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Dr. Phil, MD
Dr. Phil, MD, Medical Doctor
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Follow-up question on the surgery to my knee and recovery.

Customer Question

Follow-up question on the surgery to my knee and recovery. I am home now and can cite the procedure in detail from the hospital report:

".....through an inferolateral portal the knee had a grade II chondromalacia, which was debrided. The lateral compartment was clean. Crucial ligaments were intact. Medially there was a complex tear of the posterior horn of the medial meniscus, which was resected using upbiting shaver to a stable rim. Chondroplasty of the medial femoral condyle was carried out. It had a grade II lesion which had significant delamination of the weightbearing dome. The wounds were irrigated free debris."

Does the above in any way mitigate the justification for the Chondroplasty? I would hope that the surgeon would use good judgment as he is the chief of orthopedic surgery at two of the hospitals in my city and also named one of the top five orthopedic surgeons by his peers in my city's magazine. However, I do realize the no physicians is perfect and that surgeons sometimes have a tendency to due surgery than to rely on less conservative methods. After the surgery though, I did see through an internet search that he was cited by the FDA in 2004 for violations of procedure in a trial procedure for not properly informing his patients among other violations.

Secondly, following up on my prior question, can further exercise, especially riding of bike for significant periods, still build the fibrocartilage to help the knee recover and fill in the areas, including the area that is causing my knee to click, or is it too late? The prior doctor from this site recommended two hours a day in 15 minute intervals; however, he or she merely cut and pasted that recommendation from a web site. If beneficial, however, I would be willing to do this, or certainly step it up from three times a week thirty-minute bicycle rides. I could also again start doing the exercises I was doing in therapy, especially those that build up the quadriceps. Your thoughts?

Thank you!
Submitted: 3 years ago.
Category: Medical
Expert:  Dr. Phil, MD replied 3 years ago.
Hello. I would like to help you find an answer.

I will get back to you in morning.


Please reply
Customer: replied 3 years ago.
Thank you for your assitance. I know it is a complex subject. I appreciate that you are taking the time to analyze my condition. Let me know if I can provide you more information. I have access to all my medical records; e.g., pre and post surgery MRI; hospital surgery report; x-ray.
Expert:  Dr. Phil, MD replied 3 years ago.

Let's go back for a minute.

 

Did you ever question the surgeon about this?

Customer: replied 3 years ago.
Let me go over my records, and I'll get back to you tonight. Thanks for the interest to ask follow-up questions.
Expert:  Dr. Phil, MD replied 3 years ago.
You're welcome.
Customer: replied 3 years ago.

About six weeks after surgery, when my knee was not healing as fast as expected, I asked the doctor about the recovery time, and he showed me a model of a knee and pointed to some cartilage on the knee that would take time to heal. I didn't really understand what he was talking about until I saw the bill and saw that I had two charges from the doctor: one for a meniscopy and another for a chondroplasty. So I looked the term up on the internet and was dismayed by the number of people who talked about long recovery times fro chondroplasty, and by medical web sites that said it was even common in high school kids (usually girls), but that in most instances physical therapy is tried before surgery, and that type 1 is usually not even distinguishable (surgeon cited type II in hospital report).

So I tactfully bring up the subject of the need for the chondroplasty, and he showed me a page full of circular slides taken during surgery that showed fragments rather than clear edges. The doctor said that the chondroplasty would help put off arthritic advancement by ten to fifteen years. In a later appointment, I asked him if the chondroplasty was purely preventative or whether it was needed for the tear, and he said it was not just preventative, although I got the impression he was just trying to appease me. Thoughts on this?

So after the appointment, I thought that although it may not be standard procedure to do a chondroplasty with stage 2, that in the instance of performing a meniscopy, and the knee already being "opened", that surgeons may routinely debride and shave rough cartilage. I still don't know if this is standard procedure. Your opinion?

I have notes from an appointment I had with the surgeon on 8/23/10, where I noted that dull pain is present when I walk, with the degree of pain varying. I also noted that my knee was popping right above the patella when I extended my right leg. I told him I also had pain when squatting, and he told me to avoid this.

The doctor stated that if I would continue riding my exercise bike that the fibrocartilage should fill in. He also recommended gludosamine/chondroitin supplements which I take daily.

