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Author Topic: Meniscus Transplant - 1yr post op  (Read 28201 times)

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Offline Dennis BadKnee

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Meniscus Transplant - 1yr post op
« on: October 09, 2010, 06:44:59 PM »
Does anyone have any advice to offer concerning longevity and durability of meniscus transplants?  How about activities to avoid?

I am now one year post-op and just had an MRI and follow-up on 6 Oct 2010 with Dr. Minas (Brigham and Women’s Hospital, Boston).  Details of my 22 Sep 2010 surgery:

•   ACI using BioGide Membrane - Lateral femoral condyle - (uncontained) 40 mm long x 30 mm transverse, two vials Carticel; Lateral tibial plateau, posterior one-half  (uncontained) 20 x 30 mm, one vial Carticel; Trochlea (center) - 20 x 15 mm, one vial Carticel
•   Lateral Meniscus Transplant – 40 x 40 mm meniscus using trough technique
•   TTO using Fulkerson anteromedialization – 15 mm anterior, 15 mm medial
•   VMO Advancement
•   Lateral Release – full thickness
•   Intra-lesional Osteophyte removal – center to lateral femoral condyle

Dr. Minas said my progress is excellent.  The ACI is full thickness everywhere and the meniscus is integrated into my knee.  He expects that soon I will be able to backpack.  This is great news.  He cautioned against squats (forever) because this puts pressure on the meniscus and causes tears.  And I understand, from everything I’ve read in preparation for this, I am doing better than expected.  Everything appears to be healing well. 

My exercise routine is still geared 100% for maximizing the outcome for my knee (i.e., I am doing nothing for personal pleasure alone)  – bike 1 hour, outdoors walk 5 miles, freestyle swim an hour (total at least 2 hours per day, down from 4 hours per day for the past half year – just too time consuming).  One thing to note, I do ice almost continuously to keep down swelling, and because it feels better to do so.  I hold back from getting with old friends because their intensity would endanger my knee (as I understand it) even though I walk normally without a brace or limp.

I concede I probably will give up running and skydiving (after a lifetime of both), and many other activities that could harm my knee.  But the rub I am having is finding out how fragile the newly rebuilt knee is.  I mean, even if I have a great recovery (which looks like a possibility), will I have to advise friends, “no, I cannot help lift that trailer onto the hitch, no I cannot help carry that kayak through those rocks, no I cannot help cut and stack firewood, no I am not going running, no not skydiving, no, can’t, no” etc.  My understanding is that if I cause a meniscal tear or ACI delamination – that’s all she wrote, TKA!

The more I learn, the more questions and uncertainties I have.  I know everyone is different, bodies respond differently, and knee injuries are not the same.  But I am finding conflicting data on what to expect. 

Menisci - Some say meniscus transplants (everyone!) have a very limited lifespan (~ 7 years), and that cryopreserved menisci are much more prone to tearing.  Others appear to have a return to sports, at least to non-cutting straight ahead sports like running.  Are these people highly at risk?

ACI - With the addition of my large ACI repairs, running is probably not a good idea for me – I got that!  But what I would like to know is if all of this is considered to be a temporary solution from the outset going into this type of surgery?  Is ACI considered to have a high possibility of failure, likely due to delamination? Are we expected to maintain constant vigilance over each and every step to assure we do not cause a catastrophic instantaneous failure during everyday activities?  I am not sure I can do that. 

Does anyone have anything to offer concerning longevity and durability of meniscus transplants?  How about activities to avoid?

Does anyone have anything to offer concerning longevity and durability of ACI?  How about activities to avoid?

Thanks,
Dennis

Offline Ilya

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Re: Meniscus Transplant - 1yr post op
« Reply #1 on: October 11, 2010, 06:50:01 PM »
My feelings is that it is better to have your knee wear out slowly over time than baby it avoiding activity and injure it doing something stupid like stepping wrong.  Just my theory.

Ilya N.


