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Author Topic: OATS and Medial Meniscus Transplant for 32 year old active patient?  (Read 2578 times)

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Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #15 on: March 11, 2018, 01:56:48 AM »
Just wanted to update on MRI results. So you canít actually see the chondral defect healed in, which I am being told (which seems reasonable) is because fibrocartilage is a different density than hyaline and wonít show up at around 4.5 months. What you can see, however, is that my subchondral bone edema in my femur is completely gone. I still have a touch of edema in the subchondral bone on the tibial side (which currently has grade 3/4 wear). This means that either 1) stopping high impact activities has helped the edema and/or 2) the microfracture was atleast partially able to fill in the defect. Really not too sure what to think of it. In the end I think it is really how I feel is what matters.

So hereís my new conundrum. I have a few months off this summer between jobs (would be about 8 months post the microfracture surgery) that I can think of a million better ways to use other than surgery- but if itís the best thing form my future this would be a nice time window to have an osteochondral allograft and meniscal transplant completed. I would need to start getting this set up soon. Although I have seen some benefit with microfracture I still feel like some really important activities would still be very uncomfortable for me (mainly hiking, skiing). Of course there are no gaurantees with the transplants, in fact itís a bit of a long shot with my cartilage status. So my biggest thoughts now are- is my microfracture going to keep healing and I am rushing the process? Is it worth going with the transplants, to begin with regardless of timing (eg is is realistic tho think I would be doing anything more than walking, which I already do fine with)? If the transplants fails am I ďfast trackedĒ to knee replacement? Decisions, decisions. I donít think there are good answers really. I think Iím going to start by getting a few additional opinions at this point.

Will keep the updates coming.

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #16 on: March 11, 2018, 09:30:30 AM »
If you function well in everyday life, walking/standing without limitations, no major pain/stiffness/swelling/inflammation problems with everyday activities, I would probably not go for another surgery at this point. Hiking and skiing might be difficult despite another surgery, and the fewer surgeries you do, the better. That's just my two cents. However, just as you plan, I think it is a good next step to a get few additional opinions. 

RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #17 on: March 12, 2018, 12:10:50 AM »
Brandon, would you count stairs as everyday activities? Still have a bit of trouble with those. Otherwise I do reasonably well at this point- no locking, minimal stiffness, no inflammation, occasional twinge, definatley will get sore after a half day up on it- but not too bad. Thatís about it.

Part of me totally agrees with you that I should wait this out- see if it gets better in a delayed fashion and just deal with my functionality as is- have also been interested in getting an unloader brace to see if that is helpful. Another part of me really wants the more active side of life back, even knowing itís a long shot. That and I am wondering if the transplant could offer me some less symptomatic years to come, even if the underlying arthritis progresses. Out of curioousity- what bothers you about getting a another surgery in my situation- the risk of it getting worse? The risk of scar tissue formation? The risk of altering the effectiveness of an eventual PKR?

Thanks for all your input.

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #18 on: March 12, 2018, 03:51:07 PM »
Yes, I do count stairs as everyday activities. If you cannot climb stairs (up and down) without pain, then of course that is a problem. But one thing regarding stairs, before I had my scope in 2009, I could not climb stairs at all. After the scope, it took me 1-2 years until I could climb stairs without any limitations (like 7-8 floors in fast pace up and down) and see the full benefits of that surgery. So at least based on my own experience, I still believe you might see further improvement after your scope last year.

There is nothing in particular that bothers me about getting another surgery in your situation. Just that fact that you have had multiple surgeries on that knee already, and for every surgery there is an additional risk of scar tissue formation, accelerated arthritis progression, things going wrong etc. My thought was just that if you function well without any major problem/pain/symptom in everyday life, the safest route would probably be to give it another 6-12 months and see if you will improve further from your latest surgery.

However, of course only you can decide how comfortable you are at your current level of functioning, and how important additional activities like hiking and skiing are for you, and if it is worth trying to get even better with a new surgery. These things are not easy, I know.
   
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #19 on: March 13, 2018, 01:43:17 AM »
Thanks again Brandon. Will keep you updated on my discussions- going to meet with one additional cartilage specialist over the coming weeks and also discuss my situation with my OS in a little bit more detail, see what he has to say. His major problem (not being a cartilage specialist, more sports med specific) with meniscal transplants (and the reason he didn't want me to jump to it right away) is that you are basically taking away any pivoting activity just by taking on the surgery in the first place. It truly is more salvage for the majority of us. My major problem with it is that I can't find any success stories out there to make me feel confident enough about it, and the fact that my wife may kill me if I take are long awaited 2 month break for recovery!

Offline Vickster

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #20 on: March 13, 2018, 07:55:31 AM »
Have you read this diary? Lateral meniscus plus OATS (donít think it was a big defect which will obviously impact success rates ?)

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=70076.msg671476#msg671476
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
LK New MRI shows lat & medial meniscus tear & other stuff
RK MRI lat meniscus tear
8/1/15 RK Steroid jab,
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #21 on: March 13, 2018, 05:27:07 PM »
Will keep you updated on my discussions- going to meet with one additional cartilage specialist over the coming weeks and also discuss my situation with my OS in a little bit more detail, see what he has to say.

