Patient #6 – 52 year old woman with kneecap or patellar pain

About the Patient

This patient complained about severe pain in her knee. She needed to take pain medication continuously to control her pain and still needed a cane to walk. She had had previous arthroscopic surgery on this knee. During the surgery, torn menisci were repaired. However, she had no improvement in pain after the surgery. Since the surgery had not improved her symptoms, previous doctors had recommended knee replacement surgery, an artificial kneecap, or a high tibial osteotomy.

The patient’s x-ray, as shown on the right, showed bone on bone changes in the medial, or inside, compartment of the right knee.

On exam, the patient had pain only in the front part of her knee. The medial side, which looked bad on the x-ray, showed mild tenderness only when it was firmly pressed. Sunrise views (not shown) showed malalignment of the patella in the right knee.

Treatment

Activity modification was tried first. The patient was asked to use crutches to take weight off the knee and stop using her pain medication. She tried this and her symptoms improved for about a week, but then they began to get worse again.

After a discussion of possible options, arthroscopic surgery was decided upon. During the surgery, the medial compartment showed full thickness cartilage damage. However, because the patient had no pain in this area, microfracture was not done. Some loose tissue was carefully removed, but it was felt that disrupting an area that did not currently have pain could do more harm than good. The front compartment (the patellofemoral compartment) showed some cartilage damage, however it was not severe. A lateral release surgery was performed to better align the kneecap so it would not longer rub and wear on the cartilage of this area.

Results

Four months after the surgery, the patient was almost completely pain free. She was taking no medication and she had full range of motion of the knee. She walked with almost no limp and used her cane only occasionally.

Two years later, the patient returned because of problems in her other knee. She was still pain free in her right knee. Although her x-ray still shows bone on bone changes in her medial compartment, she does not have any symptoms from this.