of OA and little cartilage.

He is correct but it's more because they just don't work anyway.

I’m bone on bone but it doesn’t hurt just rubs.

Sorry to say this but if you think that then you are kidding yourself!

I've never quite understood why people are so keen to put off a knee replacement. They are excellent procedures with a very high success rate.

 

[Meniscus]

I really want to thank everyone who has responded. I am in your debt.

I am continuing to seek opinions from doctors.

My pain in knee that I feel is just when my meniscus catches and shocks me. During one stretch I was so fearful I was keeping my leg straight while changing （I won’t go into a ton of detail).

I confirmed that the transplant is too late for me today.

Regarding the osteotomy, I have seen pics and it looks a bit extreme. But I need to find some way to alleviate the bone on bone so it doesn’t get worse.

I honestly don’t feel any pain at the moment from rubbing. I’m not trying to be stubborn. I don’t need to subject myself to pain to prove anything.

For those who had a TKR, how long was the recovery?

Thank you.

 

[Rockgirl4]

From my own experiences, I wish people had convinced me sooner to have a right TKR. I was 43 and believed in "Hail Mary"-types of surgery to buy me time. In the end, it only bought me more problems and pain. My final straw was the catching you described. That will only get worse. I had it happen on stairs once and actually got stuck, where I couldn't go up or down for 10 minutes until I could get something "in there" to shift/move.

As for shots, I was told get shots (hyaluronic acid, AKA Synvisc or Euflexxa) don't usually work if you're already completely bone on bone. That was also my experience in both knees. I also bought the sport's surgeon line of being too young for a TKR at age 43. He even tried it this year, and I'm 46. I politely told him I need my life back.

Lastly, there is such a thing as waiting too long. I'm now there. I waited too long, my bad knees have created other problems, and life circumstances in December forced me to postpone my right TKR until May. Now I'm counting the days. I only wish I knew THEN what I do now. Best of luck to you.

 

[Celle]

Regarding the osteotomy, I have seen pics and it looks a bit extreme. But I need to find some way to alleviate the bone on bone so it doesn’t get worse.

The recovery from an osteotomy is just as long, and possibly a bit more painful than the recovery from a TKR. In addition, the osteotomy is still probably only a short-term fix. Once your knee is bone on bone, nothing is going to cure it, apart from a TKR.
Why have two operations when just a TKR will do the trick?

For those who had a TKR. How long was the recovery?

Complete recovery from a TKR takes a full year. However, you will be able to do almost everything by 3 months. The first month is hard, although you will be improving all the time.
We advise going back to work at about 12 weeks post-op.

 

[kneeper]

FWIW, a meniscus tear was the last straw that led me to my first tkr. I haven't regretted it.

 

[LuisFromLA]

My history:
1997 (I was 16): Medial meniscus tear, partial meniscectomy
Very active for twenty or so years running, cycling team in grad school, a few full and half marathons.
2014: Medial meniscus tear while running, partial meniscectomy
2016: Medial meniscus allograft
2016: Re-anchoring of medial meniscus allograft
2018: High tibial osteotomy
(All surgeries on same knee.)

To address your questions:

1. I would see as many reputable doctors as possible. Yes, my understanding is that an allograft or a synthetic replacement is usually only an option for younger patients who have the majority of the surrounding tissues in excellent condition. Of course, “younger” and “excellent” should be left up to your orthos.
2. I had an osteotomy four months ago and I’m still not at a point where I can say I’m better off than just prior to the osteotomy. My doctor is very optimistic and it feels like most of my pain/soreness/discomfort is coming from where the tibia was cut and drilled into, so that’s comforting and gives me hope that this is pain that will subside and due to the cutting/drilling. However, my other doctor also felt optimistic after my allograft and the allograft didn’t wind up really help with my limited mobility or pain. My question to you, as someone whose had a bunch of knee surgeries, is is there some kind of improvement since your event a few months ago in the gym? Does the unloader brace help with mobility and/or pain? If it does, then that might indicate that the HTO MIGHT help. Might.

Here to help, so feel free to reach out.

 

[Josephine]

I need to find some way to alleviate the bone on bone so it doesn’t get worse.

I'm sorry but you just won't find a way. Bone is somewhat different to soft tissues. Once it's damaged, it's damaged and nothing will recover the situation.

For those who had a TKR, how long was the recovery?

That's not an easy question to answer because everyone's different. But the shortest time would probably be around 10 weeks and could be as long as 6 months.

 

[julie1968]

I had a meniscus repair 4 years ago and my knee is so much worse I'm bone on bone. Been thru multiple treatments that didn't help. Now getting a TKR on March 7. It's hard but I would talk to them about a replacement. The alternative treatments don't last long

 

[kneeper]

My OS said there was no point in trying to fix the meniscus tear since my knee needed a tkr and the tkr (by its very nature) would also solve the meniscus issue.

