The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: Lanterne Rouge on July 03, 2014, 06:32:30 AM

Title: Judging cartilage degeneration
Post by: Lanterne Rouge on July 03, 2014, 06:32:30 AM

I visited a doctor for my chronic knee issue yesterday and asked him if there was a big degeneration on the cartilage by checking the MRI image. He said that it is not possible to say that just by looking at the MRI image. Instead, he offered to do an arthroscopy on my knee to see what is going on. What do you think about it? Is it really necessary to do that?
Title: Re: Judging cartilage degeneration
Post by: Vickster on July 03, 2014, 08:22:47 AM
If you have the arthroscopy and damage is found, what would your doctor suggest to do and what would you do with the information?  Cartilage is very hard to reliably repair, the success rates on the patella are only around 50% with often painful surgeries and long rehabs.  Also, surgeries, including arthoscopies are not without risk.  You might find a tidy up of any rough cartilage if not through to the bone may help, but it's not certain to

Perhaps get another MRI with a more advanced machine if you can.  Try a steroid or hyaluronic acid injection.  In my opinion and experience, surgery should be a last resort after physio and conservative non-surgical methods and not used as a diagnostic tool without a clear treatment plan.  I certainly wouldn't consider it if there is nothing clear on MRI to fix.  If you have anatomical maltracking, then perhaps a TTT or similar is your option

Good luck :)
Title: Re: Judging cartilage degeneration
Post by: MDAL on July 04, 2014, 10:46:21 PM
I have to agree with the post above:

1) By making a hole just to see what's in there, it won't won't improve your situation, since that won't grow you any cartilage back.

2) He may likely decide to shave it off to "smooth it", which will only leave you with less cartilage than you had before.

3) You will trigger with the surgery a set of inflammatory response, which could cause further cartilage degradation.

4) You will take risks of infections, nerve damage, etc, etc which although rare, are not totally unheard off.

Basically he is proposing a pointless surgery just to "take a look" and eventually take some random actions, such as shaving it further, which will hardly have any benefit, and may get things much worse.

Personally, I would pass it... been there, done that, got the T-Shirt and regretted it...
Title: Re: Judging cartilage degeneration
Post by: Lanterne Rouge on July 05, 2014, 09:20:51 AM
Thanks a lot for your warning against arthroscopy. I thought it would be a simple operation without any risk of complications. Just wanted to know if the situation of the cartilage was really bad or if it was still in good condition. Actually, the doctor told me that we can do a lateral release during this operation. He thought that I don't know what he was talking about but he was wrong :) When I said that I read negative comments about it, he got angry and left the room saying that I was confused with my situation. After that I also get frustrated and filed a complaint letter about him to his university. Noone has given me a call about it anyway but at least I saved myself from his experimentals.
Title: Re: Judging cartilage degeneration
Post by: Vickster on July 05, 2014, 09:22:28 AM
Lateral Release can be useful in specific situations, like patellar tilt I believe

There's a KneeGeeks Facebook page with information

You'd want a patello-femoral expert to make the decision

There are potential complications with any surgery, however rare these may be.  If the surgery is not to resolve a specific issues, I wouldn't go there
Title: Re: Judging cartilage degeneration
Post by: MDAL on July 05, 2014, 02:37:59 PM
Well, in my opinion any joint surgery needs to be very carefully measured... when you start cutting and stitching, trimming and patching things will never be the same again. Sometimes it is needed, but some surgeons tend to be a bit reckless sometimes... it's a bit like the Nike ad... "Just do it", then we will see...

Regarding fragile egos, as you mention, that is the first sign that you are in wrong doctor. Anyone who is confident about what he/she is doing can offer wise arguments to support their view, without turning into a childish kid, whenever their opinions are questioned or challenged...
Title: Re: Judging cartilage degeneration
Post by: Canadian-Ice on July 05, 2014, 03:46:00 PM

Yeah, all these concerns fit with my understanding of any surgery for chondro. Nothing is reliable.

For Osteo, there might be better options. Here is what Dara Torres did, the 5-time US Olympian. There is quite a lot of media on her knee surgery and subsequent recovery although I couldn't find anything on 2014.
Title: Re: Judging cartilage degeneration
Post by: MDAL on July 05, 2014, 03:57:12 PM
ACIs from expanded cells, have been around for ages, but strangely very few doctors even bother to learn it, or use it, even for adequate cases, because it is apparently easier and faster to drill some holes by MFX, even with all it's short comes...

Of course, ACIs also have their limitations and failure rate, but still is a far better option than other primitive procedures, which include MFX of simply wait until you are more ready for a replacement...
Title: Re: Judging cartilage degeneration
Post by: Canadian-Ice on July 05, 2014, 04:04:08 PM

My understanding is that surgeon skill, experience, and reputation are critical guides in predicting outcomes.

Are there any top surgeons to recommend for ACI for those in more advanced stages of cartilage damage? Any idea on success rates? Wounder if success is better than 50% with the best surgeons, and how long someone like Dara Torres, for example, can expect to postpone knee replacement?
Title: Re: Judging cartilage degeneration
Post by: MDAL on July 05, 2014, 04:44:07 PM

You are asking difficult questions...

ACI procedures are basically a generic term for multiple different things. It means simply that your own cartilage will be used to close holes... but there are many differences:

- Direct transplant same day or cultivated in lab and then re-implanted (depending on size needed).

- There are multiple companies doing cultivation, each uses their own process and each claims to be the best.

