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Author Topic: ACI gets a tough challenge... multiple lesions  (Read 15616 times)

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Offline David3

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ACI gets a tough challenge... multiple lesions
« on: August 03, 2007, 04:49:18 PM »
I had ACI / TTO as planned on July 24th, 10 days ago. Background is that I had no symptoms at all 18 months ago, and was extremely active running, playing soccer, cycling and skiing aggressively (have lived half my life in Norway). After developing moderate pain in early 2006, I had microfracture in Vail to MFC, LFC and trochlea in Sep06, but this failed after 5 months (see postings in microfracture section). I was repeatedly told by local OSís in Houston that my case was too complicated and that I should just live with it, an impossibility given my growing pain. After multiple referrals, I ended up at Dr Minas in Boston.

Turns out that I have lesions on 4 surfaces: MFC, LFC, trochlea, and patella. The patella damage was not seen on either the microfracture arthroscopy or the ACI cell harvest scope. Having ACI/TTO out-of-state has its logistical challenges, but given the complexity, I feel the trip to Boston was absolutely worth it for my particular circumstances. Fortunately, the cartilage surrounding each lesion is reportedly very thick and healthy; my OS said the lesions were ideal for ACI. However, with 4 lesions, I'm facing a long recovery.

I chose to have epidural only for the 3-1/2 hour operation, so was awake all the time, on occasions receiving progress updates from the surgeon and the anesthesiologists, which was interesting.

My OS decided to use a porcine membrane rather than periosteum. He said this has yielded very good results in Europe and he just received approval to use it in the US for the first time 3 weeks ago. Apparently it significantly reduces the probability of overgrowth compared to periosteum (he said that he did not expect me to experience overgrowth problems), and is also more consistent and stronger, so he thinks there's less chance of it rupturing or leaking. And, of course, no need for periosteum harvest, so my incision is a bit shorter than it would have been.†

Pain management has been good. First 2 days post-op were epidural, then oral Oxycodone. Iíve been lucky not to experience the severe pain that others on this site have reported the first 2 weeks after ACI/TTO. Mostly my pain has been at the 2 to 3 level out of 10, sometimes up to 5 when I stand up and get a blood rush, but pretty tolerable and improving all the time.

Well, apart from the fact that I have multiple lesions, everything else has gone above expectations. My OS was reasonably optimistic and thought I'd be able to ski again (after 2 years, not one), although I know personally that those days are over - if this is successful, I'm really going to treasure the gift I've been given! Just now, I'm optimistic about a successful outcome.

Extension is not too bad, maybe 2 or 3 degrees to go. Flexion is good up to 40 degrees, but VERY stiff from 40 to 75, my max flexion so far. Have others experienced this stiffness and still progressed? I start PT on 8th Aug, about 2 weeks post-op, so will keep you posted.
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 djs60

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Re: ACI gets a tough challenge... multiple lesions
« Reply #1 on: August 04, 2007, 02:20:19 AM »
David,

Glad to hear that your surgery went well.

Are you doing more than 40 degrees of motion in the CPM?  I was told after my surgery (patella & trochlea with TTO, same surgeon as you) to stay at 40 degrees.  So, naturally got pretty stiff initially.  I'm now at 14 weeks post op, and have nearly full flexion. 

Interesting about the porcine patches.  I had fairly significant pain x 10 days postop, but I think a lot of it was at the periosteal graft donor sites.  I also wound up with a pretty long scar because he had to go pretty far down the tibia to get enough periosteum (my patella needed a big graft).

I'm now 14 weeks post op, I was up to an hour on my bike last week, with no real pain  :)

Keep us posted,
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: ACI gets a tough challenge... multiple lesions
« Reply #2 on: August 06, 2007, 03:18:22 AM »
Great to hear you are biking already DJS. I'll be really happy to be where you are at 6 months, never mind 14 weeks!

