Knee Condition
Short Summary

33-year-old male underwent reinsertion operation + stabilization of the right knee due to complex capsule-ligamentous laxity. In consequence of recent  trauma he started suffering from pathological condition of the knee: swelling with consequent pain and motor activity difficulty. The first orthopaedist suspected a lesion of the internal meniscus, the second diagnosed medial meniscus rupture and weighty laxity of the knee ligaments. The third orthopaedist diagnosed varus right knee with medial compartment chondropathy and patellar synovitis. In the meantime, the patient underwent rehabilitation exercises and rested.

Patient's Questions
Even though the advised treatments are completely different between them and also, in both cases, surgery is required, the patient asks for answers to the following questions:
 
1)         What, do you think, is the cause of the right knee problem? (meniscus? Ligaments? Off-axis tibia?….?)
 
2)         What therapies would you recommend? For these therapies which could be the times and guidelines expected either for an eventual surgery (including rehabilitation exercises) or for alternative therapies?
 
3)         Which are the most qualified doctors and centers where these therapies are performed in Italy?
Medical Background

Sex: male,
Diagnosis: Right  Knee Condition
Anamnesis:
In 1992 ACL reinsertion operation + stabilization of the right knee using the Lemaire procedure due to complex capsule-ligamentous laxity.
Case history:
In consequence of trauma due to sliding down the stairs, a swelling of the left knee appeared, blocking the knee bend and total joint extension with consequent pain.
On 06/2008 an orthopedic visit was, therefore, performed by Dr. X who clinically suspected a lesion of the internal meniscus with indication to carry out a CT scan for the meniscal examination as not indicated MRI for the presence of steel screw as a consequence of 1992 operation.
With CT scan examination and respective medical report on 06/2008, the patient saw another specialist, Dr. Y, whose diagnosis was medial meniscus rupture and weighty laxity of the knee ligaments (LCA and LCI), he advised the patient to undergo a ligament reconstruction operation or to live with this pathology.
For a further opinion, the patient, on 07/2008, saw another orthopaedist, Dr. Z, who, on the contrary, didn’t find either a lesion of the ligaments or of the meniscus, assessing that the problem was an Arthrosinovitis of the right knee in degenerative phase (patellofemoral and medial compartment chondropathy) at the surgical site for ligament lesions.   
For a diagnostic analysis Dr. Z asked for a standing view X Ray of the right knee and additional projections on 07/2008 and diagnosed "varus right knee with medial compartment chondropathy and patellar synovitis (after post ligament reconstruction). Arthroscopy + tibial valgus osteotomy for adduction correction was, therefore, recommended.
In the meantime, as recommended by all the doctors that were asked, the patient underwent rehabilitation exercises and rested (water gymnastic, clay packs, ice and less possible weight-bearing on the joint) that in several days led to a decrease of the articular perfusion with knee joint improvement. But, unfortunately, as soon as the patient started his daily activity again (not sporting activity) the pathological condition of the right knee came back as it was previously (swelling with consequent pain and motor activity difficulty).

Expert's Opinion

From the written information I received, I understand that since the operation this gentlemen led a reasonably normal life .
There is no indication of timing, but this patient sustained a trauma to his Lt knee, while sliding \ falling down stairs , as a consequence swelling of the left knee appeared as well as limited range of movement (“locked knee”).
From the information gathered until now I understand that the problem is on his Lt Knee and he was operated in the past on his Rt knee. 
 
From looking at the CT some degenerative changes are evident more so on the medial compartment. Some artifacts strikes in shape are noticed probably related to the staples that where inserted during the previous surgery.
The CT was of very little help as far as I am concerned.
In reference to the other doctors that examined the patient, I would have to suggest that probably we are looking at a combination of meniscal damage, instability , degenerative changes and deformity.
I would have thought that, it is fair to say that MRI is a good investigation in this case, in spite of the fixation devises the patient has in his operated knee .
As I mentioned before it is not clear what knee we are dealing with, if it is the left knee I think an MRI + an arthroscopy and according to the findings to proceed either with meniscectomy , or reconstruction of A.C.L, or H.T.O or any kind of cartilage repair or any combination from the mentioned procedures.
Conservative treatment, consisting from: physical therapy, hyaluronic acid injections and glucoseamin is an option, but at 33 years of age I would prefer a ”mechanical” solution rather than palliation .
Answering your questions:
1 My first choice is MEDIAL MENISCUS second ANTERIOR CRUCIATE
third COMBINATION .
Axis deviation is a possibility but I wonder why the pain followed a trauma?
2 I would offer an arthroscopy andprobably reconstruct the A.C.L this is a procedure that has a 3 week short term rehabilitation to bring the patient back to daily living. And 3-6 month to light sports.
H.T.O has about 6 weeks short term rehabilitation and 3-6 month later on, depending on the method that the surgeon will choose .
3 The best Doctors in Italy that I know are:
-        Puddu Giancarlo Puddu, MD
-       Paolo Aglietti, MD, First Orthopaedic Clinic, University of Florence
-       Maurilio Marcacci , BOLOGNA, IT

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