The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: vickster on July 03, 2010, 01:37:25 PM

Title: Chondrotissue procedure
Post by: vickster on July 03, 2010, 01:37:25 PM
I am not sure if this is the right section, but couldn't see anywhere else obvious, so Mods feels free to move!  :)

My surgeon is suggesting a new procedure which involves microfracture and the implanation of a membrane.  Although the principle is similar, it is different to MACI in that it is only one procedure and there is no cell culture.  Own stem cells collect in the membrane to form tissue rather than cells being cultured in a lab and impregnated into the membrane.  The membrane is called Chondrotissue.  It is a more controlled process than normal drilling or microfracture as the membrane acts as a scaffold and there is no impact on the surrounding bone

Info here

3 weeks on crutches, 6 weeks off work, no flying for 3 months, intensive PT for 3 months (the brochure has other details on rehab)

I was wondering if any Knee Geeks have had this done and what was their experience.  It is new and I can't find much information.  It seems MACI is more the treatment of choice (my surgeon used to do MACI but replaced with this)
Title: Re: Chondrotissue procedure
Post by: tez27 on July 03, 2010, 04:09:28 PM
Vicki I had a wee read about this treatment and it sounds pretty good, is this the only option your o.s suggests or is it a matter of deciding between this and something else? Is there much info about the sucsess of this long term, with it being quite a new treatment?
I find it all really interesting and exciting what they can now do for these cartiledge problems.
How are you feeling after your appointment today?
Take care Tez
Title: Re: Chondrotissue procedure
Post by: Lottiefox on July 03, 2010, 08:21:22 PM

Few points I'd ask or consider.....this is similar to cartifill in its basic premise - MFX plus a top level. Cartifill will work on the patella (in theory) so it is interesting that this is not recommended for it. It suggests it is more fluid in its early state and probably therefore needs a rigorous NWB period.

1. If it fails, does it rule out anything else like MACI or ACI? If it fails are you likely to have more pain, a larger defect, would the failed membrane need to be surgically removed? Or would it just be as you are currently? Can there be overgrowth? (as in M/ACI).
2. has any of this work been peer reviewed yet?
3. Does he have any approximate outcome data yet - OK it is new but there must be some and if its 80% then its good, if its 50% then I'd be concerned...
4. Does he rule out anything like OATS for your lesion? (would be funded through insurance no argument and is good for focal lesions with strong cartilage around the defect)
5. Does it create hyaline like cartilage?
6. ROM protocol - do you have a brace locked at any degree of motion to start with?

I think these types of things are very exciting for cartilage repair. I personally would far rather have this, however new, than simple MFX. However, if I only had a single traumatic lesion (like yours) I would also be exploring things like OATS or even MACI. The 2 stage process shouldn't be a deal breaker if it creates a better long term outcome. However good this matrix is it is fundamentally different to MACI or ACI in that it is not implanting cultured cartilage that has been grown - it is implanting a basis, and using stem cells to create a fix. Personally I think the future of repair probably lies in avenues such as this.....and I will definitely be going for Cartifill for the patella if I reach a stage where I can't cope with the defects I have. If that fails for me, I am PFJR material. I'd also end up with cartifill on the condyle, as it would be simpler and I have a grade 4 lesion and a larger grade 3. (god how do I still walk!???  ::) :o ;D)

Have you thought of a second opinion? Not doing down your current guy but you wouldn't buy a house without viewing others.... :P

Title: Re: Chondrotissue procedure
Post by: vickster on July 04, 2010, 01:20:16 AM
Thanks both, lots to think about

Reading around, this is the AMIC procedure which I have seen mentioned here on KG.  More searching and reading to do in the morning!
Title: Re: Chondrotissue procedure
Post by: WestPoint on July 04, 2010, 09:18:42 AM
Hi Vickster,

Yes, these one stage procedures are very interesting, that's for sure. I think the most important point Lottie brought up was whether or not this procedure produces hyaline cartilage, and to what degree. It's fine for us to be told about trapping stem cells etc., but to what degree does this actually happen? In other words, just how different is this from microfracture?

Too bad they mention that you can't travel for 3 months after the operation. I guess that rules me out, as I wouldn't be able to stay in the UK for 3 months!

Keep us informed as to what you decide to do...