Offline laura_utah

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Re: Meniscus Transplant - 1yr post op
« Reply #2 on: October 11, 2010, 10:56:38 PM »
Dear Dennis,

You go dude - that's a bioprosthesis if I ever saw one!  I haven't studied the longevity of ACI, but, for bone marrow repairs such as abrasion arthroplasty, there's some evidence that the repair tissue gets better with time  - provided it stays in place.  I'm drawing this info from Jurgen Toft's outcome studies for large-defect abrasion arthroplasty with axial osteotomy, which included both functional and histological data.

There are probably a few activities that would be wise to avoid indefinitely.  Others to be done only with extreme caution.  Others routinely....  I can't imagine the ACI repais not getting better wtih time (years), but the meniscus may not improve beyond a certain point.  Kevin Stone may have some publications on meniscal allograft durability  - in fact, I think he gave a talk on that subject at ICR's a couple weeks ago.  You could also check out his website for examples of typical activity levels for post-mensical-allograft patients.  No one was doing world cup soccer, but everyone was engaging in reasonably competitive, weight-bearing sports.

As far as disrupting your ACI repairs or meniscal transplant, is there any reason either one could not be re-done?  You may not like the idea of another 8-12 weeks on crutches, but, there shouldn't be any medical reason why you couldn't give it another go.  Add to that the increasing effectiveness of scaffolds, intra-articular growth factors, and mesenchymal stem cells, it's difficult to imagine a scenario today in which there would not be a biological repair worth trying.  If you want to see some REALLY extensive repairs, check out William Bugbee's articles on osteochondral shell allografting.  One of them includes intra-operative images of someone getting an ENTIRE allograft retropatellar surface!  I was sooo jealous 'cause mine needs replacing. 

Upshot - TKR is probably only in your future if you decide it is.

I noticed that your pre-op condition included "non-contained" lesions?  Does that mean that said lesions did not have a  complete rim of intact hyaline cartilage?  If so, the very fact that you were treated with ACI successfully represents a huge step forward in applicability of cultured chondrocytes for articular surface repair.  You're an inspiration to the rest of us.  Keep it up!

Best,
Laura

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #3 on: October 13, 2010, 02:55:22 AM »
Laura,
Thanks for the kind words and research web sites – it has occupied hours of my time productively.  Are you a health care professional or just a very informed civilian? 

Uncontained lesions?  Yes, here are a few pictures.  I have more, but I believe these show it the best.

1.   Note the bare subchondral bone on the lateral femoral condyle.  Also note the ineffective micofracture scab (from 2005) as a white blotch near top of the defect.  My ACL was also reconstructed in 2005 and is shown.  You can see the trochlea defect as an indentation.  On the far lower right you can see the cut tibia for the Tibial Tubercle Osteotomy.

2.   The markings are for drill holes to suture the BioGide membrane through the bone on the uncontained lessions on both sides.  I was told this is a tedious and difficult procedure.  The bone slot in the center is the trough for the meniscus transplant.

3.    This shows the tibia BioGide sutured in place as well as the transplanted meniscus.

Any other advice will be appreciated.

Regards,
Dennis

Offline laura_utah

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Re: Meniscus Transplant - 1yr post op
« Reply #4 on: October 14, 2010, 03:05:10 PM »
Thanks Dennis,

Your knee pictures are beautiful, and will be more so when you new cartilage grows!  Thanks for sharing.  No, I'm not a healthcare professional, just a well-educated and determined civilian who wants to hike when I'm 80 like all of my great-grandmothers did.

Like you, I've got defects on nearly every surface, but, hopefully not quite so big.  I've still got an intact meniscal rim on the medial side, so, I'll be trying to restore my medial meniscus with the CMI at the same time we try bone marrow stimulation (abrasion or micropicking) repairs on the articular defects.  To give the bone marrow repairs a little help, we'll be adding some iliac crest bone marrow aspirate during the surgery  - more mesenchymal stem cells always help!.  With any luck, the mesenchymals from the bone marrow aspirate will also populate the CMI, which is, after all, just a "cell hotel".  During the 8+ week non-weight bearing period, I'll get PRP and BMAC injections just to keep the cells and growth factors working hard and see what happens.  If it all fails, then I'll try what you just did.

