New Member, I am having ACI in mid October, Help!

[cdubb]

Youthist,
Are you home yet?  Mine will all be done outpatient and I'll probably be sent home about 3 hours after it's done.  Seems kinda scary for the magnitude of the procedure, but a lot of people have also been done outpatient on these boards...even when the AMZ is done like I'm having.

Markld,
I did e-mail my docs PA yesterday because I was curious about the Denovo you mentioned.  She said it is a different and newer technology and that it's use in the patellafemoral joint doesn't have the data to support it's effectiveness, so it isn't being used for patellafemoral lesions as often yet.   Makes sense to me....traditional ACI wasn't initially used on patellafemoral defects either.  It also didn't have very good success rates until they combined it with the AMZ. 

[Youthist]

Hi cdubb,

No, I am in tonight as well.  It is a two night stay , likely to go home later tomorrow as well after some more physio sessions. I cannot actually believe this op can be done as an outpatient.  I needed the morphine drop all day yesterday and all last night, and needed to be with nurses around me - I was basically pretty much unable to move - no idea how this could be done as a day patient!

Today they have taken me off the morphine first thing this AM - and doesnt my leg know it. A lot more uincomfortable / painful today despite lots of painkillerrs being taken orally.  I am sitting up in bed right now with an aircast ice packet around it, and it feels GREAT.

Other points from today
 - took some tentative steps down the corridor earlier with the crutches with physio with me, slow and steady but fellt ok
 - I have just had the dressing changed, they have removed all  bandages - seeing the knee / leg exposed was quite a shock, with the staples, shape of the leg and numbness to the touch etc. It didnt look like my leg / knee, if that makes sense.
 - have to start with the basic physio movements as much as I can right away, static quads and straight leg raises I can do but need a lot of concentration and effort to do a few.

Dr Skinner came to see me earlier, and he actually did two grafts yesterday, one to the medial lesion, and also he has grafted some to the patella as there was quite a bit of grinding and scraping when trying to do an open chain movement prior to the op. He says this will make that a lot smoother later.

Thats about it for now, I am going to be going home tomorrow but they want me to do stairs with the crutches first.

[cdubb]

A lot of docs here do them outpatient. I've been in contact with another one of my docs patients who had an ACI/AMZ last year and he said it was manageable and that his first day and a half were actually okay and that the severe pain didn't set in until day 2 post op, so if that's the case, in or outpatient shouldn't make a difference.  He also had a 4 hour car ride home after it.  I think they inject a bunch of long acting numbing agents into the knee, so it's not until that wears off that you really feel the pain. Due to the magnitude of operation, going home does seem a bit daunting though, but enough people do it, that I figure I should manage okay.  Not that I actually have a choice in the matter. 

Glad to see that you're up and about. Will they send you home w/ a CPM?

[Youthist]

I am not home yet, going home tomorrow.

However, now the morphine has gone (this morning, so like about 10 hours ago, its 7pm here) and I have been on time based oral painkillers, I have been in agony for the past 3 hours, so I guess that is about 36 hours after the op.  Had  my allowed dosage at at 6.00pm but I am definitely struggling.
Have put the aircast back on (you have to open the brace to do this, which leaves you feeling a bit vulnerable) and am just putting ice through it for 15 mins then taking it out for 5. It  is at this point saving my sanity, thank god I have one.

[mlashmar]

cdubb - amazed that you are having done as an outpatient, I would much prefer to be admitted and on morphine, I was very happy with that despite a relatively small repair site.  Personally I would challenge your doc on that and seek to be admitted, it would be a benefit to have the physio and doc check you post op, it is not a minor procedure such as an arthroscopy.  They do use a nerve block, but that tends to wear off after 24hrs (which is the likely reason for Youthist's increased pain).

Youthist - hang on in there, it does calm down and will get easier by the day!  Ice is just great, even now after 8 weeks!

[Youthist]

Cheers for the words - I am hanging in. Been on the Aircast and just putting icy water in for 15 and taking it out for 5 for the past few hours. It has really helped.  I just need to stay focussed on other things but damn, it was tough earlier. And seeing the leg with no bandage was a bit of a shock too.

[Rennschnecke]

I think a lot of people in the US have ACI on an outpatient basis or 23 h stay.  This is an insurance issue and the Drs have honed their procedures to make this possible.  The main thing to check with the OS is provision for pain relief.  The only problems I've come across are where the patient has left hospital with insufficient meds causing them to go to ER later – not brilliant for the knee.

