Pretty awesome stuff

[janee.taco]

Hi etrusc,

I was wondering if you had any idea why your MFC graft didn't harden as well as your other grafts?  How many months post-op should one expect a graft to reach its maximum hardness?  I am 17 mos post ACI on my MFC and was scoped a month ago to remove a membrane that was covering my graft and causing pain.  My graft was described as somewhat soft, which is really concerning me.  Could I expect my graft continue to harden at this point?

Any info/advice is greatly appreciated!

Thank you

[scmba]

Hi Everyone

Just wanted to give an update (and increase my posts so I can eventually PM).  I had both knees MRI'd and left is a patella lesion, roughly 30-40% of the patella and the right is a kissing lesion (Patella lesion 50% of surface, and Lateral Trochlea lesion (not sure of size, but longer and narrow).  Was pretty down when I actually saw this and I am so lucky to have people on this site to help me. 

My Stanford docs want me to just do a scope/lateral release on my right and since my left if so messed up - just get Suparz shots.  My SF doc says to do TTO & DeNovo (or ACI) on both and I go see Mandelbaum on Tuesday.  I'm pretty sure he'll say do DeNovo on both, but not sure about TTO.  I know TTO has better success, especially with the kissing lesion - but I'm trying to convince myself that a lateral release on that one will move it enough so it won't shear the same place. 

Does anyone know the recovery time/difficulty between DeNovo/ACI along vs. DeNovo/ACI coupled with TTO?  I'm sure its longer, but really, I'm not sure how much longer.  I know its more painful.

Also, I'm reading that Osteotomies last only 8-10 years?  Is this for HTO, TTO, or what?  I know its About.com, but their articles are pretty legit overall and if you google osteotomy, they do generally say the same thing.

http://orthopedics.about.com/od/hipkneearthritis/a/osteotomy_2.htm

Excerpt:

"How successful is this surgery?
When done in the right patients, knee osteotomies are usually successful at decreasing pain caused by arthritis. They surgery tends to last about 8 to 10 years, and after that time, many patients will require total knee replacement. In a large group of patients, knee osteotomy gives good to excellent results in about:

80% of patients for 5 years
50% of patients for 10 years
30% of patients for 20 years
Because of this, knee osteotomy is generally reserved for young, active patients, who want to delay the time until knee replacement. "

Then people move onto TKR?  If so, I am depressed!  Is that true if you are doing ACI/DeNovo?  I think I don't know the difference between HTO and TTO.  My SF doc said HTO is much different than TTO and that osteotomies only lasting for 10 years is hogwash and old material.  What do you guys think?  Also, is TTO/AMZ/Fulkerson the same thing?  How is it different than HTO?  Is it reasonable to assume you can be "fixed" for life if the TTO and DeNovo success?  Or is this just a stop gap? 

Here's the thinking:  I'm 41 and needabout  40 years of good knees.  If I go thru 2 years (assume getting 1 Denovo alone, 1 DeNovo w/ TTO) of PT to recover and get 10 years more, then I'm done at 51.  Still got 15-20 years till you can do TKR.  Not a great tradeoff - I want 20+ years!

My wish is that DeNovo data comes out saying its lasts, replaces ACI, they find it hardens at 8-12 months, and becomes the gold standard.  Then medical device companies make minimally invasive instruments to deliver DeNovo for new and "touchups" and they find it can be reapplied as needed.  Of course, I'm dreaming, but that would save many of our knees.

If anyone has insight on the osteotomy questions I had above, would appreciate it.  Thanks!

[scmba]

Cdubb - hope you are doing well.  Wondering if you got your DeNovo/TTO and would love to hear how it went and how you are doing!