Right now, walking across the living room hurts pretty badly, so, it's hard for me to imagine that I'll ever descend a scree slope gracefully, or cross country ski again.  I just keep trying to remind myself that, if the necessary load-bearing structures are back in place in my knee, it will function again fine.  Same with yours.  You cartilage is growing and strengthening even as we speak.  Don't give up.

Best,
Laura

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #5 on: October 18, 2010, 06:25:09 PM »
TO ALL:
WHAT IS THE LONGEVITY OF A TRANSLPANTED MENISUS?  I am hearing it is only 7 years.

Laura,

Keep us informed of how you are doing.  I see you’ve been to Jurgen Toft.  Wow!   I have his knee book.  I contacted him in 2005 and he mentioned his colleague in NYC, Dr. Stuart Springer which is where I had microfracture and my ACL reconstructed.  As you can see, my microfracture was not very productive on my advanced knee damage.  I am hoping this time is the charm.

You live in a great place.  In April 2007, then again in 2008, I went to Moab for 25 consecutive days camping and all day mountain bike riding.  Great area!  I hope to return soon.  I did many of the trails in these guides.

http://www.discovermoab.com/biking.htm

http://www.utahmountainbiking.com/trails/idx-moab.htm

I too hope to be hiking when I am 80.  I feeeelll the ACI healing as I type but I worry more about the meniscus.

Dennis

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #6 on: November 10, 2010, 03:43:29 AM »
ACTIVITY RISK MANAGEMENT is apparently very much required of all who have had meniscus transplants.   Further, the life of the transplant is very limited.

A friend sent the following by PM. 

"Patients with malalignment or advanced degenerative changes have the
greatest risk of graft failure. Most of the failures in the study by Van
Arkel and de Boer" were related to mal alignment and joint instability.
Noyes and associates reported that patients with advanced degenerative
disease had an 80% failure rate, and it should be kept in mind that the
biomechanical properties of cadaveric tissue are not as robust as are
those of the native meniscus.  Vigorous activities that place high
shear forces on the allograft create an environment for structural
failure. To maximize the longevity of the allograft, the patient needs
to understand and apply a new concept of "activity risk management."
This concept is developed in patient education before the operation and
reinforced throughout postoperative rehabilitation."
 
Page 73
 
"Ultimately, full -function activities are limited to light sports.
This restriction should be emphasized during the preoperative education
period and reiterated throughout rehabilitation. Meniscal allograft
transplantation is a salvage procedure that is not intended to return
the patient to intense athletic or high-impact activi ties that involve
jogging, running, or jumping."
 
from page 73 of:

http://orthodoc.aaos.org/provencher/Meniscal%20Allograft%20Transplantation.pdf
 
and more
 
http://www.stoneresearch.org/pdf/Stone.MeniscusSurvival.JBJSBr.2010.pdf

Offline Aggiecatcher

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Re: Meniscus Transplant - 1yr post op
« Reply #7 on: November 22, 2010, 07:26:49 PM »
I had mine done by Dr. Kevin Stone...he encourages full return to  activities!  I'm three years out, and now training for a half-ironman. I have to baby my knee during the running portion of this adventure, but I'm going for it nonetheless.

 I ski (can't wait to get some of this fresh snow), played basketball (gave that one up), boxed for the past year, and otherwise go for it.  I hope mine will last as long as possible, but if I have to redo it after 7 years I'm okay with that.  I'll have had 6 years I wouldn't have otherwise had. 

Good luck, send me a private message if you have specific questions and I'll be glad to share.