It appears that post-op procedures are not standardized.  Hence, I did not have a nerve block, morphine or a PCA post-op.  I also struggled to get any ice whilst I was in hospital.  (I couldn't believe that the orthopedic hospital had no ice whatsoever.)  Even the times when I had a cryocuff changing the ice was haphazard and at times like that quite frankly I'd have been better off at home.

Dr Minas is a leading OS for cartilage repair so will be well up on the latest practices for ACI in the US.  So I imagine that anyone having this procedure outpatient will be well catered for.

Hang on in there, Tony.  It sounds like you're getting good attention.  It will be better before you go home.

[Melissa S]

Tony,
Good to hear from you and glad to see everything went smoothly with you.  So I am assuming they had you stay overnight in the hospital.  Do you just stay one day? 
As far as I know, I will go home the same day of surgery.  I am surprised that they are saying you are PWB right away.  They are telling me NWB for the first 6 weeks approx.  I guess it is a difference in doctors and a difference in location of lesions.  Mine is under the kneecap.  Just hoping for success because from what I read the patellar ACI's have the lowest success rate.
Good luck and keep us updated with how everything goes when you get home.

Melissa

[cdubb]

Melissa,
Patella ACI's' do have the lowest success rate, but when they began combining them with AMZ's the success rates jumped dramatically. Something like from 50% to 80%.  Below is a link to an article my Dr. co authored that was published last October discussing these findings.

http://www.cartilagedoc.org/downloads/knee/Autologous_Chondrocyte_Implantation_Patellofemoral_Joint_Outcomes.pdf

If for some reason the link doesn't work, just go to www.cartilagedoc.org and go to the resource library, knee library and then I think it's like the 9th article down.   Also, if you go to the knee video library, there is a video of a patella ACI being done, which is pretty cool to see.

I know your doc says your alignment is fine, but it's my understanding that the AMZ unloads the defect and protects the graft even if you don't have an alignment issue.  I know that all docs have different theories and approaches based upon their experience, but it's worth asking about just to confirm why he doesn't feel that it is needed.  Perhaps he feels yours is a traumatic defect and that unloading wouldn't be of benefit since it wasn't caused by maltracking?  Now clearly, my Dr. was co author of this article and study and I pulled it from his webpage, so of course he is a proponent of the AMZ done in conjunction.  There may be other studies out there that support different theories. 

Courtney

[Youthist]

Tony,
Good to hear from you and glad to see everything went smoothly with you.  So I am assuming they had you stay overnight in the hospital.  Do you just stay one day? 
As far as I know, I will go home the same day of surgery.  I am surprised that they are saying you are PWB right away.  They are telling me NWB for the first 6 weeks approx.  I guess it is a difference in doctors and a difference in location of lesions.  Mine is under the kneecap.  Just hoping for success because from what I read the patellar ACI's have the lowest success rate.
Good luck and keep us updated with how everything goes when you get home.

Melissa

Hi Melissa I Have been in for two nights, and had my op right at the start of the first day, 0800. Going home later today (so arrived Saturday 0700, op at 0800, going on Monday afternoon). I have needed the time tbh, and I am apprehensive about going home today if I am honest. PBW is really me touching my foot on the floor while taking most o fthe weight on the crutches.

Dr Skinner has explained that putting pressure on it from standing is a "good thing" as it actually presses down on the grafts and pushes them where they want to be pushed, and encourages growth. Its the shear / twisting / sideways movements which are a total no-no, and the brace prevents those from happening. The brace is a lot more uncomfortable as well now they have removed the bandages. I have been up this AM and crutched to the toilet on my own, and had my foot touching the floor with each step of the crutches (but I would hardly call it weight bearing, its too painful - but there is very light rolling on the floor of the foot while cruthces bear 99% of the weight).

He also told me he did graft the knee cap as well so I had two grafts, one of kneecap and one on medial femoral condyle, as I was getting  painful scraping and clunking during an opening knee bend while in a sitting position.  I didnt lknow he was doing the patella, he just did it at the time of the op based on what he saw.

I have just woken from my second night (first night off morphine) and got about 4 to 5 hours rest, I had a sleeping tablet as well as various medium strenght / strong oral painkillers.  

I already have it in the aircast  cyro cuff / cooler and icing it - I cannot recommend this highly enough to anyone coming up to have the operation.  Note I bought mine for £115 last week only to be told yesterday that the hospital provide them free of charge for the aftercare period :-) - So look out ebay once I recover!  So you might want to check if you get provided one before you splash out. But if they dont provide, its the best money you will ever spend.

Overall the  second night is defintitely worse than the first as I dont have the morphine to rely on, so you deal with the pain and discomfort.  You also look forward to the time when u get to have the next set of painkillers!  

