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Offline bsonday

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Does ACI last?
« on: April 15, 2008, 06:06:43 PM »
Hey everyone,

Last May 18th, 2007, I dislocated my patella.

I had my first MRI a week later which showed damage to my patellar articular cartilage.  A month later I had an arthroscopy to remove a total of three cartilage pieces.  Two were "very minor" but one was about 1cm^2 and went all the way down to the bone.  At the time, my doctor expected me to make a full recovery.

Three months later, I subluxed it while running on the beach (it hurt to run anywhere but sand).  My doctor was not alarmed and expected a full recovery.

From October until quite recently, I spent tons of time with a PT strengthening my quads.  They are now stronger than they have ever been.  My knee now feels better than it ever has since the May 18th injury.  Still, though, my pain hasn't gone away.

I finally went in for an MRI March 15th to try to figure out what is going on.  My doctor and I looked at it a few days later and discovered that I now have a 2.5cmx2.2cm lesion in my patellar articular cartilage.  Neither one of us knows how it could have gotten so big since my September injury was so minor.  Nevertheless, we finally understand why my pain was not going away.

I'm 22 years old, and until recently, I had planned on getting back to a relatively normal life someday.

Does anyone know anyone so young who needed such drastic patellar articular cartilage repair, and if so, what did this person do?  I feel like I am the only person in the world who dislocated a patella severely enough to really mess up my cartilage.

It seems like ACI plus a MPFL reconstruction would put me pretty much back to normal assuming that both of these operations are successful.  I think ACI is in my favor since I am young, haven't had microfracture, I have a meniscus, etc.

Thanks in advance for any information.

-Ben

Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline Chondrosoldier

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Re: Been there, done that, ACI worked
« Reply #1 on: April 15, 2008, 06:36:45 PM »
Just have to be patient and realize you're going to give up skiiing over the next few years for the chance to save yourself big time problems later on.

Recurrent patellar dislocations and subluxations occur for a number of reasons, most of which involve less than optimal alignment coupled with an active lifestyle. 

I got ACI at 24 following a patellar realignment at 21. Just got my other knee redone with ACI last week and now can look at moving forward and moving on.  I'd do it again the exact same way in a heartbeat.  How your knees got that way are out-of-your-control and a thing of the past. Your ability to get them fixed is something to take advantage of

You sound like you have a great surgeon.  I'd go with his recommendations.  The great thing about having it done when you're young is the lack of career and family commitments.  You can have your parents help you out and not sacrafice the lost income if you wait to have it done a few years from now (if and when ACI is still an option). 

You're obviously being pro-active in the process.  Trust your surgeon and don't listen to the nay-sayers on this board.  Best of luck, keep in touch,

Brant
1997 L Traumatic dislocation/ACL
1997-2001 L recurrent sbuluxation
2001 L TTT Realignment
2006 L Patellar Carticel biopsy/debridement
2006 L Carticel 4cm patellar reimplantation
2007 R Carticel biopsy/debridement
 Insurance Battle
2008 R TTT 4CM Patalla/3CM Trochlea Carticel implant
Happiness!

Offline bsonday

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Re: Does ACI last?
« Reply #2 on: April 15, 2008, 08:24:24 PM »
Brant,

Thanks for the response.

Are you pretty much back to normal, then, after your carticel operation?  And were the carticels on your patella?  Have you thought about getting an MPFL reconstruction to prevent future subluxations/dislocations?  For my own mental health I'm trying to tailor my expectations to what they should be.  A lifetime without competitive sports breaks my heart, but I realize that each of these operations is not 100%, and patella carticel is only 75%-85%.

Best,
Ben
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline Chondrosoldier

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Re: Does ACI last?
« Reply #3 on: April 15, 2008, 10:19:20 PM »
Took 16-18 months to resume all normal activities, including ice hockey.  Had a textbook recovery and was jogging around 9 months post-op.  I don't know much about MPFL reconstruction by itself.  Most typically, they'll do a Tibial Tubercle Transfer (Osteotomy) and move your VMO down on your patella and tighten the retinaculum to correct the alignment in combination with the ACI.