AC

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #8 on: November 24, 2010, 02:30:00 AM »
Thanks.  Your reply is what I was hoping to see.  I will reply by PM.

Offline JuhaH

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Re: Meniscus Transplant - 1yr post op
« Reply #9 on: November 24, 2010, 02:09:03 PM »
Hi Dennis and Rich,

Do you know what happens if transplanted meniscus fails in future? Is it possible to have second transplant? Do you know is there some risks for example with scar tissue?
Skiing accident in january 2010. Left knee, medial joint space narrowing and constant pain following partial meniscectomy (30% medial meniscus left). Trying to prolong the knee replacement as long as I can.

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #10 on: November 25, 2010, 01:00:06 AM »
Hi Juha,

I do not know how many, if anyone, has gone through a meniscus transplant failure to get a second transplant.  You should ask your doctor.   I suppose it should be possible, but I think you are looking too far into the future.  I would think whatever caused the transplant to fail would be working against another attempt.

How much damage has your deficient meniscus caused on the articular cartilage?  You might want to look earlier in this post to see my pictures of the related damage caused by my highly active lifestyle with a deficient meniscus and non-existent ACL.

According to your posts, you are going through insurance battles the same as I did here in the US.  A second meniscus transplant for me would be a huge insurmountable insurance battle even I could locate a surgeon who is willing.

It might be better to research the best procedure first time around to give you the best, most robust quality of life, then fight to get that done.  Once you have done that, you need to follow through and rehab back to health.  If that procedure fails, at that point in time, you might want to see what best technology has come into being.

Although I am doing very well, albeit at a restricted level of activity due to my being 14 months PO, I am conducting a parallel research path into the best total knee replacements.  This is not what I want, but I need to be ready.

Good luck to you.
Regards,
Dennis

Offline JuhaH

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Re: Meniscus Transplant - 1yr post op
« Reply #11 on: December 03, 2010, 01:57:25 PM »
Hi Dennis,

I'm just thinking what will happen if/when transplanted meniscus is worn out for example after a 5-7 years? Like you wrote earlier that cryopreserved menisci's are weaker and much more prone to tearing. I'm 35- years old and I'm just worried what will happen to us in long term. Personally I should work for more than 30- years. By the way, how old are you Dennis?

MRI pictures taken in august 2010, reveals that I have articular cartilage damage in medial side. My OS said that It's hard to tell precisely how huge damage is. Practically, I have almost the same situation as you had before your surgery.

I'm too tired to continue the fight with my insurance company, so  I ended up to the public healthcare. My OS would like to do endoscopy to my knee in february 2011. OS planned that he is going to make microfructure to the damaged area of articular cartilage. I still have intact rim in my medial meniscus so my OS wants to try first Actifit treatment. If Actifit treatment is not going to be unsuccessful, the OS is going to proceed to meniscus transplant.

Personally, I would choose straight away meniscus transplant and ACI repair instead of Actifit and microfracture. Because Actifit implant has been in the market for only 2-years, no one knows about long term consequences how it will affect to the patiences.

I have also started to research the total knee replacements.

*Sigh* I'm so tired to live with this broken and painful knee.

Good luck wit your knees :)
Skiing accident in january 2010. Left knee, medial joint space narrowing and constant pain following partial meniscectomy (30% medial meniscus left). Trying to prolong the knee replacement as long as I can.

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #12 on: December 24, 2010, 02:29:01 AM »
Juha,

Sorry for the delay in my reply.  Good news is I was doing my outdoor activities.

You might want to click on my name on the left and read my earlier posts about my history and fight with my insurance company.  Couple things I believe.  You should fight for what you believe to be the best for your own self.  Also, I do not believe microfracture ever does any good (I am sure others might disagree, but you are talking to me now and this is my experience).  See my surgical pictures earlier in this post.  My microfracture from 2005 did almost nothing (just a little white scar on top of a huge defect).

