KNEEtalk

The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: Vickster on October 12, 2010, 02:02:28 PM

Title: Symptoms from cartilage defect(s)
Post by: Vickster on October 12, 2010, 02:02:28 PM
I have now been dealing with my gammy left knee for 13 months and am getting more and more frustrated with lack of change, progress, recovery, whatever you want to call it :)

I came off my bike ( ::) ) at a reasonable speed onto concrete and tore the lateral meniscus (partial meniscectomy in Feb which resolved the locking and buckling), bruised the bone of the lateral femoral condyle and knocked a chunk of cartilage off the LFC on a WB bit (I also have a grade II defect of the tibia opposite, assume caused by accident), I also have grade III wear & tear to the patella (shaved during February scope). I never had a great deal of pain even at the time and hobbled around without crutches or anything else. The scope was primarily to sort the meniscus but there was also a possibility of microfracture depending on the state of the osterochondral defect. However, this wasn't done as the defect has already naturally filled with fibrocartilage.

So where am I now? I realise that scopes can take months to get over, but it was 8 months ago and I have the same level of swelling and soreness I had after about 4-6 weeks. Sometimes better on the soreness front - can get a burning from the defect area and it is puffy around there and if I push against or twist on it, I get a sharp pain. It also starts to ache laterally with walking - after say 10-15 minutes not miles by any means! It can also burn or be sore just lying in bed. The whole knee also gets really stiff when I sit for any length of time (maybe 30 minutes plus) which does ease off with a bit of a hobble!

The kneecap also pops and grinds when I bend and straighten, not usually uncomformatble. The OS said this wasn't unusual after the shaving as suction can occur!

I am able to walk fairly quickly (but any sort of running / jogging is a no no) and I can use the gym - static bike with some resistance, stepper, XT, walk on treadmill. With rowing, it feels ok at the time as long as I don't over bend or over straighten but the knee seems to react quite badly the next day (may just be a coincidence).

I take minimal painkillers - it is uncomfortable rather than downright painful and I think I have just got used to it feeling 'off' the whole time, sometimes with sharp pains which pass.

My OS firmly believes all of the swelling and discomfort is the result of the scar tissue over the defect.

I was going to have AMIC but my insurance company wouldn't cover it. My OS suggested I see another OS at the RNOH in Stanmore about the possibility of cartilage / repair on a clinical trial which I did. He however, was not of the opinion that my functions and symptoms really warranted such major surgery and said I should decide what level of restriction I could live with. He did say he would be happy to scope the knee again and have a look (fresh MRI showed improvement versus the one done about a month post injury).

I am 38, probably 6 kg overweight (I have lost 16 already this year) and have an office job that does require travelling / visiting clients from from time to time. Try to go to the gym 3 x a week and do around 30-45 minutes of cario leg stuff - not painful per se, but none of it feels smooth and comfortable. I can't do any sort of medium-deep squat (pain through kneecap), nor can I kneel on it.

I saw the physio again yesterday but I think he is at a bit of a loss as to why the pain and especially swelling persists - something in there is angry and irritable it seems. he says that if I wasn't doing any sort of exercise then the stiffness could be explained perhaps and he doesn;t think I am overdoing it given the amount of time that has passed since injury and op.

The knee had been more settled for around a month but has flared again recently - I don't think I have been doing anything more or unusual (perhaps more walking as have been carless, but again only 10-15 minutes at a time really to stations etc)

I think I am at a bit of a loss as to what to do as nothing I do or don't do seems to maike any difference for a sustained period of time :( I know lots of you have cartilage defects and I was wondering what sort of (level of) pain you have, qwhat level of function impairment and how you deal with it and what you can do that doesn't upset your knees? 

Maybe this is just now 'normality' for me and my knee, but it would be great to know how to deal with this new reality and not feel so damned frustated and fed up all the time!  >:(

Thanks in advance and apologies for the ramble!

Title: Re: Symptoms from cartilage defect(s)
Post by: AndrewH on October 12, 2010, 03:21:12 PM
You say that the insurance company won't cover ACI? Who is your insurance company? Are you in the UK? As far as I am aware, AXA, BUPA & Prudential all cover ACI.

I considered ACI but the hospital wasn't licenced. The only option was to try another hospital or go on the clinical trial you mentioned (which would have meant getting randomised to either ACI or mosaicplasty - and would have been done by the very same surgeon!)

There is also the option of mosaicplasty which I had 3 months ago after a failed microfracture last June. So far I am happy with the results of the mosaicplasty on 2 lesions plus microfracture on the patella. It seems to be working.

My surgeon said to me that the most important thing with articular cartilage defects is to get them treated as soon as possible. I also wouldn't say that the mosaicplasty surgery I had was *that* major. If you can cope on crutches then 6 weeks non weight bearing is really not too bad. I was back at work after 3 weeks (sedentary job) but could have been back much quicker. I've already got my full ROM movement back as well - and I had full open knee surgery with a massive incision down my knee and work done on 3 different lesions.