I'm now at 12 days. Yes, I've been told to limit my CPM to 40 degrees for 6 weeks, which I'm sticking to. However, my OS also asked me to hang my leg over the side of the bed a few times each day, and use gravity to gradually flex the knee as tolerated. The PT at the hospital showed me a variation, which I prefer. I sit on the bed, with my heel resting gently on the floor. With my brace unlocked, I then pull upwards on the hinge of the brace to ensure passive flexion. It's been getting a bit better each day, but is very stiff and sensitive on the graft sites. I'm about 75 to 80 degrees now. I'm debating whether to cut back on this, because the underside of the patella is very tender when I do this.The OS also said that we should speak again at 3 weeks by phone. He mentioned that he's considering adjusting his protocol for P-F lesions to increase the angle on the CPM from 3 weeks. We'll see.

My incision, by the way, is exactly 6" long. It's probably long due to having to open the knee sufficiently to reach all of my different lesion locations, but shortened by not having to harvest periosteum. Don't know how this compares with others?

I'm now completely off pain medication (everything). I'm not pain-free, but what pain I do have is definitely tolerable (level 2/10). I don't want to be taking medications. A benefit of getting rid of pain meds is that I can manage "a number 2" properly again instead of being all stopped up. Phew.† ;D
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 joew

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Re: ACI gets a tough challenge... multiple lesions
« Reply #3 on: August 07, 2007, 06:38:33 AM »
David,

Glad to hear things are going well.  Just a few questions:
1.  Any explaination on how two previous scopes missed the patella defect(s)?  How big was it?
2.  How long did you stay in Boston?  (I imagine the flight back was no fun.)
3.  Did you stay in a hotel there after the surgery? 
4.  Did your wife stay at home with the kids? 
5.  How long before you expect to be back to work? 

Joe
7/02: ACL and medial meniscus tear playing basketball
9/02: ACLR; meniscus repair (local OS)
2003-2005: Patella grinding and pain after surgery.
12/05: Scope. Patella and trochlear groove debridement (kissing lesion).† Partial medial meniscectomy. (local OS)
5/07:† LOA/AIR, plica removal (Vail)

Offline David3

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Re: ACI gets a tough challenge... multiple lesions
« Reply #4 on: August 07, 2007, 04:17:03 PM »
Hi Joe, Good questions.

1) Both scopes saw possible damage on the patella, but clearly underestimated the extent of the damage. When my microfracture was done in Vail, "diffuse grade 2 patella damage" was noted, but it was not deemed prudent to debride an apparently non-full-thickness defect to bone in order to microfracture. Possible patella damage was also seen during my ACI harvest scope, but it was not expected to be full thickness. I think the reality is that even for an experienced OS, a scope is a better diagnostic tool than MRI, but neverthelesss has its limitations. I believe other ACIers on this site have also experienced similar discrepancies (+ve and -ve) between scope and open ACI diagnosis. My patella defect was, in fact, the largest of all my defects. At about 4 sq. cm, it covered about 20% of my patella.

2 and 3) ACI out of state required ALOT of planning. Dr Minas and his PA were excellent in advising me. On their advice, I was in hospital 5 days/4 nights, and in a hotel another 4 days/3 nights. 9 days in Boston altogether. He told me not to fly before 1 week after surgery, hence the extra hotel nights. Flight back wasn't easy, but was tolerable. I think this was partly due to them doing a great job on my pain control.

4) I went alone for the ACI harvest scope, but they asked me to have somebody with me for the big ACI op. Unlike when I had microfracture, I could not have managed alone after ACI. My wife and children came with me. My in-laws also came, so that it made a bit of a holiday for them all, instead of a tedious wait for them. Worked well for everybody.

5) I'm keen to get back to work, but don't see it happening before week 5 (4 weeks off). Even this will require good support from home and work, which I'm lucky to have. I have started to work from home by PC, on and off, this week. I may choose to delay further - there is no way I want to jeopardise these grafts.

