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Author Topic: ACI vs patella femoral replacement  (Read 4262 times)

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Offline erinee

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ACI vs patella femoral replacement
« on: December 30, 2006, 09:15:18 AM »
Hi there-I've come back to ask advice.  Back in May of 04 I had scopes that showed bilateral patellar grade IV lesions, requested Carticel and was repeatedly denied by my insurance.  Had Synvisc injections about every 6 months which managed my symptoms to a good extent.  Then my left knee pain goit severe again and I had a left knee scope and debridement 12/11/06.  This scope showed I have worsened and now have kissing lesions at the patella and lateral femoral condile down to subchondral bone.  The patellar defect is global.  My OS feels that Carticel would still be a treatment option, however of course the insurance issue is still there.  We've begun the authorization process.  However, even with the Carticel because of the size and location of the lesions I'm by far not a perfect candidate and am looking at an even longer than usual rehab course.  My patellar tracking is perfect and normal.  I have been able to remain very active (perhaps at my own expense) although low impact-I use the treadmill walking on an incline, elliptical, and I lift weights, I've competed in several figure (fitness without the gymnastics) competitions over the past 2 years.  I'm afraid the mental aspectof being so limited post-ACI would be very hard for me.  So I'm reading everything I can find and trying to weigh the cost/benefit of ACI vs. patella femoral replacement given my age (33) and activity level.  I'd appreciate any thoughts or insight anyone can offer!  Thanks.
« Last Edit: December 30, 2006, 09:20:58 AM by erinee »
37 year old physical therapist, Left lateral release '92, bilateral debridement and scope '04, bilateral patellar cartliage defects, denied ACI repeatedly by insurance.  Scope and debridement 12/06 L knee.Bilat patellar ACI with Fulkerson 4/23/07.

Offline Nick_Knack

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Re: ACI vs patella femoral replacement
« Reply #1 on: December 30, 2006, 11:48:27 PM »
Where do you live?

i would recommend Dr. Minas in Boston or Dr. Levy in Summit NJ or Dr. Mandelbaum in L.A. or Dr. Brian COle in Chicago or Dr. Gillogly in Atlanta for ACI.

33 is very young for metal in your knee. An fulkerson osteotomy w/ ACI is what you may need.  The osteotomy can pull the kneecap away from the femur to relieve contact forces and aci to plug lesion.

I had this procedure and feel much better since it was done 6 months ago.  I am 35 and would not have opted for a replacement of any kind. 


GOod Luck,

NIck
Age: 35
1989 rt ACL (+25 degrees ext loss)
1994 rt ACL resection (+ 10 deg)
2001 rt ACL revision (+ 10 deg)
2003 rt med meniscus repair (+10 deg)
2004 rt LOA and post capsulotmy (zero degrees)
2005 rt LOA and tib bone plug removal (even w/ other leg)
2006 rt Fulkerson TTT & ACI Carticel

Offline erinee

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Re: ACI vs patella femoral replacement
« Reply #2 on: December 31, 2006, 12:15:20 AM »
Believe me, I agree that 33 is young!
I have no alignment/subluxation issues with my patella, so I'm not sure about the Fulkerson-maybe only for some elevation if possible.  The problem with the ACI is two-fold:
1)insurance-multiple lesions which are kissing and include the patella
2)the lesions are so large now-the ACI may not even take.  I'm afraid of being laid up for 18 months with no result.
I am glad to hear you are doing well though!
37 year old physical therapist, Left lateral release '92, bilateral debridement and scope '04, bilateral patellar cartliage defects, denied ACI repeatedly by insurance.  Scope and debridement 12/06 L knee.Bilat patellar ACI with Fulkerson 4/23/07.

Offline DJF

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Re: ACI vs patella femoral replacement
« Reply #3 on: January 03, 2007, 03:10:52 AM »
You are very young for the replacement.  I had the procedure you describing on October 18th 2006.  I am still on one crutch.  I had to have a manual manipulation on December 15th.  I was stuck at 70 degrees of flex.  I am now at 115 and gaining about 5 degrees per week.  Becasue of being stuck at 70 for so long, I think my quads wasted more than they should have.  We are working at it and I go to PT three time per week.

