Questions about next steps and what it all means

[ColoradoSnowman]

I have a bit of a weird life style, I've been working internationally for the US gov in a developing country, a job coming to and end in a few weeks and I'm returning back to the USA for good and will be in a position to start dealing with my left knee.

About a year and a half ago we were evacuated from our post due to COVID and I was home in Colorado for the winter, while there I cleverly I injured my knee skiing on a double black diamond. As this was in the middle of COVID, pre-vaccine I decided to tough it out wait for the swelling to go down, skied the rest of the season with my left knee kind of being weak and taking time to warm up but it was OK. Once I had a bad flare up when I was experimenting with single knee bends and the knee gave way, sharp pain, swelled up a bit, took it easy for a couple of weeks. Sharp pain at a given angle of pressured knee bend, while doing yoga it felt bruised inside, and I had the sharp pain in a lunge position with the left knee extended behind me, but not if it was the bent front knee baring most of the weight.

Anyway eventually saw a knee doc before leaving returning to post, X-rays looked good, he said to PT it, offered a shot but I declined. So returned to post in a developing country that was in crazy endless COVID lockdown doing my PT exercises, kind of getting better, then while lightly playing some basketball with my teenage son, the knee started to ache feel worse and I eventually had to limp off. That was last August and the last time I have been able to do any kind of dynamic movement.

Eventually got an MRI in October "Left knee pain secondary to patellofemoral chondromalacia. There are 2 small patellar chondral defects, one on the lateral facet with near full-thickness cartilage loss with underlying subchondral bony edema. There is a smaller more mild chondral defect on the medial facet just medial to the patellar apex with moderate chondral thinning and mild subchondral bony edema. There are 2 trochlear chondral defects. There is a near full-thickness to full-thickness chondral defect of the central trochlea with mild subchondral bony edema. There is a near full-thickness to full-thickness chondral defect of the lateral trochlea with moderate subchondral bony edema. This is likely the most significant lesion."

Did a telemedicine with my knee doc back home, he said I shouldn't be as bothered by it as I am but to continue PT and when I got back, which I now am this June, we could revisit but he said there weren't great options mentioning microfracture, ACI, etc.

So continues to be a problem/somedays better some days worse, knee isn't hot, isn't visibly swollen, absolute pain is bearable except when knee is bent under pressure, through PT I've gotten to the point that I can get down the stairs relatively pain free, the leg is clearly smaller than the right, but I've always been a non-competitive athlete, MTB, ski, hike, trail running.

Now that I am going back home I really want to pick back up those activities. I can't imagine doing them in my current state, should I steel myself for the fact that PKR/TKR my only answer going forward?

Thanks

 

[Layla]

Hello and Welcome to BoneSmart! Thanks for joining us.
This is a decision between you and your surgeon, but ultimately yours alone once you weigh out all of your options. If the state of your knee is limiting your mobility, causing pain and interfering with life, it may be time. I’ll leave some pre-op reading material that includes a Score Chart that may interest you. I wish you the best as you contemplate options and make decisions.

KNEE PRE-OP
If you are at the stage where you have joint pain but don't know for sure if you are ready to have surgery, these links may help:
Score Chart: How bad is my arthritic knee?
Choosing a surgeon and a prosthesis
BMI Calculator - What to do if your surgeon says you're too heavy for joint replacement surgery
Longevity of implants and revisions: How long will my new joint last?

If you are at the stage where you are planning to have surgery but are looking for information so you can be better prepared for what is to come, take a look at these links:
Recovery Aids: A comprehensive list for hospital and home
Recliner Chairs: Things you need to know if buying one for your recovery
Pre-Op Interviews: What's involved?

Regardless of where you are in the process, the website and app My Knee Guide can help you stay organized and informed. The free service keeps all the information pertaining to your surgery and recovery in one place on your smartphone. It is intended to be a personal support tool for the entire process.

And if you want to picture what your life might be like with a replaced knee, take a look at the posts and threads from other BoneSmarties provided in this link:
Stories of amazing knee recoveries

 

[ColoradoSnowman]

Thanks I guess the question I have is for the hive mind. Does the MRI report look like something where a MACI type things would be possible or likely TKR only option?

 

[Jamie]

@ColoradoSnowman I'm afraid this is something that is best addressed by your surgeon, as Layla mentioned. There are other factors that need to be considered beyond just the report you have received from the MRI. Procedures such as microfracture may not be the best option to get you back to the active life you desire. Usually with these treatments, a person must be a good fit for the procedure in order to realize lasting improvements. When they are done on a less-than-ideal candidate, it can just delay the inevitable joint replacement surgery and mean you are dealing with a diminished lifestyle for an extended period of time.

If the suggestion from your surgeon is to have a joint replacement, it is possible for you to return to the activities you mentioned once you have recovered from the surgery. Because you have problems in more than one compartment of your knee, if a joint replacement is advised, you might be better off to consider a full TKR instead of a partial. I would suggest that you consult with one or more other surgeons before making any decisions so that you get the benefit of several sets of eyes on your knee.

