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Author Topic: OA, medial, given 3 choices...HELP!!!  (Read 5215 times)

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Offline seegalone

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OA, medial, given 3 choices...HELP!!!
« on: February 06, 2004, 08:36:10 AM »
Hi, everyone,
I only posted on this board once before,  as things were not too bad. I was originally told by a prominent Chicago "cartilage" OS that I do not qualify for any of the cartilage replacement procedures. Mind you he never sent me for MRI, and I was dumb enough to know that I needed one. It perhaps was not so bad, relatively speaking, comparing with those in constant pain, but it changed my whole life. I am 59 but have always been v. active, skiing, hiking, biking etc. I can't do any of the above.

As the pain has been getting progressively worse in the past couple of months I went to see an other OS. By an MRI  I have a medial compartment gr.III-IV chondromalacia, about 3-4 sq. cm and a complex meniscus tear, some patellar chondromalacia. I had arthroscopy for a torn cartilage, presumably meniscus, some 18 years ago (seems like a textbook story). I was given 3 choices:  HTO and possibly microfracture at the same time but no Carticel,  Unicompartmental knee replacement (would that be "UKA"?) or a TKR. Well I am considering only first two.

Am I too old or the defect is too large for OATS? My new OS recommended HTO (it happens to be his sub-specialty) to " buy time". My fear is, that the lateral part of the knee will be carrying most of the weight, possibly "wearing it out" faster, as it shows already some signs and symptoms of OA. I am terrified of a knee replacement, even if it's "only" unilateral. I've been reading about this procedure done a minimally invasive way, as it's called, namely through a  much smaller incision with faster healing. I only know of one OS in Chicago, who was on Fox news as supposedly the only one who does the procedure and, as they said, will be training others to do it. I had a bit of disapointing experience with him years ago, unrelated to current problem.  I have found a whole bunch of OSs with web sites around the country who  do the procedure, so obviously it was a marketing gimmick. I found  a couple more in Chicago, but I'm not familiar with any of the names. my OS does not do TKR, and I am not too sure he does a lot of UKRs ether... Anyone here had an experience  or knows of an OS in Chicago area, who specializes in minimally invasive UKR? I don't care how far I have to drive...

Any input would be most appreciated. I am also considering Synvisc, however my OS gives me less than 50% odds that it will work. It's a matter of falling into the right half...  Joking aside any advise on that would also be most appreciated. The fact is that there is not much to lose and everything to gain. I read some of the painful synviscs stories in here, but I am only concerned, that with the amount of damage I have that my chances are really slim... Genzyme study, a short version on the company's site, disputes any correlation between the age, amount of damage and the success ratio.
So, where do I go from here????  ???
Thanks much in advance for any replies,
Krys

Offline dm

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #1 on: February 08, 2004, 02:50:16 AM »
Given the level of uncertainty in your message, I'd go for another opinion. Ask around for an OS with a reputation for treating OA patients. Be prepared to take your mri films, reports etc with you to save time. if you don't they'll just tell you they need them and reschedule you.
multiple arthroscopies 2/00,3/01,6/01,1/03, 12/07,10/10. chondromalacia, severe medial joint space narrowing following 3 partial menisectomies, chronic pain problems, kneecap problems, OCD lesion, failed mfx.

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #2 on: February 09, 2004, 04:12:18 AM »
dm,  thanks for your advice. I've actually came to the same conclussion.
I've been asking if anyone knows of an OS in Chicago, involved primarily in treating OA and skilled in HTO and  PKR . In the meantime I've decided on Hyalgan injections, It seems that the results are quite unpredictable, and don't seem to have that much to do with the amount of damage. So I'd give the shot a shot  :)
Thanks again,
Krys

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #3 on: February 09, 2004, 04:19:51 AM »
Darn typos! It's  "conclusion"...
Krys

Offline mj/usa

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #4 on: February 09, 2004, 11:10:29 AM »
Hi Krys--

3-4 cm defect doesn't seem to me to be too large for OATS, but there are probably other factors that are preventing your os from recommending it--I had OATS about a year and a half ago for a much smaller defect (1.5 cm sq. roughly) and my os said the rest of my knee was in great shape given my age (55) that I should go for it.  So age shouldn't be a factor; maybe it is the meniscal tear?
I wish you all the best and hope that you can get your knee "fixed".  
Incidentally, I also tried the synvisc injections first and they did help, but only for periods of between 6-9 months and then the pain would return...
Good Luck

MJ
« Last Edit: February 09, 2004, 11:13:14 AM by violin1 »
plica excision 05/01,  followed by OATS 09/02

Offline Beauzer

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #5 on: February 09, 2004, 04:43:39 PM »
Hi Krys,

I've done a lot of research lately about OATS. ;D  First off, you can only do it on the full-thickness areas (grade IV).  There are some case reports of OATS on larger lesions (a mega-OATS, as it were), but the results aren't encouraging.  It only really works well for lesions under 2 cm sq.  