I am 57 (soon 58) year old.  For me, this is a last resort.  I must make it work.  You are not wrong to be looking downstream with an algorithm of “if this fails, what options then….”.  I did the same.  I think I am doing so extremely well, that an unanticipated thing might happen.  Perhaps they would do another meniscus transplant if this one wears out and fails if my ACI takes as well as it seems so far.  At least I am hoping.  For now I am walking (wish I were running!) about 25-30 miles a week plus biking a few days indoors.  This is far below what I intend to be the end state, but it seems to be good progress at 15 months PO.

I truly feel for you folks who are going through this at an age so young.  At least I had many good active years.   But then again, I am not ready to roll over and become sedentary –  as the insurance companies think I should by wanting to give me TKR.  On the other had, I am not as convinced now that TKR is so bad.  I see they have many new developments such as replaceable wear parts and 30 year knees (hopefully one with both qualities).  Perhaps the outcome of TKR besides being 10x faster might be more guaranteed than what I am reading on what I had.  Let me know what you discover.

I sympathize with you comments on being sick of living with the bad knee limitation. 

Good luck,
Dennis

Offline JuhaH

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Re: Meniscus Transplant - 1yr post op
« Reply #13 on: January 25, 2011, 10:37:39 AM »
Hi,

Dennis, You might like to read this chapter from the book called 'The Meniscus'.
Here's a variety of clinical studies about meniscus transplants.
Here's Long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage.
Here's Stone clininic: Lessons learned from our first 100 meniscus allograft transplants in arthritic knees.
Here's Stone clininic: Long-term survival of concurrent meniscus allograft transplantation and articular cartilage repair.
Here's about meniscal transplant sizing.
Here's video about medial meniscus transplant operation, made by Kevin Stone.
Here's video about lateral meniscus transplant operation, made by Kevin Stone.

About the meniscal allograft post operation rehab protocol. Here's, here's and here's couple of documents.

In the literature, no consensus exists on the criteria for failure or success. In the majority of studies, a clinical success rate of 70% and higher has been reported at the final follow-up. Based on the available survivorship data, a clinical survivorship of 70% at 10 years can be anticipated for both medial and lateral allografts. Ligament instability, axial malalignment and cartilage degeneration are con-sidered by most authors to be associated with a higher failure rate and inferior results, although some authors have reported satisfactory results in degenerative knees.

I talked with Rene Verdonk and I did ask the question: Is it possible to transplant another meniscus allograft if the prime allograft wears out, for instance within 5-years? He answered: Yes, it possible to transplant the second allograft and I don't see any problems in this procedure.
« Last Edit: February 05, 2011, 08:49:54 PM by JuhaH »
Skiing accident in january 2010. Left knee, medial joint space narrowing and constant pain following partial meniscectomy (30% medial meniscus left). Trying to prolong the knee replacement as long as I can.

Offline Dennis BadKnee

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Re: Meniscus Transplant - 1yr post op
« Reply #14 on: January 29, 2011, 05:36:44 PM »
Juha,

That is very good information - excellent paper at your link – thanks.  If you have the opportunity to again speak with Rene Verdonk, I propose you ask about your expectation of active lifestyle activities and the resulting effects on meniscus survivability.  (BTW - What are you desired activities?)  If the surgery goes well, what limitations would be imposed?  I would be very interested in the response.

Aggiecatcher above comments that Dr. Stone said to him that he “encourages full return to  activities.”  Yet, other research shows extraordinary (based on my definition of a meaningful existence) restrictions are necessary to protect transplanted menisci. 

My next MRI and visit with my operating surgeon, Dr. Minas is 22 Sep 2011.  I plan to formulate a list of detailed questions and would solicit input from anyone.  At 16 months post-op, I continue to do very well with exercise, but have not done any of my desired sports activities for fear of causing failure.  Fortunately I sense the knee improving as time passes.

Juha, do you have any surgery scheduled?   Have you given up fighting the insurance company?  What are you doing, just wearing an unloader brace?

Dennis