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Author Topic: Looking at options for cartilage replacement  (Read 1784 times)

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Offline [email protected]

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  • Jennifer Stroh
Looking at options for cartilage replacement
« on: May 02, 2008, 01:40:22 AM »
Hi,
My name is Jennifer Stroh and I'm looking for some advice about cartilage replacement therapy. I had my ACL reconstructed in 2003 after and injury that completely tore it in 1986. I developed osteoarthritis between the time of the initial injury and the ACL reconstruction (~ 7 yr gap). Before the time of the ACL reconstruction, I  was seen by 3 orthopedic surgeons in Santa Barbara, CA, where I live (Dr. Zmolek, Dr.Gainer, and Dr. Rui) and was also was seen by Dr. McAllister at UCLA. Dr.Zmolek did the ACL reconstruction in 2003. 

The advice that I've been given by the doctors above is to get a full knee replacement, but at my age, I'm very resistant to this idea. I've explored osteotomy (sp?) with Dr. McAllister at which we concluded would not be beneficial. With assistance from these doctors, I've examined three types of cartilage replacement therapy and we keep running into the same problem. I don't seem to have enough healthy, existing cartilage to  be a good candidate for any of the procedures.
Are there any new techniques out there or new technology with cartilage replacement that I might be a potential candidate?

The advice now from the doctors in SB is to prepare for full knee replacement at some time in the future and I am trying to avoid that at all costs.

Advice would be of great value from people around my age, 33, who have had a full knee replacement, or who are dealing with a similiar situation. Does anyone know about new cartilage repalcement therapy and would be able to help me understand my options?
Please email.
Thank you,
Jen

 
 
 
Injury: Age 12, completely torn L ACL
Surgery: Age 28, allograph L ACL reconstruction
Current: L ACL and PCL comletely torn
with tricompartmental osteoarthritis - grade ?

Offline Army John

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Re: Looking at options for cartilage replacement
« Reply #1 on: May 02, 2008, 01:08:21 PM »
Jen-

  Well I'm not a doctor and I don't play one on TV but from everything I have ever heard or been told from an OS is that

1) knee replacements are for older patients and 33 isn't old
2) knee replacements have a finite life-- I've heard from 10-20 years.  Of course it would depend a lot on the wear and tear you put on it and a 33 yr old is going to stress it more than a 63 year old
3) you can only get so many knee replacements-- I've heard 2-3 is the max.  Of course medical technology advances all the time so that will soon be a non-issue (IMO)

  I too have torn my ACL and had it repaired.  I found myself on the OR table in January thinking I had torn my meniscus again.  I was told after surgery that I had two options-- be prepared for a knee replacement or have a cartilage implant as most of my cartilage was gone.  I decided to have the ACI surgery.

  Have you been told you are a candidate for an ACI procedure?  If so, I would consider it.  While it is an invasive surgey, it is not anywhere near as invasive or radical as a knee replacement.

Good luck... John
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 MegTX

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Re: Looking at options for cartilage replacement
« Reply #2 on: May 02, 2008, 02:46:16 PM »
Well, the "newest" procedures that I've heard about/researched are all variants on the ACI/Carticel, where they harvest a small (size of a pencil eraser) piece of cartilage, grow more of it in a petri dish, and then put it back in your cartilage defect.  If you don't have even enough good cartilage for that, then you may be beyond the scope of any of the other available procedures.  There's another one, I can't remember the name of it, where they harvest cartilage from a cadaver and transplant it into you, but there's also limitations on how much can be transplanted.

You didn't mention exactly where your cartilage defects are, and how large/severe they are.  If you have a lot of diffuse cartilage damage in the joint (common with OA) these techniques can't really help, they're all for specific lesions (though even if you have several, they can still be treated as long as they're within a certain size and are well-defined).  Also, all of these procedures are only for lesions that are Grade IV, which is exposed bone, as are the myriad marrow stimulation procedures like microfracture, which have similar (but not exact) restrictions

See where it gets confusing?  There's quite a lot that can be done, within a certain set of conditions, and specifics within those conditions point toward one technique or another.

If you are not a candidate for any of the cartilage restoration procedures, then you may have to face an early partial or total knee replacement.  Again, you didn't say where exactly your problem is in the joint.  There are several people over in the partial replacement board (one in particular) who have had excellent results with a partial replacement, if the problem is confined to the patello-femoral area (patella & trochlea).  And there have been lots of people who have had excellent results with an early total replacement, if that's truly the only option available.

Here's the thing with early replacements... the new materials are incredible, and the joints are getting better and better.  But (and this is the gotcha) the way they attach hasn't changed much... (and this is referring to a total replacement) they have to cut out the joint itself (making this a one-way deal) and drill holes in the bones to put posts from the artificial joint in, and cement them in place.  These are tricky to fit, and sometimes don't fit right and get loose, and they have to pull them back out and re-do them (a revision) which takes more bone away.  Or, through wear and tear, they get loose, and they have to do a revision, again losing more bone.  Typically, in an older patient who isn't terribly active (low-impact stuff like walking) they last 15 years or so, and it's not an issue, they may need one revision before they die.  A younger patient usually wants to be more active, putting more stress on that connection and sometimes causing revisions earlier, and they will have longer to live with the artificial joint, thus by definition needing more revisions.  There's only so much bone there to lose to revisions.  When there's not enough left, the options are disastrous.

Now, since I've played the doom-and-gloom, let me also say that if ACI doesn't work for me, or if it hadn't been an option, I'd have looked at a partial replacement (I am 38, not quite as young as you, but still "too young" for a replacement and I've been dealing with this knee since I was 14, and it's been really bad for about 6-7 years now).  My quality of life was for crap, and I couldn't be active and it was killing me (literally with the 80 extra pounds I'm carrying).  My problem is limited to the kneecap, so a partial is an option for me.  Partials are still kind of hit-and-miss, so I'd go into it knowing that the partial might end up as a total in only a few years, but I'd take the gamble.  Everything, to me, comes down to quality of life.  BUT, if I'd had to go the replacement route, I'd have made damned sure that I found a specialist in replacements, who has worked with younger patients and doesn't just do geriatrics.  I'd also evaluate every activity I have for the wear and tear it would do to my knee, and as much as it would hurt, stop doing the ones that would increase the chances of earlier revisions.

In your case, I would want to know what procedures the docs you've seen are well-versed in.  I wouldn't go with a replacement until you've been evaluated by someone who is proficient with cartilage repair.  A lot of docs unfortunately don't admit what they don't know, and their recommendations are always within the scope of what their practice does.  That's why when I sought out an OS, I specifically went looking for a sports med ortho clinic, and when one of their docs specialized in joint preservation, I knew I had the right guy.

Good luck, I hope you find the right answer for your knee.  There's a LOT of information on the KneeGeeks boards, if you use the search feature you can find older threads that have tons of good advice, and maybe even some doctor recommendations in your area.
« Last Edit: May 02, 2008, 02:48:01 PM by MegTX »
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 MegTX

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Re: Looking at options for cartilage replacement
« Reply #3 on: May 02, 2008, 02:56:44 PM »
Oh, and... every so often I run across a report of a new cartilage procedure in Europe (I think it was Sweden, which makes sense) where they can replace the entire cartilage with a synthetic, so if you are in a position to go overseas and pay out of pocket for a procedure, you may want to see what you can dig up on that.  It sounds promising, but I'm not in a position to do that so I've not investigated it seriously.  Anything like that is easily 10-20 years away from approval here in the US, assuming it's already in use in Europe.
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)















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