Title: Re: Chondrotissue procedure
Post by: vickster on July 04, 2010, 12:00:46 PM
That's a shame if the procedure were indicated for you.  He was very clear on no flying for 3 months due to the DVT risk and that I'd need to stay around in case of a problem

He explained that it is not possible (yet) to produce hyaline cartilage and indeed, until around 10 years ago there wasn't even anything very much in the way of cartilage repair (he said that the few docs like himself who were looking into this were seen as a bit mad - the wisdom was that once the cartilage was gone, that was it).  However, this procedure like MACI produces 'hyaline type' tissue which is better than fibrocartilage/scar tissue produced by standard mfx/drilling (or indeed the body as in my case)

In terms of success, he explained that it is very dependent on the site of the lesion (up to 80%) - it doesn't work on the patella - too much shearing force, but he would be hopeful for my defect as it is not in the way of the patella tracking. He didn't just trot out a number when I asked him about success rates

I don't think he would be suggesting it if he thought it would fail - he's pretty honest!  If I didn't have the constant swelling and other symptoms, he would be leaving it alone

Given that he now does this instead of MACI (he did explain the process of that with the 2 operations, the sending off of cells etc), I assume that in his experience the outcome is the same.  I did check that he has done this before  - he has done a few ;D 

Lottie - I didn't get into the specifics of the rehab.  It was a lot for me to take in and he is keen that I read up on it!  I need to actually confirm that it will be funded before talking about post op.  I presume I'd need to have an in depth chat with the physio beforehand.  He didn't mention a brace, although the literature does mention it.  I think these tend to come down to surgeon preference and individual case.

I should get a letter from him in the week - will see what else that says :)

Title: Re: Chondrotissue procedure
Post by: WestPoint on July 04, 2010, 01:06:11 PM
Sounds very interesting. This is especially so if the hyaline-like cartilage is equal to MACI. Now that you've explained that this is superior to the fibrocartilage of MFX, I guess the key here is: What is the degree of superiory of MACI hyaline-like cartilage to Chonrotissue hyaline-like cartilage? If they are the same or essentially the same, then why go through 2 operations when you can just do one?

Sorry, didn't catch what you mean by DVT risk.

80% sounds standard, so maybe you have the right break in your case with this treatment. Don't forget the Cartifill option for your patella, especially when Dr. Shetty starts adding the mesenchymal cell treatment to it...
Title: Re: Chondrotissue procedure
Post by: Lottiefox on July 04, 2010, 01:06:56 PM
I still think you should seek advice on OATS. This WILL produce hyaline cartilage as it is a graft/plug from a NWB area of your own knee. It has good outcomes on focal, traumatic lesions. I'm all for these one step grafting type repairs, but in the right case. I'm not sure a small, focal, traumatic lesion is the right one for it as a first line of treatment - or maybe it is, but you might not get the longer term durability that an OATS graft would give. Questions for an OS really!!

Title: Re: Chondrotissue procedure
Post by: vickster on July 04, 2010, 03:52:05 PM
DVT - Deep Vein Thrombosis - knee surgery carries an elevated risk of developing and flying, especially increases the risk more, hence the no flying

From what I can tell from surfing a bit more, chondrotissue is just the trade name for the collagen membrane from this specific manufacturer, there is another one called Chondro-Gide from a different company.  Chondro-Gide can be used for either AMIC or ACI, suggesting they are the same.,1495,1496

I think the difference is that AMIC uses MFX to produce the stemcells which go in to the membrane to form the tissue, while in MACI/ACI the cells are taken in the scope op and grown and put into the membrane which is then implanted. In AMIC the cells proliferate in the membrane in vivo rather than in the lab
Title: Re: Chondrotissue procedure
Post by: WestPoint on July 05, 2010, 12:08:30 PM

Have you considered the OATS option?
Title: Re: Chondrotissue procedure
Post by: vickster on July 05, 2010, 12:14:36 PM
It is isn't something the OS has mentioned.  I believe he is offering me the best option for my probelm as he is the one who has followed my case from 3 weeks post injury and has scoped the knee  :)   He is also the knee and cartilage expert for my local NHS trust
Title: Re: Chondrotissue procedure
Post by: Lottiefox on July 05, 2010, 05:41:47 PM

I know docs always advise against flying because of DVT - would you be doing long haul? I only ask because Marc Rubin (he is a member on here and had De Novo NT graft about 7 weeks ago with excellent results so far) flew inter state in the USA about 6 days post surgery. That may have ben a short trip. Crankerchick also flew after her triple osteotomies if I recall correctly? Clearly it isn't ideal, but people have done it and perhaps with the right support and stuff it is not a huge risk. I suspect anything long haul would be out though.