[cdubb]

Hey scmba,
I did get my patella DeNovo NT with the AMZ as planned on Dec. 13th.  I'm just over 5 weeks post op and doing quite well.  I seem to be doing better at this point than I was when I had my other knee patella ACI/AMZ.  I think there are a lot of factors involved with that though and not just the graft material.  My core and hips are stronger overall and I was in better shape coming into this surgery than last surgery, which just makes everything easier and my left knee defect was also slightly larger (20 mm x 20 mm for left knee vs. 18 x 15 mm for right knee)..plus having been through it before, I am no where near as uptight about everything as I was last time.  I'm more comfortable with knowing that the osteotomy and the graft are not as fragile as one might thing...essentially....as long as I stay within the guidelines established by my physican's protocol...I'm fine.  At 5 weeks, I'm not 50% weight bearing, but in all honesty, I think I could bear more weight...just don't want to exceed what I'm supposed to do.  I should be able to ditch my brace at 6 weeks post op, only a few more days left in the CPM...can't wait to not be tied to that thing 6 hours/day!!  I returned to work this week, but only from home still.  I started driving this week also, which even though it's my right knee, it's no problem at all.  I probably could have driven earlier, but for the fact I'm 5'11" and have long legs and just didn't fit until my brace was able to be unlocked to 60 degrees.  I'm going to return to the office next week.  It's right at the point I'll be able to ditch the brace and begin weaning off crutches, so it will be a lot to put on the knee to have to be up all day with the leg down, no brace and weaning off crutches, but I did it last year at the same point and other than some increase in ankle swelling, I wasn't worse for the wear.  I think it actually helped me to lose the limp and get a normal gait back more quickly.  Hoping this time around it will be the same thing.  As everything else has been easier to date, I'm hoping the process of weaning off crutches is also...although, I suppose it's not really a race and I should be safe and take my time... 

So, that's where I'm at.  Things are going quite well.  Also...I recall some discussion about the DeNovo NT pricing....can't recall if it was this thread or elsewhere.  I did not have to pay upfront at all for the DeNovo NT material and I have see others have.  It was submitted through the hospital bill charges and my insurance paid it at the same % that my insurance covers any other billed charge.   The billed charges were roughly $30K for the graft material, contracted rates somewhere around $10,500 and my insurance paid approx $8900. 

Thanks for asking and I'd be happy to answer any other questions you may have.

[scmba]

Hey Cdubb!
Firstly, thanks for checking in.  I know you were weaning off the site, but let me tell you, your experience is invaluable as there aren't a ton of patella lesions out there.  I met Dr. Mandelbaum this week and he did give me hope.  I have a 1.6cm x 1.6cm (central/lateral) patella lesion on my right knee with a TT-TG of 16mm.  My left is 2.4cm x 3.2cm (lateral) patella lesion with a kissing lesion on the trochela of 8mm x 8mm and TT-TG of 24!!!  Doc says right does not require TTT, but left does require it.  Both are burning/irritated after 20min walking or biking, but no sharp pain.

1.  Does Dr. Cole do TTT for patellas with cartilage restoration regardless of TT-TG length?  My right (non-TTT) is more central, but it was my jumping knee and I don’t plan to jump much anymore.  My doc is conservative on TTT for some reason.

2.  Did your doc say why he believes in DeNovo and when does he use it vs. ACI now?  I know about ease of use, cost and but thinking about the durability of DeNovo vs. ACI.  Cole, Farr and Mandelbaum have to know something we don't to start using DeNovo so much.

3.  Did you do anything w/ a physical therapist during the 1st 6 weeks or is it primarily a sedentary time?  Do you massage the scar?  I think you said you did 90 degree bedside sitting for ROM, SLR and maybe some straight leg lifts.  What type of exercises did you start after 6 weeks?

4.  Did your doc talk about the success of his TTT/ACI patients and how long they last?  If all other compartments are pristine, is this not just buying time until TKR, but providing a potential lifelong solution?  Has your left knees’ TTT healed and you get pretty much back to normal?    Some articles say they leave the screws in and some pull them out at 8-12 months - did they take yours out yet?

5.  How did you decide which knee to do first?  My doc is saying to do the Right Knee (Easier, No TTT, only DeNovo+Lat Release) 1st to give me confidence before I do the Left Knee  (TTT+DeNovo), but I think I’d rather do the TTT knee 1st because then the hard one will be done and I won’t be worrying.

6.  My doc said either knee is outpatient surgery.  I'm a 5-6 hr car ride from home.  Would you suggest staying in a hotel, close to the doctor the 1st week(How many days are the worst days?) or get home ASAP?  Is it reasonable to survive a long car ride in the state or pain you're in?

