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Offline markld

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ACI failure determined
« on: March 15, 2011, 09:17:11 PM »
 I am almost 20 months post op and it was just determined that my ACI fits the classification of failure. I will be having Denovo NT soon and have started a new post/thread under the Denovo heading.........
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 Rennschnecke

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Re: ACI failure determined
« Reply #1 on: March 15, 2011, 10:47:03 PM »
Hi Mark

In what way has your ACI failed?

Sorry you're about to embark on another turgid knee journey!  :(
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 markld

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Re: ACI failure determined
« Reply #2 on: March 16, 2011, 04:39:02 PM »
Only about 2/3 of the defect filled for some reason, leaving an area of 8mm x 12 mm full thickness defect. I will have Denovo Nt to fill the remaining area that did not fill, providing the area that did fill has good quality cartilage.....
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 Rennschnecke

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Re: ACI failure determined
« Reply #3 on: March 16, 2011, 07:16:26 PM »
I find your diagnosis interesting.  My MRI said that my defects where not filled in at 14 months, yet my OS said that the MACI has taken, that the defects are covered and integrated with the native cartilage.  I find it tricky to do steps up (never mind down) and I feel that this could be due to the thin (1mm) coverage of the main defects (v 3mm elsewhere).

Would be very interested to know why DeNovo NT is the way forward for you.  Do you have any papers you've read about this?  I haven't come across any that covers this specifically.
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 markld

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Re: ACI failure determined
« Reply #4 on: March 16, 2011, 08:33:44 PM »
Some but not a lot of literature available yet. Procedure is not available in UK therefore you wont find much.....  Have spoken to many folks that had the Denovo procedure and have seen nothing but positive outcomes, including much faster recovery than ACI, therefore it's not a difficult decision to make based on the results I have seen.....
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 Rennschnecke

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Re: ACI failure determined
« Reply #5 on: March 16, 2011, 09:29:56 PM »
When I asked my OS about the factors governing growth of cartilage and infill he said it was due solely to knee biology.  I've found a paper on the effects of exercise on cartilage and this seems to confirm what he said.  ???

Has your OS every mentioned which factors affect cartilage growth?  If it is down to knee biology would this be a potential negative for a successful outcome from Denovo NT following lack of growth with ACI?  In other words, why is Denovo NT likely to succeed where ACI has failed?

Not trying to be negative, just trying to work out what issues might arise in a discussion with an OS.
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 markld

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Re: ACI failure determined
« Reply #6 on: March 17, 2011, 12:39:41 AM »
There is no guarantee that any procedure will work. As far as growth factors, there is no conclusive evidence that points to what your Dr said. The fact that Denovo uses juvenile cells rather than my own which are much older and not as viable increases the success rate.
If you are familiar with cartilage procedures then you well know that options are very limited therefore I am surely not gonna have a TKR nor am I gonna have an allograft. Perhaps you can see where I'm going with this, hence why I'm choosing Denovo NT route. It's kinna a no brainer.....
There are a multitude of reasons why a focal defect still exists, ranging from partial delamination to numerous other possibilities. Since there is no way to determine which it is, I must move forward with the procedure which not only makes the most sense logically but has shown better results than ACI.......
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 Rennschnecke

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Re: ACI failure determined
« Reply #7 on: March 17, 2011, 01:49:32 AM »
I fully appreciate why you would opt for Denovo over the other options I'd probably do the same, but at the same time I'm interested to learn more about the arguments that might be raised and wondered whether they had been raised in your own conversations with the OS.  I wasn't intending to change your mind and as I've said, I'd do the same in your position.

Where I'm at is trying to work out whether I'm in the same position as you.  I had my MACI done towards the end of June 2009, so just a bit ahead of you.  I've had complications along the way  :'( but with a radiologist's report that says 'no infill at this stage' at 14 months post-op I'm trying to work out whether I can realistically expect more improvement in the time ahead.

I have clung to the idea that my infill may be delayed because the size of the defects were large (virtually the whole of the patella and suitably larger in the trochlea) and because my rehab has been stalled at around the 3 month stage because of arthrofibrosis.  I'd love nothing better than to learn that I can resume rehab with a good outcome at the late stage.  However, I can't find anything that would support my rosy view of things and so I'm open to options that would save me a PKR at the moment.