As noted earlier, I have concerns over the results of a 9/20/10 MRI ordered due to my concern for knee pain, with stiffness and popping. The doctor wanted to rule out a new tear. The results of the MRI had the following impressions:

IMPRESSION: Postop change of the posterior horn medial meniscus. The signal in the posterior horn extends to the tibial articular surface maybe slightly more prominent, but is probably related to postop status. Findings suggestive of a small new tear at the apex of the body segment medial meniscus. A new tear in the posterior horn lateral meniscus also. Chondromalacia of the posterior articular surface of the medial femoral condyle may be slightly more prominent. Chondromalacia of the patella, stable. Continued on page 2.'85 Probable mild tendinosis of the distal quadriceps tendon and proximal patellar tendon. Possible chronic strain of the ACL.

My surgeon dismissed the tears as MRI artifacts as he said he did not see them when he did the surgery, and I had no pain on the outside of my knee. However, he did not specifically bring up the radiologist's impression of findings of a small new tear at the apex of the body segment medial meniscus, which gave me concern in that the absence of pain on the outside of the knee would not rule out a new medial tear.

The findings on the MRI are, with areas I find of concern bolded:

There is a slight amount of fluid within the knee joint felt to be within physiologic range, and it is also smaller when compared to prior study. Minimal signal intensity to the articular cartilage patella is noted with a tiny surface irregularity to the lateral patellar articular cartilage near the junction of the facets, stable. Area of cartilaginous hyperintensity and irregularity to the posterior articular surface in the medial femoral condyle appears to be slightly more prominent than before with possible slight subchondral edema, series 3, image 9. There is interval blunting of the apex of the posterior horn medial meniscus most likely postsurgical in nature. A small hyperintense signal oblique in manner extending to the tibial articular surface of posterior horn medial meniscus is seen such as on image 7, series 2 appear to be slightly more prominent than before. This is probably due to postop change. There is a new horizontal to slightly oblique hyperintense signal to the apex of the body segment of the medial meniscus seen best on series 2, image 6. This may be due to a new tear. The rest of the medial meniscus is normal. The lateral meniscus reveals a hyperintense signal at the tibial articular surface of the posterior horn, image 22, series 2, which is more prominent than before and also seen as an oblique line on image 7, series 4. This is concern for a new tear. There is no definite tear of the retinacula patella, medial and lateral collateral ligament complexes, distal quadriceps tendon, patellar tendon or popliteus tendon. There is minimal signal to the distal quadriceps tendon and proximal patellar tendon on fat sat images maybe due to focal tendinosis. No popliteus tear. No definite ACL or PCL tear. There is slight increased signal to the distal portion of the ACL not significantly changed maybe due to some chronic strain.

Question: Should I be concerned over the above MRI? Even if no new tear is present, I am concerned with the many references to postop changes, and areas noted a more prominent than before. Is this normal? Should I be concerned?

At my 9/19/11 appointment I brought this up and he stated that it was the result of the surgery and that at this time he had hoped the fibrocartiage would have filled in this area. In your opinion, with stepping up my bike riding (prior doctor on "Just Answers" recommended two hours a day in 15-minute intervals, although he or she just cut and pasted the recommendation from a web article as I cited earlier), could this area still fill in, or is it as good as it gets by now? What aggravates me about this is that the clicking is often cited as a reason for surgery; yet for me it was the result of surgery! I take it that this is not normal? Is the clicking on leg extension permanent or could it still go away with increase exercise and fibro cartilage fill in?

I had a follow-up MRI on 11/30/10 with the following results (different radiologist):

FINDINGS: There is stable mild generalized deficiency of the medial meniscus compatible with post surgical change of prior partial meniscectomy. At least 75% of the medial meniscus is remaining. There is a stable tiny intermediate linear hyperintensity involving the undersurface of the mid to medial posterior horn of the medial meniscus compatible with residual postoperative meniscal signal. No new medial meniscal tear is seen. A stable tiny horizontal linear intrasubstance hyperintensity is seen in the posterior horn of the lateral meniscus that closely approximates the undersurface of the meniscus and might represent Grade III signal of a meniscal tear. The cruciate and collateral ligaments are intact. The extensor mechanism is intact. The visualized bones are intact. There is minimal lateral subluxation of the patella. There is slight heterogeneous signal alteration and surface fibrillation of the lateral patellar facet compatible with Grade I chondromalacia, which appears relatively stable. There is stable focal mild cartilage thinning of the posteroinferior lateral medial femoral condyle at the level of the posterior horn of the medial meniscus compatible with stable chondroplasty of previously seen Grade II chondral lesion. Articular cartilage of other portions of the medial compartment and lateral compartment are normally maintained. A minimal knee effusion is present. No popliteal cyst is seen. Visualized muscles about the knee are unremarkable.