7.  How long was the process to get insurance to approve the surgery and did you have to appeal?  What insurance was it? 

8.  Back to work at week 5-6 – is that mainly because you could sorta walk or another reason?  I'm thinking 2-3weeks and back to desk job.

Sorry for the amount of questions, so take your time in answering.   Glad you're doing well.

[cdubb]

Hey there scmba,
Let's see if I can help you out some here.  See answers below:

1.  Does Dr. Cole do TTT for patellas with cartilage restoration regardless of TT-TG length?  My right (non-TTT) is more central, but it was my jumping knee and I don’t plan to jump much anymore.  My doc is conservative on TTT for some reason. - I believe that he does do TTT for patella providing the location of the defect fits his algorithm.  I think there are some spots it is contraindicated (medial I think??), but both of mine were central and for those, he recommended both cartilage restoration and the TTT.  The day of my initial scope on my left knee, it was scheduled as "arthroscopy, possible ACI biopsy, possible microfracture, possible AMZ".  Lots of possibilities.  My MRI had shown my defect as lateral; however, in the knee, it was actually central.  During that surgery (I stayed away because of the many outcomes and I'm too much of a control freak to just let go), Dr. Cole said you can't microfracture a central defect and an isolated AMZ would only provide 50% success rate whereas the ACI inconjunction with it would be closer to 80-85%.  So...surgery was a biopsy and bail....very anticlimactic day.... So, I believe he takes each patient's specific's and then determines if the AMZ/TT is indicated, but more often than not, I believe he does it for patella and trochlea defects. 

2.  Did Dr. Cole say why he believes in DeNovo and when does he use it vs. ACI now?  I know about ease of use, cost and but thinking about the durability of DeNovo vs. ACI.  Cole, Farr and Mandelbaum have to know something we don't to start using DeNovo so much. - He still does both ACI and DeNovo NT.  I ended up having an issue with my cells in storage where the quality was not good enough to proliferate them, so it was either another biopsy scope (with the hopes it was good enought) or switch to DeNovo NT.  That was his recommendation, so that's what I went with.   Not really sure on the durability of DeNovo NT vs. ACI, but it's a good question.  Probably nobody knows yet, as DeNovo is a relatively new product. I was told that they had sufficient experience with it and felt I would do well with it. 

3.  Did you do anything w/ a physical therapist during the 1st 6 weeks or is it primarily a sedentary time?  Do you massage the scar?  I think you said you did 90 degree bedside sitting for ROM, SLR (what are those?)and maybe some straight leg lifts.  What type of exercises did you start after 6 weeks? - I started formal PT right around the 2 weeks point.  It suppose it could be done at home though.  It's mostly ankle strength 4 way, SLR's if you can do with no extensor mechanism lag (my PT had to assist for about a week each surgery until I could do independantly), 3 x's per day, I was allowed to dangle off a bed to 90 for 30 seconds, but other than that ROM is pretty restricted in the first 6 weeks.  Most is done in the CPM and the purpose of the CPM for this surgery doesn't have anything to do with ROM, it's more of a benefit to the graft.  I did massage the scar and my PT also does as well.  About 15 minutes of my PT is scar massage and patella mobs.  Once you hit 50% weight bearing (5 weeks for my protocol), then you can do more in PT because you can stand with weight evenly distributed, so calf raises can be added, standing on foam mats and doing some upper arm stuff and core stuff with bands.  After 6 weeks, when ROM isn't restricted, then it opens more up also and at 12 weeks, protocol opens up even more.

