Denovo NT underneath patella

[Soccergunner]

I’m 28 years old, 165 lbs and 5’10’’.  Underwent left knee surgery at HSS in NYC (Mosaicplasty/Denovo NT) underneath the patella on Jan. 10th 2011. The cartilage defect was about 1.5 x 2 cm. located right at the center of the patella. The defect was perpetrated by a different surgeon in a different facility about a year ago when he removed a benign tumor (PVNS).

Prior to first surgery I was playing soccer for at least 6 hours a week until I started feeling some discomfort at my left knee at the end of each game. When I first went for MRIs the Dr found a small mass attached to the joint and recommended to go for surgery. After surgery, I went through rehab for months but could never return to sports nor anything involved with running or jumping because the pain.

After several months filled with frustration, I decided to go to HSS in NYC just to see what they could do for me. My present Dr. is a very well known surgeon who specializes in cartilage repair. He recommended to go for Denovo.

During the first month after second surgery, I was on crutches/non-weight bearing and rehab consisted of typical AROM and PROM exercises. On the second month I was allowed to put weight on it, but kept using the crutches for the first two weeks of the second month, and continued with the AROM and PROM exercises. Now in my the third month after surgery, I have recuperated some strenght and most of my muscles are back.  I go regularly to the gym, do lots of quad exercises some light spinning and elliptical, however, I’m still unable to do certain exercises because there is still some pain. I’m scheduled for my first post-surgery MRI this week just to see how much the implant has grown and filled the void. I’m very anxious about this.

The Dr has warned me that complete results can only be expected after six months post surgery. Its been three months and I’m still having difficulties descending stairs and performing certain type of exercises in the gym. I cant even attempt to do some light jogging.

I’ve noticed there are a couple of folks in here who have gone through a similar surgery, How has the rehab been after the third/ sixth/ninth month? . How long did it take you to get back to light jogging/jumping?. Do you still experience any pain.?

[markld]

If you had Denovo ET then you must have been in a clinical trial because ET is not FDA approved yet, unless you had Denovo NT which is an off label product.....
So I take it you must be in a clinical trial?

[ajschnelk]

regardless if you had NT or ET, i would not expect to be able to run at 3months and/or be pain free.  There are folks that are able to run near the 6month mark, but I would have to say typically that's more likely with a defect outside of the patello-femoral area.  Both the trochlea and patella require more time due to the sheer force that is involved.  Some docs that specialize in denovo would say 12+ months before feeling comfortable running, if then. No reason to risk things at  3mos.  good luck!

[Soccergunner]

- Yes, after checking back with my Dr., I found out that the surgery performed was in fact Denovo NT and not ET. Either way I believe there is no much difference in terms of procedure and recovery.

- Its been four months post surgery and I’ve been feeling better every time. I had my first MRI post op. 2 weeks ago and the Dr. was very enthused at the results. The MRI shows a complete fill, those were the words expressed by my surgeon. Even though the density of the implant contrasts slightly with the rest of the natural cartilage of the patella, the fact that the MRI shows a complete fill at three months after surgery is a massive improvement according to the Dr. From what I understood, all its mechanical properties are still developing at this stage. I can now do leg extensions from a sitting position which used to cause a lot of pain weeks ago. I continue to go to the gym and the PT, building up my quads and my VMO’s in particular. Hopefully I’ll be able to start jogging in a couple of months.

[Soccergunner]

 It has now been 7 months since surgery. I saw my Dr a couple of weeks ago, and everything goes well.  I have been working out religiously at the gym every other day , I have actually gained more muscle in my legs than I had prior to my surgery. I am now convinced that the success of a surgery, like the one I had, depends 50% on physiotherapy and rehab exercises. I feel that my knee becomes more stable and pain free as my VMO’s become stronger. 

Even though I just started jogging lightly on the treadmill machine for the past couple of days with almost no pain, I think is gonna take me a while longer before I can start running comfortably again. The Dr has also recommended  me to stop using the Leg Extension machine at the gym, which is the only exercise that still causes some pain. The reason, as ajschnelk points out in his previous post, the shear forces exerted on the patella are too strong and causes some irritation.

