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Author Topic: A tale of two (or more) orthos  (Read 2363 times)

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Offline danix

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A tale of two (or more) orthos
« on: April 19, 2014, 04:25:26 PM »
Glad I found this site but it's a little scary how many people have knee problems out there.

I've had some knee issues going back at least 7 years, but in hindsight I think it was longer than that.
I have pretty flat feet and an accessory navicular on each foot, so I've been wearing orthotics for a long time.
Pretty much the only sport I play is tennis, and I used to play tournaments and leagues on a regular basis.

In 2006 I moved to the San Francisco Bay Area and saw a doctor for foot and knee pain.  That doctor (Akizuki) turns out to be one of the top orthos in the area, and the SF Giants team doctor.  He sent me to a podiatrist for custom orthotics because the rigid orthotics I had been using were causing a lot of foot pain.  Those worked out well and the foot pain went away, and the knee pain got better.

In 2009 I was playing a match one day and felt like my patella was randomly popping sideways.  The doctor noted a lot of fluid in the knee and recommended scoping the knee.  I had the scope done, along with "cleaning out" and also microfracture on a small area of cartilage loss.

About a year ago, the floating kneecap issue came back.  Doctor recommended another scope.  I wasn't eager to have another surgery so I let it go for a while - stopped playing tennis for the most part, dropped 20+ lbs due to diet and exercise, but it didn't get much better.  In fact, I started having a lot of pain on the inside of the knee, just below the knee, on the tibia.

In January of this year (2014) I had the scope done.  The results reveal two grade 4 2x3cm lesions, one in the trochlea, the other on the medial femoral condyle.  Small bits of cartilage was harvested for possible future Carticel/ACI use.

Post-op, the doctor explained that my damage was bad and if I were older, I'd be looking at a total knee replacement.  The doctor's proposal is to do ACI (Carticel) which in theory I am OK with.  However, he also wants to do an osteotomy, to correct my "bowleggedness".  This, I learned, means breaking the bone and resetting it in a different position, with pins and screws.  He says that if I do not correct the alignment, the new cartilage will wear out just like the old.

I explored the idea of OATS with Dr. Akizuki and he says I'm not a candidate because OATS uses very small plugs of bone and cartilage, and I'd need a lot of them to fill the area, plus it would never perfectly fit the area of damage.  He recommended a carbon fiber knee brace as "the last thing we have to protect your knee".

It's now April and I have been researching all avenues of treatment.  I had a 2nd opinion from a local ortho, who treats several high school and college teams around here.  Not in the same league as Dr. Akizuki, sure, but a respected guy.  He thought ACI sounded reasonable, but took one look at my xrays and said there's no way he would ever recommend an osteotomy.

I had a 3rd opinion from Dr. King at Palo Alto Medical.  He patiently listened to my story, and when I told him I had explored the idea of OATS and that I was not a candidate, he stopped me and said "Actually you are a perfect candidate."  He explained that in OATS (open allograft) they use a plug of cadaver bone and cartilage, from a young donor, and that the size of the plug matches the size of the (trimmed) lesion on your body.
On the subject of osteotomy, he seemed in favor, but after taking his own xrays, said "I think you could argue for or against it."  I asked about recovery time and he estimated about a year for full.  On the topic of tennis, "oh - tennis is tough on the knees."

I am trying to get yet another opinion from Dr. Ries who was in San Francisco but has moved to near Tahoe and I have an appointment in May.  I'm willing to fly pretty much anywhere if there's a better solution, but I'm not sure there is.

I'm a bit shocked that there are two top orthos that have such differing opinions on how to treat the same problem, but I guess it's not an exact science.

The only avenues I am aware of are:
- OATS (open allograft) either self-donated (not a candidate) or donor
- ACI/Carticel
- Denovo NT.  Not a lot of info out there about this, or many doctors who do it.

From the research I have done on ACI, especially with osteotomy, I have not found anyone who has returned to a high level of sport even 2 years out, let alone a year.