4.  Did your doc talk about the success of his TTT/ACI patients and how long they last?  If all other compartments are pristine, is this not just buying time until TKR, but providing a potential lifelong solution?  Has your left knees’ TTT healed and you get pretty much back to normal?    Some articles say they leave the screws in and some pull them out at 8-12 months - did they take yours out yet? - All other compartments in both my knees are pristine.  I am purely a patella issue with a postivie "J sign".  I don't know about how long these are to last, but I was told that with somebody whose knees are bilateral and the problems are more multifactorial (vs. a specific trauma), reduction in pain and improvement in function and endurance are the goals.  He did tell me that there are people with cartilage problems that he can pretty much get back to normal and full function (although he did say he never tells people that...), but bilateral patella people are not in that group.  Improvement is the goal.  I would agree that is where I am at.  My left never became normal, but since I've had knee pain since I was a teenager, I'm not sure what "normal" really is.  I improved a lot from the time that my left knee VERY rapidly tanked.  Right was always worse and left just kind of nagged.  I actually started treating again for my knees after about an 8 year hiatus (since I didn't think there was much to be done for PF issues) for the right because I wasn't able to play tennis any longer without the crazy sharp pains.  Had some Supartz injections in right and then out of nowhere, the left was crazy swelling, sharp pains when walking on flat ground...it was weird how fast it went very bad.  I ended up having a very large osteophyte in the middle of my defect, which was probably the trigger for the severe pain and swelling.  I don't believe my right had that.   So anyway...in my situation, I believe I am mostly "buying time"...I'm hoping that time is 20 years though and then there is amazing technology! There may be situations where it is more permanent.  Another friend of mine who has similar knees and also treats with Cole was told by one of his p/a's that the "patella people always seem to have more problems". As for the screws, I had mine taken out the same day as my this right knee DeNovo NT procedure.  It's a really minor thing.

5.  How did you decide which knee to do first?  My doc is saying to do the Right Knee (Easier, No TTT, only DeNovo+Lat Release) 1st to give me confidence before I do the Left Knee  (TTT+DeNovo), but I think I’d rather do the TTT knee 1st because then the hard one will be done and I won’t be worrying. - My decision was very easy.  I explain above for the reasoning.  Right was always my "bad knee", but the left went VERY bad VERY fast.  It was weird how bad it went and how much it was affecting me every day.  I could walk on flat ground and get stopped with that crazy sharp pain.  The fact is was so bad, helped with comfort going into surgery that I had nowhere to go but up! When right knee was affecting my progress with the left, I knew it was time to do that one.  Your doc probably doesn't want you to do the TTT one for fear you won't go back!! Just kidding...it's not as bad as many people on these boards make the TTT to be.  Don't get me wrong...it's not fun and I was grateful for pain meds, but it's not as bad as I thought it was.   

6.  My doc said either knee is outpatient surgery.  I'm a 5-6 hr car ride from home.  Would you suggest staying in a hotel, close to the doctor the 1st week(How many days are the worst days?) or get home ASAP?  Is it reasonable to survive a long car ride in the state or pain you're in?  Dr. Cole also does outpatient surgery, but I only live about 10 miles from where surgery is done.  Glad I live in Chicagoland! The outpatient part is fine and I was glad to be home.  Pain can get intense, but not what you might thing.  Worse thing is the blood rushes when you go from horizontal to vertical and that lasts about 30 second, but the pressure is intense.  It stops about 2 weeks. I also did not have a femoral block for either surgery, but many people do.... that's a call for your anesthesia and surgical team and if you're going to a hotel or home... it was not recommended for me because they said that it really only goes about to the knee and most of the pain is below.  They waited until I woke up from the first surgery (which I woke up crying from- I was embarassed) to see if I would need it and they just jacked up the morphine and said it wouldn't get worse (and it didn't) and kicked me out the door an hour later.  This time, it wasn't even discussed.  They also took about 4 hours after surgery to discharge me and I was doing better.  If you are going home and will be in the car for awhile, then I maybe it would be of more benefit than it would have been for me.  As for the hotel...total judgement call by you.  I personally would rather be home and make the drive back and forth.  I think that it would be easier to be in your own home and I think a car ride immediately after surgery would be easier than the few days. They're worse.  I started dropping my pain meds by about day 3, but still took pretty consistently (just reducing amount and spacing out doses) until about 3 weeks. I actually kept a pain med log on my phone, so I didn't accidently overdose.... if you PM me with your email, I can send it if you would be interested.


7.  How long was the process to get insurance to approve the surgery and did you have to appeal?  What insurance was it?  My left knee ACI/AMZ went through in about 2 weeks..easy breezy.  When my right knee ACI/AMZ request went through, it was denied and appeal denied.  Weird because same insurance approved it a year ago...  Anyway, it ended up being a moot point because US Bio was getting my cells out to look at them anyway and they weren't looking too hot.... So, a new request under allograft coding went out and it was approved in less than 2 weeks.  I was stressing about that after the ACI denial.  I have BCBS FEP. 