Even though I’m still on the road to full recovery, I believe this procedure was the best option and fully recommend it.

[Jwin138]

Hey Soccergunner,
Glad to read you are doing so well!! how are you now? I see my dr again next monday to discuss Denovo or ACI for 2 grade III lesions under my patella (he thinks it might actually be 1big lesion since the pc between the 2 might need to be replaced) -  I see you had a pretty successful patellar cartilage surgery done in NYC! would you mind emailing me the name of the surgeon? I dont think I can PM you as this is my first message on the site (although I am a daily KneeGuru forum reader ! this site has helped me so much!) My contact : Jwin138@Aol.com

28 yo Active female.. now.. very inactive.
2009 - Rt knee plica excision
May 2011- Rt knee daily pain! countless therapy, shots, pills, RICE, MRI, Xrays (none of these tests caught the lesion!)
Sept 2011 - Debridement arthroscopy found 2 Grade III patellar lesions...
now waiting to see if I am a good candidate for ACI or Denovo. Doc says the lesion may been too big for microfracture...

[Jwin138]

Hi All - So my rt knee pain never went away after the debridement in September and I went to another doctor - a cartilage specialist- who also recommended the Denovo procedure - but to be conservative and safe that this is actually the surgery I need - we did a diagnostic scope this past Tuesday - where he found a central chondral lesion under my patella (the surgeon from September said it was medial) and measured to be 18mm x 8 mm (it is indeed a flap that is very close to coming off and not 2 seperate lesions).

So right now my current doc wants me to heal from this diagnostic scope and see him in 10 days to get the sutures out and discuss my treatment options for surgery in January.
He mentioned an AMZ/osteotomy/TTT procedure that helps increase the success of the patella denovo surgery - but in all honesty - that procedure scares me to death!!
I am not sure how my cartilage degeneration happened - it may be from needing a lateral release a few years ago (that I declined to do at the time bc of all the bad stories i read - how its overdone and i only had a slight tilt.. I opted to only have a plica dissection and i was fine for 2 years!!until i stretched in bed and felt a pop and had pain 5 days later for the past 5 months)

My current doc told me he does do a lateral release at the time of denovo to get better access to the patella - so I am not sure if the LR will be enough to help the aligment issue casued by the slight tilt or if i would need an osteotomy...

I am leaning toward not doing the osteotomy - since it may not be needed. I am doing more research and reading through all of your post op diaries, and posts and trying to come to an educated decsion.

thanks for reading my post -
I am also trying to find a way to post private messages to a few ppl that I would love to speak to - so I will be hitting the game bulletin board I guess!

Jessica

28 yo Active female.. now.. very inactive.
2009 - Rt knee plica excision (declined to do LR since felt excessive)
May 2011 and on- Rt knee daily pain after heart pop during stretch! countless therapy, shots, pills, RICE, MRI, Xrays (none of these tests caught the lesion!)
Sept 2011 - Rt knee Debridement arthroscopy found 2 Grade III patellar lesions...
Nov 2011- Rt knee Diagnostic scope confirmed lesion to be cause of pain and need LR 18mmx 8mm lesion

[Soccergunner]

Hey Jessica,

Sorry I didn’t get back to you sooner. Its been 11 months from my last surgery and up until now I've beeing doing ok. I havent been able to play soccer again because I still feel some instability and some discomfort in my knee. Even though I religiously continue to go to the gym every other day, (and have strenghtened and increase the size of my quads, adductors and abductors) there is still some level of instability and yes, some insecurity when it comes to running and/or jumping.

The only way I can run comfortably is right after I finished working out at the gym. Ususally, after doing some spinning bike for like 15 mins and doing some lunges and other leg exercises for like an hour or so, I then get on the threadmill and run for like 10 mins or so.  At that moment I feel that my muscles surrounding my knee are tight and restrain my kneeecap from moving out of place and allow me to do things that otherwise I wouldn’t be able because the pain. Once I have ran for like 10 mins or so, I then begin to feel some minor pain right at the affected area and then stop.Hopefully things will change, and will be able to run comfortably again, but for now I continue on my road to recovery.