Also, in order for it to work, the rest of the cartilage in the area needs to be relatively normal.  Only about 20% of people scheduled to have it actually turn out to be candidates once examined under arthroscopy.  I was scheduled for OATS last month, but had too much surrounding damage and ended up with a chondroplasty instead (not quite deep enough for microfracture either).  

Microfracture's not great, but I've had two in the past and actually got good results and pain relief for 4 years after the last one.  I've been offered and am also scared of HTO for the reasons you mentioned.  It seems to have really fallen out of favor where I live.  Let me know how the Synvisc goes, I'm scheduled for it later this week.  Has your OS considered an unloader brace?  It seems like a pretty noninvasive thing to try.

Good luck,
Danielle 8)
32 - R knee gone to hell
lat. meniscus 94
ACL, chondroplasty 98
Chondroplasty 99
Screw fell out into joint, med. meniscus, microfracture 99
MCL/med. capsule recon, med. meniscus 00
Chondroplasty 04
Chrondroplasty 1/05
OATS 4/05 for OCD lesion
AVN, MFC fracture 10/05

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #6 on: February 09, 2004, 11:19:08 PM »
Hi, MJ,
thanks much for replying. Yes, there is a complex meniscus tear by MRI. Part of the defect  might be from the former (18 yrs ago) arthroscopy for meniscus tear repair.  I feel better in a way, after your post,  that I was not missing out on a simpler procedure. All the reading I've done so far brought me to the same conclusion.

I am scheduling Sybvisc, hopefully later this week. If I can buy 6-9 months I will be grateful for that. I can work on my quads in the meantime, get my life under better control, push myself to lose that extra 20 lbs that I accumulated from being so much less active, at least that the excuse...

By the way, my OS said 5 shots, an other one - 3, most synviscs sites (under whichever name, Hyalgan 20 used here most commonly) quotes 3. How many did you have? I was under the impression that 3 is standard.

Thanks again,
Krys  

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #7 on: February 10, 2004, 12:01:58 AM »
Hi, Danielle,

Thank you so much for writing back. It's a scary world out there. Anyway, you are right, I have too much damage for OATS.

About HTO, I was just reading a very favorable opinion about it, but every case is different, and my fears remain. The other lousy part of  it is a painful and long recovery...  Full weight bearing starts partially after 6 weeks. I wouldn't moan, if I had a reasonable reassurance that IT WILL WORK...
My OS uses the external fixation device for several weeks. I can't even imagine sleeping with that thing attached.

The other choice given - unicompartmental KR (or partial), however much more serious type of surgery, but recovery seem so much faster, especially if done through 3 inch incision, but (always a "but...")  it's  success rate was quoted as 75% only by at least one resource. I can't find any meaningful statistics... It's nice to know the odds.

As far as the brace you've mentioned, I would really hate that. I think what I am looking for is a "fix" not a crutch... Perhaps a lot of us do.
Well. I should go for a second opinion as soon as I find someone in Chicago, and hope for the best with Synvisc.

You seemed to have gone through quite a lot, however "buying" 4 years with microfracture, that's not bad at all. The only way that would potentially work for me, if it was an added procedure to HTO. I sincerely hope Synvisc works for you again!

Thank again and GOOD LUCK!
Krys  ???

Offline JG

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #8 on: February 10, 2004, 01:21:25 AM »
Krys,

I had what Danielle refers to as a "mega-OATS" procedure.  Mine was more like "mega-mega OATS".  I normally refer to it as mosaicplasty using osteochondral allograft plugs.  Basically, I had 13, 10-12 mm plug placed in my trochlea (extending from lateral to medial side) and 5 in my medical femoral chondyle.  So far the results are very encouraging.   My PT just shakes her head when she sees what I am able to do during my sessions.  

I spoke to many surgeons before making the decision to have the surgery including Brian Cole in Chicago.  I believe you may have been referring to him in your original message.   My physician and I also spoke to Bugbee, Minas, and Gross.  All agreed that my damage was about 3x what you would want for an OATs type procedure.  Only Bugbee thought I might do okay.  The others just said plain and simple it was way way too much.  However, all said I had many thing going for me, including no joint space narrowing, excellent function given the damage, relatively young (35), and very dedicated to rehab.