8.  Back to work at week 5-6 – is that mainly because you could sorta walk or another reason?  I'm thinking 2-3weeks and back to desk job. -  The TTT/AMZ really is the main driver for taking longer time.  The first 2 weeks, there is no way anyone would really want to work...in too much of a narcotic haze..and CPM and the ice machine.... Without the bony portion of the procedure, I think recovery and return would be much easier; however, seeing as both had the bony portion, I can't really speak to that.  Any other surgery I have had for knee scopes, a stupid toe surgery, some shoulder reconstruction type stuff, I was back in just a few days and off meds, but this is much more than those procedures. Had I wanted to push it, I could have returned earlier and I know I could have worked from home also, as I did this past week.  I just didn't really want to push it.  6 hours/day in the CPM is a lot to get if you're at work all day and it's hard to work from the couch on a laptop for me.  I don't sleep well in the CPM.  Plus, I also ended up with a periostitis again (inflammtion in the lining of my bone from blood tracking down from the osteotomy), which creates this awful burning/nerve pain in the foot and ankle.  I had it last time also.  Dr. Cole put in a drain to try and track blood out instead of down the leg and it took a pint off in about 18 hours, but I still had crazy bruising from ankle to upper thigh.  It set in both times about 10 days post op.  Last time I didn't take them up on a medication that might work, but this time I did (I couldn't face going through it again and I wasn't sleeping at all because I was up swapping out ice packs every 2 hours).  So, they put me on amitriptyline this time, which totally worked in about 3 days, but had a side effect of making me sleep about 11 hours/night (quite a switch from virtually none)...and even then, I kept falling asleep all day. I stopped it after 2 weeks when I knew I had to start waking up earlier and not sleeping in until 10:30 am! Very mild flare up getting off, but totally manageable. So, with everything going on, I just kind of paced myself in a return to work.  You certainly could return earlier though if you were so inclined.  I have a good short term disability through work, so I wasn't out any money. It's a benefit we have, so why not use it.

Hope that helps.  Feel free to PM me with your email address if you would be comfortable sharing (completely would understand if not) and I can email you some photos of my incisions and how the TTT on my left knee really left a pretty decent bump.  My right hasn't yet molded into the large protruding tuburcle, but it took about 4-5 months last time.  It looks pretty strange actually.  My incisions look pretty good acdtually.  Odd though that my hardware removal incision has not yet fully healed?? I think it's because of the large bump is constantly causing it to break open every time I bend my knee.  I am supposed to get surgery pics emailed to me from my DeNovo surgery, but they are still pending. I'll ask at my next post op on the 30th if I don't have prior.   I have my ACI/AMZ surgery pics that I can email.  I know that they aren't particularly common surgeries, so it's hard to find people have been through it.

[scmba]

Hi Cdubb

LOL, about your comment about, "Your doc probably doesn't want you to do the TTT one for fear you won't go back!!"  I'm a chicken - especially when I read about the erinE who did bilateral TTT/ACI and is riding 54miles a day 4.5 years after.

Keep positive about the permanence of your fix.  Did you see the paper that Farr and Cole published on exactly how to do the TTT?  I can send it to you, but they had listed all the indications and contraindications and  - they had all these instruments measuring angles, pressure, using reference pins, (Angle = tan -1).  Gotta think they're correcting something.  I know lots of it is inexact - but if you have new cartilage and better angles/pressures, its not unbelievable to get another 30+ years. 

I just PM'd you. 

Thanks a ton

[cdubb]

Not sure if I've seen the paper Farr and Cole published...is there a link on Cole's website?  I check out those sometimes and read a bunch, but can't recall which one's at this time.  I know as far as my knees goes, I was anteriorized more than medialized...thus the bump.  Got your PM and sent you an email.

