KNEEtalk

The SPECIALIST'S OFFICE => The patello-femoral joint => Topic started by: mknmaa on August 04, 2015, 05:24:32 AM

Title: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 04, 2015, 05:24:32 AM
Greetings, I had ACIs and AMZs on both knees about three years ago for patellar defects.  My left knee was a great success...the right one, not so much! I knew very early on that something was not right. It seemed to always catch when I bent it and there was a great deal of pain shortly after the procedure- within the first 6 months (not related to surgery). The pain has gotten worse- same type of pain, grinding and popping as when I was bone to bone- only worse. When I look at my knees and compare, the right one protrudes where the AMZ was done, and the left one looks as it did before I even had the AMZ- so it's as if I didn't even have it done.

I know the ACI has failed. So my question is, should I try for the ACI again with a revised AMZ (assuming that is the cause), or do I try a different approach like DeNovo, OATS or something else (not real familiar with all options)? Obviously an AMZ is necessary for a successful ACI, so can I assume the ACI failed because of a poorly done AMZ? I would so appreciate and desperately seek any opinions.  I have an appointment on the 14th, so I need to be prepared and knowledgeable about all options.

Thank you so much for the input!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 05, 2015, 11:05:35 PM
Any experience with failed ACIs or general knowledge about other cartilage transplants/implantation procedures? Can another technique be done now? Someone has to have experience!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: Vickster on August 05, 2015, 11:25:52 PM
The availability of other techniques will depend to some extent on what country you are in and your access to healthcare/insurance cover

There's a section of the forum for cartilage repair which may shed some light on other possible options
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 06, 2015, 02:33:53 AM
I'm in the US (Indiana).  I need to know specifically if there are procedures that can or can't be done after an ACI.  I know some are contraindicated once certain procedures have been done- like no microfracture after an ACI. So I really need to know not about the procedures, but rather what to try after a failed ACI (or if I could try another ACI).
Title: Re: Failed ACI...now what? Try again or something else?
Post by: RGrelsamer, MD on August 10, 2015, 03:28:07 AM
If you're in Indiana, go see Jack Farr, MD (unless of course he's your surgeon to begin with. In fact, even if he is).
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 10, 2015, 04:24:36 AM
Hi! I have heard of Dr. Farr, but he is not my ortho. I'm about three hours from Indy, so I would rather not travel that far.  I was going to Dr. Cole (he did my AMZs), but with a change in our insurance, unfortunately, I can no longer go to him. Dr. Farr is my back up choice if my current ortho (he did my ACIs) is unable to help.  My current ortho is a wonderful dr., but his practice isn't quite as advanced as Dr. Cole and Dr. Farr.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on August 11, 2015, 02:49:59 PM
I am getting cartiform on my patella defect by Dr. Jack Farr on Sept. 8th.  This is a procedure that came out in 2014.  It is a cryopreserved chondral allograft.  It has a very limited bone portion, so it won't burn any bridges like osteochondral allograft does.  Dr. Farr even published a study alongside Brian Cole showing how superior the repair tissue was when comparing it to Denovo.

If your surgeon is Dr. Cole, then I am positive he has performed some cartiform implants because he has a demonstration video on the arthrex website. You should google it.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 15, 2015, 12:09:31 AM
So, it looks like I'll be seeing Dr. Farr, as well.  Today I saw the ortho who did my ACIs.  I now have bone damage and a large bone spur.  I'm so upset.  I could tell right after the AMZ on my left knee that it was not right.  The crepitus continued and my patella started to get stuck on the trochlea when I bend it (subluxation).  He said he has no doubt that the ACI failed. He also said with the bone damage, I may not be a candidate for another ACI, or similar, surgery.  He thinks I will need a PKR- I told him I'm 38 and not ready to have anything artificial in my body yet.  He's setting up an appt. with Dr. Farr in hopes that he will have more options. I'm so upset! I brought my concerns to Dr. Cole's attention (he did the AMZs but not the ACIs) that I thought something was wrong very early on after the AMZ, and they were dismissed. I just can't help but think that if I had stuck with my gut feelings and gotten this taken care of sooner, I wouldn't be as bad off as I am now. Sigh...
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 15, 2015, 12:23:39 AM
Ok, so I think it would be a PFJR not a PKR.  We didn't really discuss this much other than that may be the direction I'm headed. PFJR would be done on the petello-femoral joint.  Either way, it's a scary thought!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 15, 2015, 04:54:13 AM
Willrunagain (and any others who have gone to Dr. Farr), did you have to wait a long time to get in with Dr. Farr for your initial appt.? I'm hoping since my ortho is setting it up, I'll get in a little quicker.  I'm just so ready to get this ball rolling.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on August 17, 2015, 03:05:59 PM
Hi mknmaa,