My primary goal is to first and foremost be pain-free, so that I can do normal everyday activities and exercise.
My stretch goal is that I'd like to return to tennis - perhaps not full-on competitive tennis like singles, but at least being able to play some doubles.

I'm going to search through this forum and learn everything I can, but if you have any info that can help me, I'm all ears. 

Thanks for reading.

Offline danix

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Re: A tale of two (or more) orthos
« Reply #1 on: May 31, 2014, 04:43:02 PM »
Someone messaged me but I cannot reply yet since I have <20 posts.
I am back from vacation and need to make a decision on which way to go.
I am pretty set on avoiding osteotomy, as it sounds like an extreme procedure I don't really want to experience.

My normal ortho (Dr. Akizuki) mentioned a doctor in San Diego who does allograft and who insists on doing osteotomy almost all the time.  Any idea who that is?

Offline danix

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Re: A tale of two (or more) orthos
« Reply #2 on: May 31, 2014, 04:48:42 PM »
Did a search - looks like Dr. Bugbee in San Diego:
http://orthodoc.aaos.org/williambugbeemd/

Has anyone here seen him?

Offline danix

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Re: A tale of two (or more) orthos
« Reply #3 on: June 18, 2014, 09:59:00 PM »
Guess I will keep bumping my own thread. 
Called Bugbee's office, they asked to review my MRI, Xrays and reports to see if I am a candidate before coming down for an appointment (they are also booked until October!)

After some comments here, read about Dr. Williams at HSS (Hospital for Special Surgery) Institute for Cartilage Repair in NY.  He's the editor of an interesting book, "Cartilage Repair Strategies". 
It's fairly dated at this point but seems to have the statistics on both ACI and Fresh OATS, so I ordered a copy via ebay. 

I contacted HSS to see about an appointment and have been playing phone tag for 2 days, currently on hold in fact...

Offline hopalong2

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Re: A tale of two (or more) orthos
« Reply #4 on: July 06, 2014, 10:34:30 PM »
I've seen Dr. Bugbee.  In fact, I'm on his waitlist for osteochondral allograft transplant (Dr. B. doesn't call it "OATS").  In my case, a tennis injury led to a ruptured ACL and a cartilage defect in the medial femoral condyle.  My doctor friends in NY have good things to say about Dr. Williams.  You'd get great care either way.

Offline danix

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Re: A tale of two (or more) orthos
« Reply #5 on: July 06, 2014, 11:49:56 PM »
Thanks for the reply.  I have to get my MRI and Xrays to Bugbee.
Williams is out, doesn't participate with my insurance.
I also saw Dr. Stone in San Francisco who is offering an appealing arthroscopic procedure.
Apparently he's the only guy in the country who does this procedure, which is a little concerning.
He also agreed that I don't need an osteotomy.

Offline buddy1741

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Re: A tale of two (or more) orthos
« Reply #6 on: July 08, 2014, 11:38:00 PM »
Glad i found this post I am having HTO with OA graft scheduled for Sept 9th with Dr Cole in chicago I am also nervous about this surgery. I have read a lot on Bugbee and Stone and they a very well respected Cole also is a top doc when it comes to cartilage restoration.  I have already had and OA graft surgery 3 years ago and it was going great until the cartilage around the graft broke down now i am going in for a second time and having a second graft along with the HTO the doc says he needs to unload the joint even though i am only 5-7 degrees bow legged. Stats just came out showing grafts lasting up to 25 years that is amazing.  Sometimes I wonder if the HTO is too agresive but i can't disagree with the doctor because the first OA surgery he did gave me my life back and more.

Offline danix

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Re: A tale of two (or more) orthos
« Reply #7 on: July 15, 2014, 08:32:19 PM »
Got another MRI (Stone wanted it) and will follow up with him.  Saw that HSS was ranked top in the country for ortho, so I am again attempting to contact them to see if I can see Dr. Williams or someone of his caliber out of network.  The only possible match there who is in-network for me is a Dr. John D. MacGillivray.  Has anyone seen him?