Vicks - sorry to hijack the thread! I think you have a very reasoned bunch of arguments for why this guy is proposing a solution (got your message!). Sometimes a second opinion can help, sometimes it can muddy the water. I am extremely glad I have sought 3 opinions but my history is VERY different to a focal traumatic lesion. i have longstanding alignment issues, complex lesions and there is a host of "possible" treatments. Choosing the right one is not clear cut for me, and probably won't ever will be but will be based on risk versus possible good outcomes. Indeed, the choice at the moment is conservative, purely because of all those other factors that come into play with the biomechanics. I am VERY glad I didn't go with the first recommendatio of shaving and MFX - I fear I'd have had 6 weeks NWB, 6 weeks weaning off, and probably had more discomfort than I have now and probably no better covering of scar tissue!

So, looking like September then?! ;D

Title: Re: Chondrotissue procedure
Post by: vickster on July 06, 2010, 07:58:00 AM
Cheers Lottie

I think my OS and indeed the whole hospital is cautious on the DVT issue - TED stockings for 2 weeks after a simple scope does seem unusual actually!  I was given a whole leaflet about DVT at the time. I am not the lightest, and being overweight/obese does increase the risk I believe (along with smoking etc).  I suspect if I HAD to fly and felt able, then it would have to be discussed and the risk balanced with the need to fly.  But the OS also made it clear that it was also simply about staying put in case of an issue!
Title: Re: Chondrotissue procedure
Post by: WestPoint on July 06, 2010, 06:55:41 PM
Thanks for your replies Lottie and Vickster.

Vickster, I think this treatment sounds really interesting for you. Now that you know that the degree of hyaline cartilage is superior to MFX, I think the key issue here is to ensure that the degree of hyaline cartilage is comparable to MACI. If it is, then one procedure would certainly be superior to two.

Title: Re: Chondrotissue procedure
Post by: vickster on July 06, 2010, 10:53:33 PM
It won't ever be proper hyaline cartilage - cannot be reproduced, just something that is better than the fibrocartilage that I have right now

If it gets rid of the pain, swelling and I can get back in the gym and on the bike for next spring, then that's all I can ask for ultimately :)
Title: Re: Chondrotissue procedure
Post by: vickster on May 20, 2012, 05:07:47 PM
Oh dear, am going to resurrect this thread after nearly 2 years   :'(

After a year or so of relative knee calmness, the pesky joint started to play up again earlier in the year and I am having a course of hyaluronic acid injections to try to settle it.

However, I asked the OS (my original one) yesterday what my options would be if the jabs didn't help as wehope and his view is that the time has come to try to fix the defect and his recommendation would again be AMIC.  I had a second opinion on his recommendation and indeed a second scope with a view to potentially having MACI - however, the MACI wasn't done due to a valgus alignment and kissing lesions (grade 2 on tibia) and the deemed the chance of success too low and suggested an osteotomy as a potential future step.  So he had a bit of tidy and gave me a Durolane jab and all had been ok for a year

Surgeon number 1 does not think the alignment is that bad and does not need correction (probably a good thing as the thought of the osteotomy terrified me more than the cartilage repair (although that's no walk in the park either!

AMIC wasn't done previously as it is not approved on the NHS (or it wasn't back then), nor would my then private HC company pay for it due to lack of data etc (same reason why it is/was not offered on the NHS). 

I don't know if my current PHC company would pay (apparently back then, this company did cover it, but I am not sure now, given they have also recently stopped paying for MACI apparently)  :-\

As far as I know, the defect is still full of its original fibro, although the area has become progressively more tender and walking any distance can be painful, with the knee feeling like it may give out  :-\

Has anyone actually had AMIC (mfx + membrane to form a scaffold)?  No one piped up last time but perhaps now - it would certainly appear to be a newer theory than (M)ACI?

I don't really want to even think about any of this - but if in 6 months, things are no better, I may have to  :-\  so any thoughts would be appreciated  :)