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Author Topic: Insurance Coverage for Micro-Fracture Surgery/Questions Success/Failure etc?  (Read 4045 times)

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Offline mebel01

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Hey gang,

First time on the board, so I will give you a little background.  I have been a martial artist for most of my life. Karate/Aikido/Tai Chi.  Last September I was diagnosed with a 1.5 cm osteochondritis discans on my right medial femoral chondyle.  In December of 02, I underwent surgery to remove the torn cartilage.  After surgery I was referred to sports medicine specialist, who recommended that I try micro-fracture.

Long story short.... I ended up going to the Mayo Clinic down in Rochester Minnesota to see a Doctor Michael Stuart for a second opinion.  Dr. Stuart agreed with the recommendation to try micro-fracture, and discussed the possibility of doing an OATS Osteochondral Allograft, if the micro-fracture didn't work.  He advised that he had done hundreds of micro's  and had had success on defects ranging in size from less then .5cm up to 3cm.

I have done a fair amount of research on the procedures that are being recommended, but have some questions, and would like to hear from folks who have had similar problems and undergone procedures to repair.

Questions: 

My first one is...... what insurance companies are you guys aware of the pay for the micro-fracture... OATS.... or others.  My HMO is HealthPartners up here in Minnesota, and they refused to pay for the surgery saying it was still considered experimental  I appealed, and they denied my appeal......

Second, for those of you who have had the same type defect on the medial femoral chondyle, can you advise how your surgical interventions have gone.... what changes did you notice afterwards..... how long was the recovery...... are you better now then before the surgery.....was there any loss of range of motion.... etc...

Lasty, has anyone out there had any success with non surgical interventions.  I have read a number of pieces of literature that suggest that suggest that an alkaline food diet can help with preventing a number of disease conditions including Arthritis, and that alkaline diets support bones, and connective tissue.

I am exactly 9 months post surgery to remove the defect.  I have not run on the leg since the injury, nor have I done anything impact oriented.  I have been practicing yoga for the last 9 months and have full range of motion, which for me is being able to sit on my heels.  The knee is still a bit tender to the touch on the medial side of the knee cap.  It also swells a little bit if I put full weight on it as is common in many balancing postures, and in Tai Chi.  It has improved since the surgery, but is still somewhat sensitive.
Dec 2004, Osteochondritis Dissecans removed from medial femoral chondyle

Offline stgiles16

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first question, I have blue cross/blue shield and they paid for 2 microfractures for me. Many insurance companies will not pay for OATS or ACI without you first trying micro because micro is cheaper.

second question, I have full ROM. The recovery is very long and painful.I am talking months not weeks.  All cart restoration procedures are. I cannot say that I am better but the defect is no longer growing in size. I still have pain on a daily basis but I am not the norm, I had many complications. When I had my micro on my mfc, I was nwb for 8 wks, partial for 2 more weeks and used a cane for 2 more months.

third question, there is no real non surgical way to heal articular cart. It does not have a blood supply and will not heal on its own. Some people swear by glucosamin but there is no scientific evidence to prove that it does any good.
If you have any more questions , feel free toask. I had to keep this short as I am leaving in a few minutes to go out.
good luck
keep us posted
missy
2 ligament recons right ankle
2 arthroscopic,
5 open knee procedures
2 Plica removals
bone spur removal
2 microfractures
4 debridements
2 open LOAs all on left knee
Arthritis,both knees, ankles, shoulders, elbows, hands,spine
Fibromyalgia
Arthrofibrosis
LOA & PKR 2/15/06
RA
in pain mgmt
TKR JAN 2012

Offline casey2291

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Hi,

I am a little over 5 months post op from microfracture.  I have Kaiser Permanente (HMO) and they paid for my surgery without any questions.  As for my recovery, I am at a point where if I don't do any kind of physical activity on my knee, I have minimal to no pain.  If I do physical activity on the knee, I get pain in the microfracture area.  My knee is much better for activities of daily living (such as just walking around) than it was before the surgery.  I have full range of motion in my knee at this point.  I still have some swelling in the back of my knee but it doesn't affect my ROM.  I have a post op diary in the post op section of the board if you are interested in reading about my recovery.  It is titled Play by Play of My Surgery Recovery (microfracture).  Also, I tried non-surgical interventions for almost a full year with no success in healing the articular cartilage.  I tried a month of PT without any success and then I quit all physical activites at one point for a good four months to see if the knee would heal on its own.  No luck.  As for glucosamine, I have been taking it for the past 5 months.  According to a recent MRI, I may also have a  chondral defect on my "good" knee.  About three months into taking the glucosamine I stopped getting pain in my "good" knee.  I know only get pain in it when I am exercising where before I was getting pain when I was walking.  I have no idea if the pain has decreased from the glucosamine or not.  The pain may have also decreased b/c I was no longer using my "good" knee as much to compensate for the bad knee.  So, that is just my own personal experience.  Like Missy said, some people swear by glucosamine and others don't really see any difference when they take it.  Good luck and keep us updated on how you are doing.