I like the idea of the less intrusive procedure that Dr. Stone does, but the fact that he is the only one in the US (or anywhere?) doing this procedure concerns me.

Offline danix

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Re: A tale of two (or more) orthos
« Reply #8 on: July 22, 2014, 09:11:46 PM »
Was able to reach Dr. Williams office and they are reviewing my records.  Waiting to hear back from Dr. Bugbee as well.   I will go back to see Dr. Stone and maybe Dr. King with my recent MRI.  So many orthos, so little time...

I am dead set against HTO unless more than one doctor (aka most of them) tells me it's absolutely necessary.

Offline hopalong2

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Re: A tale of two (or more) orthos
« Reply #9 on: August 02, 2014, 03:23:46 PM »
I've had my surgery--got the call shortly after my other post.  Everything went really smoothly, and I'm doing much better post surgically than I had dared to hope.  The day after, I asked Dr. Bugbee if he thought I'd be able to get back to tennis and skiing.  He laughed and said we'd talk about it in six months.

Offline danix

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Re: A tale of two (or more) orthos
« Reply #10 on: August 08, 2014, 12:32:47 AM »
Dr. Bugbee agreed to see me and I'm going down on 8/20.
I dislike the "we'll see in 6 months" part.  You either think you're going to make a full recovery or you're not, just lay it out before I go under the knife so I know what to expect.

Offline hopalong2

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Re: A tale of two (or more) orthos
« Reply #11 on: August 08, 2014, 02:35:16 PM »
I was okay with it because of my context.  I'm over 50 and was afraid that age alone made me a poor candidate for the surgery.  I didn't present as an athlete looking to get back in the game.  My goals are more modest:  to walk steps, and to be able to walk or hike for a few hours at a time.  At this point, I'll be thrilled if this surgery gets me there.  To pout about tennis and skiing just feels greedy.  I also know enough about medicine--and life-- to know that everyone is different.  Two equally compliant patients with the same surgery on the same day can have quite different outcomes.

Offline tinydinosaur

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Re: A tale of two (or more) orthos
« Reply #12 on: August 08, 2014, 08:16:25 PM »
^ to the 'we'll see in six months'

it really depends on your recovery, i was told to expect to be skating and doing stairs 1-2 months out from my initial surgery a long time ago. if your recovery goes well you may infact return to whatever sport it is you love.. some people despite being advised otherwise do it anyway (it is after all their life and choice and the surgeon's job is to preserve it/advise you to stick to activities that will preserve it). and this can depend on your recovery, what they advise.

i had an osteochondral allograft (live cartilage bone plug), and their expected full recovery is one year, but my leg muscles were so wasted and i still have problems that last year (two years out) i was still being told to avoid standing for too long, ladders or lifting and carrying anything. so it does really really depend.

if you aren't comfortable with something going under the knife, then don't do it. you need to be comfortable with what is going to happen. i do encourage you to keep an open mind, nothing in healing/medicine is set in stone, i've seen people who have had the same surgery/more surgery in the same clinic/doctor get on their feet a lot faster with seemingly no setbacks or problems.

i have always wanted to get back to hockey, it's my first love - i started skating at two and was a goalie by four - but i know now that if i do return it won't be under the mask most likely. at this point i'd feel lucky if i could skate pain free. i would unhappily give up the dream to be pain free again. if you're not willing to give up an activity then work on finding a route that will take you there and a surgeon who will talk things out/look for an avenue that could lead to the possibility of you returning to your sport, however as i mentioned above *most* surgeons will advise against any activity that is deemed hard on the knees. tennis has lots of hard stops and torquing motions on the knee, running is another one but i talked to a woman who ran on her TKR without issue, she's had it 10+ years with no signs of wear.

i hope i didn't scare you off of anything, go with the surgeon you're comfortable with and the procedure/option you feel is best for you. good luck to you, i hope you find your solution!
















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