Please let us know how things go for you. Have a safe trip home!

 

[Jockette]

I agree with Jamie about getting more than one opinion. I regret that I didn’t do that.

Partials can be iffy, if not done by a surgeon who really does a lot of them. Some members are happy with their partials, some are not, and I am not happy with mine.

And if you want to picture what your life might be like with a replaced knee, take a look at the posts and threads from other BoneSmarties provided in this link:
Stories of amazing knee recoveries

 

[ColoradoSnowman]

Thanks so much for the input everyone.

It is hard when your job, in this case serving my country precludes you from getting proper medical care. With the time growing close that I can actually take action about this, the level of disfunction on my knee has become a more prominent issue in my mind. While overseas doing whatever unnamed stuff I do, other than keeping healthy having a good knee is neither here nor there, going home where I want to hike and bike and ski, suddenly my feeling that I can no longer do that becomes a big deal.

From what I read here from everyone, if I am a fit 51 year old athletic type with no issues other than my knee who is dedicated to remaining active there is no reason to believe that even if it comes to a TKR I should be able to move around again freely with strength and confidence, right?

 

[Jaycey]

if I am a fit 51 year old athletic type with no issues other than my knee who is dedicated to remaining active there is no reason to believe that even if it comes to a TKR I should be able to move around again freely with strength and confidence, right?

Absolutely! TKR is not a life sentence - it's a new beginning. Plenty of our members return to very active lives post joint replacement.

Have a good conversation with anyone you are considering working with. It is important to let a surgeon know your expectations.

 

[Irongirl56]

Hey Snowman, I was where you are, unable to do the activities I wanted to ie biking, running, hiking etc
Had 2 meniscus repairs, one of which failed and finally a medial partial knee replacement. I was trying to train for 2 Ironmans and my knee kept side tracking me so finally did the surgery. I am now about 1 year out, knee pain has been gone for awhile and I am almost back to my previous level of activity (I train about 15hrs a week) although not training for an Ironman this year. I have done numerous trail races and have a couple of shorter triathlons on the schedule this summer. I am also planning a multi day backpacking trip in Sept.
A replacement if needed is not a sentence to life on the couch, it is actually very freeing as the pain is finally gone.
I am a retired Air Force Nurse and understand ”serving your country” and I thank you for your service.

 

[ColoradoSnowman]

Hey Snowman, I was where you are, unable to do the activities I wanted to ie biking, running, hiking etc
Had 2 meniscus repairs, one of which failed and finally a medial partial knee replacement. I was trying to train for 2 Ironmans and my knee kept side tracking me so finally did the surgery. I am now about 1 year out, knee pain has been gone for awhile and I am almost back to my previous level of activity (I train about 15hrs a week) although not training for an Ironman this year. I have done numerous trail races and have a couple of shorter triathlons on the schedule this summer. I am also planning a multi day backpacking trip in Sept.
A replacement if needed is not a sentence to life on the couch, it is actually very freeing as the pain is finally gone.
I am a retired Air Force Nurse and understand ”serving your country” and I thank you for your service.

Thank you so much for your post and thanks. I take heart in messages like yours that suggest that one way or another I’ll be able to regain reasonably full use of my leg and athleticism. It would crush me to think I am just on a long slow downward slide. 10 days till my deployment is over, 14 days until I finally get to meet with my knee doc face to face and start working on a plan.

 

[Roy Gardiner]

I want to hike and bike and ski

I neither hike nor ski, but cycle to a competitive level (those against whom I 'compete' would laugh, mind...). It's better than before BTKR. By a long way.

I have a friend who is a ski instructor for whom his biological knee is now his weak one.

Take heart!

 

[ColoradoSnowman]

I want to hike and bike and ski

I neither hike nor ski, but cycle to a competitive level (those against whom I 'compete' would laugh, mind...). It's better than before BTKR. By a long way.

I have a friend who is a ski instructor for whom his biological knee is now his weak one.

Take heart!

Thank you. I do take heart in this. I’m just so tired of the pain, limitation, and continual weakening, I get used to things only getting worse. Thanks for the assurance things can get better

 

[Roy Gardiner]

Things WILL get better. No doubt.

 

[ColoradoSnowman]

Quick question to the hive mind....I want to get a second set of eyes on my knee. I live in Durango CO, so super outdoor town, lots of blown out knees, I have no reason to be unhappy with the doctor I've got locally.

Do you think it is worth making the trip to Steadman Clinic in Vail (4-5 hours away) both for a second opinion and to have TKR if it comes to that?

 

[Jaycey]

If you have a surgeon you want to see in Vail then you need to weigh up all the pros and cons. Traveling 4-5 hours for any procedure and the follow-up appointments may be difficult. You would need to stop at regular intervals during the journey as sitting for long periods post TKR is difficult.

