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Author Topic: Bilateral patellar and trochlear ACI  (Read 29598 times)

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Offline erinee

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Bilateral patellar and trochlear ACI
« on: March 28, 2007, 10:56:42 AM »
Hi all-
My surgery has finally been authorized (almost 2 years after my original harvest) and scheduled for April 23rd.  I will be the first (according to Genzyme) to have the procedure bilaterally.  I am a PT  and know exactly the craziness I am getting myself into, and really wanted to do bilat, although they were VERY cautious to warn me that it was goig to be a tough road.  I will also be having a tibial osteotomy, and my OS is trying to obtain a synthetic patch to replace the periosteum patch, which Dr. Minas has been using with great results.  Wish me luck!  (And imagine the comedy of bilateral CPM's!)
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 LadeeStingray

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Re: Bilateral patellar and trochlear ACI
« Reply #1 on: March 30, 2007, 05:54:57 AM »
erinee,

First off i must ask "Are you crazy??"   lol   More power to you if u can go thru both at the same time.  Now i can picture 2 CPMs at once  my second question is ... will u have the going the same direction at the same time or opposite.  The mental picture i have at this point.   Ok now for a serious question .... you said 2 years after you original harvest..... so because it took so long to get authorized u had to have a second harvest?  Or a second due to it being bilat.?   My cells have been sittin in a lab waiting for me since Nov, my doc was gonna attempt the surgery then decided i needed to see someone more experienced.  Now this my insurance company loved and they decided they would find a doctor for me .... which was another waste of 2 months.  So here i sit, i think i have finally backed the insurance in a corner and ill be going to either Indy or Boston (i hope).  So Dr Minas is using a synthetic patch now?  interesting!!  I wish u the best of luck.... and post some pics of the dualing CPMs!! 
Ladee
10/05 Rt medial meniscal tear repair 1/06 synvisc injections
3/06 cortisone injection   6/06 open OATs MFC
9/06 drained/cortisone  11/06 biopsy for ACI surgery
6/07 scoped again....failed OBI plugs
awaiting approval for HemiCAP

Offline David3

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Re: Bilateral patellar and trochlear ACI
« Reply #2 on: March 30, 2007, 07:57:19 PM »
Hi Erinee,   

I can only say 'wow' to you going through bilateral ACI. You must be in alot of pain to consider doing both knees at once. I hope people really rally round and give you lots of help when you need it most in the early months. This sounds like a 'first' - who is doing your surgery?

Also, I really sympathise that you had to wait so long for insurance approval. I'm concerned that I am going to face the same issue. May I ask how you have managed the pain if you've had to wait 2 years for authorization?   

You mention that this is for trochlear and patella lesions. Is this trochlear in one knee and patella in the other, or does at least one of your knees have lesions on both the patella and the trochlear? (in the same knee). I am particularly interested in this because the MRI of my right knee shows lesions on both the trochlear and the patella. It's painful, and I'm wondering what the outlook is and how successfully this can be treated. Would be interested to hear any feedback you've had from your OS.

Anyway, very best wishes on Apr 23rd.

David


2006: Left Knee (LK) microfracture (MFC, LFC, Trochlear), failed at 6 months
7/07: ACI/TTO of LK (MFC, LFC, trochlea, patella)
2014: Considering ACI treatment on RK.

Offline erinee

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Re: Bilateral patellar and trochlear ACI
« Reply #3 on: March 30, 2007, 11:10:21 PM »
erinee,

First off i must ask "Are you crazy??"   lol   More power to you if u can go thru both at the same time.  Now i can picture 2 CPMs at once  my second question is ... will u have the going the same direction at the same time or opposite.  The mental picture i have at this point.   Ok now for a serious question .... you said 2 years after you original harvest..... so because it took so long to get authorized u had to have a second harvest?  Or a second due to it being bilat.?   My cells have been sittin in a lab waiting for me since Nov, my doc was gonna attempt the surgery then decided i needed to see someone more experienced.  Now this my insurance company loved and they decided they would find a doctor for me .... which was another waste of 2 months.  So here i sit, i think i have finally backed the insurance in a corner and ill be going to either Indy or Boston (i hope).  So Dr Minas is using a synthetic patch now?  interesting!!  I wish u the best of luck.... and post some pics of the dualing CPMs!! 
Ladee
Ladee-
Yes, craziness has been mentioned.  The 2 CPM-opposite directions, like riding a bike.  And the 2 years-the delay was insurance related only, and I did not need a second harvest.  The original cells were still good.  The synthetic patch is off-label use for orthopedics-it's only FDA approved a this point for oral-maxillofacial surgery.  Good luck to you!
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 erinee

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Re: Bilateral patellar and trochlear ACI
« Reply #4 on: March 30, 2007, 11:16:06 PM »
Hi Erinee,   

I can only say 'wow' to you going through bilateral ACI. You must be in alot of pain to consider doing both knees at once. I hope people really rally round and give you lots of help when you need it most in the early months. This sounds like a 'first' - who is doing your surgery?