Had the combined procedure done last Wednesday an wish I had had them done together back when I was in your situation (instead I had the realignment alone, returned to normal activity and the cartilage got worse requiring ACI)  You obviously have a great surgeon and the knowledge to avoid inferior techniques like microfracture.  Do whatever your surgeon suggests, play guitar hero for a couple months and you won't have to deal with this crap again.

I'm convinced that the few cases that fail simply overdo it in rehab.  If you have a highly Carticel experienced surgeon, he has a Carticel experienced PT that he outsources such cases to so don't worry about that.   If you're OS has done a high number of patellar ACI cases, I'd get it done and look forward to hitting the beach next summer.   
1997 L Traumatic dislocation/ACL
1997-2001 L recurrent sbuluxation
2001 L TTT Realignment
2006 L Patellar Carticel biopsy/debridement
2006 L Carticel 4cm patellar reimplantation
2007 R Carticel biopsy/debridement
 Insurance Battle
2008 R TTT 4CM Patalla/3CM Trochlea Carticel implant
Happiness!

Offline MegTX

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Re: Does ACI last?
« Reply #4 on: April 15, 2008, 10:41:50 PM »
If the ACI procedure "takes" and the hyaline cartilage forms correctly, AND they correct whatever caused the problem in the first place -- and in your case since it was an injury and not a tracking problem you're in better shape than a lot of us -- then it should last a long time.

The hyaline cartilage is the type of cartilage we're born with, and it's designed to pretty much last a lifetime, if we don't abuse it **TOO** badly.  The procedures in Sweden that are now over 20 years old are showing virtually no wear, but those are primarily on the condyles, the patella takes more shear forces than the condyles.  The patellar grafts don't have as much history, but the data we have indicates that if the underlying problem that caused the lesion is corrected, then the graft should be durable.

There's no guarantees with any of this.  But, I've researched the hell out of this, I had an isolated patellar lesion due to maltracking, and I'm pretty confident this will correct my problem and last well into my old age.  I'm *not* looking at this as a stop-gap to put off a TKR, and neither is my surgeon.
Lateral Release, Medial "Reef" - '91
{16 years of grinding, pain, swelling and lots of ice}
'scope 7/07 - .7cm2 tibial plateau microfracture, 2.5cm2 grade4 patellar CP debridement
ACI & Fulkerson TTT 2/08 (patella lesion then 4.5cmx3cm)

Offline David3

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Re: Does ACI last?
« Reply #5 on: April 16, 2008, 12:48:46 AM »
Ben, 

Sorry to hear that you have joined us in the patella lesions club. Although I'm sure you could have done without all this, one consoloation is that young patients (<30) apparently do extremely well with ACI. Older patients can do pretty well too, but you youngsters simply have stronger, fitter little chondrocytes that proliferate and heal better and form better cartilage.

Agree totally with the remarks on rehab - conservative rehab is the way to go. Be patient, don't push it and you'll get there. Good luck.

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 Army John

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Re: Does ACI last?
« Reply #6 on: April 16, 2008, 01:57:44 AM »
Ben-

  Well you're not alone in having this injury.  I think it's important to note you're in your early 20s so a year seems pretty significant.  Well, it's not.  The surgery is the easy part.  The rehab is the hard, and most important part of the process.  There's no prize for being done with rehab first, but there is a prize with doing rehab correctly.  It's called a complete and full recovery. 

  You're young so you'll heal quicker than most but everybody is different and the rehab for an ACI is long, even for your age.  There will be some bad days littered in rehab--- it's normal.  Deal with it and move on.  There will be many more good days-- trust us.