If I were you I'd find a surgeon who will get you sorted.
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 12, 2010, 03:48:38 PM
Andrew, thanks for your reply

It is one of the three companies mentioned (and they do not cover, not going to say which one it is) - their stance is that as (M)ACI is not approved by NICE, they won't cover unless part of the trial.

My OS doesn't like mosaicoplasty, an old procedure and he doesn't think the success rate is high enough.  Also, the defect is on a curved surface and given the size (1.5cm2) would be very difficult to plug successfully.  He said he would do it as a last resort - I dk if I am there yet, this is my quandary.   He did say none of this stuff really works for the patella.  i assume when you say the MFX failed your defect was through to bone.  I guess mine is currently similar to a successful MFX as it is well filled with fibrocartilage, but is just tender - so fixed, just not settled. I do trust his judgement, have no problem with any course of action followed thus far and cartilage repair is one of his special interests and has experience.

The issue is it is not easy to get sorted due to the insurance being buggers (they do have a rep for querying claims and being difficult, corporate policy so no choice).  I have never been in the NHS system for the knee.  I have seen 2 surgeons, one would operate but can't due to the funding, the other could possibly operate but not able to recommend it based on what he has seen (but he hasn't seen me 10+ times in 9 months, nor the inside of my knee).

Was your op very painful, everyone say (M)ACI is but not sure precisely which bit cause the pain and issues?  I had major back surgery when I was 20, 6 inch incision on lower back, hurt like h*** for a few days (try sleeping!) but then not too bad.  Can it be worse than that (it would seem so reading the ACI section and diaries).

All highly frustrating!
Title: Re: Symptoms from cartilage defect(s)
Post by: k66yla on October 12, 2010, 06:34:21 PM
Hi Vickster
I don't know anything about knees but I can understand how you are feeling regarding the burning pain & swelling. I've had the burning pain since my fall back in Jan 2009. Everytime I attended physio they done ultrasound massage on it but that did'nt relieve it. The only thing that did relieve the pain for a couple of weeks was an injection in that area. Do you think you could of torn your meniscus again?
I'm still waiting for my lateral meniscus op, next 4 weeks hopefully. You have me worried now if after 8 months you have'nt recovered.
Title: Re: Symptoms from cartilage defect(s)
Post by: Lottiefox on October 12, 2010, 07:21:06 PM
I'm just going to chime in...playing devil's advocate there is no guarantee that the current knee issues are due to the defect/fibrocartilage per se. It may simply be an unhappy knee due to the traumas of accident and surgery. Undertaking a cartilage repair is no guarantee that the knee will become happy. If the lesion were down to the bone, you had severe issues with weight bearing or when the patella catches on it, then I would definitely say that a repair is in your future...but.......

Transient issues that may be down to the defect, may be down to a joint that won't settle, may be down to a menisectomy, may be down to constantly irritated synovium........that is a harder one to call and is basically what the RNOH doc was saying in my view.

I also think that one OS's views are not always gospel and not always right for your knee. Mosaicplasty isn't outdated, under the right circumstances. It has gained a reputation for failure when used in LARGE defects (and yours isn't clinically large) without adequate structure around them. Not dissing your OS, but they all have their bibles and views. My London OS says don't even bother trying to darn my multiple defects with any form of fix. (I know my knee is different in aetiology to yours) Mr Shetty however thinks that Cartifill would work. Who do I believe??! At the end of the day - it isn't their knee and future mobility!!!

Any form of cartilage repair is an unknown. Its still very new apart from the MFX which is the OS's first line of attack as it has fewer risks, is easier to recover from and might just work.

Fundamental question is how bad does the knee have to be that the risk of a more in depth repair is worth it? If this is your knee for good now can you deal with it?

Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 12, 2010, 07:53:01 PM
k66yla - I don't believe the menisectomy is the cause of the problem - as I said it has removed the meniscus related pathology in my case - locking and buckling from walking. There are no guarantees with any surgery, but if you do have symptoms that aren't going away that the doctor thinks is due to a meniscus tear, then in my view, time to get it fixed. I followed a conservative course for 5 months and it didn't get better, if anything the tear got worse and I ground away a bit of the mensicus. I could never straighten the knee but the buckling was a late addition to the party! I don't think the meniscus is re-torn as I have had an MRI since the scope and nothing mentioned (not seen the report)

I don't regret having the scope, it's certainly not made anything worse. I would just have hoped to see more improvement, nearing normality after so long.

Stuff to think about Lottie, thanks as ever :) I could see 10 doctors and get a different answer from each! I could have mosaicoplasty, the insurance would pay for it, but the OS has not seen good results especially in defects on the curved bit of the condyle which are harder to patch. I already have 3 areas of cartilage damage to my knee already, do I want to have a 4th from the donor site with more lovely fibrocartilage even if it in an NWB area? The lateral area is tender if I press it gently and it's also swollen.

I am really looking for some sort of feedback from folks with similar issues to assess whether the swelling and pain is just a normal consequence of the pathology or more unusual.  Ultimately, I am just at a complete loss what, if anything I should do  ???  If nothing can be done, then so be it!

