The OSTEOARTHRITIS DEPARTMENT => KNEE ARTHRITIS - Articular cartilage repair => CARTILAGE REPAIR - Osteochondral autografts and allografts (eg OATS & mosaicplasty) => Topic started by: hopalongcasualty on December 29, 2005, 03:27:16 AM

Title: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: hopalongcasualty on December 29, 2005, 03:27:16 AM
I'm back  ;D

In January I was doing Ice Hockey blue line drills with my son and during a hockey stop my left knee buckled and partially dislocated the tibia head went forward and medially the patella went to the lateral side it was the making of an unhappy triad but I was kind of lucky.  The EMTs put the leg in an Air immobilizer which actually set the joint.  I then followed up with OS that did MRI and found there was damage and there was evidence that scope would be needed to repair damage in the knee including a possible micro fracture of the defect found on the lateral condyle.  I was sent to pre-op PT to strengthen the quads it was the 2nd or third session when the articulate surface of the lateral femoral condyle actually slid off the bone and protruded (visible deformity) in the joint capsule and was palpable.  I was able to squish it back into the joint line but it later floated over to the medial compartment of the knee and would occasionally lodge up by the patella in the upper compartment of the knee capsule.  While like this it caused the knee (patella)  to physically jam, the only way to free up the joint was to manipulate the loose body to the joint capsule.  

When he got in there was great news, the ACL was intact the MCL was repairable and then he was able to do a lateral release with medial tightening because the patella was not tracking (significant tilt).  The bad news  :-\ there was a “big ass” chunk of articulate cartilage sheered from the lateral femoral condyle.  This defect was too large to remove with the scope and had to be chopped up to get it out (I have the pictures).  The defect was too large to do micro fracture, ACI, or OATS.    

There has been a delay in getting my allograft due to complications which surfaced in my post-op PT sessions.  I had a skin abscess show up on my calf.  When I went into the OS for post op-follow up, he said  “What the hell is that?”  :o.  He knew right away that it was MRSA and wanted me to see an infectious disease doc to treat me for the nasty bug before he would do the allograft.  He explained that if the MRSA bug got into the bone, I could loose my leg if not worse.  

So I went to see the infectious disease doc, got the old nose swab (culture) and he initially thought it was something else prescribed an anti-biotic and told me that he would call back with the test results the next week but he did not think it was MRSA but another condition similar to acne.  The next week I got a call from the doc telling me to discontinue the other meds and that he was calling in to the pharmacy a prescription for vancomycin and mupriocin ointment to be applied nasally several times per day.  I have had no other lesions since then and it cleared up my chronic sinus infections  ::)

The left knee had been mostly asymptomatic only with occasional twinges of the “huge” lesion of the anterior lateral condyle during extension while weight bearing.  If I kept the knee flexed to 5 to 10 degrees I could avoid most symptoms; not the best answer but I thought I could avoid further surgery (denial – it is more than a river in Egypt).  

The occasional twinges have become more frequent, bracing and partial flexion does not avoid the pain now.  I am having over 20 episodes daily now when walking, standing, getting out of a vehicle and forget stairs.  The best I can describe the pain is: someone taking an old shoe horn and stabbing it into the anterior lateral compartment of the left knee and then twisting.  (I know overly dramatic) I have had numerous sports related injuries and this pain rates right up there in the top end.  It might be due to the exposed bone abrading the meniscus; which at time of the March scope was healthy.

My OS has experience in this procedure and when I compaired his stats to my research in the American Journal of Sports Medicine Vol 33, No 3, 2005 I found he is right in line.  He also was realistic with expectations, he said that this would put the left knee back to good, don’t expect perfect.  Perfect went out with the dislocation in January.  

I am scheduled to have the surgery on Jan 13, 2006.  I know it will be a drag, to be on crutches for 6 to 8 weeks and lengthy rehab.

Anyone out there been through this procedure that can give advice or insight?

Thanks in advance,

Hopalong Casualty
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: blackbeltgirl on December 29, 2005, 01:55:59 PM
Let me start by saying - I don't mean to make you second guess your surgeon or your decision.  But there's no "going back" from a large allograft procedure, and I want to be sure you've considered all options.