I still have grade IV in my lateral compartment including a large spot (3-4 cm2) on my lateral tibial plateau and a another spot on my lateral femoral chondyle.

Do you have any joint space narrowing?  That can quickly rule you out.  I can see your age being a problem it you are having an allograft (which it sounds like that what you would need).  Unfortunately, when you get older, healing doesn't happen as quickly.  When I went in for my surgery April 03, an 18 year old guy was scheduled for the same procedure as I was but only on the medial femoral chondyle.  He had 8 smaller grafts and was walking sooner and actually started running at 6 months.  I won't start running until 1 year.

Looking back, recover has been very time consuming.  If I am not cycling or swimming or doing my leg strengthening exercises, I am think about it.  It has taken a toll on my hip and back.  So it is not an easy surgery by any stretch of the imagination.  12 weeks with crutches, many hours of PT, etc.  

I am considering having microfracture on my tibia.  If it can buy me 3-5 years, I would be delighted.  Also, synthetic cartilage is around the corner (see www.salumedica.com).  I recently saw another physician in my surgeons office who thought this was the way to go eventually.   She also said that the goal of any of the cartilage restoration procedures is to alleviate pain.  Nothing more.  Doctors might spin it another way, but that's what it is.  I am very realistic, I will absoluately need a TKR eventually and probably by the time I am in my early 50's.  The way I look at, I have really bad arthritis.  I can call it a "defect" or whatever else, but that's what it is.

I would encourage you to continue looking into microfracture.  There are a few studies out there regarding microfracture on larger defects.  Also, I view Synvisc as a very good option.  Right now I don't feel I would need it, but will eventually try it.  Also, I would talk to as many people as you can about TKR and UKR.  I see people in my PT that seem to be doing very well.

Good luck...Janice
Sept-99 - L knee LR
Aug-02 - L knee LR/menisectomy
Apr-03 - L Knee Mosaicplasty Using Allograft (18 grafts)/LR/debridement/menisectomy; Right Knee menisectomy.
Apr-04 - L Scope - LR/Lysis Adhesions

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #9 on: February 10, 2004, 09:24:44 PM »
Janice,

Thanks very much for replying. You can't imagine how helpful you all have been.

I found the info about Solu Medica sometime ago, showed it to my OS, who dismissed it as unproven. Besides, it's not approved in the States. It's been available in Europe for about a year, but I don't know yet how many have been done, if any, and what is the success rate. It does seem extremely promising.
Yes, I did see Dr. Cole, unfortunately he had nothing to offer. The docs you mentioned - Bugbee and Gross are in California, San Diego and LA, respectively, and  Minas in Boston, am I correct? You really did get around.
Did you find a long and tedious recovery from mega mega OATS frustrating? Going back in time would you have it done again?

My OS did mention micrfractures, but only in combination with HTO. I'm slowly warming up to it. The other option was unicompartmental KR. The recovery seems easier from the latter, but any complications could cripple me. The other one is safer, but possibly lasting a shorter time, but again it's "buying time"...  I just talked to my OS last night, and he does not seem to think that there is a danger of "wearing out? the lateral compartment after HTO.

The more I post on this Forum and the more responses I get, the more I feel that I should go for one more opinion. I located one OS in Chicago who pioneered the "minimally invasive" unicompartmental KR thru a smaller incision, claiming it safer and less damaging to the surrounding tissue. His name is Dr. Sheinkop. Have you by any chance heard of him even though you were seeing mostly "cartilage" docs, it seems.
The disturbing fact is that my knee seems to be  getting worse almost daily now. Synvisc be kind to me!
Thanks again,
Krys

Offline JG

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #10 on: February 11, 2004, 02:29:38 AM »
Krys,

Allan Gross is in Toronto (U of Toronto), William Bugbee is in San Diego, Minas is in Boston.  There is also Buckwalter in Iowa.  I just have read some of his stuff, but not talked to him.  I know Gross is doing some really cutting edge stuff, so you might want to try him.   If you can afford it it might be worth seeing these guys.  I was able to see everybody but Gross, but my OS talked to him while I listened in.  The biggest issue is making sure they schedule enough time with you give that you are making a special trip.  