My right kneecap (which the 2nd OS observed to have crepitus) was grinding on the leg press at the gym too today, marvellous ::)
Title: Re: Symptoms from cartilage defect(s)
Post by: AndrewH on October 12, 2010, 10:12:33 PM
Vickster, I am suprised that you say that one of those 3 companies don't approve ACI. I have seen ACI named as an available op for 2 of them on their procedure lists for certain.

My original defect was on the medial femoral condyle on a weight bearing surface. It was around 1.5cm2. I had microfracture last June. The pain never went away and I went in for mosaicplasty this July. The surgeon said that when he went into my knee, the original defect had completely covered over with fibrocartilage. Unfortunately it just wasn't doing the business.

He performed mosaicplasty on the defect this time and used 4 plugs. The gaps should fill in with fibrocartilage. Unfortunately he found 2 new defects on my patella this time around as well. I was suprised as I wasn't really having any issues with my patella. They are both small lesions. He filled one with 1 plug (mosaicplasty) and did microfracture on the other.

Title: Re: Symptoms from cartilage defect(s)
Post by: AndrewH on October 12, 2010, 10:21:39 PM
Sorry for the 2 posts Vickster.

To continue, I have done extensive research on mosaicplasty and would disagree that the success rates are not high. There is only one study where the researchers came out in favour of ACI instead of mosaicplasty and they stated that the continued use of mosaicplasty was of dubious value. There were several issues to notre with this study though. The study was small, the average defect was very large (over 4cm2) and the plugs were placed prominently. If you look at other studies, particularly Handgody's studies, the average defect is around 1.5cm2 and the plugs are placed flush.

Handgody's study (over 800 surgeries) gave a success rate of 92% on the medial femoral condyle. Mosaicplasty on the patella is more unusual. Nonetheless, he has a success rate of 79% on the patella. My own surgeon has done loads of mosaicplasties and says he has only ever had one where the patient had continued problems.

I am still at a very early stage (3 months) but feel that mine is working. I should know better at the 6 month mark, although improvements may continue up to a year.
I would advise you do some research on the many studies out there. Mosaicplasty has a very good success rate. My surgeon hinted to me that he expects the ACTIVE trial to show that ACI is superior.... but that goes back to the issue again of the type and size of defect. Mosaicplasty may not work very well with larger defects.

Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 12, 2010, 11:08:20 PM
Hi Andrew,

Thanks for taking the time to post again.

One of the three companies definitely turned me down for the AMIC repair that my OS recommended (who as I said has been treating the knee for a year now on and off), despite it being disputed at a corporate level by HR and the OS writing to explain his reasoning at their request.  They were adamant - no AMIC, MACI or ACI unless part of a trial which is in line withe NICE guidelines (I even trawled through the 50+ page PDF)!  They basically expected the OS to produce long-term data.  Unfortunately, my OS was invoved in the Genzyme trial (SUMMIT?) but that has finished and is in the analysis and reporting phase or I would have been ok.  Mosaicoplasty isn't approved by NICE either but they seemed more willing to cover (assuming the OS wrote again - believe me this was all a royal pita), I guess because it take spare parts from the patient's knee, no need for costly membranes and cell culture (not that they ever said cost was a reason of course).

What sort of symptoms did you have from the defect that led to the MFX and then the mosaicoplasty?  Was the defect from an injury or wear and tear?  Sharp pain, ache, specific things set it off, were you able to walk ok - how far? What are you able to do now, 3  months post op? Sorry for all the questions, but I am trying to measure my own experience :)

I think that, for whatever reason, the lateral side is more problematic than the medial?  Ref the lack of success for mosaicoplasty, the OS said that he has been doing for 7+ years and had seen 50% success in his patients, certainly nowhere near 90% and the curved surface where the defect is located is problematic.  he said if it was a small punched hole, no problem.  My defect is around ~1.5cm2 too, for him, 2cm2 is about the max (I guess surgeons may try on larger if major symptoms no other options).

Nothing I do seems to make any sort of consistent positive impact, nor does anything obvious cause more issues than anything else.

Sorry for the wiffle!

This stuff is all really confusing, I think ultimately I am looking for a solution but I don't know what that is.  The physio even said that there is no magic bullet - he's as frustrated as I am!  We have a family friend who is a retired Consultant OS (and knows me as he operated on my back all those years ago), maybe I'll give him a buzz (he is aware of my knee woes from my mum lol).  He will definitely be on the conservative end of the spectrum, and was a general OS rather than a knee spec, but he will have some insight :)

Title: Re: Symptoms from cartilage defect(s)
Post by: Catsmum on October 12, 2010, 11:27:01 PM
Hi Vickster,

First time posting on this site so here goes....