I have alot more detailed info for anybody considering doing ACI 'out of state', especially in Boston. Let me know if anybody wants to discuss off-line.

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 djs60

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Re: ACI gets a tough challenge... multiple lesions
« Reply #5 on: August 07, 2007, 06:21:14 PM »
David,

I don't think I'd let the limited flexion worry you too much.  I recall that I worried about this, but after I saw the OS for my 6 week f/u and he told the PT she could do more with me, things rapidly improved.  At this point (14.5 weeks), I am probably just short of full flexion, but I think the small amount of swelling I still have in the knee is the reason I can't fully flex.

On Joe's question about the patella, I had the same experience.  At my bx surgery, the OS called my patella grade II.  However, at my ACI, it turned out there was only a minimal covering of cartilage on the patella (I guess that would be grade III+), so he would up grafting a 4 x 4 cm area of my patella (this was actually more than my trochlea, which was 3 x 3 cm, but was grade IV).

When I asked him about this, he told me the patella is difficult to accurately assess arthroscopically, so he wasn't really surprised by this turn of events.  He had fortunately had planned for this possibility, so he had enough cells to do the patella.

Dan
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

jonhark

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Re: ACI gets a tough challenge... multiple lesions
« Reply #6 on: August 09, 2007, 03:59:56 AM »
David,

You were in good hands with Dr. Minas. He did a TTT and microfracture for me last Jan. 29th. My microfracture subsequently failed and am now having the ACI surgery on  Aug 14th. Dr. Gersoff--a surgeon Minas recommended is doing the surgery in Colorado. Fortunately I only have a 1.5CM lesion in the patella. I'm convinced the microfracture made my condition worse. It is water under the bridge now as I'm going for the real deal next week.
I'm really impressed with the TTT results. My kneecap tracks perfectly now with no subluxing or popping. Now it is just a matter of filling in the lesion before it grows even worse.

Good luck with your recovery!!!

Jon

Offline David3

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Re: ACI gets a tough challenge... multiple lesions
« Reply #7 on: August 09, 2007, 06:05:01 PM »
DJS, Good to hear that you made good progress on flexion in due course. I'm at about 80 deg now, so may only just make 90 deg by 3 weeks, we'll see. However, flexion 0-80 is becoming less stiff, and the sensitivity and tenderness under the patella when I flex is definitely diminishing. I don't want to push too hard at this stage for risk of over-stressing the grafts.

Jon - good luck with your ACI. Great that you've already had the TTT. I'm sure you'll do well. Only a few days to go. Keep us posted.

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 joew

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Re: ACI gets a tough challenge... multiple lesions
« Reply #8 on: August 12, 2007, 05:34:22 AM »
David,

I hope things continue to progress well for you.  I have a few more questions, if you don't mind.

1.  What is the follow up plan with Dr Minas during your recovery?
2.  I assume you menisci were in good shape and didn't get torn up by the chondral defects?
3.  Once you are fully recovered, is there any way to minimize degradation of your new cartilage, besides staying away from high impact activities?  In other words, does Dr Minas have any idea why your original cartilage degraded and hopefullly set you up for long term success?  (I'm sure the TTT will help the patellofemoral joint problems, but what about the medial and lateral compartments?
4.  Are you doing any patella mobes and wall slides like you did after your microfracture per the the S-H protocol or is this rehab totally different (I'm sure it is a least somewhat different)?

By the way, if you recall I have a full thickness chondral defect (13mmx15mm) on my troclea in my LK and I also have grade 3 on the patella and grade 2 in medial compartment.  I recently got an MRI on my RK because it has bothered me some for years, but more over the last 6-12 months.  I have a full thickness defect on that patella (only 3mm long according to the MRI) with thinning and grade 3-4 around it.  So, although I have no current intentions of going through what you currently are, there is a chance down the road that I will.