  How long it will last is dependent upon many things.  If you go back to high impact sports and injure your knee again, well it won't last as long as you want.  If you take care of it, it'll take care of you.  I will tell you from personal experience that you have to be "kind" to your knee from this point forward.  My profession places a lot of physical demands on my body and I suspect that I probably haven't done myself any favors.  However, I'm a Type-A personality and I was never not going to jump out of a plane, or not do a 25-mile road march with gear on.  No regrets but I am starting to wonder, for the first time, if I haven't overdone it these past 10 years.
L knee meniscal repair- 6/89
L knee scope- 11/95
L knee ACL reconstruction- 2/96
L knee scope (included a lateral release, cartilage biopsy, and the ever fun bone shaving)- 1/08
L knee ACI/TTO- 4/08
L knee scope/manipulation- 7/08

Offline bsonday

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Re: Does ACI last?
« Reply #7 on: April 16, 2008, 05:21:46 AM »
Thanks for all of the replies so far, everyone.  They really mean a lot.  I am actually starting to sleep better, mostly due to these posts, as I adjust to the tough news delivered by my most recent MRI.

I haven't done hardly anything active over the past year because my patella has hurt too much, so waiting another year or two is something that I will get over.  It might be a good time to work on my golf game, learn some good guitar songs, and really work hard on my PhD.

Any suggestions on how to find a good doctor?  I must have misspoke when I gave everyone the impression that I already have a good OS.  I've seen three different OS's so far and each does not seem very knowledgeable and has basically said a variation of the same:  I hope you like golf.  I guess I would ideally like to see a doctor with tons of experience with patellar ACI's.

It appears that I also have a tough insurance battle ahead of me.  I've been pretty good about saving my money, but even so, I'm only 22 and I don't have $40,000 to spend.

My favorite thing to do in life is beach volleyball.  I hope to get back to it someday in the next couple of years, but like I said, I don't mind waiting.  And as long as I don't sublux or dislocate again, sand is soft and keeps cartilage quite healthy.  The key is having something done to my knee that will really prevent future subluxations and dislocations (in addition to having an awesome brace and awesome quads).  It seems that TTT, MPFL reconstruction, lateral release, etc. are all good things.  Any experiences with any of these out there?

I probably won't have the surgery until fall since I will be moving to California for the summer to do research in Berkeley.  Although I can run and jump in sand almost 100% pain-free (with 400mg ibuprofen taken a couple of hours before), I still think I will try to avoid the volleyball courts for fear of subluxing or dislocating again and hurting my articular cartilage more (I have read that bigger defects perform slightly worse with ACI).  Is this what you would recommend also?

Once again, thanks everyone!  Even though I am still tempted to punch holes in the wall and yell "Why me?", my devastation is slowly subsiding thanks to you all.

Best,
Ben
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?

Offline Army John

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Re: Does ACI last?
« Reply #8 on: April 16, 2008, 01:02:43 PM »
Ben,

  If you're headed to Southern California, I am sure there will be plenty of well qualified OS' out there.  When I was stationed in southern California, the Army sent my wife to a doctor in Loma Linda.  It was an incredible ortho goup.  I suspect they aren't the only one out that way that is good.  (She saw Dr. Cohen-- he only works on knees)

  One of my lesions was on the patellar- my defect covered about 80%.  How do you pick a really good ACI doctor?  Honestly, I don't know.  If they have graduated med school, completed their residency, and are trained in the ACI procedure then I don't know that I am one to say they aren't good at the procedure. 

  I can't offer any advice on insurance.  I'm pretty fortunate as I am in the Army and my OS was also an Army doctor and it's an automatic approval for us to get the surgery.  It is certainly something the Army is doing more of these because of the benefits of the surgery.  However, plenty of experienced folks here with it.  You do not want to foot the entire bill yourself!

  Good luck!!
L knee meniscal repair- 6/89
L knee scope- 11/95
L knee ACL reconstruction- 2/96
L knee scope (included a lateral release, cartilage biopsy, and the ever fun bone shaving)- 1/08
L knee ACI/TTO- 4/08
L knee scope/manipulation- 7/08

Offline Chondrosoldier

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Re: Does ACI last?
« Reply #9 on: April 16, 2008, 03:30:58 PM »
Insurance: What insurance company do you have Ben?  Nobody pays for this crap out-of-pocket, unless you see it as being that urgent.  If an insurance company doesn't cover it immediately, you'll just have to fight them until they do.  This is a topic that's been discussed in many prior threads but is a ways off in your case. 