I too have a cartilage defect in LFC on my L knee and was struck when reading your post how similar my symptoms are to yours. Constant swelling in knee, burning pain not too severe but definately uncomfortable. I am also getting some burning at night and stiffness in the morning. I too can walk reasonably fast but with a slight limp when I get tired but would struggle to run ( & I love running). So, yes, I guess your issues may well be caused by the cartilage defect rather than some residual inflammation from your meniscectomy.

I had no knee problems at all until an injury in May this year. My MRI showed a complete ACL rupture & meniscal tear. I had ACLr & meniscectomy and the cartilage defect was picked up during the surgery. My OS offered me microfracture, OATS or referral for ACI and after a lot of deliberation I have been referred to Stanmore for possible (M)ACI.

 I am now 3 months following ACLr & have not seen much improvement over the last 6 weeks in terms of swelling & pain. So I am now hoping for some joy when I go to RNOH next week!
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 12, 2010, 11:58:22 PM
Hi Catsmum
Thanks for posting (especially your first time)!
I didn't damage any ligaments (fortunately) - the meniscus tear and damage to the bone.  The pain is manageable, I could take more painkillers but I tend to be someone who takes them for acute pain only and am not happy taking long term for chronic.  I did discuss with the physio perhaps seeing my GP for a course of a prescription NSAID to see if that helps settle the knee but I don't think it is a long-term solution.  My surgeon also suggested hyaluronic acid injections as a possible help to lubricate the joint, but again he seemed less than convinced of their worth in my case (although people with OA do get immense benefit from them, and won't do any harm so might be my next course of action)

It will be interesting to know how you get on at Stanmore (presumably an NHS referral) and that they can offer you a solution. I actually saw the surgeon from there privately for the second opinion and his view was that MACI would send me way backwards from where I am now (a few nights in hospital, pain, brace, crutches) and that it would be a year to return to meaningful activity and 2+ years to clear benefit.  He did say it was very much my choice however and for me to decide what level of restriction I could live with.  I am not the most decisive, so am obviously still agonising over this.  If I was 68 or even 58, I would just live with it, but at 38 it is a tougher decision clearly especially with no guarantees :( 

I can't even fly comfortably - recent 2 hour flight to Berlin, bulkhead seat in business but both ways it was decidely uncomfortable for much of the flight and the knee was a s stiff as ever.  The physio said it should be better now - I don't know if it's the yomping around the airport that is the issue or the cabin pressure, the sitting or what! I'd like to fly long haul for holiday next year but economy would be impossible if I am where I am at now still.

Hope it all goes well for you

Vickster
Title: Re: Symptoms from cartilage defect(s)
Post by: knee always hurts on October 13, 2010, 01:23:43 AM
Hey Vickster,

If you are feeling poorly the day after doing an exercise, perhaps there is a connection between the two. If you are overdoing exercises at the gym on a regular basis, that could definitely prevent your knee from recovering. It may be a bit unconventional, but take a look at this post here:

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=53006.0

This individual had severe patellofemoral pain as well as significant chondromalacia defects, and yet ultimately made a complete recovery. I'd strongly recommend reading the blog linked in the first post.

If you don't mind wading into the abyss of medical research papers, these three might cast an interesting and novel light on your condition:

http://docs.google.com/viewer?a=v&q=cache:sIxlKJaiqGYJ:rehabeducation.com/main/wp-content/uploads/Therapeutic%2520implications%2520of%2520tissue%2520homeostasis.pdf+synovium+irritation&hl=en&gl=us&pid=bl&srcid=ADGEESiMFOXRVhxrNp-vyd2N412erMdLYT51ZxagCtws0q--x1BuKdZhvDaCJzzNAvqpjcUGZ6zJEMCf60Yg4McSC8qyqJswR9Yv4SvprHm0UDbt3e-W1MSLtb4nHXQiwt47Nx3sCd5a&sig=AHIEtbTwvpWG6Zql7FWhLn0MInvJsws4Ng

http://docs.google.com/viewer?a=v&q=cache:w42Ub7Mx5UYJ:rehabeducation.com/main/wp-content/uploads/Patellofemoral%2520Pain%2520-%2520Current%2520concepts.pdf+role+of+synovium+in+patellofemoral+pain&hl=en&gl=us&pid=bl&srcid=ADGEESiaF03W7rL6sHTpe32GnYPBQAMLDeDDd65xw95lieCutrCa3-E5p-CdgsisjCmBshwwO3lx_cPk-STSseTcMJ6u-D-lkHWoZ0ZMlhe4jaQra7YrZAZUXxFE90dII0ydmboKuHJx&sig=AHIEtbTtD9pPn0RwGicAjcPFm1nzDR2LhQ

http://docs.google.com/viewer?a=v&q=cache:4msKEpZCA24J:prdupl02.ynet.co.il/ForumFiles_2/19447772.pdf+The+Pathophysiology+of+Patellofemoral+Pain&hl=en&gl=us&pid=bl&srcid=ADGEESgGIVZMNaVoTwM0D9wAvqt3-f2aEHuIF0hnWOdEYXFiLlGFVJnjfQmbs4FsQ7VbWO_OiUmt_jxBwg1wHu5bY24AhdW6X80qJx4w2S-iEiDd8zoQPXkWnPg1c5484uLbMXHdnzTC&sig=AHIEtbRuEhbHlhgdwVnugn-_0eOiBdncTQ
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 13, 2010, 08:14:28 AM
Thanks KAH :)