I'm therefore interested in the nature of your 'failure' to ascertain whether it matches mine.  If not, then clearly Denovo may not be suitable for me even if it were available in the UK.  However, the world of articular cartilage repair is small enough that they all know each other and I'm sure that if it were suitable I could get referred onto another OS even if it were to someone in Germany, Italy or the home of ACI (Sweden).

But, I don't wish to keep opening your wounds.  The hopes and fears of ACI are monumental and facing the worst of it is surely not something you could ever be prepared for, so if you just want to let this drop, please do so.
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 markld

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Re: ACI failure determined
« Reply #8 on: March 17, 2011, 02:51:11 AM »
As you know, no two peoples situation is ever the same. Comparing mine to yours is kinna like comparing apples to oranges.
If you are at 14 months, the fill will not improve from here out, just as it really doesn't improve much beyond the 3 month mark as that's when the majority of filling takes place.
Denovo would be an excellent option for you. It uses juvenile cells which are much better than yours. All the studies show that the younger the ACI patient is, the better the chances are of having a successfull outcome.
As my Dr. put it; younger cells are just much better than older ones. I am only in my 30's and he said the juvenile cells are much more robust and viable than my own......
Denovo is not terribly expensie, one could realistically get it done here in the states for under 15k if they did not have insurance.
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

jonhark

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Re: ACI failure determined
« Reply #9 on: March 17, 2011, 03:12:37 AM »
Have to agree with Mark on this subject. ACI cells expand and multiply into the defect at the earlier stages of recovery--12 weeks or so. After that stage, the cells begin to mature and harden in the defect. I have had multiple ACI's and MRIs along the way 4, 6, 9, 12, 24 months. In my case, the cells didn't change at all after 12 months according to the MRI reports. If you are more than a year out, you really shouldn't expect to get anymore "fill" into the defect. You can expect to get improvement of symptoms as your legs should get stronger and the cells should become more like mature hyaline cartilage.  I am approaching 11 months on my last ACI and am anxiously looking forward to my 12 month MRI with Dr. Minas. Most people who have full or nearly full at 12 months can expect continued improvement out to 3 years with PFJ ACI. In Mark's case, his MRI showed a partial fill and therefore the prognosis wasn't acceptable going forward.

Offline Rennschnecke

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Re: ACI failure determined
« Reply #10 on: March 17, 2011, 09:27:58 PM »
Thanks for your opinions, Chaps!

I fully understand what you're saying but I'm also trying to get a grip on the situation I'm in.  I know that no two people will ever be the same, but I've become increasingly aware that the health systems across the pond not only differ as to the procedures available but also in the terminology etc.

I'm battling with the idea that on the one hand the MRI says no infill at this stage, yet a visual of the grafts indicate that they have taken.  There is good integration with the bone and with native cartilage but my contemporaneous notes from my last review state it was 1mm deep compared with the native cartilage of 3mm.

At this stage it seems (to me) that whether or not to go further is not a clear cut issue.  The bone is covered so the pain is different than pre-op.  Presumably treating it again even with Denovo would mean excising some of the cover as I am not longer technically down to bone.  Mark, are you in a different situation, i.e. lack of infill mean the bone is still exposed?

Jon, how many ACIs have you had?  I read your posts avidly and had you down as having 2 successful procedures, but it seems you might have had at least one more procedure I wasn't aware of.

I wonder if the reason I think that the cover will thicken up is that I read somewhere that it takes longer for the patella to get comfortable because it needs to be thicker than other regions and so needs more time.  But since I can't put my finger on it just now I could easily have misunderstood this.  As I have kissing lesions I was following these posts most closely to get an idea of what I'd be facing.  As it turns out my journey was rather individual but aren't they all?

