Advertisement - Hide this advert





Author Topic: ACI - 1yr post op  (Read 21914 times)

0 Members and 1 Guest are viewing this topic.

Offline Dennis BadKnee

  • Regular Poster
  • ***
  • Posts: 59
  • Liked: 0
ACI - 1yr post op
« on: October 09, 2010, 06:49:01 PM »
Does anyone have any advice concerning longevity and durability of ACI?  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 Rennschnecke

  • SuperKNEEgeek
  • *****
  • *
  • Posts: 881
  • Liked: 1
Re: ACI - 1yr post op
« Reply #1 on: October 09, 2010, 07:15:40 PM »
Hi Dennis

You sound like you're doing very well indeed given that you've had two very specialized procedures on your knee.

I haven't had a meniscus transplant so don't know anything about that.  Also, although ACI has been around since the late 80s, there probably still isn't enough data on durability to satisfy your main concern as to whether it is a permanent fix.

Long term studies that have been reported and in the public domain have been limited to 4 years only.  This probably reflects the fact that the technology is developing all the time and funding for studies tends to be quite limited.

As far as I'm aware, OSs will still approach the graft as a temporary fix, for although it may be almost like new at 4 years, the people who damaged their knees in the first place are likely to do so again - after all you can't plan accidents etc.  However, temporary fixes that can buy you a decade or two before a knee replacement is preferred as there are only so many revisions that can be made and a limited lifetime on current joints.  The main objective is to restore you to a functional life and maximize that as much as possible.  I guess they haven't factored in issues such as people being adrenalin junkies like yourself with a whole life built on high demand activities.

There are some papers suggesting that a return to sport can enhance outcomes, including some cutting sports like soccer, but I haven't read the full papers in detail, so can't say more.  Studies on this topic are limited as many people elect to limit their activities.  Hope others may be more helpful.
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope – debridement, trochlear cartilage lesion (Gr4); 12/08 Scope – chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope – LOA, IPCS & patella infera; 9/10 Scope – AIR & LR.

Offline ajschnelk

  • Forum Faithful
  • ****
  • Posts: 155
  • Liked: 0
Re: ACI - 1yr post op
« Reply #2 on: October 13, 2010, 02:24:26 PM »
I am unsure of the mesicus transplant, but as far as the ACI goes, it's my understanding that once enough time has passed and it is fully intergrated and mature that it will withstand high impact activities.  I mean for many folks, high level activities is the reason for having ACI.  I know I fall into this category... i could do most things pain free, but elected for ACI so that I could get back to skiing, running, bball, hiking etc.  I have read where people that had successful ACIs back in the 80s are still doing well and remain active.  I know there are a few NFL players that recently had the Denovo NT(advance ACI prodecure) procedure and are planning to recover and continue with their pro football career.  So outside of your meniscus issues, i don't see why you couldn't become fully active again.

Offline mlashmar

  • Regular Poster
  • ***
  • *
  • Posts: 54
  • Liked: 0
Re: ACI - 1yr post op
« Reply #3 on: October 13, 2010, 06:21:48 PM »
Like the other posts on here, I'm unsure about the meniscus transplant.  Ultimately the ACI is just buying you some time before partial/full joint replacement, it doesn't make the joint like new and any condition that predisposed you to require the op in the first place will still remain.

If you are looking to get longevity, then avoid sports which involve a high degree of torsion through the knee joint (i.e. running and twisting the knee - sports such as soccer, american football, rugby etc) and heavy pounding of the knee (running etc).  The better sports are cycling and swimming (although breast stroke is particularly bad for the knee). 

It is worth keeping up with strengthening exercises, particularly the inner range quads through leg presses etc (worth seeing a physio to get a good programme).
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline ajschnelk

  • Forum Faithful
  • ****
  • Posts: 155
  • Liked: 0
Re: ACI - 1yr post op
« Reply #4 on: October 13, 2010, 08:27:39 PM »
Ultimately the ACI is just buying you some time before partial/full joint replacement, it doesn't make the joint like new and any condition that predisposed you to require the op in the first place will still remain.


I guess this would be true if your defect was due to "unknown reasons"  Many defects arise from an old, isolated injury or a particular repetition over a long duration.  I tore my ACL 12yrs ago and we are almost certain my cartilage was damaged during the injury or as a result of the new ACL graft.  Either way, if i didn't have the injury, I am sure I would not be on this board today. If the remaining cartilage is healthy and show no signs of wear, i don't see why someone's graft wouldn't last a lifetime barring no new injury.   
 
« Last Edit: October 13, 2010, 08:29:56 PM by ajschnelk »

Offline Rennschnecke

  • SuperKNEEgeek
  • *****
  • *
  • Posts: 881
  • Liked: 1
Re: ACI - 1yr post op
« Reply #5 on: October 13, 2010, 10:36:59 PM »
AJ, I understand where you're coming from and logically it would make sense.