I should have added that, on the advice of my OS, I had around 12 weeks away from any exercise other than swimming in the summer after returning to the gym post scope (on the OS's advice to keep the muscles strong to reduce the load on the patella especially). No gym, no bike, no physio exercises, just lots of very unstylish front crawl ;D made no real difference. The knee did settle (less discomfort, but no less swelling) for a few weeks (around the time I saw the second surgeon) but has since flared again. Although I actually don't like swimming, I did give it a go and when I went back to the gym I took it pretty easy. The thing is, although I am not an exercise fiend like some, it is not acceptable to me to not be able to use the gym - both from a fitness but more importantly weight control point of view. Indeed, the 2nd OS also encouraged me to carry on doing all the 'right things' in the gym - cycling, stepper, XT, rower 9although this does annoy the knee, not so much at the time but the next day) and walking on treadmill. Also, to get back out on the roads on the bike - not had much opportunity due to the weather recently!  I am caught a bit between the devil and the deep blue sea on this.  Certainly, the physio is encouraging exercise for flexibility (cycling etc) and strength (leg press) - finding the balance between too much for the knee and too little for the rest of me is tough!

I think my frustration really stems from the fact that whatever ever I do or don't do, I see and feel no change in the knee - it suffers if I sit for 30+ minutes in a meeting, but I have to be able to do this for my job! 13 months ago I was 16kg heavier (the weight loss has been for both the knee and the rest of me) but my knee was fine! >:(
Title: Re: Symptoms from cartilage defect(s)
Post by: AndrewH on October 13, 2010, 01:40:04 PM

What sort of symptoms did you have from the defect that led to the MFX and then the mosaicoplasty? Was the defect from an injury or wear and tear? Sharp pain, ache, specific things set it off, were you able to walk ok - how far? What are you able to do now, 3 months post op? Sorry for all the questions, but I am trying to measure my own experience :)

To give you the background, I am now 41 and I gave up smoking 6 years ago. For a year I was putting on weight and doing little exercise apart from playing 5s once a week. I then decided to get fit. I went running, joined a gym, etc then did a couple of 10ks and then a half marathon. I discovered that I really liked running and my times were quite good despite not training seriously.

I then entered a marathon for April 2007 and started training seriously with some group of serious runners at my work. Over the course of the next 2 years I became totally addicted and very competitive. By the time I got injured I'd got my 10k time down to just over 35 mins and my half marathon time down to 1.22. I was finding myself lining up at the front of big races with hundreds or even thousands of runners behind me. It was a big rush because I didn't believe I belonged there and everyone around me looked like *real* runners and fitness fanatics - yet I was beating them and posting faster and faster times. I wastraining around 70 miles a week. The beauty of it was that I could run to or from work (or both), which was 6-9 miles depending io if I drove part of the way and did 2/3 lunchtime sessions. I could run to work quicker than any other method of transport. It mean I had this great hobby that took up virtually no family time whatsoever. My wife had no problems with ity, apart from the fact that I'd become very skinny (despite eating around twice what I do now!)

Anyway, something went wrong in November 2008 and progessively got worse from there. I went to physios, etc but it wasn't until I saw my surgeon in April 2009 that I was finally diagnosed. Ity took the surgeon off of 5 mins to diagnose my problem!

My sysmptoms were very like yours. Sharp, burning pain that got progressivly worse. I was able to still run until Jan 2009 and then it just got worse from that point on. Before the microfracture I could hardly walk. Despite the microfracture, the pain never went away and that is what led to mosaicplasty.

Quote
I think that, for whatever reason, the lateral side is more problematic than the medial? Ref the lack of success for mosaicoplasty, the OS said that he has been doing for 7+ years and had seen 50% success in his patients, certainly nowhere near 90% and the curved surface where the defect is located is problematic. he said if it was a small punched hole, no problem. My defect is around ~1.5cm2 too, for him, 2cm2 is about the max (I guess surgeons may try on larger if major symptoms no other options).

I suppose all surgeons will have their own experience. My defect is around 1.5cm2 on the weight bearing curved part of my condyle. That is the area which actually has the highest success rate according to studies. My own surgeon reckons its the most successful area. The use of mosaic plugs is what allows the surgeon to replicate the curviture.

I think my surgeon actually enjoys doing these types of surgery. He described my surgery as "beautiful"! Each to their own!

If your surgeon doesn't have a great success rate and isn't keen doing it then I'd be wary. My surgeon was very confident and, as I said, he reckons he's only had 1 person with continued problems. One of the keys to success for this surgery is technical ability. That is one big reason why I am confident that my surgery is working. My surgeon is confident and had no qualms about going ahead with it.