- How it is implanted, with underneath micro-fracture, or sealed with scaffold gel, etc... etc... each doctor has it's way.

Success rate? I wish I knew... I have one doctor near me, who invented his own process and even surgical tools and in over a 100 procedures claims to have a success rate of way over 90%... In this things I would like to interview each individual patient to make sure, since I can't I will just trust his accuracy of judgement.

Have also read study reports, where they claim that the major success rates come from implants where there wasn't prior MFX. Patients who had prior MFX in that zone, had a far higher failure rate.

Apart from this, it depends on size of the hole, patient age, alignment of knee bones and mechanical forces that derive from it, post-surgical protocol (how fast you go weight bearing) and not mention accidental damage, like slipping while on crutches, etc...

Current outcomes, according to the studies I have read, seem to be way above 70% success rate... but even this is always hard to measure, with so many different procedures and methods out there...

Title: Re: Judging cartilage degeneration
Post by: Vickster on July 05, 2014, 05:37:38 PM
It also depends on what you mean by success while will depend on the start point for the patient, what they are seeking in terms of function, pain relief. Success could mean the defect has some degree of fill but that may not translate to any meaningful positive outcome. Just like some bone on bone patients have little pain and full function while others with chondromalacia, grade 1 softening may have lots

Success rates are lower on the patella due to shearing forces and often done with realignment like a ttt or the repair just rubs away again. It is very fragile. Better success on non weight bearing surfaces but potentially less necessary.

This is a good link from the uk, although a little older

Usually aci refers to the carticel procedure from Genzyme if I recall. Cells harvested, grown in lab, reimplanted. Reserved for grade 4 defects, as the hole has to be clear. There are also allografts like de novo but that's not aci, autologous chondrocyte implantation. Done for focal defects not as an alternative to replacement in widespread arthritis

Ask in the cartilage repair forum for suggestions of us based surgeons doing these operations. If in Canada, I don't know of it's widely available. In the uk, there are few centres licensed, less than 10 offering on nhs.
Title: Re: Judging cartilage degeneration
Post by: Canadian-Ice on July 06, 2014, 02:23:07 PM
MDAL; thanks for those insights. Getting good information can be so difficult with surgeries. Even if doctors or companies keep reliable, valid, complete studies or raw statistics that are not misleading, they don't seem to release them. Probably because the results are too imperfect to justify the costs for most potential patients. Keep hope alive, and keep the intake numbers higher.

But what we can do, is post and publish our own experiences. Who was the surgeon you found near you? Do you have results yet?

Actually, 70% plus success rate sounds pretty good. But the question you raise is a good one: what affects do these surgeries have on success rate of any future surgeries, especially joint replacements? I might at some point check with some top level joint replacement specialists for their opinions on that one.

Vickster, good point about cause of the Chondro affecting surgery outcome long term. Clearly a structural cause might just wear off the replaced cartilage very quickly ! Cartilage repair forum, I will check that out.

More pressing, in my case anyway, is that my troubles got exponentially worse after Synivsc 13 months ago. Think I will post on what might have caused that regression: and what, if anything can be done now. That gets into issues like what causes pain in Chondro, as the cartilage itself has no nerves but the thin membrane that surrounds knee cartilage has many nerves and seems to be what we feel.
Title: Re: Judging cartilage degeneration
Post by: Vickster on July 06, 2014, 02:55:18 PM
My understanding is that pain also comes from damage to the subchondral bone

I don't think that having cartilage repair affects TKR success, as essentially the damaged bits are taken away to fit the replacement.  Having microfracture can adversely affect the success of an ACI though, bit of a catch 22 though as the healthcare system often requires a first attempt at repair before funding the very costly more 'experimental' repairs
Title: Re: Judging cartilage degeneration
Post by: MDAL on July 06, 2014, 05:09:33 PM
I don't think it would cause much trouble for a knee replacement, since all that area is supposed to be wiped out for the TKR itself... there could eventually be soft tissue problems from repetitive surgeries... scar tissue for example. If in the patella for instance, it needs to be flipped around, and that is a bit hard to heal, healing problems could arise from it...

But the all point of a ACI is to at least delay a knee replacement if not for the rest of your life expectancy (not clear how much it would last).

I didn't have any ACI done, just talked to the doctor, it doesn't seem that I am candidate though. ACIs are for localized defects with good definition... I am a cartilage breaking apart all over the place case...

About what causes pain, that is an issue with such a wealth of speculation around, that you can get lost around it. Issues to consider is where the pain comes from, could it be just cartilage thinning alone, or could it be a teared meniscus which no one saw? Could it be plica symdrom? Could it be a tendon?

My point is, it could be many other things since diagnostic methods are basically pre-historic, and even with what there is, not many OSs feel like digging too deep, they often just take a look, and throw a 5 minutes diagnostic while scratching their own genital mycosis. Image diagnostics aren't too precise either, it's not uncommon that during surgery huge holes or meniscus tears are found which skipped the MRI analysis.

Aside that we need to make some separation of pain, cartilage doesn't have nerve endings, true... but as cartilage is breaking apart, it throws stress signals that may trigger synovial inflammation, causing locks (reduced ROM), soreness and pain... however arthritic pain is often explained by some doctors as bone marrow bone lesions, tiny bone fractures bleeding bone marrow... however this is all too subjective, I know people who had total meniscus removed, cartilage totally devastated and go running... symptoms? Ah, just a bit of inflammation sometimes... (huh ?!?!)