Will mull over everything and pose my Qs to the OS later (June appointment).
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 markld

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Re: ACI failure determined
« Reply #11 on: March 18, 2011, 12:30:55 AM »
Your patella will not thicken from 1mm to 3 mm at this point in time. What takes longer about the patella is; the new tissue takes 2-3 years to fully harden, not thicken. The fill stage has already occured thus you should not expect it to thicken from here out. 1mm is not sufficent thickness to expect any kind of positive results.
Yes, just as I said before, I have a FULL thickness focal defect, which means down to the bone.
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

jonhark

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Re: ACI failure determined
« Reply #12 on: March 18, 2011, 12:48:00 AM »
I am 2 of 3 for ACI. First ACI was a success. My second ACI "failed" because I had massive adhesions and a poorly done AMZ. I had it revised last May by Dr. Minas in Boston. The graft had filled in 100% percent, but due to the adhesions and compression of the patella, Dr. Minas re-did the ACI graft due to poor quality. I am now 10 months out and doing well.
Really don't undertand how you can have 1mm deep cartilage and have cartilage which appears filled in with the surrounding cartilage. It is possible, that when compressed with a probe, your cartilage retracts to 1mm vs. 3mm for the surrouding native cartilage. Generally speaking, patella cartilage is 6mm thick and every other surface is about 4mm in the knee. That along with sheer force, is why the patella takes longer to provide symptomatic pain relief.
It is really pretty simple, if you have a quality MRI with gadolinium injected prior, your MRI should mirror exactly what your doc sees in your knee when scoped. If your new cartilage is flush with surrounding cartilage and is "filled" in well, then you will see this when scoped. MRI's aren't good at showing the firmness of the cartilage. This is just as important as "fill". Your doc should have probed your new cartilage when scoped and provide an assessment: moderately soft, mildly soft, or firm. It should progress in firmness along the way.
I wouldn't read into this recovery too much. The bottom line is your knee should be improving incrementally every 6 months and you'll usually max out improvement at 3 years for Patella ACI. If you plateau or regress then it is a good sign that the cartilage is poor, didn't fill, or your algnment is bad which is causing compression of the joint surfaces. My personal experience is that if you are still having really sharp pains at over 12 months and you aren't able to activities of daily living, then the prognosis isn't good and you should consider another option. At 10 months, I am mostly symptom-free, except for when I over-do activities like squats and hill walking. Based upon the size of my defect (8CM^2), I was advised it will be 18 months before symptoms post activities dimiinish. Listen to your body and don't "chase a dream" which has little chance of coming true. Act quickly as the longer you wait the greater chance your only solution will be a PFJR....

Offline Rennschnecke

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Re: ACI failure determined
« Reply #13 on: March 18, 2011, 08:51:40 AM »
Thanks for your continued input.

I know I didn't have a contrast MRI as I didn't have an injection prior to the scan, so I'm somewhat bemused by the whole process.

I've had massive problems with adhesions as well scopes to clear it and I've also had to fight a diagnosis of CRPS by someone (not my OS but his fellow) who didn't even bother to examine the knee visually, physically or functionally so I've had a big fight for a year and am quite literally burned out by it all.

Currently improving in symptoms so am content to let this happen while I sort out the longer term future.  As much as anything I need my body to recover from the multiple surgeries and exotic cocktail of pain meds which have kept me from doing much work-wise for a while.  I had very severe pain which was delayed for most of last year and could not progress anything.  I have to say that although the cover is thin in places I don't really have sharp pain except for steps.  I think this is partly strength and until I can sort that component out I can't really comment any further.

I am regarding my window till June as an opportunity to finish my current research project, try to secure funding for my next and work out where I am with my knee as well as get stronger.  I know that one argument is that I should just cut my losses and try to get my life back with a more tested technology, but on the other hand I still dream of getting back to my tutoring position with my sport governing body.  But if I can't progress after 6 months then I clearly need to do something else.

If you have any links to articles re. ACI since 2009/10 (early part of) then I'd be grateful to learn about them.  I have all prior articles but haven't had much time to catch up on that along with everything else.

Once again, thanks for your continued input.
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 markld

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Re: ACI failure determined
« Reply #14 on: April 05, 2011, 07:02:22 PM »
I will be having Denovo NT April 6th and will be posting with my rehab progress under the Denovo section from here on out.....
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