Whether my surgery has actually worked, time will tell, I'll find out over the next few months. I might end up needing a TKR.

Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 13, 2010, 02:59:45 PM
Thanks Andrew.

I don't think it is a lack of confidence on the part of my surgeon, he is very experienced, specialises in knees and is one of the UK based cartilage repair pioneers.  I just got the impression, that in my case, he favours a MACI /AMIC type of repair (it may be that it is newer and funkier  ;D ) - mosaicplasty is one of the options he put forward, just not the preferred.  However, given the situation with the insurance company, if I am still struggling like this in the new year, I will talk to him again and possibly go down the mosaicplasty route.  I have not seen him again since seeing the other OS, because until the last few weeks the knee had been feeling a bit more settled.  Work is also utterly manic so there is no chance of me basically taking 6+ weeks off.  February will possibly be better!
Title: Re: Symptoms from cartilage defect(s)
Post by: Lottiefox on October 13, 2010, 05:44:01 PM
Surgeons are more fickle than a teenager and a boxed set of Twilight......they go for whatever their research interests lie in a lot of the time, especially if they are pioneers in a particular field.....and Vicks has your chap specifically talked about mosaicplasty or OATS? There is a difference. If he is thinking of one plug, then the success may be low. As Andrew says, using mosaicplasty allows them to replicate the curvature.....I remember seeing a research paper with pics of this in it, and the fit of them was amazing. All down to skill though, its not like tiling a bathroom I guess.  :P

I'd be seeking yet another view too.......there is no right solution to fixing cartilage holes. Its a case of weighing up what, when, how, who and the risks of success versus the risk of worsening or no improvement....

Andrew - who did your mosaicplasty out of interest? Vicks - might be worth chatting to whoever it is....I agree with Andrew that I would want someone doing the repair who had confidence it could help.

I would also urge trying a visco shot. It is painless, and has helped my lesions. I have less catching, less pain on direct pinching. Mine are just off WB so I am able to adapt a bit, but the Euflexxa has certainly assisted. Nowt to lose. If it stops the knee getting irritated then its a win. Not a long term fix, but whats to lose??

Lottie
Title: Re: Symptoms from cartilage defect(s)
Post by: Catsmum on October 13, 2010, 06:24:42 PM
Vickster

Sorry to hear about your problems with the insurance company. You're right that I have been referred to Stanmore on the NHS. Is this a route that is open to you?

I am sure that your OS is right in warning you about the drawbacks of (M)ACI in terms of prolonged recovery etc. I've been quite daunted by some of the stories I've read on this site. I guess at the end of the day you've got to decide what symptoms you're prepared to accept. For me, although the pain is not too severe it is at a level where I am taking increasing amounts of painkiller to make it managable. I also would not enjoy the prospect of never being able to run again although I realise this is still a possibility even with MACI. It sounds as if your symptoms are not at a level that you would put up with forever. I'm sure it is the right thing to speak to your OS in the new year if it hasn't improved.

 
Title: Re: Symptoms from cartilage defect(s)
Post by: Lottiefox on October 13, 2010, 06:43:14 PM
Catsmum (great name BTW  ;D)

Not wishing to hijack Vicks' thread but check out threads on here by JulianUK - he had MACI through Stanmore some 6 years ago and is a big success. Similarly member called thevoice had MACI about 8 months back and is now doing well. Cricket is another success story with ACI and has her own blog on her experience. Its detailed, graphic and not for the feinthearted but it illustrates the process and rehab very well. Serach for her posts and it will link to her blog too if you want to know more. Its a fine line I think with knowledge and having some trust in the process that is recommended. However I'd always recommend being advocate for your own knee/health. Good luck with the RNOH appt.

Lottie  :)
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 13, 2010, 07:07:02 PM
Lottie - Mosaicplasty ... I quote from last letter from OS to GP in mid August... Should she have difficulty with this (trial etc), then I would be happy to perform a mosaicplasty to the area  :)

I could try the shots - again, I don't know whether the insurance will cover (not asked).  The lesion mostly burns simply when sitting, it is not linked to movement specifically

Andrew is in Scotland - I looked at his profile (I am not a crazy stalker, honest  ;D I was going to PM you to ask, then noticed Scotland in the profile :)  Frankly, Stanmore / Bushey was pushing the realms of practicality at a 2 hour journey each way, Scotland would be a complete no no lol I don't feel the need to seek a third opinion (reasons discussed before), especially given the restrictions imposed by the insurance company (they will pay for MFX and I think mosaicplasty under sufferance)

catsmum - indeed, I would put up with it if there was nothing that could be done.  I don't need to take painkillers, as much as I could, because they are also not without problems.  The pain comes and goes, it is unpredictable, so not the easiest to control I guess

Running is not my thing, but it would be nice to be able to for a train etc, rather than a rather weird hobble-skip-run as at present lol

Title: Re: Symptoms from cartilage defect(s)
Post by: AndrewH on October 13, 2010, 07:42:56 PM
I am indeed based in Scotland. My surgeon is Sanjeev Chitnis. He leads the ACTIVE trial in this area but I had my op done privately (lucky enough to have work insurance).