On the plus side, when the OS did the manipulation, we got to see the graft and it looked good.  I also got a 4 minute movie ofhte inside of my knee that I think was cool.  (It makes my wife sick)

I am not against the procedure in any way and am still positive my outcome will be positive.  It is a long rehab though.  (At least for me)  You have to be prepared for the rehab.

The OS and I talked about Carticel for about a year before I finally decided to do it.

Let me know if you have any specific questions.

Don
50 y/o male
Houston TX 

4 surgeries
Manual manipulation Dec 2006
Carticel implant with TTT October 2006
Carticel Harvest August 2006
The following done October 2005:
Chondromalacia Grade III to IV
Scope with chondromalacia
plus lateral release
plus plica resection

Offline erinee

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Re: ACI vs patella femoral replacement
« Reply #4 on: January 03, 2007, 10:21:15 AM »
Thanks Don for sharing that.  Was your graft on the patella, trochlea, or both?
The fact that I may go thru it all and still have a failed procedure (which there is a relatively high chance of, from what I understand.) is what really gets me.  I was all for the Carticel a year and a half ago, when I only had one lesion, but now I am much more leery.  I'm wishing the CaRes procedure was more widely approved by the FDA!  (Hopefully when I need the right side done it will be.)  I am a physical therapist so the idea of seeing a movie of the knee is cool!
37 year old physical therapist, Left lateral release '92, bilateral debridement and scope '04, bilateral patellar cartliage defects, denied ACI repeatedly by insurance.  Scope and debridement 12/06 L knee.Bilat patellar ACI with Fulkerson 4/23/07.

Offline chr121ne

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Re: ACI vs patella femoral replacement
« Reply #5 on: January 03, 2007, 03:19:38 PM »
Having had ACI back in 2001 thought I'd share some insights with you esp as you need to make an educated decision.  I was offered a TKR age 39, this was a big shock and couldnt get away from the OS fast enough.  However, since I was still struggling to get back to activity 18mths later I decided to find out if there were any other options, I was very excited to find out about the ACI treatment and jumped at the chance of an attempt to help salvage the knee in order to delay the TKR for a few more years at least.  I also had kissing lesions on the patella & LFC and because of this my OS grafted the patella, both sides and used microfracture on the trochlea and LFC, I also had a defect on the MFC grafted.  It was at least a year before I started to feel any real benefit and at the 1st yr scope was told the grafts were doing really well.  I did pretty well for the next 2 yrs and then started experiencing symptoms of locking and pain.  At arthroscopy the MFC graft was almost as near normal cartilage but the patella grafts were still soft and hadnt fully covered the defects, nor had the microfracture but the real blow was another large defect that had developed on the MFC and this was causing my new symptoms, plus the MFC graft had overgrown slightly.  1yr later I had a TKR.  ACI treatment delayed this by 5yrs and I'm sure had the rest of the knee stayed sound the TKR would've been delayed even further.  If you opt for ACI, with
agreement from your insurance co., then I'm sure you wont have to wait 18mths to get back to activity.  At least with ACI after the initial rehab, you shouldnt have too many restrictions on your activities, with a PKR you will be permanently restricted.  I know many people are anxious to have this CaRes and from what I understand this is similar to MACI just badged differently and I would be the first to vote MACI over ACI because it is certainly a much less painful procedure post-op, but my MACI failed in the first 8 weeks because the graft delaminated, my only option left was TKR.  I've got no regrets about having either MACI or ACI, I figured it would be better than to go straight to metal and plastic and I always remained optimistic it would finally work for me.  You do need to be mentally tough to cope with the rehab and of course possible disappointment but my ACI knee was brilliant for a few years and my MACI knee failure was just down to some real bad luck!  I hope you do finally end up with a choice to make, if not good luck with the PKR, I'm loving my new knees!