Having said all that many surgeons are scheduling remote follow-up appointments these days. It's worth having a discussion with the surgeon's office.

 

[InkedMarie]

I personally could not travel that far for non life threatening surgery. Best case scenario: your new knee surgery goes as it should and you only have to go back to see the surgeon for regular post op visits...however often that is. Worst case scenario: you don’t have a textbook recovery and need to see the surgeon more often. How often are you willing to travel so far?

Things to ponder....

Marie

 

[ColoradoSnowman]

Well my wait is finally over, I returned home and saw my knee doc. Long and short of our plan and my interpretation is: the bone spacing looks really good on X-ray, but clearly my leg is atrophying due to pain from the 2 patellar chondral defects (small) and 2 full trochlear chondral defects (larger). Because the knee looks good on X-ray and my age (51) he wants to proceed conservatively.

So I got a steroid shot today, plan is to really work the PT and other exercises as much as I can while under steroid effects and see where the knee is at at 3 months.

At month 3 if not in the right place, we try PRP see if it can make things good enough (he really doesn't want to cut into my knee unless we need to)

If PRP doesn't work then he thinks I should go to Vail's Steadman Clinic for a consult to see what they think about ACI/OATS and whether it would be worth it at my age.

If that doesn't see like a workable treatment he said a pkr is all he's recommend as the meniscus is in good shape, all damage is at the patella/trochlea.

So that's my plan, hopefully I can regain enough strength and function that I can put off next steps for a few more years, or if not at least I have a road map forward.

Thanks for all the support, it really helped me when I didn't have access to direct medical consultation..

 

[Irongirl56]

Snowman, sounds like you have a great plan in place. Please keep us updated as you work through your treatments. I am very interested to hear about the PRP as I think the evidence on efficacy is mixed but fingers are crossed if you would need it for it to work for you.

Definitely keep us posted on how things are going!

 

[ColoradoSnowman]

Well 3 months of PT did very little. I went back into my knee doc today, we'll probably do viscosupplementation because it is covered by insurance but he seemed pretty unexcited by it. He seemed to prefer PRP but I don't see how that would do much and he mostly agreed.

So we went over my MRI again and he said that my knee looks really good except for the patellofemoral. 2 focal lesions on the patella and 1 on the trochlea. He wants me to consult with Steadman clinic in Vail as they are the regional experts in regeneration, but we both agreed it is hard to imagine that they will say I am a good candidate for OATS/MACI because of my age (52) and the multiple defects, but as overall my knee pretty good he wants me to explore this before looking a PKR.

He told me flat out that no ethical surgeon would do a TKR on me because my knee looks too good except where it doesn't, which to his eyes are clearly focal and limited to patellofemoral compartment. So now I spend a couple hundred on a consult to tell me I'm not a good fit for MACI. I get a couple of shots to see if I can make it through a ski season (doubt it but worth a try) and then go do a PKR I guess. I told him I wanted to run, ski, hike and otherwise enjoy my life post PKR and he said I'd be able to do so without restrictions. I live in an outdoor adventure town so I think they get a lot of young athletic knees. I also asked him about experience. He said that their in house surgeon does ~500 knees a year and that he does plenty of partials

thoughts?

 

[ColoradoSnowman]

OK so the viscosupplementation didn't do much, my knee continues to get worse.

I had my consult with the Steadman clinic the Doc there says my knee looks pretty good from MRI and x-ray, but obviously the focal lesions on my patella and trochlea are a problem for me. He said some folks with this sort of damage are out running ultra marathons, others may be disabled. I'm in-between.

He suggested a scope + PRP, he gave it about 40% chance of helping. He said once inside he could tell whether an OATS or a PFJ would be more appropriate. He said that with how the damaged lined up that MACI wouldn't be appropriate.

So the thing is this guys is clearly an expert. He is the PFJ guy for Steadman and does hundreds of these a year. He writes papers, works with NBA players, etc, etc. The problem is Vail is 5.5 hours from Durango. The local surgeons don't offer OATS and if they did, they wouldn't be doing many of them. Likewise we have good surgeons here, they may do 300 knees a year, but probably only do a small number of PFJs annually not hundreds.

So is it worth it to go down the road of working with a surgeon which I need to get a hotel room in Vail (time and $$$$) for every checkup or work with qualified local surgeons?

 

[DJL1967]

Well for what it's worth I took two flights and a total of 9 hrs travel time to have BTKR's. For me it was worth the pain and discomfort as 14 months later I am finally feeling normal again and resuming an active lifestyle. Skiing will wait at least a couple more months as I want to work on my quad and hamstring strength before I hit the slopes.
Is it an inconvenience having to travel post surgery, yes but I would definitely do it all over again. I had a few appointments virtually and 3 in person so it really wasn't that bad.

Good luck and all the best with your situation.