Denovo NT (patella) with TTO

This is my first blog so I’ll give some background.  Anything pertained in this article is solely based on my experience only.  Before my surgery, I was very active and social. I would hike, do pilates, go to the gym, do a little zumba, went out frequently during the week and weekend.  All this changed when I had my first surgery.

I had a failed microfracture in 2011 for chondromalacia patella Grade IV.  Immediately after the microfracture procedure, I had severe pain which was ten times worse than my initial complaints of knee pain.  The pain never went away and as a result of the surgery, I was unable to squat, kneel, or go up and down the stairs normally, couldn’t sit or stand for long periods. ( I was able to do all these functions prior to surgery). I had a feeling (from the very beginning of my recovery) that my microfracture had failed and tried to tell the surgeon.  I was never a medication person, but I was in constant pain and had to take Percocet on a daily basis.  My knee also was still swollen even a year after my surgery. At last, after 10 months, this surgeon concluded that I was not growing any new cartilage based on an MRI scan I had (which I already knew from the MRI taken 4 months postop) and referred me to another surgeon for further options.

I sought the opinions of 6 other surgeons, including the surgeon who founded the microfracture surgery. All these surgeons had differing treatment options.  Some suggested I have another microfracture (which I will never do ever again),  OATS procedure, partial knee replacement and  one suggested I live with the pain and limitation. I am not one to give up and after many endless nights of thinking and praying about what I should do, I found a surgeon worth consulting with.

I went with this new surgeon who made me feel hope again after suffering for a long time. I also felt a sense of confidence in him.  I had the Denovo NT on my patella with TTO (tibial tuberosity tubercle osteotomy) on Sept 2013.  When I saw my current surgeon, we initially planned for the ACI (autologous chondrocyte implantation) surgery. I had gone through the first stage of the ACI surgery which was harvesting my cartilage cells, sending it to a lab in Boston, where it will continue to multiply for a couple of weeks.  However, plans changed after my insurance denied the second stage which was implantation of the ACI graft. Therefore, a second option was the Denovo NT graft.  I am my surgeon’s first Denovo NT patient.

For those having this surgery, please do some preparation. I made sure I had a plastic chair in my shower, outside the bathroom (to prop your leg) when you’re using the restroom, and in my living room.  Another helpful thing was I had a handicap placard from my last surgery. Lastly, I had ordered a bedside commode too late. Believe me, I could’ve used this during the first week of recovery! Please make sure someone stays with you not just for 1 week, but for a couple of months. You are gonna need help getting in and out of bed (initially), going to the bathroom, getting in and out of the shower, getting food and water, etc.  I made sure I had my water and medications within reach. I am a very independent person and I needed help. Lastly, the recovery is based on the patient’s willingness to do some hard rehab work on their own and learning the art of being patient.

My surgeon told me the first two weeks of recovery would be the hardest. He was right.

FIRST week: After surgery, I stayed overnight in the surgery center.  I was discharged the next day. I came home with my knee wrapped up in bandages and my leg in a Ted’s hose. I also had a long leg brace on in a locked position in which I was to sleep with it on. I was also on crutches.The  first week was tough. I was nauseous, in severe pain, weak, pale and had no appetite or desire to drink fluids.  I needed help getting in and out of bed, lifting my leg up, going to the bathroom. I was using crutches, but I felt my leg brace weighed 30 lbs and everything was an effort. I also had a low grade temperature which I had to keep an eye on. I was taking my pain med around the clock to minimize the pain. I needed help lifting my leg up and placing it on the CPM machine the first day I got home. I even slept with my leg in the CPM machine, partly because I did not want to get any blood clots or a stiff knee.  My knee still felt numb from the femoral block I received in surgery.

SECOND week: Still feeling blah.  Still having low grade temperature, weak, pale, nauseous and no appetite. I had to force myself to drink fluids, even if it wasn’t too much. Had my long sutures taken out today and covered with steri strips. I was cleared to do straight leg raises.  Continued to have knee pain, but not as severe as the first week post op.  My knee was very stiff and tight.  I started PWB per the rehab protocol. This is the time to just eat, sleep and get plenty of rest. I also kept using my CPM 10-12 hours a day.

THIRD week:  Got cleared to start Physical therapy. My physical therapist has never worked with a Denovo NT and TTO patient,  however, my surgeon gave me the rehab guideline for Carticel ( used for the ACI surgery) for my therapist to follow. First session consisted of quad tightening, straight leg raises, side leg raises and leg raises lying down on my stomach.  The heel slides (while lying down on my back) were the most difficult because I felt the insides of my knee was being ripped apart with each bend.  I could barely bend my knee (felt so stiff and tight), but I knew it was only my first PT session and shouldn’t be too hard on myself.  I only took off the leg brace when exercises did not require me ambulating. My knee was pretty sore and experienced sharp and sometimes achy knee pain. I was not allowed to have any e-stim or ultrasound during physical therapy ( per my surgeon).  My knee continued to be stiff and tight.

FOURTH, FIFTH AND SIXTH WEEK: My exercises at PT is getting easier. I still have knee pain especially at the bottom of my kneecap. I was cleared to start Aqua Therapy along with land therapy.  It felt good to be in Aqua therapy again.  Getting in and out of the pool is still challenging for now. I had to sit down and use my tush to go down the stairs in order to get into the pool. Getting out I went up the stairs one at a time, however I had to use the trainer to lean on and my crutch to pull myself up at the last step. Once I got in the pool, it felt good to walk finally without the crutches. I was still in pain, but it’s not bad in the pool. I was able to do lateral walk, abduction exercises, step ups and mini squats. My knee is still swollen.  I am now FWB.  I did have a fall followed with a slip at my 6 weeks post op. I don’t know yet if the slip will have an impact whether the denovo graft delaminated or not. I am anxious about it, but I have to forge ahead with physical therapy and pray the fibrin glue was strong enough to keep those little baby cartilages in my knee!  I still have tenderness and sensitivity on my kneecap. My surgeon told me I am still healing. I still have numbness along the lateral side of my knee and a bit on my shin area.

SEVENTH WEEK: I am able to do a full revolution on the stationary bicycle now. The heel slides continue to be a challenge, but it is getting easier. I was very proud of this. My ROM is now 117 according to my physical therapist. I am trying to walk with one crutch, but I think I overdid it or an not quite ready yet to let go of the other crutch. My knee hurts especially on the lateral side. I have a hard time using 1 crutch when I first get out of bed.  I am diligent in doing my home exercises. As much as my PT and I want to be more aggressive with my rehab, we also have to be cautious in overstraining my osteotomy site and my cartilage graft.  I am always using my CPM machine as well. It’s important to also ice and elevate as much as you can. This rehab is a full time job. I have noticed towards the end of this week that the knee stiffness and tightness has lessened.

This journey is a constant roller coaster of emotions. I have felt depressed, beaten down, stressed out, feeling no light at the end of the tunnel, etc.  I consider myself an optimist, but having to go through this for the past 2 years have broken me down. Yes, I have my family and friends to lean on, but sometimes I don’t think they really understand what I am going through. I count the many advancements I’ve made since the surgery to get me through my day.

In my head and heart, I feel this is the final surgery I will have on my knee.  There are times when I feel I am doing great and other times when I question if my cartilage cells are multiplying and filling out the defect in my knee. I sometimes ask myself, “why am I still having this knee pain, did the surgery work or didn’t it?”.  I feel at times I should not be having any pain at all at this time and fear that the DeNovo graft did not take. Other times, I feel the pain is still present because I am starting to really move my joints to build up my muscles again and regain strength. Only time will tell.