One thing, that you mentioned on one of your previous post, is that your Dr told you that he needed to do a AMZ/TTT to get access to your patella. I had a NT Denovo at the mid region of the underside of the patella, and my Dr did not have any incovenience turning my patella face up and implanting the cells (the pics prove it). The tendons should be elastic enough to do this. Maybe I'm missing something??

On the other hand Its good that your Dr. recommend you to continue doing PT before the surgery. Try to put some weight on your routine, and increase the intensity of your workouts moderately, traditional PT exercises alone don’t help a lot, you have to do your homework as well. Attached you will find some links of good exercises I found online.
http://www.physioadvisor.com.au/8290850/quadriceps-strengthening-exercises-vmo-strengthe.htm
 
Again Good Luck,
Soccergunner

[Jwin138]

Hey Soccer gunner - thanks for getting back to me!
yes, I am in the 'pre surgery' PT for 6 weeks in hopes of A) not needing surgery at all ??!!! and B) healing from the diagnostic scope i just had in November to diagnose the size of the lesion and C) gaining some strength before surgery in January/February

My Doc said he does the lateral release in order to get to the underside of my central patella, and the AMZ/TTT is done to unload the force onto the patella to help increase the chances of the Denovo grafts success. (I have a slight lateral tilt and tight lateral reticulum(spelling??) causing a slight tilt.

The AMZ/TTT part of surgery scares the **** out of me.. but Im reading, being told and advised by my doctor that it will increase the chance of success of the denovo...

Sorry to hear you are having trouble running / jumping. I hope that you will continue to improve since the recovery may be up to 16months
(i remember reading that somewhere)

Thanks for your link! and advice. Right now I will give PT all the energy I have.. but I have doubts it will knock out the need for surgery as I still have pain at rest..

good luck to you as well..

[RunnersKnee2009]

I was diagnosed with chondromalacia patella about 2 years ago (MRI and XRays). I went through the normal process of PT and NSAIDs that allowed me to regain exercising and focus on non-impact strength training. The last couple of months have been rough with constant pain while sitting, driving and sleeping in some positions; walking, stairs etc is fine. Got a second MRI in November and looks like the articular cartilage has worn through on the patella and the articulation part of the bone. I am 36 and have been a runner for about 20 years until 2 years ago.

I have been seeing an OS from HSS that visits the clinic at work once a week and is planning to give me Synvisc next week to see if it will get me through for some time. Else he wants to do micro-fracture arthroscopy.

I was hoping you can email me the doctor you dealt with at HSS (mistralvr6@gmail.com) as I want to look into Denovo NT as a possible option as it seems less "invasive" ...  also how was your experience at HSS?

Thanks.

[surfbum]

I was diagnosed with chondromalacia patella about 2 years ago (MRI and XRays). I went through the normal process of PT and NSAIDs that allowed me to regain exercising and focus on non-impact strength training. The last couple of months have been rough with constant pain while sitting, driving and sleeping in some positions; walking, stairs etc is fine. Got a second MRI in November and looks like the articular cartilage has worn through on the patella and the articulation part of the bone. I am 36 and have been a runner for about 20 years until 2 years ago.

I have been seeing an OS from HSS that visits the clinic at work once a week and is planning to give me Synvisc next week to see if it will get me through for some time. Else he wants to do micro-fracture arthroscopy.

I was hoping you can email me the doctor you dealt with at HSS (mistralvr6@gmail.com) as I want to look into Denovo NT as a possible option as it seems less "invasive" ...  also how was your experience at HSS?

Thanks.

If the only thing being offered as an option is microfracture, you're not seeing a true cartilage specialist. I unfortunately was subjected to a microfracture (we didn't see damage before hand on MRI) and I wouldn't wish it on my worst enemy. Archaic procedure with 30% success rate (according to my OS who is a cartilage specialist).

