Osteonecrosis of the knee

[artsprite]

I just got a depressing diagnosis of Osteonecrosis of the femoral medial condyle in my right knee. I had an MRI to find out about a torn meniscus, which I also have, and I'm having surgery on Dec. 20th. But, the MRI also showed the Osteonecrosis. The doctor is going to try to drill holes in the affected bone to stimulate some new blood flow to the area to try to revive the dead bone. I asked about bone grafts, but he didn't think that would be a viable treatment. It will eventually mean a knee replacement, and at this point the surgery to fix the meniscus will not have the desired effect of reducing my pain because of the necrosis.

What do you think this will mean in terms of my diving? I'm afraid that carrying the weight of the equipment will aggravate the codition. I haven't asked my Orthopedist about this as he will not know the extent of the necrosis until he looks inside of my knee. I have an idea that it's not going to be pretty, and I'm pretty upset about it right now. ;-0

 

[artsprite]

Well, now I have read some articles on the Internet, and people with rheumatoid arthritis and Lupus are at risk for this disease. I don't have either of those, but I do have Fibromyalgia. FMS is an immune system disease like RA and Lupus. People with FMS have a problem with lack of oxygen getting to the tissues and brain. I also read that divers who have had the bends are at risk for osteonecrosis because nitrogen bubbles can destroy bone marrow cells. I wonder if scuba diving with Fibromyalgia could have caused this condition.

Any ideas docs?

 

[Walter]

From the NOAA Diving Manual:

"Bone necrosis seems to be a significant occupational hazard of professional divers, caisson workers and other who spend great amounts of time compressing and decompressing at depth. There seems to be a definate relationship between length of time exposed to depth and bone lesions, although cases have occurred with minimal exposure."

Hope this helps.

DSSW,

WWW™

 

[Ladydiver]

Hi Artsprite,

I am sorry to hear about the worsening situation with your knee. I hope for your sake that the attempt at stimulation works.

From what I understand about knee replacement surgery, it is not as bad as it sounds. My grandmother has had both of her knees replaced in the last 4 years. She actually has titanium joints. She has to carry a card with her when she flies so she can get through the metal detector. We even tease her about being the bionic woman. (hehe) She is now able to do things she hasn't been able to do for years and part of her rehab was swimming.

I don't know what, if any, increase risk there would be of DCS when diving after a knee replacement. I just wanted to give you what little anecdotal experience I have had. Good luck to you.

 

[artsprite]

It's not the replacement surgery I'm afraid of. My father is 77 and snow skiis 3 times a year on his two replacements, and one of them is 12 years old. I just don't know how bad this is yet, and most people get it in other joints as well. It's whether or not I can dive anymore that I'm thinking of, and the fact that it means more pain than I'm already in from my Fibromyalgia (which is severe). This is a disease that you can get from dicompression sickness, so I don't know how wise it would be to keep risking the nitrogen in my body when it contributes to this. But thanks for the encouragement.

 

[BillP]

Hi Patty:

It's virtually impossible to tell a particualar individual what a particular diagnosis means to their diving from within the confines of an Internet message board, but maybe some general information will help.

Osteonecrosis means death of bone. The list of medical conditions that can lead to osteonecrosis is quite long. Diving is one possible cause of osteonecrosis, but it is only rarely the cause of the condition in recreational divers. Osteonecrosis in divers usually is seen only commercial/military decompression divers and caisson workers. (In divers it is sometimes called Dysbaric Osteonecrosis.) It often affects the shafts of the long bones of the arms and legs, but when it does affect the bone next to a joint it is usually in the shoulder or hip. It is uncommon to see it in the bone next to the knee joint in divers.

Osteonecrosis of the shaft of a long bone is usually asymptomatic and doesn't affect the diver. Osteonecrosis next to a joint can lead to damage of the joint and is much more serious. As you've already mentioned, weight bearing and carrying heavy objects can hasten the appearance of bone collapse and joint injury. The disability of the joint damage can be severe enough that some diving authorities recommend that commercial/military/caisson divers stop diving once they have the condition next to a joint. This precaution seems to be based more on a concern about accelerated injury to the bad joint from activity and also the possibility of a second joint being affected (an unlikely event in a recreational diver) leading to a worse total disability rather than other concerns. Osteonecrosis is so rare in recreational divers that I don't know that there's a "party line" for recommendations for those divers.