Vickster - I too waited before rushing into this surgery. I was told I was being redundant just under a year ago so wanted to wait until I had a new job lined up before jumping in. It also allowed me the time to really see if the microfracture had any chance of success. I also had my brother's wedding in the summer so wanted to get that out the way and also didn't want to start a new job then tell them I needed time off straight away for a knee op! I actually took 3 weeks holiday rather than take time off sick.

However after 13 months there was no real improvement in the microfracture and my surgeon advised that what was important was to get the defect attended to sooner rather than later.

I considered ACI but the problem was that with some new transplant rules or other (I did research it at the time), my surgeon's private hospital was not licensed. He told me I could get a referral back to him on the NHS to go on the ACTIVE trial and the op would ironically be done at a hospital just round the corner from my house. However I would be randomised to either mosaicplasty or ACI and go on a waiting list for a number of months. It didn't seem logical to me to do that when there was a 50% chance I would have mosaicplasty anyway and I wasn't sure which option would be best anyway.

I also considered going to see a surgeon in Oxford who specialises in ACI. I even phoned up and made an appointment. However my wife didn't think it was very practical if I had an op down there. Personally I thought it was doable and wanted the best for my knee. But again, I wasn't convinced that ACI would be better than mosaicplasty.

As I mentioned, there is only one study that came out in favour of ACI over mosaicplasty and, as I mentioned, the average defect size was twice mine and they didn't place the plugs flush. I also noted that the authors were being paid by a medical equipment company. I made my own conclusions on that. All other studies on mosaicplasty that I have read had had very good success rates and either been as good or better than ACI. They have also been better than microfracture. Indeed, from the studies I have read there is some controversy whether ACI is better than microfracture. If you look at the ACI section of this forum there are plenty of examples of ACI not working. However as Lottie points out there are many success stories. I know that former Manchestr United footballer Ole Gunnar Solskjaer had ACI and he made a comeback. I also note that Andrew Flintoff the cricketer has had to retire after having microfracture last year. The Dundee goalkeeper Rab Douglas had microfracture on 2 lesions this year and he is on the road to recovery.

I will state however that its still early days for me. I cannot say for certain yet whether mosaicplasty will work for me. I have also had work done to 2 lesions on the patella. I am not counting my chickens yet.

Re your point about the burning pain at the lesion just sitting down - I know that feeling very well. If its burning when just sitting then its far from okay! Since having mosaicplasty I have not really had that sensation. I keep waiting for it but its not happened yet. It doesn't feel 100% but I am confident. I went for a 1 mile walk this afternoon and it felt incredibly normal and there has been no burning sensation that has hit me yet.







Title: Re: Symptoms from cartilage defect(s)
Post by: Catsmum on October 13, 2010, 07:56:25 PM
Vickster - ha ha- yes I know all about the hobble-skip-run for the train have done that one myself on a few occasions! :-\

Lottie - thanks for the advice, will check out the threads you mentioned.

Catsmum :)


Title: Re: Symptoms from cartilage defect(s)
Post by: knee always hurts on October 13, 2010, 08:46:34 PM
"...it suffers if I sit for 30+ minutes in a meeting, but I have to be able to do this for my job!"

That could be your answer right there. That's the conundrum with these sorts of problems with the knees. Everyday life intervenes, and you are simply unable to do what is necessary to properly rest the knees. In my case, I'm able to do anything necessary to rehab the knee, and I'm still having problems with it. Physical therapy helped a bit, but made some other problems worse, and I've found through experimentation that my knee's level of tolerance is very (http://very) low. Perhaps there is a procedure that your surgeon will be able to perform that will allow you to achieve a higher level of tolerance to loads and ultimately allow your knee to heal, but remember that all injuries need a period of real rest without irritation to heal.
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 13, 2010, 09:16:16 PM

I will state however that its still early days for me. I cannot say for certain yet whether mosaicplasty will work for me. I have also had work done to 2 lesions on the patella. I am not counting my chickens yet.

Re your point about the burning pain at the lesion just sitting down - I know that feeling very well. If its burning when just sitting then its far from okay! Since having mosaicplasty I have not really had that sensation. I keep waiting for it but its not happened yet. It doesn't feel 100% but I am confident. I went for a 1 mile walk this afternoon and it felt incredibly normal and there has been no burning sensation that has hit me yet.



Hi Andrew
Good to hear the burning symptoms are relieving, what other improvements have you felt since the op 3 months ago?
I can't walk a mile comfortably, in fact pretty much all the time I can feel the knee after 5 minutes of walking - normally a tightness which feels like the knee is being squeezed - uncomfortable rather than painful. Any distance and I get a tugging laterally and sometimes the burning. Not normal I guess :-\
It is so damn hard to know what to do ultimately, there is no perfect cure, no doctor can give me a guarantee, not even how long the fibro will hold - pretty much the first thing the OS said when I came round from the scope was that it is anyone's guess! All complicated a little bit more by the insurance situation - of course, I am lucky to have had everything covered to date.
I just think the whole taking cartilage from a 'good' bit of knee and that the donor site will heal over with fibro again does not fill me with joy given how the knee is reacting to the fibro over the defect. Also, do I want a major open surgery to do something that may not help or even make the knee worse...tough tough tough decision! Wish I'd never fallen off the damn bike ::)

Title: Re: Symptoms from cartilage defect(s)
Post by: Lottiefox on October 13, 2010, 10:57:48 PM
I'd just add in a couple of things...