Casey  :)
LOA #2 and hardware removal 12/15/08-new cartilage from ACI looks "GOOD"
LOA on left knee 3/18/07
ACI and HTO on left knee 10/22/07
scope of right knee on 6/21/07
microfracture left knee 3/18/05

Offline mebel01

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Hello Casey,

Thanks for the information.  Can you tell me how you injured you knee?  How large was the defect? and iin what location was the defect ?  Also, jusr curious whether or not you did anything with your diet.  I have been reading alot about the benefits of an alkaline diet, and one of the reported benefits is the reduction of arthritic conditions.  Apparently, the western diet, or how most of us eat, is high in acid producing foods.  When the body is more aciidic then alkaline, it must steal nutrients from the bone, including calicium.  I recently altered my diet signifcantly as kind of an experiment to see whether it has any effect overall, and in particular with my knee.

Looks like I may have to change insurance carriers because mine is pretty well set on not paying for a micro-fracture.  At this juncture, I am kind of in the limbo stage, but I wouldn't do a surgery until sometime this winter anyway.  I live in Minnesota and the summers are so short that there is no way I would intentionally be laid up for an extended period of time during the warmer months. 

I can tell you that at 9 months post op, my knee does not feel worse.  In fact it has improved to a certain extent.  I know that the western docs opinon is that the body cannot heal cartilage injuries, but I am not fully convinced that given the right environment, the body won't form its own scar tissue in the hole.  I recognize that cartilage has no blood flow, and as such, is not capable of regenerating like skin and other tissue can.  However, there isn't any part of the body that does not undergo renewal through fluid exchange, and movement.

I plan to have the knee checked later on this year to see if it has gotten worse, better, or not changed.   A surgeon down at the Mayo told me they can do an MRI that will kind of landscape the defect, so we can see if there has been further damage, or improvement. 

I will keep you posted.

Thanks,

Marty
« Last Edit: September 11, 2005, 03:45:25 AM by mebel01 »
Dec 2004, Osteochondritis Dissecans removed from medial femoral chondyle

Offline casey2291

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Hi Marty,

When you had your surgery, did they just remove a piece of cartilage that was floating in your knee or what?  I guess I don't really understand what they did for your surgery. 

I just cut and paste a portion of my post-op diary to put in this post, so if you happen to read my post-op diary some of this may look familar.  To answer your questions, I injured my knee when I was out jogging.  I stepped down and got sharp pains in it. I had what was considered to be a relatively small lesion on my medial femoral condyle which is in the weight bearing portion of the knee.  My lesion was 3mm in width, 15 mm anterior posterior and 8mm transverse.  My pain prior to the surgery was VERY inconsistent.  My knee typically hurt when I was doing weight bearing activities, such as walking or exercising.  My pain consisted of sharp pains when walking and occasionally as time progressed some aching in my knee.  My knee never swelled, very rarely hurt when sitting around and when I backed off completely from all exercise I had little to no pain, just a weakness in my knee.  I had my injury for almost a full year before my operation, however I went through several surgeon's and was told several times to take a wait and see if it will heal on its own approach.  However, my injury got worse and I didn't even know it.  Over a matter of three months, a comparision of MRI's revealed a change for the worse.  During that time, I did not have increased pain and at times it felt better than previously because I was not exercising.  My surgeon told me at that point that she needed to go and in do something about it because she could see on the MRI that the bone and the cartilage were separating and that could cause a piece of the bone or cartilage to break off in the knee and float around and that would be bad.  Turned out when I had my operation that I had a piece of cartilage flapping around in my knee and the MRI didn't show that.  So, I guess our knees can be deceiving as to what is actually happening inside.  Even though your knee may be feeling better, I think you are wise to follow up and get another MRI to see if there have been any changes.  I was very surprised how much my MRI changed in a matter of three months.  I know putting off microfracture surgery sounds very enticing b/c no one wants to go through the long recovery, but if it were me I wouldn't put off getting a new MRI for too long.  I think if you go down to the bone marrow stimulation section, blackbeltgirl has posted an article that states that microfracture is more successful if done within a year from the time of injury.  As for my diet, I didn't make any dietary changes.  My OS has plans to conduct a new MRI study of my "good" knee in the next several months to monitor for any changes.   Even though my "good" knee has been feeling better, I plan on going through with it just to see if there are changes that are taking place that I am not aware of.