Sounds like a good next step!
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #22 on: March 13, 2018, 07:28:42 PM »
Vickster, I have been reading that blog- its fairly promising - we will need to keep following him for 3-4 years to see whether or not it was worth it. The major difference in my case that worries me is cartilage status- mine is more severe.

Some recent studies below: basically, bipolar cartilage lesions do benefit from meniscal transplant but are more likely to tear over a 5 year period (this is with concominant treatment of cartilage injuries). Also, lateral meniscuses seem to do better than medial. Unfortunately, the cards are seemingly stacked against me a bit more.

https://www.ncbi.nlm.nih.gov/pubmed/28075154
http://journals.sagepub.com/doi/full/10.1177/2325967116663185



Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #23 on: May 07, 2018, 04:02:31 AM »
Hi all, some updates.

I haven't improved any since my last update, and maybe slightly worse, going on 7 months now. Despite that, I think I am in a better place mentally than I have been prior. I still get around for the most part without major difficulties, although I have noted more twinges with say every 10th step or so. Prolonged walking, say through the city, is doable, but I find myself constantly adjusting my gait and after some time look forward to a chair. I have learned my knee is now very reactive to activity, for example a hard session on the bike or in the pool may feel great, but will be increasingly tender the next day. Stairs are hit or miss with discomfort, and I still couldnt pull off any sort of sustained uphill. Even any significant weight on the bent knee, around the house, will cause a quick twinge.

So, basically, I have arthritis.

I've had several discussions with loved ones, physicians, and several folks who have undergone meniscus transplant and OATs since I last posted.

I was able to see a cartilage specialiast out in Chicago while I was out there for a wedding, one of pioneers of meniscal transplant, I'm sure many of you know the name. He felt I would benefit from OATs and MTS, despite having bipolar/kissing lesions, and that he recently published a paper stating that by establishing femoral cartilage coverage, despite grade 4 tibial lesions, significant benefit is seen. In addition to femoral OATs and MTS, he would try microfracture of the tibial plateeu, to see if some additional tissue growth/protection could be obtained. Talk about a bioknee! I was actually able to speak with an individual who had the procedure done and with very similar cartilage status to myself (grade 4 "kissing" lesions) - she isn't perfect now but is able to bike and swim competetively, hikes to some degree, and has no challenges with basic ADLs (stairs, etc), this 8 years out. She does not run, or ski, or do additional high impact activities. I spoke with another ex-D-1 cross country runner who had the procedure done, unclear cartilage status but presumably fairly advanced, who 5.5 years out has a similar functional status to me at the current time. He had little to no benefit, in the end, although he will never know of course if he slowed progression and at this point, without the procedure, possibly would have pain with every step. Finally, I found this blog, http://kealohathoughts.blogspot.com/, which is a very recent ACI and MTS story well detailed and seemingly having success returning to pain-free ADLs. Of course the great story by Lateral Meniscus Issues on this site is also very well detailed, and clearly having success although he was one of the smart ones whom caught his disease progression early on prior to extensive cartilage loss.

In addition to the doc in Chicago, I spoke with a doc in California, who does free imaging review, whom concurred that trying something was necessary, offering a cartilage graft paste technique rather than OATs, along with meniscal transplantation. I'm sure many of you know the name there as well. For several reasons this wouldn't work for me- much of which lies in cost given that the payment is made up front and then potentially reimbursed by insurance.

There is also a new clinical trial for a device by a company called Moximed I thought I would update folks on, previously called "kinespring" but now has been repackage as "atlas", which is attached (outside the joint capsule) to your femur and tibia and separated by a joint unloading spring- and can absorb around 30 lbs of pressure. The idea is to unload the joint in a "non-invasive" fashion, and without shifting the weight to the lateral compartment as in HTO (device is marketed only for medial joint arthritis). The thought is that it would become another bridge to prolong the inevitable joint replacement. It seems intuitively like a good idea, and I believe around 90 patients have trialed it with good results, even up to 5 years. Be wary though, there are rare reports of "metallosis" (local metal shedding that gets into the blood stream), joint capsule infiltration, and persistent joint instability after removal of the device. Check it out.

So I am at a bit of a stand still. I have decided, as many of you advised, to take a breath and have finally stopped frantically looking for a solution, which is much healthier. My wife was becoming exhausted with the process, I don't blame her. I start a new position in September and will likely focus on my career for atleast several months, more likely a year to two, before revisiting a possible solution. I am becoming crafty with ways to get a good workout in, and my upper body and core is as strong as its ever been. Although of course I would absolutely love to get back uphills as to hike with family and friends, this remains a tough pill to swallow.  I am hoping I don't have a rapid progression of my cartilage loss between now and my readdressing of a possible solution, although I honestly feel that by cutting out high impact stuff it should steady out. By the time I re-visit this, I will likely need new MRIs, X rays. That will put me around 34-35 years old dependent on timing, still much too early for a resurfacing procedure- so I will likely try the long-shot OATs and MTS if I can ever get work to let me off. One additional concern I have is that there is some literature out there about OATs worsening outcomes of eventual resurfacing joing replacement surgeries. I actually asked one of the cartilage specialists about this and the response I got is that it shouldn't alter the resurfacing procedure from a technical standpoint, and that perhaps low pain thresholds were to blame (e.g. those folks were destined to fail with any procedure).