I did not have to wait long at all to get my first appointment with Dr. Farr.  They had something available within 1-2 weeks if I recall right.  I have United Healthcare for insurance.  Not sure if that made any difference.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 17, 2015, 08:30:13 PM
I have an appointment this Friday already! I couldn't believe how quickly they could get me in!  I also have United Healthcare. I switched from Anthem about six months ago.  Anthem was great as far as paying for my previous procedures. My ACIs were on the patella, so I thought they would put up a little fight.  Thankfully, I didn't have any problems with them. I'm a little nervous with UHC- never having been through getting patellar defect surgery approval with them.  Did they fight coverage for the cartiform? Do you have any bone damage? Thank you so much for your help!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on August 17, 2015, 09:15:17 PM
My UHC plan approved the cartiform procedure within 3 weeks of the request.  I was very pleased with the turnaround because I thought for sure I would have to fight it. Cartiform falls under UHC's Osteochondral Allograft billing code, so it should always be approved if the surgeon deems it necessary.  Especially if you're too young for a knee replacement. I think it's also important to mention I haven't had any prior surgeries to repair this defect.  This will be my primary procedure.

Dr. Farr told me that he has had much more luck with his patients getting approval for cartiform vs. ACI and Denovo.  I think he rarely performs ACI or Denovo anymore.  Cartiform is the most innovative treatment on the market now and the clinical studies prove it. 

As far as I know my bone damage is very minimal.  I think the MRI showed a small edema under the patella, but Dr. Farr didn't seem to be too worried.  He thinks it will heal just fine once he implants the cartiform.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 20, 2015, 12:49:57 AM
Thank you for your reply! That definitely makes me feel a little more optimistic, as far as UHC's coverage.

I had my MRI done yesterday. It was definitely worse than I thought. I don't think I will be a candidate for cartiform, or possibly any allograft/autograft procedure. I have moderate thinning of cartilage in the petallofemoral compartment, the lateral trochlear facet and the femoral condyle.  It is all the way to the bone in areas and greater than 50% everywhere else.  There is also joint effusion and subcortical degenerative cystic changes (I'm assuming this means osteoarthritis). In the past, only my patellar cartilage had defects; I can't believe all of the new damage.  I'm definitely a little less optimistic about the type of surgery I can have now.

I guess I'll find out on Friday. 
 
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on August 20, 2015, 03:17:50 PM
Sorry to hear about the additional damage.  On the bright side, you are in good hands with Dr. Farr.  I am positive he'll put together a plan and find a solution for you.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 20, 2015, 04:46:58 PM
Thank you! I definitely feel like I'm in good hands.  If anyone can come up with a plan, it's Dr. Farr! I'll update tomorrow after my appointment.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on August 23, 2015, 06:22:51 PM
I had my appt. with Dr. Farr on Friday. As expected, he cannot do another ACI or other similar surgery (DeNovo or Catiform). I'm going to have a scope- if not this week, it will be next week.  He said he will either do an osteochondral allograft or a PKR (same thing as a PFJR he said) depending what he sees when he does the scope.  I asked him if the allograft would be similar to OATS. He said no because my entire patella is bad. He would cut my patella in half- front to back- and attach a new back side with cadaver bone and cartilage. The allograft only addresses the patella. Since I'm not having a lot of pain in other areas, he's hoping this will buy me about 10 years before he does a total knee.

He also confirmed that my patellar tendon was not anteriorized, only medialized, with my AMZ and that is more than likely what caused the ACI to fail- and the new damage in other areas. I'm so mad about this! 
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on August 24, 2015, 02:54:58 PM
Thanks for the update. Hopefully Dr. Farr can perform the OCA on your patella instead of a PKR.  The longer you can avoid metal and plastic the better.  I am only two weeks out from my cartiform surgery with him.  Needless to say, I am very nervous but ready to be on the road to recovery.
Title: Re: Failed ACI...now what? Try again or something else?
Post by: dal_knee on August 24, 2015, 03:24:27 PM

mknmaa,

Just an FYI but Dr Farr himself recently has had a Partial knee replacement....I would ask him who did his and consult with the surgeon that performs knee replacements on fellow orthopedics, if in fact a PKR is indicated.  If you do get that information, please post it here for others benefit.   

Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on September 04, 2015, 05:05:15 AM
I had my scope on Tuesday, and I will be having a PKR on Sept. 29th (he wants to wait until I'm healed from this surgery).  Dr. Farr said PKRs are a little more reliable and last longer than OCAs; OCAs either work or they don't- no middle of the road. He said if I was younger, he would recommend OCA. I'm only 38, so still pretty young. I just want to return to an active lifestyle; I know it's not completely unrealistic!

dal_knee, I forgot to ask Dr. Farr about his PKR.  I'm always interested to know who drs. go to for their own care.

willrunagain, your surgery is getting closer!  I wish you the best of luck and speedy recovery! I can't wait to hear how it goes!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: dal_knee on September 04, 2015, 06:07:19 AM

I wish you luck, I hope this works out well for you.   Did he give you a sense of which activities are allowed vs not?   Did he give you any indication on how long the PKR will be good for?   

 
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on September 12, 2015, 07:03:58 AM
Hi mknmaa. I hope your pkr goes well for you on the 29th. My cartiform surgery went very well. Dr. Farr said he barely had to trim the cartiform implant as it fit very nice and snug on my patella. My defect ending up measuring a little smaller than expected at ~3.25cm^2 compared to the anticipated 4cm^2 on MRI. He feels confident that I can be another cartiform success story since the defect is in the medium-small range. Plus, he said the rest of my knee looked perfect. It was just the patella that had wear.

Before implanting the cartiform, he removed a 3mm patellar cyst and plugged it with bone from my femur. He said it was common among patella cartilage restoration to see these cysts, so it shouldn't make my procedure any less successful.

I'm now almost 4 days post op and the pain has been quite manageable except for a few bad hours here and there. These however, only occurred when I tried to go without as many pain meds. Now I'm just doing some basic PT exercises and 8 hours of CPM a day! Oh how fun it is!

Overall the surgery is not as agonizing as I thought it was going to be! I'm even weight bearing about 30-40lbs when locked in my brace. Good luck and best wishes to all!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on September 16, 2015, 08:17:49 PM
dal_knee, thank you so much for the well wishes! I, too, hope this helps. I spoke to Megan from Dr. Farr's office today. She told me at least 90% of patients who have this done feel completely normal and pain free- other than having a robotic feel which they usually get used to.  I told her I used to be a runner, but I never felt like I could return to running after my ACIs and AMZs (mainly because of my botched AMZ). She said I will definitely feel like I can run...but shouldn't. I've sadly come to the realization that my running days may be over. :(

As far as activity, high impact activity is not recommended and no kneeling. He said I could do hiking, swimming, cycling, etc.

He told me he would be happy if I got 10 years out of this. I do have thinning on the tibial plateau and femoral condyle.  As long as I am asymptomatic in those areas, he does not want to do anything. So the hope is that the PFJR will be enough to get me by for as long as possible- with 10 years being the goal.

Thanks again!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: mknmaa on September 16, 2015, 08:37:00 PM
willrunagain, thank you so much for your well wishes! I've been thinking about you and wondering how your surgery went. It sounds like you're doing great! Hopefully you will be a success story! It helps a lot, as far as treatment options, that only your patella was defective; you become very limited in treatment once other areas are affected.

I also have a very large osteophyte on my patella. I think they become common due to repeated trauma. It's the bone's/body's way of healing.  Obviously I won't have to worry about mine for much longer. :)

I am not looking forward to the CPM at all! Oh the hours I have spent in that thing! The Vascutherm on the other hand, I love it!

You know what really surprises me? I may not need PT! I don't know if it's the same with you. I go to their PT department and hour before I check in at surgery. They will go over all of the exercises with me that I need to do at home. When I go back for my post-op apt., Dr. Farr will determine how I am doing on my own and decide then if I need to go to PT. I think that's great! I am a very determined patient and always do awesome with my therapy (especially on my own).  The last thing I feel like doing while I'm recovering is going to PT. 

Thanks again, and I'm happy to see you coming along so well!
Title: Re: Failed ACI...now what? Try again or something else?
Post by: willrunagain on September 17, 2015, 09:08:38 PM
mknmaa, I also went to PT a few hours before my surgery.  They went over my exercises for the first two weeks and gave me the quad stimulator and CPM.  10 years out of a pkr would be great!  if Dr. Farr says that it's possible then I definitely believe him.

I personally have a lot more physical therapy ahead of me.  I will be going to a local PT 2-3 times per week over the next two months.  I traveled from Cincinnati to see Dr. Farr, so that's the reason it's more convenient to do my therapy locally.  Fortunately, Dr. Farr and his PA Megan write word for word instructions for whoever ends up doing your PT.  They are well aware cartilage restoration is not very common and they'll make sure your physical therapist knows what they're supposed to do and not do.

On a positive note, Dr. Farr has approved me to return to running if the physical therapy goes well and I have no pain a year from now.  This is a huge motivator for me to work hard in PT.  My first OS acted like I would never be able to run again.  Running was my a huge part of life before my injury, so I am going to fight like hell and religiously follow my PT over these next 12 months.