Surgeon:  Easiest way to find a Carticel surgeon is to go to carticel.com and search by zip code.  Finding one whose done a lot of patellas is trickier as Carticel won't tell you and you just have to call the doctors offices and ask. Dr. Thomas Vangsness is the best cartilage surgeon in the L.A. area.  Don't know the Northern region that well but certainly San Fran has some good OS's. 

To kill two birds with one stone, find a surgeon in the area you're going to who has done a lot of patellas and take a job with their healthcare system that gives health benefits.  That will ensure that everything that surgeon needs to do is covered in full.  If that means Berkley, it might be optimal to take a job out there now and work for the 1-3 months it takes to pick up health benefits.   If you need to quit, you can still keep your coverage by paying around $300/month.   I did that moving to Austin from St.Louis and it worked perfectly.

Have to be objective and practical in the matter.  Most big insurers fight the patella ACI tooth and nail.  Have to choose the path of least resistance that will allow you to get it done as quickly and inexpensively as possible.
1997 L Traumatic dislocation/ACL
1997-2001 L recurrent sbuluxation
2001 L TTT Realignment
2006 L Patellar Carticel biopsy/debridement
2006 L Carticel 4cm patellar reimplantation
2007 R Carticel biopsy/debridement
 Insurance Battle
2008 R TTT 4CM Patalla/3CM Trochlea Carticel implant
Happiness!

Offline runnerbeth

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Re: Does ACI last?
« Reply #10 on: April 16, 2008, 04:27:14 PM »
Ben,

My cartilage damage was also from dislocating my knee cap.  It happened during a soccer game and tore off a 2cm x 2cm chunk of cartilage.  I've had a series of surgeries since then - 1. scope to remove the loose body, 2. microfracture and lateral release, 3. ACI biopsy, 4. ACI and Fulkerson osteotomy, and 5. scope to shave down overgrowth and remove the TTT screws.  Since mine was injury based and not overuse, our situations are probably pretty similar.  I'm also on the younger side - 27 when the original injury occured.  Feel free to ask me any questions.

Also, I had my first two surgeries in the LA area.  If you can make it down there, Dr. Burt Mandelbaum is excellent and well known for articular cartilage injuries.  Don't know anyone up north but he's probably worth the trip.

Good luck and keep us posted!
Beth

Offline casey2291

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Re: Does ACI last?
« Reply #11 on: April 16, 2008, 05:16:55 PM »
Hi,
I'm sorry to hear of your knee problems and that you have to consider having ACI.  I just wanted to tell you to do your research when you pick a doctor to do ACI.  I have been monitoring the Carticel website for the past two to three years to see who is qualified to do ACI.  The number of OS's in my area that now do Carticel has almost doubled in the past two years.  So, to me that means that there are more and more OS's that are now doing Carticel (which is great!), but may not be very experienced in it.  I discovered that most of the OS's in my area only do one or two ACI procedures a year and to me that is not very many, considering that the procedure has only been performed in the US for about the past ten years or so.  I think it is very important to ask your OS how many ACI procedures they have done.  I worry about folks who have ACI done by OS's who don't have experience.  It is such a big procedure to be an OS's first or second patient to have done the procedure on.  If you have the opportunity to travel for your surgery, there are some top doctors in the country who have lots of experience with ACI and have done lots of ACI procedures.  Of course, traveling for surgery is not always an option and that is not to say that the OS's in your area are not qualified.  I know that for me traveling to see an OS who some might consider to be the "best of the best" was not an option but I was able to travel within four hours of my house to go to an OS who has done about 100 ACI procedures.  Of course, I personally think that my OS is the "best of the best".  I just wanted you to be aware that this is NOT a common procedure and I would imagine that on the patella it is even less common.  Do your research on the OS's in your area, make sure you find a "good" OS and you will be just fine.  Good luck to you!!!   
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

jonhark

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Re: Does ACI last?
« Reply #12 on: April 16, 2008, 07:27:08 PM »
It sucks no-doubt. But you really can makes things worse by pushing the activity before your surgery. I had a 1.5CM^2 defect that grew to 4 cm^2 in six months and I really didn't do much other than walking. With ACI of the patella, it is critical the surgeon debrides surrounding cartilage to good cartilage margins.