I don't regret the decision at all, but it is basically my number 1 priority every day.   If I don't stay on top of my cardio work or my strength work, my knee feels worse.  Interesting enough, the physician I see for pain management reasons agreed 100% with me on the exercise thing.  She said that most people stop exercising only to get worse.  She thinks it is very important for the health of the synovial fluid.   Even if I do some water walking or swimming, it is very helpful.

On big difference is that you OS recommends a HTO.  The structure of my knee is actually very good, I just have articular cartilage that is falling off the bone.  I have many theories behind why my knee fell apart, but that is another discussion.

Janice

Sept-99 - L knee LR
Aug-02 - L knee LR/menisectomy
Apr-03 - L Knee Mosaicplasty Using Allograft (18 grafts)/LR/debridement/menisectomy; Right Knee menisectomy.
Apr-04 - L Scope - LR/Lysis Adhesions

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #11 on: February 11, 2004, 07:05:45 AM »
Hi again, Janice,
And thanks again. I was just reading about Dr. Sheinkop surgery ( the min invasive unicompartmental KR), and apparently he had some training with a Dr. Gross, I'm not sure, if it's the same one from Toronto. To actually go to Toronto for a consultation, I'm not sure about that, I would not be able to have surgery there anyway.

The reason for an HTO consideration is, that apparently my R leg is 10 degrees off axis congenitally, and I have slight outward tibia bowing after a break in a ski accident in my teens. It supposed to last  from 2 to 10 years, so I've been told.  By that time we might have a really good artificial cartilage.
Have you ever seen the  heavy, waxy, greasy packing that goes into gears ? That's what we need!!!
No one so far had considered me a candidate for any cartilage procedure, but again no one here does mega OATS.

I am scheduled for this Thursday for Synvisc... I need lots of luck!!!!!!

Krys

Offline mj/usa

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #12 on: February 11, 2004, 10:46:30 AM »
Krys---

Good luck with the synvisc injections.  I found that they really hurt (sorry to say this) for about 24-48 hrs and then the improvement was quite dramatic.  Of course, this led me to believe that my knee was fine (which it really wasn't) and so I started back "wogging" (fast walk) and doing other sports that probably damaged my knee further.  My first os was really no good and basically didn't say anything except this shot will do the trick.  
In total I had 3 shots. After the pain returned (about 8 mos after the last shot) I decided I had to get to the root of the problem and went to a different os.  Second, third and even fourth opinions are very valuable; in my case 3 out of 4 said the same thing and so I ended up going for the oats operation.
Do go for that other opinion; it can't hurt.  
Again, good luck and I hope the synvics helps buy you some time.

MJ
plica excision 05/01,  followed by OATS 09/02

Offline seegalone

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #13 on: February 11, 2004, 05:16:30 PM »
MJ,

Thanks much for your support. I certainly can use plenty. And I'm glad you've warned me about pain, better to expect the worse... I will report on synvisc. And I will go for a second opinion, for sure!

Krys   :-/

Offline neil

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Re: OA, medial, given 3 choices...HELP!!!
« Reply #14 on: February 12, 2004, 07:43:21 PM »
I have had carticel implanted in sept 03 and progressing slowly. I am 42, I was told I was to young for a tkr. I injured my self in sept 02. I live in mass and went to "the Best in The Business" at NE Baptist Hospital. He was reluctant to discuss any surgical procedures until My quad healed. There was no time table except he said it could be a few years. I went to another surgeon who does carticel, and 3 months later after fighting workers comp, I was on  my way with the first of 3 surgeries.
Looking back, I would have gone with a TKR because it would have offered me the opportunity to get back into society and do the activities that I always did. I can not do any of those things now and am awaiting the cartilage to grow and heal my knee. My OS has me on a month to month basis, and does not have a long term outlook except that I will possibly have a tkr eventually , maybe in the next 15 - 20 years. My knee will be arthritic regardless of the carticel implant, but I may get back to skating, tennis, biking and piggy back rides for my kids.  The quality of life is the most important thing for all of us. Why should an insurance company determine how long we live in pain. I have pain every day and the carticel is supposed to stop the pain eventually.  My father in law has had his hip replaced twice and gets around better than I do.  Plus the cost for carticel is very expensive. and by the way, I was fortunate enough to have a friend work at genzyme and have visited them before I was approved to have the operation. fascinating how they regrew my own cartilage in a lab and put it back in, but A new knee would have been better.
9-13-02 - present, 4 surgeries to right knee. quad severed, piece of femoral condyle cut off, shaving of patella. had cartilage implant 9-22-03, fluid drain, cultures & manipulation10-21-03