Joe
7/02: ACL and medial meniscus tear playing basketball
9/02: ACLR; meniscus repair (local OS)
2003-2005: Patella grinding and pain after surgery.
12/05: Scope. Patella and trochlear groove debridement (kissing lesion).† Partial medial meniscectomy. (local OS)
5/07:† LOA/AIR, plica removal (Vail)

Offline David3

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Re: ACI gets a tough challenge... multiple lesions
« Reply #9 on: August 13, 2007, 01:52:06 AM »
Hi Joe,† I've benefited so much from other peoples' postings here that I'm always happy to try and give something back by answering questions.

1) Dr Minas and I discussed follow-up in detail when he visited me in hospital 2-days post-op. He felt that the 6 week follow-up could be done without visiting Boston IF all is well. He wants a PT report to check that flexion, extension, patella mobility, swelling etc are making satisfactory progress. He also wants me to have digital X-rays taken and sent to him so that he can assess the osteotomy healing. If everything looks good, I can progress to the 7-12 week rehab protocol. He definitely wants to see me at 12 weeks - he says that he can assess progress much better by 12 weeks, and says that most patients have alot of questions by then. I don't mind going to Boston at 6 weeks if necessary, but I do see travel at 6 weeks as a possible risk factor which I'd rather avoid.

2) No mention from S-H or Dr Minas of any meniscus problems. Apart from the 4 lesions (hmmm), Minas described the rest of my knee as looking "very healthy". Good point though - I will enquire about this at follow-up.

3) Nobody has a perfect answer to why my cartliage has degraded, but it appears to be a combination of (i) high intensity sport while too young [lots of very heavy weights as a teenager, training for competitive rowing], (ii) high intensity sport throughout the last two decades - particularly aggressive skiing, (iii) minor biomechanical issues [my TTO was primarily unloading, only very minor realignment], and (iv) possible genetic susceptibility, although there is no history in my family. I'm convinced that skiing has been a major factor - my trochlear and LFC lesions were long and thin, with the LFC lesion going to "deep flexion", a position common in free-heel, telemark skiing, but well beyond the flexion experienced in running. If ACI is successful, I'm hoping a diet of swimming, cycling, X-country skiiing, hiking and golf will be possible in the longer term. We'll see. Whatever happens, I will definitely drop skiing, running and other impact sports after what I've been through.

4) Patella mobs, yes. Wall slides no. This rehab is more conservative than even the S-H microfracture protocol (e.g. no CPM beyond 40 deg, no SLRs). I'm OK with that. Slow and steady wins this race.

Your knee sounds not dissimilar to mine. I'm now convinced that microfracture could not have solved this, but that ACI has at least a chance.
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 joew

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Re: ACI gets a tough challenge... multiple lesions
« Reply #10 on: August 13, 2007, 04:03:13 AM »
Thanks, David.  I really hope this works for you.  I agree on going easy with the activities once you have mended.  I would do the same thing.  At this point I'm just hoping I can get back to some aerobic activity that will get my heart rate up and be able to do basic day to day things around the house and with my familly without having to go through any more surgery.  I don't think I will know that answer for another six months.

Joe
7/02: ACL and medial meniscus tear playing basketball
9/02: ACLR; meniscus repair (local OS)
2003-2005: Patella grinding and pain after surgery.
12/05: Scope. Patella and trochlear groove debridement (kissing lesion).† Partial medial meniscectomy. (local OS)
5/07:† LOA/AIR, plica removal (Vail)

Offline David3

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Re: ACI gets a tough challenge... multiple lesions
« Reply #11 on: August 29, 2007, 02:28:50 AM »
5 WEEK UPDATE:† Things are hopefully progressing according to plan. Still non-WB (only TDWB) until 6 weeks. The sensitivity and tenderness at the graft sites that I was experiencing at week 2 has steadily diminished and is now at a very low level, frequently absent altogether. The 'shin-splint' type feeling at several points on my shin has now also disappeared almost completely, so hopefully the osteotomy is healing well. I haven't taken or needed any pain meds at all (not even Tylenol) since day 12 post-op.