Also, I really sympathise that you had to wait so long for insurance approval. I'm concerned that I am going to face the same issue. May I ask how you have managed the pain if you've had to wait 2 years for authorization?   

You mention that this is for trochlear and patella lesions. Is this trochlear in one knee and patella in the other, or does at least one of your knees have lesions on both the patella and the trochlear? (in the same knee). I am particularly interested in this because the MRI of my right knee shows lesions on both the trochlear and the patella. It's painful, and I'm wondering what the outlook is and how successfully this can be treated. Would be interested to hear any feedback you've had from your OS.

Anyway, very best wishes on Apr 23rd.

David



Hi David-
Yes, the pain has gotten to the point where I don't "have a good leg to stand on" so to speak.  IF I only did one, I think theother would just buckle.  I have had Synvisc injections every 6 months which were very helpful symptomatically-unfortunately they also allowed me to do things I perhaps shouldn't have been, so I have larger lesions now.  My lesions are both patellar ans trochlear on both knees.  Dr. Roche in Ft. Lauderdale is doing my surgery.  From what he told me from when he spoke with Dr's Minas and Petersen at the Academy meeting, the success rate in patellar ACI had improved dramatically recently from implementing an unloading osteotomy at the same time.  Even though I do not have patellar tracking issues, he will bedoing the unloading osteotomy to protect the graft.
Thanks for the wishes and good luck to you as well!
Erin
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 David3

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Re: Bilateral patellar and trochlear ACI
« Reply #5 on: March 31, 2007, 01:39:35 AM »
Thanks Erinee!  This gives me hope!

I'm going to watch your case with interest. We're rooting for you!
2006: Left Knee (LK) microfracture (MFC, LFC, Trochlear), failed at 6 months
7/07: ACI/TTO of LK (MFC, LFC, trochlea, patella)
2014: Considering ACI treatment on RK.

Offline David3

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Re: Bilateral patellar and trochlear ACI
« Reply #6 on: April 03, 2007, 03:58:19 AM »
Erin (or others),

Can you tell me more about what the 'unloading osteotomy' is?  Is this a procedure to release pressure on the patella? Is this a TTT-type procedure? (pardon my ignorance if I'm way off here - I'm still learning!). If so, what is the rehab and recovery time relative to ACI? What is the success rate and what are the potential downside risks?

I'm interested because of the patella / trochlear lesions in my right knee. My patella tracking is apparently fine, as is my alignment as seen from a full toe-to-hip X-ray. However, prior to my Sept06 left knee microfracture, my patellae in both knees were described by my very experienced OS as being "tight for somebody who has never had surgery" (I notice that I cannot manipulate them sideways anywhere near as much as my wife can move her patellae). I'm wondering whether I will be facing an 'unloading osteotomy' on my right knee surgery if my knee is found to be suitable for ACI.

David
2006: Left Knee (LK) microfracture (MFC, LFC, Trochlear), failed at 6 months
7/07: ACI/TTO of LK (MFC, LFC, trochlea, patella)
2014: Considering ACI treatment on RK.

Offline erinee

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Re: Bilateral patellar and trochlear ACI
« Reply #7 on: April 03, 2007, 10:39:39 AM »
David, I would guess that your hunch is correct, you wouls probably be a candidate for the osteotomy, and from what I understand from what Dr. Minas has been finding, it doesn't even really make sense to do the patella ACI without it.  Yes, it is like a TTT-from whatmy MD has told me exactly howand where depends upon what he finds once he gets in there, (as far as high osteotomy vs TTT)  The protocols are slightly different fro rehab but can be combined (as obviously I will be doing)  it slows down recovery obviously, more restricted WB'ing for longer than with a straight ACI.  But, if it improves outcomes-so be it!  I'm anticipating PWB for about 9 weeks or so.  I combined the protocols (it helps being a PT!)-if you want to PM me your email I'd be happy to send it to you.
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 djs60

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Re: Bilateral patellar and trochlear ACI
« Reply #8 on: April 03, 2007, 03:10:55 PM »
Erinee,

I am interested in the the combined ACI/osteotomy issue, as I will be likely having this on 4/27.  I have a full thickness trochlear defect, with grade II-III patellar defect, and a "crack" in the lateral codyle.  So, the plan is for ACI of the trochlea and LFC, with maybe aci of the patella (the OS told me he will decide on this at the time of surgery).  He told me he will also do some degree of patellar realignment (probably TTT), but told me he will need to decide the exact approach in the OR (if I understood him, he will do a lateral release, & if he feels that is not adequate, a TTT.