It is my understanding that the regenerated cartilage will withstand running and sports such as soccer and tennis, but clearly there is no guarantee against injury which is just as likely as before.  So, even if the defect was the result of a trauma then you may incur such injuries again unless you modify the risk by adjusting your activities.

I suspect that is why, in the absence of any supporting data to indicate permanence, I think surgeons are reluctant to view ACI as a permanent solution.  My OS has always asserted that I will need a knee replacement some time, just hopefully not in the near future.

FWIW my defect was the result of trauma and the non-traumatized knee remains perfect!  :-X
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope – debridement, trochlear cartilage lesion (Gr4); 12/08 Scope – chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope – LOA, IPCS & patella infera; 9/10 Scope – AIR & LR.

Offline Dennis BadKnee

  • Regular Poster
  • ***
  • Posts: 59
  • Liked: 0
Re: ACI - 1yr post op
« Reply #6 on: October 14, 2010, 03:20:03 AM »
Here are some pictures, ~ 3,000 words worth.

I agree with AJ in that the reason I went with my surgery in lieu of TKR is because I want to be very active indeed.  This is likely true for most.   But the more I read, the more it appears this is a temporary fix,  … with great degree of vulnerability, and … subject to instantaneous failure for many reasons.  I hope to learn otherwise.  Granted, we are discussing ACI and I had a meniscus transplant as well.  But even the ACI appears to be vulnerable, perhaps less so than the meniscus.

Fortunately I am doing very well at this time, so we will see.  My OS told me I am far ahead of anyone (presumably he meant with a salvage knee) at this point one year post op.   And I feel pretty good.  But I am being told I will have to curtail my end-state ambitions well below my body’s abilities otherwise.    It appears I will need to significantly scale back the plans for the rest of my life.  Very sad!

Rennschnecke, my other knee remains perfect as well, so we are in the same boat.  The underlying reason for this knee being bad was a motorcycle crash in 1987 where I tore my ACL and was told I did not need an ACL by Dr. David Joyner (you have to laugh to keep from crying) even though I was doing high mileages running in mountains, skydiving, backpacking, etc.  I also had a partial menisectomy.  Another 25,000 miles and here I am.  Well, the knee wore out.  Here are some images to show the extent (with some notes).

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.

I do not want a fake knee with its limitations.  At least everyone seems to think the ACI gets better with time as far as hyaline vs fibrous content.

Regards,
Dennis

Offline mlashmar

  • Regular Poster
  • ***
  • *
  • Posts: 54
  • Liked: 0
Re: ACI - 1yr post op
« Reply #7 on: October 14, 2010, 08:14:03 AM »
Wow - thank god  had my breakfast first!!!  Looks like a pretty heavy going op, so it's great that you have recovered well after a year.  I hope it stays that way! 

I guess over time we all have to modify our activities (eg due to advancing age etc), its just we may have to much earlier than we liked.  I up soccer and running around 4 years ago now and I still miss them, but have got into cycling which, although not the same, I have found a passion for.

AJ - I spent about 8 months researching ACI in battling my medical insurer to cover the op.  The op still isn't recognised as effective in the UK and is under trial.  This was for two reasons, one being the cost, the other being a lack of good quality trials to demonstrate the long term effectiveness of ACI (albeit this is debatable).  In any event, I didn't come across any OS/consultant or research body wishing to claim the ACI would give you more than 10 years if effective, although that is not to say that there will not be instances of this happening and let's all hope that our ACIs outlive that period.

Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

  • SuperKNEEgeek
  • *****
  • *
  • Posts: 881
  • Liked: 1
Re: ACI - 1yr post op
« Reply #8 on: October 14, 2010, 12:17:20 PM »
Dennis

As someone who is way ahead of the curve as a salvage case you're already an outlier.  The recommendations are based on norms not outliers, so it's possible that you may return to a high level of activity.  Your case will add to the accumulated knowledge and may well help OSs to see that ACI may be a permanent solution for some.

However, being a risk-averse mouse I'd probably refrain from skydiving and mountain running and look for other forms of amusement, but you're clearly of a different temperament.

Talk honestly to your OS and PT about your ambitions.  Ask for the parameters to guide your return to your former activities.

I had a ski accident whilst training for a race.  If I can get my knee up to running I'd be able to get back to form.  However, I've had many more problems than yourself and my current ambition at around 15 1/2 months post-op is to get back to walking and ADL sometime next year.  I'm shelving my ambitions to return to sport for the time being, but I'm sure that once I can walk it'll change.

Try to enjoy what you have for now and not fret too much about the rest.  Easier said than done, but you never know what's around the corner of life!