Cartilage itself has no nerve endings, so cannot actually be the source of the pain. Something around the cartilage is inflammed and this is causing the pain. Clearly if you have a defect with NO covering and weight is transferred through it then the result will be pain as the bone does have nerve endings. For a "defect" to be creating pain at rest something else is irritated/inflammed - quite probably because of the pathology in the knee but not necessarily...the knee may just not be setling after surgery......the menisectomy site may be troublesome.......yada yada...knees have a mind of their own.....I have 3 areas of grade 3-4 cartilage loss (I've seen my MRI, there is bald bits!!!) but no pain at rest now my inflammation is reduced through a combination of the right exercises, the right avoidance of impact but the right use of exercise (and I still train hard 4-5 times a week...but within the parameters of my knees), the right medication and probably the final thing of the Euflexxa. I haven't covered my defects with anything (although the London OS said it isn't inconceivable I may have something protecting the holes - I suspect not!) but my pain at rest/burning is dramatically reduced, to a level that I can accept. There are times now the knee feels normal. I was sitting with my knes bent up and criss crossing them, etc and chatting to a friend at the gym and she said "Blimey - you weren't doing that 3 months ago...." I can bike 30k without a break and feel fine after. How long will it last - who knows!

All I'm saying is that try anything you can to reduce this inflamed knee before a repair. I am the world's most surgically averse person, I know, but had I chosen in February to have a MFX and shaving and possible lateral release I feel I'd be far worse than I am now. Seek out anything you can to try and resolve things. Regardless of insurance a visco injection is around 300. It might just let the knee start settling....

BTW - are you icing after the gym sessions? I never miss my ice sessions..... ;)
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 13, 2010, 11:01:38 PM
You know me...never been much of one for the ice...except in cocktails  ;D  Never seems to have any effect on the swelling

I shall think about next steps if any

Cheers :)
Title: Re: Symptoms from cartilage defect(s)
Post by: AndrewH on October 15, 2010, 06:07:03 PM
Vickster - I am having improvements daily. I went for a family day out yesterday and did a lot of walking about - totally pain free. I never ever managed to do that after microfracture. What I have now is a small area of numbness on the skin next to the scar but that's getting better and its not really an issue. My knee does feel "weak" but its not painful. I presume it will feel stronger with time.

I've not had any donor site issues so far. Bit of clicking for the first couple of months but that has now stopped.

Now considering I've had mosaicplasty to 2 seperate lesions plus microfracture on another plus have 5 plugs from a donor site and a huge great scar down by knee, I am absolutely amazed at the progress so far. I am not counting my chickens yet - in fact I'm just waiting for something to go wrong - but so far so good.

I wish I'd had this op a year ago!
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 15, 2010, 08:49:23 PM
Good to read, Andrew

Looking back at the comms from the insurers when I was planning on AMIC, they did say they won't necessarily cover mosaicplasty either due to a lack of long-term data (which seems to be in line with the NICE guidance, that they company seems to hang its hat on)

I am going to have the hyaluronic acid injections if the OS still thinks it's a good idea.  Wretched insurers won't cover that either (well they will a consultation, and strangely an x-ray) but that is much more manageable to self fund.  Hope to see the OS next Thur say for the first jab all being well.

I'll have a chat about possible next steps if the injections don't work

Vicks :)
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 21, 2010, 01:17:15 PM
Seeing the OS about the HA injections later today.  If he thinks they are worth a try, then will be done over three consecutive weeks (presumably first one next Thursday assuming the stuff is available as has to be especially ordered by the hospital).

Knee has been stiff, burny, sore on stairs and generally grouchy this week.  In the last week, I have just done 2 short lunchtime gym sessions (mainly cycling) so not overdone I think, but who knows!?  That is the frustrating thing with my knee, it is never right, but it is incredibly unpredictable.  I had to resort to paracetamol to sleep one day which is unusual  :(  Going to give the road bike a go this afternoon as I have the day off and, although chilly, the sun is shining  :)
Title: Re: Symptoms from cartilage defect(s)
Post by: Vickster on October 22, 2010, 10:45:38 PM
Well, it transpires from my latest MRI that I have subchondral bone damage under the scar tissue on a full-on WB surface of the femur - explains the pain I guess.  I have been advised by the OS to pursue MACI as part of the Active trial (thanks to my lovely insurers) as the best option with the most likely favourable outcome.  Left, the damage could be as likely to get worse as better.  Pah...  :(