IMPRESSION: Status post partial medial meniscectomy. No evidence of recurrent meniscal tear. Stable appearance of possible horizontal undersurface tear of the posterior horn of the lateral meniscus. Intact ligaments. Stable Grade I chondromalacia of the lateral patellar facet and focal mild cartilage thinning of the posteroinferior lateral medial femoral condyle at site of prior chondroplasty. Minimal knee effusion.

Question:
Again I see reference to postoperative changes. Is this normal? I am concerned with the statement that, "There is stable focal mild cartilage thinning of the posteroinferior lateral medial femoral condyle at the level of the posterior horn of the medial meniscus compatible with stable chondroplasty of previously seen Grade II chondral lesion.", because in my last appointment with the doctor on 9/19/11, he was more cautious about me running than before. In prior appointments he advised me to run on a soft surface, but at this appointment he specifically mentioned the thinning of my cartilage and that I may run but that I should limit my running due to this,although he approved tennis and light basketball. Is this thinning a part of aging wear and tear, or was it due to the chondroplasty? Since my tear occurred with very little stress on the knee (just from getting off a chair), maybe the tissue had just worn out over time? The doctor told me to come back in the spring, and stated that if I was still experiencing problems he would order another MRI.

I know this us a lot to cover, but I would appreciate it if you could go back and read my question(s) from the beginning and give me your opinion about the surgery, the MRI results, and recommendations for further action; e.g., new MRI; hydrolauic acid injections; physical therapy; exercise limitations; second opinion from another orthopedic surgeon in different medical group (I am in a PPO); etcetera. I used to really enjoy running if even for three days a week and took pride in that I still had very good speed for any age, and would, for example, often sprint out to my mailbox just for the joy of it, or run back and forth at good speed on the basketball court for fun and exercise. And I took pleasure in the interval training because I often found the long,slow jogs boring.

At this point I am wondering whether I even should have had the surgery because I felt OK a couple weeks prior to the surgery (about three months between injury and surgery). However, for several weeks I was limping, and I would still feel mild pain when descending stairs and if attempted to due a full squat, so I went ahead with the surgery because I figured it was pretty minor, having heard that recovery usually takes only a few weeks. Further, my surgeon stated that waiting could make the condition worse, and that since the tear was in a white area, it wouldn't heal because it wasn't in an area with blood supply. The surgeon also stated that although I felt my knee was better it was only because the (torn?) flap had fallen back in place temporarily. Does this make sense?

The doctor said he would try to repair rather than remove part of the meniscus (which I now wonder if even a possibility since the tear was in a white area). I believe I still have a very slight limp now (at slow walking speed my right foot is in contact with the ground slightly longer than my left foot; surgery was to the right knee).

So I've thrown a lot at you, and I really appreciate your time, and will give positive feedback and maximum bonus if you can address the above! Thank you so much, and feel free to take your time in responding.

Expert:  Dr. Phil, MD replied 3 years ago.

1)Chondroplasty is both. He probably felt that since he was in the knee already that he would save you some arthritis down the road but didn't think of potential complications.

 

2)See above-not standard but it is done occasionally.

 

3)Yes, post op changes on MRI are normal. They may always be there.

 

4)I would not start running yet. I would continue with PT for up to a year to try and get this healed up

 

5)Hindsight is 20/20 but it appears now that probably should not have had the surgery although its still early and you may improve with proper PT over time.

 

6)Yes, that makes sense and it could have healed on its own.

Customer: replied 3 years ago.

I don't fully comprehend your response given the information I supplied regarding my condition. I know the subject is complex, and perhaps I am asking a question that is too in-depth for an on-line format, or that is difficult to answer without having been present at the time, or seeing me in person, or is difficult to answer for a MD that does not specialize in orthopedics.