I am currently 46 hours post op.

cheers all, I hope this is helping, but as I am sure you know, everyones experience will be different and I am sure yours will be. if anyone has any questions I can do my best to answer them!

[Melissa S]

Courtney,
I will ask about it, but what he has told me in the past is that my defect wasn't caused by my alignment.  It was caused by my injury.  So I believe that is why he doesn't feel the AMZ is necessary.  He said my outside ligament was a little loose and that he might have to tighten that up while in there, but other than that,  just the ACI.  I am glad I won't have the AMZ but hoping it won't hurt my chances of success.  I will discuss this with him at my next visit.
Tony,
It is funny how all doctors and different locaitons do things differently.  I imagine it would be good to stay the night at the hospital but I don't think I will unless there are complications.  I am already scheduled to see my therapist the day after my surgery which I am sure will not be a fun trip.  Here's to painkillers right?  Does anyone else hate the way they make you feel though?  I had morphine after my son was born, C-section and I didn't enjoy that at all.  Painkillers in general just make me feel really off.  Oh well, I bet I am begging for them after this though, haha.

[Youthist]

Yeah re the morphine -  they actually took me off Morphine and changed to something else that was morphine based but slightly different (dont know what) after about 6 hours after I complained about the way it was making me feel when I closed my eyes (and it wasnt good, hard to explain, but bad imagery etc). When they switched,  things were a lot better in that regard, so if you are not feeling great on Morphine make sure you tell someone.

I seriously cannot understand how this op can be done as an Outpatient! Please be careful to all those people doing that and make sure you have someone at home that will be with you for the next 48 hours!

I am back home now on the sofa, not completely comfortable but sitting up with the air cast on (of course) and feeling ok.  about 60 hours post op now.

Going back to see the consultant in 3 weeks, and having the staples out in about 10 days.

Can move the knee to the  full 45 degrees set on the brace when laying down but still lots of swelling and tenderness involved, plus still some bleeding from the lower end of the wound.

[cdubb]

Youthist,
It really is fascinating how hospital stays, post op instructions, wound closures, weightbearing status and rehab protocols are all so different for the same or similar procedures.  People really do this outpatient all the time over here...even mine which is combining the AMZ with the ACI, as well as a scope on my other knee.  So, I'm having a major op on my left knee and a minor op on my right and still being kicked out home 3 hours later! My husband will be home with me the that until the following Monday when he'll return to work. So that's 5 days post op until I have to spend any length of time alone. 

Do they have you in a CPM? I have to be in one for 6 hours per day for 6 weeks. Luckily, I can break up that 6 hours anyway I want. If I'm lucky enough, I'm hoping to be able to sleep in it, but I'm not banking on it. It will make a return to work earlier more viable if I can sleep in it.

Take care, rest up and keep us posted.

Cdubb

[Youthist]

Hi cdubb.
No to  a CPM machine at this point -  I just have a few simple excercises (bend to 45 degrees, straight leg raises, etc) to do for the first week and of course ice ice ice - and then seeing the physio for my  first post-op-  session  on saturday, so one week post op.  But at the moment no plans for CPM. 

I can "walk" with the crutches now and put my foot relatively firmly (flat down)  on the floor,with both crutches supporting me,  and I just did the stairs in my house without too much trouble - slow and steady though! 

re different treatments for post op etc - I think this might well be due to the exact positions and sizes of the lesions, the condition of the knee in general, plus a million other factors that the surgeon decides during and after the op? PWB was definitely a nice surprise to me , pre-op I was being told simiar to you, NWB for 3 to 4 weeks.

anyway, its a relief being back home and starting to try to relax - but I wont forget that hospital stay  in a hurry!  Will keep posting any changes to this thread.
Good luck everyone who has one coming up.....

[cdubb]

You seem to be getting around pretty well now if you were tackling stairs! Yeah!

I agree that some of the different rehab protocol, weight bearing, etc do have to do with the defect location, size, etc. , but there are still some pretty big differences even for similar procedures.  I have been told that I'll be 20% or heel touch weightbearing for about 4 weeks, then can increase a bit after that and by 6 weeks full weightbearing.  I don't really know how you assess 20% though??  The weight bearing protection though is due to the AMZ and allowing bone to heal and if I was just having the patella ACI, I would be permitted much more weightbearing much earlier.  Whereas Melissa who is also having a patella ACI was told NWB status for several weeks and she's not having the AMZ portion.  I think a lot is physician preference and what their influences are in determining the protocols.