Offline erinee

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Re: ACI vs patella femoral replacement
« Reply #6 on: January 03, 2007, 11:30:58 PM »
Having had ACI back in 2001 thought I'd share some insights with you esp as you need to make an educated decision.  I was offered a TKR age 39, this was a big shock and couldnt get away from the OS fast enough.  However, since I was still struggling to get back to activity 18mths later I decided to find out if there were any other options, I was very excited to find out about the ACI treatment and jumped at the chance of an attempt to help salvage the knee in order to delay the TKR for a few more years at least.  I also had kissing lesions on the patella & LFC and because of this my OS grafted the patella, both sides and used microfracture on the trochlea and LFC, I also had a defect on the MFC grafted.  It was at least a year before I started to feel any real benefit and at the 1st yr scope was told the grafts were doing really well.  I did pretty well for the next 2 yrs and then started experiencing symptoms of locking and pain.  At arthroscopy the MFC graft was almost as near normal cartilage but the patella grafts were still soft and hadnt fully covered the defects, nor had the microfracture but the real blow was another large defect that had developed on the MFC and this was causing my new symptoms, plus the MFC graft had overgrown slightly.  1yr later I had a TKR.  ACI treatment delayed this by 5yrs and I'm sure had the rest of the knee stayed sound the TKR would've been delayed even further.  If you opt for ACI, with
agreement from your insurance co., then I'm sure you wont have to wait 18mths to get back to activity.  At least with ACI after the initial rehab, you shouldnt have too many restrictions on your activities, with a PKR you will be permanently restricted.  I know many people are anxious to have this CaRes and from what I understand this is similar to MACI just badged differently and I would be the first to vote MACI over ACI because it is certainly a much less painful procedure post-op, but my MACI failed in the first 8 weeks because the graft delaminated, my only option left was TKR.  I've got no regrets about having either MACI or ACI, I figured it would be better than to go straight to metal and plastic and I always remained optimistic it would finally work for me.  You do need to be mentally tough to cope with the rehab and of course possible disappointment but my ACI knee was brilliant for a few years and my MACI knee failure was just down to some real bad luck!  I hope you do finally end up with a choice to make, if not good luck with the PKR, I'm loving my new knees!
Thanks for sharing your experience!  Are you in the US?  From at I understand CaRes is MACI-from what I understand there really is no MACI available in the States-if I'm wrong (and I hope I am!!) please let me know.  And what do you mean by "permanently restricted" by a PKR-it was my understanding that there were no real "restrictions, just to tolerance.  The patellar grafts are my real concern, especially given their size and severity.
37 year old physical therapist, Left lateral release '92, bilateral debridement and scope '04, bilateral patellar cartliage defects, denied ACI repeatedly by insurance.  Scope and debridement 12/06 L knee.Bilat patellar ACI with Fulkerson 4/23/07.

Offline chr121ne

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Re: ACI vs patella femoral replacement
« Reply #7 on: January 04, 2007, 11:35:01 AM »
Am in the UK so have no idea what's available to you in the USA.  I also dont know very much about the PKR seeing as I had 2 TKR's but seeing as you will still have metal and plastic I assume the same restrictions apply ie no high impact stuff such as running etc..  With ACI I was told I could return to my previous level of activity with no restrictions, I did in fact reduce my level of activity but that was because I decided to preserve the knee for as long as possible so high impact activity didnt seem like a good idea.  I did get back to some running, however. 

With regard to the patella grafts, I was told a few years ago the OS would've simply removed my patella based on the level of damage but fortunately my OS was a bit more clued up to the adverse affects this has, he also mentioned that metal plates had been tried, to resurface the patella but that this had also had poor results so didnt advise that either.  I know that patella grafts have not had a huge success with ACI including my own but the knee still felt a lot better even if it wasnt fully restored at least the patella was no longer getting stuck in the groove, for me it was pretty successful!

Offline DJF

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Re: ACI vs patella femoral replacement
« Reply #8 on: January 04, 2007, 02:51:58 PM »
Okay, I have gotten the movies posted on the web.

My defect was a Trochles defect.  The surgeon said it was about the size of his thumbnail or a little bigger.  I have not been able to get the post surgery report yet.