Flexion is improving, but slowly, despite lots of cryo-cuff and ice-massage. I'm not allowed to exceed 40 deg on the CPM, which may explain the slow progess on flexion. I reached 89 deg of flexion at 3 weeks, and am now at 102 degrees (I can almost cycle, but not quite!). The patella is very mobile, so neither my PT nor I are concerned about scar tissue - I still have a fair bit of swelling, which inhibits flexion, but swelling and ROM are getting a bit better each day. By next week, I hope to be within a few degrees of my OS's 6-week ROM target of 110 degrees. I got full extension back at about 3-1/2 weeks. In general, I'm optimistic so far, no cause for concern.

Otherwise, I started work last week, shorter days and only 3 or 4 days per week at the moment, but good to be back and see people! My legs are elevated all day on a stool, so I'm reasonably comfortable.
 
I have my 6 week follow-up with my OS next week, Sept 6th. X-rays to check the osteotomy, then hopefully progression to 1/3 WB for weeks 7&8, 2/3 WB for weeks 9&10, full WB with crutches for weeks 11&12. Looking forward to it. Hope there's as much progress in the next 5 weeks as there has been in the first five!

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 David3

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Re: ACI gets a tough challenge... multiple lesions
« Reply #12 on: September 11, 2007, 11:26:23 PM »
7 WEEK UPDATE:† Saw my OS last week. Looks like everything's going well. X-rays showed good healing of the osteotomy and flexion appears to be nice and smooth (no crepitus), so I got the go-ahead to start PWB with 1/3 body-weight. PWB is going OK, with very little pain, but occasional mild soreness in the evening. One more week and then I can increase to 2/3 body weight.

Otherwise I'm cycling 10-15 mins daily without resistance on a stationary bike, which feels good and really loosens up my knee. I can just manage a few SLRs with alot of effort - there has been pretty amazing muscle atrophy, because I was doing hundreds of these before surgery! Anyway, once I'm comfortable doing SLRs, I can d/c my brace, hopefully by the weekend!† ;D† I've also started driving again, which deserves another smiley grin† ;D

Still a long way to go, but I'm happy with progress so far.
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 joew

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Re: ACI gets a tough challenge... multiple lesions
« Reply #13 on: September 13, 2007, 12:47:24 AM »
David,

Glad to hear things are going well.  How is your other knee holding out? 

Joe
7/02: ACL and medial meniscus tear playing basketball
9/02: ACLR; meniscus repair (local OS)
2003-2005: Patella grinding and pain after surgery.
12/05: Scope. Patella and trochlear groove debridement (kissing lesion).† Partial medial meniscectomy. (local OS)
5/07:† LOA/AIR, plica removal (Vail)

Offline David3

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Re: ACI gets a tough challenge... multiple lesions
« Reply #14 on: September 13, 2007, 04:43:24 PM »
Ah, that little matter of the other knee! It's definitely a concern.

The first 4 weeks post-op were great. Because my activity level was so low with the ACI knee, my non-op knee was really rested. From 4 weeks onwards, the pain in my non-op knee has increased again as activity has increased. I'm being really careful to protect it. The damage in my non-op knee is mostly trochlea, so walking is OK, but loading it too much when bent does hurt. I'm avoiding stairs, avoiding sitting with my 'good' leg bent (aswell as keeping my ACI knee elevated and straight of course), and using my arms to get out of chairs, etc, rather than using my 'good' leg. I'm hoping I can last through until I can get ACI done on my RK about 1 year after my recent surgery on my LK.

Cycling is a predicament - my ACI knee feels good when I cycle, but my non-op knee becomes pretty sore. Cycling is going to end up being a compromise. Any suggestions on how to cycle with one leg gratefully received.

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.















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