[paininmytrochlea]

My 2 cents, or 3 I guess as I actually am somewhat in the field--

1. Microfracture has been shown to be extremely poor for the patella. It works best for small contained lesions of the condyles, and less well for the trochlea, and poor in the patella. A good review of cartilage restoration techniques: http://www.laboratoriosilesia.com/upfiles/sibi/T12071003.pdf

2. Synvisc for a 36 year old? That's generally a temporizing solution for people much older (and less active) than you... Def doesn't fix the underlying problem, and you have a definite problem given that you are on this site and complain of worsening MRI and pain. Certainly many cartilage defects are asymptomatic (61% of men in the NFL combines had cartilage injury by MRI, 17% full thickness and they were obviously pretty good symptomatically).

How to fix the underlying problem? Fix alignment if needed, meaning possible lateral release, distal femoral and/or high tibial or tibial tubercle osteotomy.  ACI with realignment does much much better than ACI without realignment. (Most Denovo NT rehab protocols and theory follow ACI.) Fix the cartilage (Debridment, Microfracture, OATS, allograft, ACI, Denovo NT). I don't believe OATS and allograft are performed on the patella, you are currently failing debridement, and mfx doesn't do well, as above . That leaves you with  ACI and Denovo. Every case is unique, and malalignment and/or kissing lesions will complicate if not exclude you from certain procedures. 

Find a cartilage expert who can work with you on this stuff, or at LEAST one who is comfortable and has done lots of ACIs.  I get the general feeling if a surgeon has done lots of ACIs, then they are really cartilage guys who know all the tools...and Denovo NT is technically much less demanding than ACI (no periosteal patch harvesting, no sewing to cartilage).  By expert I mean either a guru like Mandelbaum, Minas, Gillogly, Farr, Marcus, Cole (There is another famous guy in NM, and one in Alabama, i believe) OR someone very familiar with their work and up to date on new cartilage resurfacing technologies.  As an example, I emailed Zimmer to find out who they supply Denovo NT to, and that's how i found my surgeon. 

Attached is a capture of the first Denovo NT study. PM me if you want the whole thing; too big to attach. I also have a .ppt on Denovo from David Caborn, MD

[RunnersKnee2009]

Thanks for the messages Jwin. Shoot me an email as I cannot repond to messages here for some reason (mistralvr6@gmail.com) and I will share some information with you regarding your current doctor - NY is a small world when it comes to some of these OSes

I went to a Sports Medicine place and saw the doctor there to get a second opinion on the MRI. His recommendation was to start with Synvisc and some more PT to continue building up my quads since he thinks the right quad is still weaker than the left. He also said that given my age, I should try and avoid thinking surgery at this point and try building muscle and manage symptoms for some more time with Synvisc/Cortizone/Prolo. I am not on any pain killers at this time and the last few days have been quite tolerable as well.

I have also started communication with Dr. Dunn (www.iagh.com) to get his take on my condition and keep that open as a possible option for regrowing cartilage using his IAGH shots. His rehab process seems to mimic ACI/Denovo as well with crutches for a month or two etc. But after reading about Denovo NT and Soccergunner's improvements, I think Denovo may be a better option - now if I can convince my OS about Denovo. Else I may go see Soccergunner's OS at HSS for an opinion as well who works with my OS.

I will keep you guys updated on my progress but for now I am hoping to delay surgery for a little bit.

[paininmytrochlea]

I'd be highly skeptical of any intra-articular injection claiming to "regrow cartilage."  While such procedures may decrease symptoms such as pain and clicking, do you really think itra-articularly injected cells will somehow layer into the defect and figure out what USED to be there, and create the complex archicture required?

I'd love to read some articles on it.  Injecting ANYTHING (stem cells, growth hormone, steroids, synvisc) into a joint is easy. if it this IAGH thing really worked, people would be doing it left and right.  On Dr. Dunn's website he lectured on it in 2002...what's been happening the last ten years?

[RunnersKnee2009]

Agreed Re: intra-articular injections - but he has had success regrowing cartilage. As as Dr Hauser at CaringMedical ... not sure why this is not mainstream yet. However, I do agree with you that something like Denovo where there layer the juvinile cells on the affected areas is a better procedure. I hope I can hold on for a couple more years until Denovo becomes more mainstream.

I am trying to trim back my active lifestyle to maintain the knee and am trying to find out a good set of exercises to continue building muscle on the legs. For cardio, I am going to try freestyle swimming once or twice a week and see how that goes.