Hang in there!

Casey  :)
LOA #2 and hardware removal 12/15/08-new cartilage from ACI looks "GOOD"
LOA on left knee 3/18/07
ACI and HTO on left knee 10/22/07
scope of right knee on 6/21/07
microfracture left knee 3/18/05

Offline mebel01

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Hi Casey,

Yes, when they did my knee the surgeon removed a piece of cartilage that had torn loose from the medial femoral chondyle.  It wasn't floating around, it was basically hanging like a flap, attached on three sides, but protruding down into the joint space.  Unlike your knee, I didn't know that I had injured mine.  I went to martial arts practice on a Saturday, taught class, and felt fine after.  Then, the following morning when I woke up, I was in tremendous pain, and the knee had swollen considerably.  The flap they removed was approx 1.5 cm, in diameter and approx 6mm deep, which is basically a full thickness tear.  I don't have any of the sharp pain you describe.  Mine is less frequent, and I would describe the pain more as more like a 1 or 2 on the pain scale.  Its more prevalent on the back side of the knee, and unlike yours, my knee does seem to maintain kind of a constant state of slight swelling.  If I am load bearing for extended periods of time, you  can see that the front of the bad knee appears larger then the good one.  Again though, the pain  scale is relative, so that may not mean too much.

I appreciate your advise, and any advice that others can give me.  I will have another MRI done on the knee soon, in order to see if there has been any change.  At present, I am writing another appeal to my insurance company to try to get them to cover the microfracture.  However, I have an open season coming up in December and may look to slide over to Blue Cross, since they seem more apt to pay for this kind of procedure.

I will keep you posted on my progress.  I

Incidentally, if your interested in how diet may help with your injury, let me know.  I think some of the changes I have made may be helping me on a cellular level, and while the injury might not heal with additional surgical intervention, creating an internal environment that fosters healing,instead of one that gets in its way, could have an effect.  This might be why I don't really have much pain despite the size of my defect.

Talk to you soon,

Marty
 
Dec 2004, Osteochondritis Dissecans removed from medial femoral chondyle

Offline papbouv

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I was a nurses aide for 31years,I did have a arthosopic L knee in 92 the in 04 a second arthosopic surgery with microfractures the dr just did them with out saying anything to me first.If I would have known, I would have said just do the Total knee and get it over with the microfractures did not do anything was off work so long that in the end lost my job of 14 years.The  right knee gave out since it was doing all the work while the left knoee was getting all the surgeries. I did have the Rooster Comb Injections in my right knee 5 injections 1 aweek for the 5 weeks it has been over a year no pain in my right knee so far knock on wood.had the Total Left Knee done since the microfractures did not work at all yes at the time i had an HMO insurance they paid for the microfracture surgery, the Rooster Comb Injections on the rt knee and the HMO paid for the Total Left knee. Now No job ,no health insurance ,going to a clinic for low income persons.?

Offline blackbeltgirl

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marty -

I'm amazed that microfracture was considered experimental.  I have Blue Cross in VA, and they paid for my surgery without any problems.

As a fellow martial artist, I will tell you, no matter what procedures you go through to replace the missing cartilage, you may find it impossible to return to true martial arts practice.  I have significant damage to the lateral side of the knee and the trochlear groove.  I am now 9 months post-microfracture, and I couldn't train properly if I wanted to.  Too much pain if I do repetitive or forceful bending, making kicks something I just can't do anymore, not to mention pivots.  While I'm still considering additional surgery, if I go through such an extensive recovery process, the last thing I want to do is return to an activity that I know stressed the lateral side of the joint and the trochlear groove, after I've just had them repaird.  I'm just hoping to be able to ride a bike again, swim the breast stroke, run a few steps without wishing for painkillers.....

So I will wish you luck, but I will also advise caution.  Make sure you know what the best case recovery is, and also the most likely case.  That way you can make a more informed decision, and you won't end up disappointed.

Jess
ACI was supposed to be 2/21/06.  On 6/29/06 Insurance co said have another scope, and if it still looks good, they'll ok the ACI.
Microfracture Dec 7, 2004
   3cm x 6cm lesion, LFC; 3cm x 1cm lesion, trochlear groove; lateral tibial plateau lesion
2nd degree black belt, tae kwon do (had to stop)















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