Have you had a 2nd opinion from someone considered a "salvage expert"?  I don't know how old you are, but there are doctors doing incredibly successful ACI procuedres on lesions over 36 sq. cm.  That's pretty much an entire femoral condoyle.  My local surgeon was concerned a bout the size of my lesions, so I sought out one of these cutting edge docs.  I was told that if they tried a shell allograft (the only way they could do cartlage plug transfer due to the size of my lesions) and it failed, the only option would be TKR.  The bone is already damaged from rubbing bone-on-bone, and an allograft requires additionsl damage to the bone.  If ACI fails, I can still try a shell allograft before moving ahead to ACI.  I can't even begin to tell you the difference in how the salvage guy handled my knee vs. my local doc.  My local doc is great, and has had advanced training in ACI.  But many OS's won't do ACI on tibial lesions, or anything bigger than 15 sq cm.  Then you meet the guy who handles the extreme cases with a great success rate.  He starts rattling off cases more extreme than mine (and my lesions are big - see my signature).  I'm not a stretch for him, he has an arsenal of tools available, and he'll make me better.  (Most docs only offer OATS-type procedures or ACI - very few offer both.  I specifically wanted someone who offers both, because then he could tell me which is really best for my knee, instead of telling me about the one surgery he performs.)  I don't know where you're located, but these salvage guys are scattered around the US.

No matter what you decide, best of luck to you in your recovery.
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: JG on December 29, 2005, 03:43:17 PM
Hopalong Casualty,

How is it that you are having a scheduled allograft procedure?  Are they using a frozen allograft?   I would find out because using a frozen allograft is not the optimal choice due to chondrocyte death during the freezing process.  I had a fresh allograft procedure.  It like being on organ transplant list.  Because it's fresh and must be transplanted within about 5 days of death the surgery cannot be scheduled.  I got a call late on a Sunday for a Wednesday surgery.

Like Jess, I have really large defect with the only difference being my bone was affected (I have an osteochondral defect rather than chondral defect).  ACI is not something my surgeon advocates nor something he felt was right for me so didn't refer.  Now they used the allograft hemichondyles (two of them were needed to cover the two defect they were fixing) to created plugs rather than a large allograft procedure or a shell procedure.

I agree with Jess, second opinions are good.  My surgeon made me get a half dozen before he would do the mosaicplasty on me because it was such a large defect. 

Good luck,

Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: hopalongcasualty on December 29, 2005, 05:19:40 PM

My OS is using large plugs rather than a shell procedure.  Due to my med insurance situation my choices of Docs are somewhat limited in-network.  I am in the Dallas/Ft. Worth Metroplex.  I have had several consults with other in-network Docs.  I also took my MRI films, Surgical report with photos for an out-of-network oppinion (Dr. Frank Gottschalk, UT Southwestern Medical School) He is really good, he specializes in knees and back in 89 was the one who did the TTT maquet procedure on the right knee (which gave me years to the right knee). 

Concensus was the approach that my current OS is pursuing is my best option, I am 37 years old, the large lesion was due to a traumatic injury with some bone loss not OA.  The rest of the knee surfaces were intact. 

I will follow up with my OS, he stated that he was able to secure fresh materials from the tissue bank he uses.  I will follow up and make sure he uses fresh rather than frozen (shaken not stirred)  :P   

As a reassurance to BBG, my OS offers both OATS and ACI in his practice. 

Oh one of the 2nd oppinions stated that he would wait and do a PKR when the pain got too bad  :o.  Aghh I ran away (ok hobbled away) as fast as I could...

JG and BBG, thanks so much for your advice.  No turning back once the procedure is done is right.  MAJOR decision requiring lots of research and soul searching. 
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: hopalongcasualty on December 29, 2005, 05:27:42 PM
check out the American Journal of Sports Medicine web site

Access to articles are free, it also appears not to be simple propoganda that we see so often on clinic web sites.
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: blackbeltgirl on December 29, 2005, 07:18:16 PM
hopalong -

glad to know this wasn't a hasty decision.  From what I understand, you can only do ACI with minimal bone loss.  One of the reasons my surgeon was so urgent about scheduling my surgery.  He's afraid the bone damage will get to be too much for ACI. 

I wouldn't be too terrified of a PKR, however.  Some of the recent studies have shown amazing results for PKR patients, and recovery is supposed to be easier.  I'm only 31, so I understand the hesitation - I'd rather have an allograft than metal and plastic too.  But you don't necessarily need to panic.