 

The orthopedic surgeon told me that my tear was in the inner part of the meniscus, and that the inner two-thirds of the meniscus lacks a blood supply. From both what the surgeon told me and in the medical literature, without nutrients from blood, tears in this "white" zone cannot heal. These complex tears are often in thin, worn cartilage. Because the pieces cannot grow back together, tears in this zone are usually surgically trimmed away. The prior doctor on "Just Answers" stated that "Complex tears have to be removed by surgery for fear of future infection and knee problems" Given the preceding, I don't follow you statement that I should not have had the surgery and that it could have healed on its own.

 

Now the knee did start feeling better for a while prior to surgery, then it got worse again, and then it got better again for a couple weeks prior to surgery. The surgeon stated that waiting could make the situation worse, and stated that it probably "got better" because the torn flap had fallen into place, but that if I did something like sprinting it could have caused further damage. Your opinion on the preceding sentence?

 

The chondroplasty is another matter. I am still not certain this was necessary; however, it may be standard practice while performing a meniscopy if fibrillated (ragged) and damaged joint surface is found, that the surgeon will debride or shave that area in the hope that the healthy joint surface will heal over the defect.

 

According to the hospital report of the surgery:

 

"Through an inferolateral portal the knee had a grade II chondromalacia, which was debrided. Medially there was a complex tear of the posterior horn of the medial meniscus, which was resected using upbiting shaver to a stable rim. Chondroplasty of the medial femoral condyle was carried out. It had a Grade II lesion which had significant delamination of the weightbearing dome."

 

Perhaps such procedure may not be taken without the mensicopy, but when the knee is already being operated on and the defects are found, the above procedure is performed? I believe this is the view of my surgeon when he showed me the slides taken from the surgery that showed the jagged cartilage edges. The prior doctor on "Just Answers" stated that "Chondroplasty can be done while doing meniscopy as you had chondromalacia and a second operation is not advisable as cartilage repair can be performed as a single procedure. You had osteoarthritis prior to the surgery mostly between the small knee bone (patella) and the long bone of the thigh (femur).

Perhaps in most patients this has a beneficial effect, but for whatever reason (either my anatomy, or poor surgery, or other reasons the chondroplasty had a deleterious effect on me). So at this point I really don't know definitively if the surgeon was too aggressive or following accepted practice.

 

Do you know if the above is standard practice?

 

If a chondroplasty is done, I still don't know if it is done to help relieve the current systems that brought you to surgery, or if it is strictly preventative in nature. Your opinion?

 

I am concerned about the popping/clicking of my knee (just above the patella) when I extend my leg, especially since the literature states that this is can be sign of damaged cartilage, and I did not have this prior to surgery. The surgeon stated he hoped that this would have filled in with fibrocartilage by this time. I have made an appointment to see my orthopedic surgeon is a couple weeks, and will ask about the advisability of another MRI, continued physical therapy, exercise guidelines, and whether I can obtain a referral to a physiatrist. Any other questions that you believe I should ask him? I want not only the best recovery, but piece of mind, but I don't know if I should challenge or ask for justifications at this point.

 

Thank you for your help!

 

Expert:  Dr. Phil, MD replied 3 years ago.
I will review your case more and these questions thoroughly and get back to you. Probably tomorrow.
Customer: replied 3 years ago.
Ok. Thanks. Awaiting your reply. Let me know if you need more information, or if you feel another physician has special expertise in orthopedics.
Expert:  Dr. Phil, MD replied 3 years ago.
Sorry, I haven't had time to review. Can you reply to me tomorrow morning so I can review it?
Customer: replied 3 years ago.

That's fine. I know the question is a bit lengthy, and takes time for a thorough review. Thank you.

Expert:  Dr. Phil, MD replied 3 years ago.

1)This was not necessarily your source of pain. It could have contributed to the problem but the torn flap not healing may have simply gotten better over time. It's hard to say. The reason I suggested waiting instead of surgery is that you are young and these things tend to get better over time. You could have always had surgery later.

 

2)This is pretty common but I wouldn't call it "standard practice". It depends on the surgeon.

 

3)It is preventative.

 

4)I would just be honest and ask him if its too early to say that you should not have undergone surgery. It still may be too early but he will be able to give you an honest opinion regarding all of this (hopefully

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