1 - this movie is the shortest one (13 seconds) and shows the graft
site. You will see the trochlea groove that is mostle red and
inflamed looking. The graft is actually just to the right side of
that. You cannot distiquish the edges of the graft site.

http://www.expressionsfinechocolates.com/Matt/knee/carticel.mpg.mpg

2 - This movie is 40 seconds long and shows the lower edge of the
implant and the knee going through a range of motion test.

http://www.expressionsfinechocolates.com/Matt/knee/carticel%20lower%20edge.mpg.mpg

3 - This is the longest movie 3 minutes. The moviw is actually
longer, but my FTP freezes after the 3 minute mark. This one shows
a lot of cutting and burning to release the adhesions and allow my
knee to move. Most of the work was done in the upper knee
compartment where the patella attaches tothe femur. It gets out of
focus in the middle. I think there was afair amount of blood
running through the fluid.

http://www.expressionsfinechocolates.com/Matt/knee/carticel%20graft.mpg.mpg

You will need patience to get the last one downloaded.

Update:
I can now move my knee to the 120 degree mark with only a fair
amount of pain.

I have developed a catch in the knee around the 50 degree mark. If
I sit onthe table and let the knee bend down, it is not too bad. If
I do heel slides where I lay on my back and let my foot slide down
the wall, I have a hard time getting past the 50 degree mark. Once
by the catch, I can get to 120. PT thinks the once my quads get
stronger this will go away.

I can walk with one crutch on a cane for short distances, but I get
sore and start to swell if I push it too much.

Don
50 y/o male
Houston TX 

4 surgeries
Manual manipulation Dec 2006
Carticel implant with TTT October 2006
Carticel Harvest August 2006
The following done October 2005:
Chondromalacia Grade III to IV
Scope with chondromalacia
plus lateral release
plus plica resection

Offline erinee

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Re: ACI vs patella femoral replacement
« Reply #9 on: January 04, 2007, 09:35:46 PM »
Very cool-thanks for your input.
Don-as your lesion was trochlear only there is where we are different.  I would have no hesitations about pursuing the ACI if mine was a trochlear lesion only.  As it is both patellar and trochlear that is where my problem lies.
chr121ne -so you're in the UK-ow it makes sense! 
Unfortunately here in the US we are way behind with cartilage repair.  ACI is the only widely available modality, and it is very tightly regulated by the insurance companies.
Thanks everyone and keep the opinions coming!
37 year old physical therapist, Left lateral release '92, bilateral debridement and scope '04, bilateral patellar cartliage defects, denied ACI repeatedly by insurance.  Scope and debridement 12/06 L knee.Bilat patellar ACI with Fulkerson 4/23/07.

Offline DJF

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Re: ACI vs patella femoral replacement
« Reply #10 on: January 05, 2007, 01:20:44 AM »
That does make  BIG difference.  Are they kissing lessions?  I don't think Carticel recommends the procedure for kissing lessions.  I know there is at least one person on the board that has had both lessions and had successful Carticel implant. 

Don
50 y/o male
Houston TX 

4 surgeries
Manual manipulation Dec 2006
Carticel implant with TTT October 2006
Carticel Harvest August 2006
The following done October 2005:
Chondromalacia Grade III to IV
Scope with chondromalacia
plus lateral release
plus plica resection

Offline erinee

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Re: ACI vs patella femoral replacement
« Reply #11 on: January 05, 2007, 10:52:54 AM »
Yup-kissing lesions they are.  I know a successful implant is still POSSIBLE-but I guess I'd like to see better chances of success.  The lesions are also quite large on both the patellar and trochlear surfaces-patellar is basically global.
37 year old physical therapist, Left lateral release '92, bilateral debridement and scope '04, bilateral patellar cartliage defects, denied ACI repeatedly by insurance.  Scope and debridement 12/06 L knee.Bilat patellar ACI with Fulkerson 4/23/07.

Offline DJF

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Re: ACI vs patella femoral replacement
« Reply #12 on: January 06, 2007, 05:53:41 PM »
That sounds like a very tough condition.  Keep us posted on how you are doing and what you find out.

Good luck
Don
50 y/o male
Houston TX 

4 surgeries
Manual manipulation Dec 2006
Carticel implant with TTT October 2006
Carticel Harvest August 2006
The following done October 2005:
Chondromalacia Grade III to IV
Scope with chondromalacia
plus lateral release
plus plica resection