Anti-inflammatories can be dangerous as they mask pain and have been linked to cartilage degeneration.

ACI is a long road without a doubt. There are some advanced ACI procedures that some of the more advanced surgeons such as Dr. Farr and Dr. Cole are experimenting with. I know Dr. Cole is taking applications for the Neocartilage trial this fall for patella defects. The results have been pretty promising so far. It would be worth contacting them about these options.

The results of those on the board have varied. I'm out of pain for ADL's at 8 months post op. I haven't been able to push the rehab too hard with anything that loads the patella. That will come with time.
I'm happy with not being in pain for a 3 mile walk these days. Your improvement will be incremental month to month. Patella defects are almost twice as deep as Condyle defects. So the maturation takes upwards of 18-24 months. The smaller the defect the more predictable the result. That is why I suggest keeping your defect at a moderate size and not letting it grow to >10CM^2. Carticel is a graft of mostly hyaline and some fibrocartilage and has never been proven to be as durable as your body original hyaline cartilage.


Offline MegTX

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Re: Does ACI last?
« Reply #13 on: April 16, 2008, 08:45:40 PM »
Amen to what Jon said about taking it easy until you can get your lesion taken care of.  I had an insurance fight of 7 months to get my patellar ACI covered, and in that time I did nothing but daily activities and the PT following my initial scope and my lesion increased significantly.  Patellar ACI is still classified as Experimental and Investigational by almost all insurance companies and they WILL fight you.  Many times you'll end up with a TTT or similar procedure concurrently with the ACI to offload the patella, but your OS will have to determine if that's necessary.

As for finding a good OS, just question the hell out of them about their experience, and move on if you're not comfortable.  Do your own research on the procedures, and familiarize yourself with the work of the leading experts and quiz your doctors on what they think about those experts and their new trials and publications.  (This is not only a good way to find out if they really know what they're talking about, it's also fun because they freak out when you start talking their language and naming their colleagues!)

For most of the good patellar ACI studies, you'll be looking at work by Tom Minas out of Boston.  Find out if the surgeon has collaborated, studied with, attended seminars by this guy.  If he's never even heard of Minas, leave.  :-D
Lateral Release, Medial "Reef" - '91
{16 years of grinding, pain, swelling and lots of ice}
'scope 7/07 - .7cm2 tibial plateau microfracture, 2.5cm2 grade4 patellar CP debridement
ACI & Fulkerson TTT 2/08 (patella lesion then 4.5cmx3cm)

Offline bsonday

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Re: Does ACI last?
« Reply #14 on: April 17, 2008, 11:55:41 PM »
In the papers I've read, it basically said that patellar ACI is much more effective when extensor realignment is performed.  This could be and MPFL reconstruction, and tibial tubercle osteotomy (spelling?), etc.  My defect is on the medial part of the patella, though, so wouldn't a tibial tubercle osteotomy put more pressure onto my medial patella and hurt me overall?  Thanks in advance for answering my questions.  Even if they decide that my alignment is fine, I still want to have an MPFL reconstruction just to be safe and prevent future subluxations/dislocations.  I've had trouble finding information on success rates of MPFL reconstructions, but they seem quite good from what I've read.

Best,
Ben
Removal of loose bodies (cartilage pieces)--7/2/2007
Lots of rehab (quad strengthening) which didn't help much
Biopsy for ACI, 1.5cm x 1.5cm patellar cartilage lesion found--5/7/2008
Patellar ACI with Fulkerson, slight lateral release (to get under the patella)--7/2/2008
Happiness--Early 2010?