I did try an Ossur One unloader brace, without succes. It seems to unload the joint well in full extension of the knee, but in flexion does not really give that much relief (exactly where my problem is) unless I really crank the degree of unloading- but I am fearful I will stretch/tear my MCL with this- as others have described on this site. I may try a compression knee brace next.

I will keep the updates coming, perhaps a bit more spread out now than previous, but will certainly update with any major breakthroughs.

Thanks for letting me rant!

Offline LateralMeniscusIssuesGuy

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #24 on: May 08, 2018, 08:41:37 AM »
Hi badleftknee,

I'm sure I know who your specialists are, I spoke to them too despite being in the UK, luckily I found a surgeon domestically who I found I trusted more, seemed as competent, honest, and covered by my UK insurance.

It seems I absolutely have smaller articular cartilage legions, but despite that it hasn't been plain sailing, am obviously still mid rehab, and my current conclusion is surgery vs doing nothing is still a very difficult decision in my eyes, despite my living through it in (so far) a positive way, luckily.

With regards to knee unloader braces, I'm planning to be fitted for a CTI OA custom in the next fortnight.  I have been advised that it provides unload through full ROM where other braces are only designed for unload through the first 15 deg of flexion, you may try to find that information somewhere online, although I struggled through online information, instead I got it from the UK's seeming most respected fitter of Occur and Donjoy products (Dave Fewster).

You seem very balanced and appreciate it is refreshing to have a change of focus and not be constantly searching for solutions, instead just getting stuck into the grind of incremental gains.  I recommend you look into blood flow restriction training (BFR) as a way of doing minimal load work for your lower body, but maximising muscle gains.  Perhaps you want to desist from lower body work entirely but I can't imagine that atrophy will be helpful to your joint preservation.  There's lots of information on it all over the web.

Even if it is far less frequent, still be great to hear how you continue to progress, and I obviously wish only good things for you.

Good luck
JT
Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #25 on: May 10, 2018, 01:29:21 AM »
Lateralmeniscus Issues,

Thanks for the reply, much appreciated. Very helpful on the unloader brace, I will see if I can get a script from the OS too have that covered by insurance and give it a try- you said Ossur CTI custom? I have heard from others with medial arthritis that they have also had luck with compression braces, so may give one of those a go too.

I will keep tracking your progress, its very exciting and certainly hoping you can get back in the game.


Offline LateralMeniscusIssuesGuy

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Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?

Offline LateralMeniscusIssuesGuy

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #27 on: June 01, 2018, 02:16:51 PM »
How's everything going badleftknee?
« Last Edit: June 01, 2018, 02:25:54 PM by LateralMeniscusIssuesGuy »
Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #28 on: June 02, 2018, 06:22:40 PM »
Hey there, this past month was actually a pretty good one. It's all relative of course. Prolonged walking is now much more doable, and for 95% of the time my left leg feels like my right. Uphills require a slight adjustment, but my mind and body seem to be doing it in a more automatic fashion, as to let my mind let up thinking about it a bit. I did a moderate 1 hour hike with my wife, which I tolerated well. Again, steps require adjustment which is not ideal; but, I am just happy to be out there again. Swimming and biking remain pain free, for the most part that's even with pushing hard out of saddle, and my knee seems to be reacting better meaning I don't feel tender the day following. I rarely ice anymore unless I really over do it. I'm certainly not out of the woods given that weighted knee bends at certain angles can cause pain, as well as any form of cutting movement or attempts to run.

With that in mind I will say its definately tougher to get a solid workout in now. Requires more time and more thought. I used to be able to throw my shoes on and go for a long run at any time from my front door. Now I have to abide by pool or gym hours, have a solid lifting workout plan and make sure I don't slack off to keep my heart rate up, etc. There are worse things of course but at times it is less convenient and I can see how if working out was never your thing, how arthritis could further discourage any form of movement leading to further health decline.

So all in all, I remain in a tough situation given my hopes for higher activity levels. But, I am very thankful where I am at, given my degree of cartilage deficits. I do, of course, hope that things keep improving.

I still have to get that custom knee brace set up, I hope to get the script this week. I spoke with my local ortho on the phone last week and updated him on my endeavors with seeking out cartilage specialists opinions (which he has encouraged)- after I explained everything to him he though that the best thing to to do is keep waiting it out and rehabbing rather than jumping into anything too quickly. I do respect his opinion, but am unsure if his opinion is the right one either (symptomatic management for as long as possible followed by partial knee replacement).

Thanks for checking in LateralaMeniscusIssues. Looking forward to your updates as well!