 

[NavyGunns]

@Meniscus, you’ve received a lot of good advice and information already, so I’m not going to add much more.

If you care to, give my recovery thread a review. You can access it from the link in my signature. I, too, shredded my lateral meniscus in my left knee many decades ago. Finally got to the point where something needed to be done. What you decide is a personal decision that you have to make once you have all the info you need.

Good luck and keep us posted on how things are going.

 

[maryo52]

I've had a few of these issues myself. Here's the gist: I tore my meniscus, had the knee scoped, and my valgus knee ended up with even more valgus, which creates more stress for the knee to bend inward, which in turns stresses the meniscus and ligaments. An osteotomy was suggested to me, but after I looked it up, I didn't think much of the idea, and since then I've seen research saying that an osteotomy complicates a subsequent knee replacement.
It's possible a partial knee replacement might serve you. I explored that too but my arthritis was in all three compartments of the knee.

Having been to way too many orthopedists over the years, I will say that the very best thing one can do is find a knee doctor who does tons of knee replacements. I had a mediocre knee replacement that was a nightmare to recover from, and a superb revision just recently that has been a breeze to recover from. The acute recovery seems to be about 2 weeks, and people return to work in a few weeks depending on their line of work. But the tissues don't become completely heal until about a year.

And about that brace, I'm with you. I find unloader braces to be difficult and uncomfortable. I used an Ossur Oasys rigid brace I bought off the internet for 6 years, and it did a decent job of reducing the stress on my knee and was fairly comfortable. I even snorkeled with it on. I love not wearing a brace any longer.

 

[robert johnson]

My OS said there was no point in trying to fix the meniscus tear since my knee needed a tkr and the tkr (by its very nature) would also solve the meniscus issue.

Ditto. I've gotten the exact same lecture.

After my MRI (2016 or so) showed a massive tear in the medial meniscus, I said to the OS, isn't there a world class radiologist who can look at that MRI and tell me whether or not I would benefit from Meniscectomy. My x-rays were up on the screen at the time, showing no space left between the bone (medial side).

He said, "no". He said I'd have to try it to find out, and I wasn't about to do that.

 

[Meniscus]

Thanks so much for the replies.

A few updates.

1) Spoke to a few more doctors and I have given up on any sort of meniscus transplant or gel type solution.

2) one of the top doctors in the US recommended a partial knee replacement (PKR). He said it recovers faster than a TKR. He says it could buy 20 years of time and could be active in sports again. But my research doesn’t seem to support the claim of 20 years. I know it’s case by case. He said that it wouldn’t affect my TKR if I needed one. Excluding surgery center and anesthesiologist it will be around 23K. Told me that if I had to wait 10 months it wouldn’t negatively impact me. Meaning that my knee won’t detoriate drastically.

3) Today I met with another doctor in my HMO. I liked interacting with him. And had a good feeling about him. He thinks an osteotomy is a good idea given that I am in very good shape. He thinks a PKR can affect a successful TKR. He says he usually likes to scope and do the osteotomy together. But unprompted he suggested that we split the surgeries. It would let him get a good look inside the knee before deciding anything drastic. I can get the osteotomy later in the year. I have a slight tilt which he said meant he has to cut very little to get me straightened out. I know I’m not using the proper medical terms.

I am leaning towards the osteotomy only because it preserves the knee for a TKR. I know it’s a tough recovery. But it affects the knee area very little. And who knows what treatments will be available down the road.

I’m even hoping a osteotomy, then a PKR would really delay the TKR.

I have read have two TKRs that the second one doesn’t take well.

We discussed a custom fit unloader brace. I said it was small enough, I might consider it. It would be custom made which might make be more open to it. The beast I wore to try out wasn’t my cup of tea.

I walk fine and not taking anything for pain. I’m just trying to get ahead of this before it can get worse.

What I hate is every doctor has a different opinion!!! Grrrrr!

Once again, I’m super grateful to everyone who has shared their thoughts and experiences.

 

[Celle]

one of the top doctors in the US recommended a partial knee replacement (PKR). He said it recovers faster than a TKR. He says it could buy 20 years of time and could be active in sports again. But my research doesn’t seem to support the claim of 20 years.

What we've found here at BoneSmart is that, apart from the occasional exception, it takes just as long to recover from a PKR as it does from a TKR.
We've had a lot of people who are worried because they were promised a faster recovery, but it didn't happen.

I've had both a PKR and a TKR and my hardest recovery was from my first knee replacement, the PKR.

As for lasting 20 years - yes, maybe, if you're lucky. But many PKRs need to be replaced long before that some even within the first year. Mine lasted for 11 years before it had to be revised to a TKR.