Lesions in the shafts of long bones generally do not require treatment. Treatment of osteonecrosis next to joints is difficult and often unsuccessful. Joint replacement is indeed sometimes necessary.

You can read what Scubadoc has to say on the subject at:

http://www.scuba-doc.com/Dysost.htm

Hope this helps,

Bill

 

[artsprite]

Thank you for the excellent information BillP. I had already read scubadocs article. That's why I'm concerned with further damage from continuing to dive. I don't think I'll ever know if it's safe, and I haven't made a decision. I don't want to make the condition in that knee worse. So far, it is not present in the left knee. The doctor drilled 7 holes in the dead part and said it is the size of a dime. That seems like an awful lot of holes. He said we'll just have to wait and see if it helps. I think I must have started getting it before diving because I haven't been diving very long, but I wish I knew what future effects it would have on that knee.

 

[BillP]

Hey Patty:

It's a tough problem, and I wish you well with it. Statistically speaking, recreational diving is so unlikely to cause osteonecrosis that more diving probably wouldn't cause an extension of a pre-existing lesion or development of new lesions, but any kind of increased weight bearing or stress on the affected knee could injure the joint. Of course, if you plan your trips carefully, there are ways around carrying heavy gear and diving in difficult conditions. I can't personally recommend it, but some people do continue to dive with osteonecrosis. (One of my good dive buddies has it.)

I found another link for you to read- more from a medical and less from a diving perspective. Take a look at:

http://www.merck.com/pubs/mmanual/section5/chapter53/53a.htm

HTH,

Bill

 

[artsprite]

More good information from you BillP. I'm kind of laughing because I had already read the Merck Manual too. My husband is a pharmacist and we own that book, but ours is an old one, so I looked up the new version as one of my first sources online. I go to it for all kinds of medical information. I broke the kneecap in that knee 21 years ago, and this is my third surgery on that knee, but my ortho said that injury didn't cause the osteonecrosis. I suppose if I'm headed for a replacement anyway with it, there's nothing really to fear from diving now. I just hate to hasten the inevitable. I've heard of wheels you can put on your tank so it can be rolled along behind you, but I've never seen them in a catalog or in a store. I could always get in the water and have my gear handed to me so I can don it in the water, but there are some times where that wouldn't go over very well. My swampster buddies were sooooooooo nice about carrying my gear the last time we dived together, but that walking into the water with everything on my back is still difficult just with my Fibromyalgia. I probably shouldn't be diving with it anyway. It makes that condition flare up so bad I'm in bed for a couple of days afterwards anyway. I know I shouldn't lift the weight of the equipment. I guess I wish there was someone who could just come right out and say yes or no about doing it in the future. How does your friend handle the weight of the equipment, and is his in the hip or knee?

 

[artsprite]

I called DAN today after my first post-op visit with my orthopaedist. My ortho said 6 to 10 months healing for this kind of surgery, but if I felt good enough for my trip the first week in May to the BVI's, go ahead and dive, it was my decision. That didn't sound very wise, and I had planned on calling DAN after this appt. anyway, so I called. My ortho is good, but doesn't know about diving. He had said that my broken kneecap 20 years ago probably didn't have anything to do with this, but the DAN doc said it and the fact that I once took low dose of prednisone for over a year probably did cause it, and fibromyalgia made that worse. The doc I talked to said that "nitrogen is NOT my friend" LOL. I knew that. Anyway, he said that the purpose of the surgery drilling 7 holes in my osteonecrosis is to get oxygen to the bone via blood circulation (I knew that too). He said that diving during the healing period would definitely disrupt the healing process and be a bad thing. In fact, he said that ever diving again would probably be a bad thing. The fact that I have Fibromyalgia makes me more at risk for decompression sickness than normal people, and when you figure the osteonecrosis in there, that it just may not be worth the danger. I have to seriously rethink diving as my sport completely. The earliest he would even consider it would be 1 yr. and osteonecrosis takes so long to show up that I could have it starting somewhere else and not know it until it's too late. He gave me the name and number of a diving medicine specialist in a nearby city, and to have my ortho talk to him. I may go to see him. So, the whole reason for my being certified has flown out the window by this diagnosis. I am very depressed. I have already given up so many sports for having fibromyalgia, and now this. I'll wait until I talk to the specialist before I decide to sell all the new equipment I just bought, but what a bummer. I'm sitting here with my knee hurting like the dickens feeling sorry for myself. I guess it's snorkel time for me. ;-0