Anyway, I would be interested in seeing the rehab protocols you mention (I don't think I can PM you because I don't have enough posts).

djs60
« Last Edit: April 04, 2007, 02:48:02 AM by djs60 »
3/06 left knee arthroscopy - grade IV lateral trochlea defect
chondroplasy & removal of loose bodies
1/07 left knee arthroscopy/cartilage biopsy
4/27/07 left knee trochlea & patella ACI with TTO

Offline David3

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Re: Bilateral patellar and trochlear ACI
« Reply #9 on: April 03, 2007, 08:15:47 PM »
Thanks Erin. I would be interested in the rehab protocols, but I'll hang on for a bit. I'll get back to you in mid-April once I see a new OS in Indianapolis for a second opinion and know more about what he recommends (I might also have enough posts to be able to message you then!).

David
2006: Left Knee (LK) microfracture (MFC, LFC, Trochlear), failed at 6 months
7/07: ACI/TTO of LK (MFC, LFC, trochlea, patella)
2014: Considering ACI treatment on RK.

Offline erinee

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Re: Bilateral patellar and trochlear ACI
« Reply #10 on: April 05, 2007, 01:41:55 AM »
Let's see if this works-I'm going to try to attach the protocol file.
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 David3

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Re: Bilateral patellar and trochlear ACI
« Reply #11 on: April 05, 2007, 02:15:47 AM »
Thanks Erin. Got it. Do you know if this is the rehab protocol just for ACI (presumably the patella-trochlear ACI which you will be undertaking) or is this the complete protocol for the combined ACI and 'unloading osteotomy'?

I must say that I'm influenced by my recent microfracture failure at 5-1/2 months when I ramped up activities an extra notch because my knee was feeling so good. This time, whatever procedure I go through, I'm going to be super conservative relative to what appears on this protocol. No way I'll be ramping up cycling resistance at 6 months or jogging at 9-12 months. This is my last chance to save my knee and I'm highly motivated to take whatever time is needed. In that respect, I've been inspired by JulianUK's story in the ACI section.

By the way, what are your plans for getting around during the first couple of months? I guess you'll be in a wheel chair, presumably with some very good help at home? I envy your strength going for this bilateral approach.
2006: Left Knee (LK) microfracture (MFC, LFC, Trochlear), failed at 6 months
7/07: ACI/TTO of LK (MFC, LFC, trochlea, patella)
2014: Considering ACI treatment on RK.

Offline erinee

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Re: Bilateral patellar and trochlear ACI
« Reply #12 on: April 05, 2007, 10:57:57 AM »
Hi David-
I'm so glad that it worked!  This is the combo protocol-myself and Dr. Roche put it together.  It will be very hard for me to stay "down"-mentally.  I've always been very active and athletic, but that is also why I'm doing it bilaterally-it would kill me to do one, get 3-6 months down the road and start feeling better  and then have to start all over with the other side.  Plus, I "don't have a good leg to stand on" so to speak-when I had my last scope to just the left knee my right knee was killing me from the compensation!
As far as post-op-yes, the majority will be spent in a w/c, and I will be using forearm crutches for short distances.  It's only for 3 months, so hopefully won't be too bad.  My practically husband will be home on vacation for the first 3 weeks after I get home from the hospital, and my dad will be coming to help for the next 2.  Hopefully by then I'll be able to transfer on my own-when the braces are locked at zero I'll literally need help everytime I want to stand up!  Temporary problem for a permanent solution, at least that's my hope!
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 djs60

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Re: Bilateral patellar and trochlear ACI
« Reply #13 on: April 05, 2007, 01:03:28 PM »
Thanks, Erin.

This is very helpful info.  I appreciate you posting it.

Best of luck to you - we will be recovering together, as I am scheduled for my surgery on 4/27.

djs60
3/06 left knee arthroscopy - grade IV lateral trochlea defect
chondroplasy & removal of loose bodies
1/07 left knee arthroscopy/cartilage biopsy
4/27/07 left knee trochlea & patella ACI with TTO

Offline erinee

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Re: Bilateral patellar and trochlear ACI
« Reply #14 on: April 06, 2007, 12:04:46 PM »
Thanks, Erin.

This is very helpful info.  I appreciate you posting it.

Best of luck to you - we will be recovering together, as I am scheduled for my surgery on 4/27.

djs60
Luck and best wishes to you as well.

Just over 2 weeks out now...
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.















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