1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope – debridement, trochlear cartilage lesion (Gr4); 12/08 Scope – chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope – LOA, IPCS & patella infera; 9/10 Scope – AIR & LR.

Offline ajschnelk

  • Forum Faithful
  • ****
  • Posts: 155
  • Liked: 0
Re: ACI - 1yr post op
« Reply #9 on: October 14, 2010, 05:29:36 PM »
I understand what you're all saying and yes i agree aci is not a perfect fix and is probably not a long term solution, but if folks are able to regain professional sport careers, I would like to think it will last close to a lifetime with an everyday joe.  This is assuming the graft had good fill and is of good quality. Denovo seems to be a promising improvement and would think it will only provide longer treatment due to the younger cell tissue.   

We are only a little over 20yrs out from the first group of ACIs, so no one really knows.    ;)
« Last Edit: October 14, 2010, 05:40:07 PM by ajschnelk »

Offline Dennis BadKnee

  • Regular Poster
  • ***
  • Posts: 59
  • Liked: 0
Re: ACI - 1yr post op
« Reply #10 on: October 15, 2010, 01:52:50 AM »
mlashmar – I had to battle my insurance here in the US as well.  It took me 8 months (Blue Cross).  The way it worked was that they paid for the biopsy for the ACI, but then denied the actual ACI even though they had pictures taken during biopsy.  I finally prevailed through persistence (it became such a battle!).  They wanted me to get a knee replacement instead.  The lesson is to do your research, then fight for your own right to live life as you want.  I take it you had your surgery?  When?  How are you?  How well is cycling going?  Any problems?

Rennschnecke – I hear you.  I am enjoying the slow 20-25 miles a week I am walking (it’s not running, but it gets me out – and it should only get better).  I have conceded I will give up running and skydiving.  The OS said perhaps I can run 3 miles, 3 times a week.  But if it puts me at risk, why bother, … I had been running 30-50 miles per week and to run so short is hardly worth it.  Skydiving is behind me as well.  99% of landings are soft, but there can be that one hard landing.   I do plan to backpack.  And I have gotten into bicycling more.  I particularly enjoy endurance sports and hope that will be possible (backpacking, walking and cycling).   OS says walking, bicycling and backpacking is good, but I am not sure he realizes the distances.  I will discuss at 2 year post op if not sooner. 

AJ, I don’t think I disagree with you.  I am just asking what will be possible with this ACI.  What do you expect for yourself?  I like your positive take on it and hope you are right.  I, being an everyday Joe (not a competitor), just want to live life to the fullest and will work hard to do so.  Perhaps the pros who come back had small lesions?  Denova will not be in my future (probably).   It was hard enough getting approval for this. 

Here is my question:  What will we be able to do after this ACI surgery that could not be done after TKR (state-of-the-art)?  Note:  they are coming out with replacement knees with replaceable wear parts (so longevity soon should not be the issue).

Regards,
Dennis

Offline mlashmar

  • Regular Poster
  • ***
  • *
  • Posts: 54
  • Liked: 0
Re: ACI - 1yr post op
« Reply #11 on: October 15, 2010, 09:02:02 AM »
Hi Dennis

Absolutely right!  I don't think you can assume someone else knows better, even when they are a qualified surgeon (having experienced a few two many pointless arthroscopies and x-rays in the past).  Insurance companies can be a real pain, especially when an operation is expensive, a lot of hard work went into the appeal and at 33 years of age, P/TKR was not an option, so a sweet victory in the end.  Your results sound very encouraging, how did you go about winning the case?

I had the 2nd stage op on 18 August, so I am about 8 weeks in now.  The first 6 weeks was quite tough, more from a mental standpoint, often felt unsure of how things were progressing and ultimately could do very little.  Luckily had plenty of friends and family about, but none the less, you kinda feel isolated then (hence finding this site). 

Last few weeks have marked the start of strengthening exercises, a real sense of panic set in at first as I had a whole week of the knee being very swollen, sore and red hot (akin to having just had an arthroscopy), this seems to have been due to adhesions (essentially gunk in the knee as a result of it not moving so much in the prior 6 weeks).  Apparently the adhesions cause pain and swelling as you break them down and get the joint mobilised, but I was completely unprepared for this reaction and really thought it had failed!  Renn pointed me in the direction of Julian UK who had ACI 6yrs ago and is doing well, he had gone through similar experiences which made me more at ease (search for his post, worth a read) and my consultant has subsequently assessed me and told me the reaction is normal.

Cycling going really well, I started off just doing a few minutes at a time, seat slightly higher than normal.  It was hard at first but after a few days, range of movement improved and speed picked up from 20rpm to about 50-60rpm.  I discussed with physio and I can now either lower the seat slightly or increase resistance slightly.  It seems to work really well and has certainly helped me move on more quickly without risking my knee.  I am keeping a diary (think its called '7 weeks and takes turn for worse').