[surfbum]

8 months post-op: Just got back from OS...deemed a success and sent out the door packing. Told to continue daily biking, continue strengthening,  and absolutely NO JOGGING of any kind for another 4 months (1 year post-op) because the "cartilage has to mature." The hard part at this point is just remembering that I'm only 8 months post-op...seriously, it feels like I had the surgery over a year ago because the knee feels normal. OS said that Denovo has been so successful and other doctors are having a lot of success with patients just like me. One last thing to add; muscles are still not 100% even at 8 months and I weight lift/rock solid diet with over 200 grams of protein a day...so don't be in such a hurry to get it back....takes time. Best advice I got from the OS, "focus more on the bike to strengthen your quads and less on squatting motions."  Good luck all ;-) 

[Himself]

Interesting.  You are a month ahead of me and I was cleared to start jogging at seven months.  I guess the docs are still working on standard post-op protocols for this.  Denovo rehab seems to be based on microfracture/ACI, but as you well know - not the same thing!

[2JTC3]

All-

I finally got an MRI and saw an orthopedic surgeon on 3/28/12 about a knee injury that had become debilitating; I went from playing in basketball games 3 times a week (and with pretty decent jumping ability) to limping each day while walking on flat surfaces. 

Based on my research prior to my appointment, I was confident I had a cartilage defect and thus was expecting the surgeon to recommend microfracture surgery.  I was totally unprepared when he recommended DeNovo, a procedure he's done several times, but that I'd never heard of before he mentioned it.  As he presented it to me, it sounded more promising than microfracture, but I was skeptical; how come I've never heard of it before? If it's so awesome, why do NBA players get microfracture surgery?

In any event, I'm trying to decide between microfracture and DeNovo, and this forum has been extremely helpful.  I'm leaning towards DeNovo and am feeling like I can actually make a reasonably informed decision.  Obviously, this is a huge deal as it affects quality of life (being able to walk pain-free and with a normal gait) and personal identity (being able to play basketball, or at least shooting around).

Thanks everyone for providing some clarity.

-JTC

[surfbum]

10 months post-op:

Just gets better and better. It's funny to think that it's still only about half way through the game. I can't imagine what my knee is going to feel like at 18 months - 2 years. Looking back, around 6 months is when it started to really turn for the better and then you can just tell little by little...it matures.

Right now, I'm visiting my PT guy about once per month to make improvements upon what is still lacking; hip muscle endurance. I ride the bike twice per day for about 15 to 20 minutes per session. I also try to get a nice 30 minute walk in a few times a week. I go to the gym 6 days a week and two of those days are spent focusing on rehabbing the knee. My routine looks like this:

75 single leg squats (50 on the machine that hits more of the glutes/hammis and 25 standing up on one leg which hits EVERYTHING hahaha).
50 reps of a standing hip exercise my pt guy has me doing where you lower and raise your hip.
50 calf raises.
15 minutes on the stair climber (this one is the true test to see how well I'm building up my endurance because I'm doing this after all the previous strengthening exercises. so far I've been adding a a minute or two every couple weeks. I was stuck at 10 minutes for the longest time because my muscles would just start shaking and give out....but then I broke through that plateau :-) no more muscle failure.
50 reps on the hip abduction machine (sometimes I'll do pyramid sets and sometimes low weight/high reps)
50 reps on the hip adduction machine (Same thing as far pyramid sets and endurance sets)
15 minute walk on treadmill (3.6 mph).
15 minute ride on bike (level 10/20).

Then follow that up with protein, protein, and more protein :-)

[Jeanknee]

Hi Surfbum,

I'm considering DeNovo NT and see the OS next week to see if I am a candidate.  Can you tell me how large your incision was? And what city you had the procedure?

Thanks,

Jeanknee

[surfbum]

1.2cm x 1.2cm on the MFC. I had my Denovo done by Bert Mandelbaum in Los Angeles.

[surfbum]

ONE YEAR :-)

With that being said, started back up the formal PT because I was given the green light to begin sports agility type training. We started this week off by incorporating a one legged lateral jump exercise into my routine. It's where you hop side to side landing on one leg. So exciting and brought a smile to my face when I realized there was no pain and my muscles were firing on all cylinders. Haha, coordination was off a little at first when pushing off with the surgery leg, but I was surprised at how quickly my body/brain relearned how to coordinate the movement and not be afraid!

Other than that; still doing a 30 minute walk a few times per week, riding the bike 40 minutes per day, and a rigorous 2 hour endurance workout once per week.

Hope you all are doing well!