Check out for the most recent research on all these things.  It's a great site.
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: hopalongcasualty on December 29, 2005, 07:42:50 PM
Thanks Jess,

I am expecting to become a cyborg eventually, my maternal side of the family is a train wreck when it comes to knees, I just excellerated the process with athletics.  I would prefer to hold off on the metal and plasic parts as long as possible. 

Because they are constantly improving the artificial joints and materials they use.  Wouldn't it be great if they could come out with a plastic that doesn't wear out so fast.  The use of ceramic is encouraging for bone end surfaces. 

Have you had your ACI yet? 
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: JG on January 01, 2006, 04:56:42 PM

I posted this in another section, but you might be interested.  It talks about being on an allograft wait list and times to transplantation.  You should double check to see if you are having an fresh allograft or an allograft at all.  The fact that you have a scheduled allograft surgery is odd and that is so far in advanced.

Here you go.

Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: blackbeltgirl on January 02, 2006, 03:14:21 AM
hopalong -
My surgery is scheduled for Feb. 21.  I won't be surprised if I turn into a cyborg, but I'm hopeful about the ACI.  The expectation is that I won't need a TKR, or at least not until I'mr eally "old enough" - 60 or 70.  Let's both keep our fingers crossed on these things.
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: JG on January 02, 2006, 03:33:43 PM

Do you have any joint space narrowing?  Are your menisci still relatively healthy?  It obviously good that there is no bone involvement.  I've kind of had that since day 1 somehow.  How is it that your know ended up in this condition?

Honestly for as much damage as I still have (just didn't get fixed...LTP and LFP which are both covered with scar tissue), I don't even consider have a TKR an option.  I don't have joint space narrowing and my menisci are healthy (lateral is about 30% gone). 

Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: blackbeltgirl on January 03, 2006, 02:46:31 AM
Janice -

I don't have joint space narrowing that I know of.  I have had 2 partial meniscectomies on the knee, but I think I've still got about 80% of both menisci.  Not sure about the 1st surgery - I was 17 and don't remember the details anymore.  As to bone involvement - it's there, it just hasn't reached the point of no return yet.  No idea about how this happened - probably a mix of factors.  There is OA on one side of the family, RA on the other.  I got whacked in the knee with a golf club when I was 12, which started my knee journey.  My kid brother had a mini-golf birthday party, and one of his friends was practicing a bit close to me.  Add in being overweight, being slightly misaligned (which I just found out at Thanksgiving - fortuneately it's not significant enough to require an osteotomy), and tae kwon do.... Apparently this was going to happen no matter what I did about it.  Then of course, I've been ignoring knee pain on and off since I was 12, so I let it get pretty bad before I mentioned it to a doctor.  As to TKR - it may be inevitible.  But no time soon.  I'm not in enough pain to warrant this surgery.  I just reognize the reality that ACI is a much better option than an allograft, PKR, or TKR - whichever was appropriate based on the level of damage when I decided it hurt enough.  SO I am being proactive, and hoping that when I have kids someday I'll be able to run and play with them.  because eventually this much damage would have caught up with me and I'd have felt the pain.  I may not want a TKR - now or in the future - but I value quality of life.  I'm doing the ACI now to preserve and improve my quality of life now.  And if I need a TKR at 60 to continue with an active lifestyle then, I'll deal with it then.  30 years or so would be great results.

Did that make any sense?
Title: Re: Left Knee Osteochondral Allograft Transplant of lateral condyle
Post by: hopalongcasualty on January 10, 2006, 04:40:59 AM
Aw Crap,

JG you were right my doc's surgical coordinator jumped the gun on scheduling the OR for the 13th.  I was talking with the PA this morning about availability of the "proper" donor material and he advised me that he was working with the bank and they did not currenly have a match for me in stock.  The PA stated the Doc only wanted to use fresh allograft instead of the frozen which is what the coordinator was expecting the Doc to use.  Ahh multiple layers of communication.   ::)  The PA advised me that the surgical coordinator should ave checked with him before scheduling an OR with me and the hospital.

And now the wait is on  :-[

Well shoot, out of my locust of control once again.

Things were falling together nicely I had scheduled vacation and sick time for recovery, I have the VPN to the office set up now and was ready to hang up the travel spurs for a while.  Now I am hanging on the whim of my graft donor to decide to turn loose of the material  :-\  Um yeah. 

It kind of makes it more personal now than when the graft was essentially a nice steak at the grociery instead of that nice steer in the field.  Melodramatic but what the heck.

I will keep you all posted.