I used to do a lot of cross country running and soccer, but I am happy to give that up, I'd rather get the most out of the joint and make the most of the op (if it works), there are plenty of things in life that I can do (recently taken up more gardening/growing veg) and I am not a professional sports person, so it is not the end of my career.

Mike     
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline rbahr

  • MICROgeek (<20 posts)
  • *
  • Posts: 10
  • Liked: 0
    • My Knee Story
Re: ACI - 1yr post op
« Reply #12 on: October 16, 2010, 03:33:48 AM »
Hi All, Dennis

Dennis and I have been sharing war stories for a bit, I have had the good fortune to have now had 2 ACIs - one on each knee. They were both classified as salvage by Dr. Minas. This was after 20 years of martial arts, running, racquetball, in general high impact stuff... I am 10 years out on one knee and 22 months out on the second knee. You can read all about it at http://www.bethnrayndogs.com/knee.htm

Early on, my attitude was that if I could buy some time, I would be happy. At this point I am a bit bored with getting cut open and fiddled with... So I would like to avoid either a full or partial replacement...

There is a lot of research out there, but to the best of my understanding the goal of creating articular cartilage still escapes people - even the product of ACI does not produce cartilage that is identical to what we started with. I have chatted with some folks at MIT doing early work in scaffolding, I have read a bit on the DeNova material, and view it as more of the same...

In terms of activity level, after my 1st procedure I really stopped a lot of the high impact activities because of a combination of discomfort as well as fear of screwing up the knee more (actually mostly a fear of screwing up things as I was pretty used to being uncomfortable)

In terms of 'guideline' or 'recommendations', I don't think that there are any that are in any way accurate. In the 10 years of being personally involved with ACI, I can state unequivocally that nobody really knows what a good guideline is or what to expect. I suspect that at some point - probably between the 1.5 and 3 year mark, you decide what you need for quality of life. I choose these points because at 1.5 years the cartilage stops changing - it is in essence fully mature, and by 3 years you should be mostly asymptomatic...

Before diagnosing my latest problem, I had decided to try running again - which in my case was really loping or something, but because of the changes to my right leg's geometry ( a 14 degree change due to my osteotomies ) it was painful... I am now getting to a point that I want to start pushing things, but I found that the average lifespan of a meniscul transplant is 7 years, which means that both Dennis and I  have (on the average) 5 or 6 years of partying on our current menisci (on the average) before we visit our favorite surgeon (again)...

This little discovery has raised a few questions, for me anyway, about just how far I want to take things... I suspect that I will need to stop caring and just enjoy myself -- which is, oddly enough, what Dr. Minas just told me...

In any case, I wish you all well and much luck with your knee sagas...

Ray


Offline markld

  • Regular Poster
  • ***
  • Posts: 100
  • Liked: 1
Re: ACI - 1yr post op
« Reply #13 on: October 16, 2010, 07:39:44 PM »
Dennis,

 I and others who have had ACI are having a hard time believing your story.
I am half your age and had only 1 lesion in both my knees, therefore I know what it is like to recover from ACI and it does not go as fast as you are claiming that you are recovering.
I believe that you are grossly exadgerating your recovery time.
I am 18 months post op on one knee and 15 on the other and in my 30's and ther eis no way Icould hike or walk 5 miles.
You should shoot straight with people on here so to not give them unfounded hope in recovering as fast as you claim to. Another member on here is a friend of mine and he too only had 1 lesion and is 10 months post op. He too cant believe what you are saying.
April 2008 microfracture left knee trochlea
Jan 2009 ACI harvest from right knee
Mar 2009 ACI right knee trochlea
July 2009 Aci left knee
Nov 2009 left knee scope to check graft

Offline rbahr

  • MICROgeek (<20 posts)
  • *
  • Posts: 10
  • Liked: 0
    • My Knee Story
Re: ACI - 1yr post op
« Reply #14 on: October 16, 2010, 08:03:16 PM »
Hi Mark,

Your comments are interesting (and sadly rather negative). I feel qualified to have this opinion because Dennis and I had back-to-back follow-ups with Dr. Minas about 2 weeks ago. He stayed with me so we could review our progress and perhaps work on questions for Minas. Oh yea, I am 20 months out on my surgery - Dennis and I are both classified as salvage by Dr. Minas, we both had meniscal allografts, and other stuff - see my above web site for my details. BTW we are both in our 50's, and fairly active - not professional athletes, but more than the average person.

In any case, The night before our visit, Dennis flew in, we walked 3-5 miles, then did 1. 5 hours of hot Yoga (I call it Yoga for Type A's), then dinner. I can attest that he is as active as he claims (since I participated in this little exercise as well)

Ray















support