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Author Topic: Failed ACI...now what? Try again or something else?  (Read 5076 times)

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Offline mknmaa

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Failed ACI...now what? Try again or something else?
« on: August 04, 2015, 05:24:32 AM »
Greetings, I had ACIs and AMZs on both knees about three years ago for patellar defects.  My left knee was a great success...the right one, not so much! I knew very early on that something was not right. It seemed to always catch when I bent it and there was a great deal of pain shortly after the procedure- within the first 6 months (not related to surgery). The pain has gotten worse- same type of pain, grinding and popping as when I was bone to bone- only worse. When I look at my knees and compare, the right one protrudes where the AMZ was done, and the left one looks as it did before I even had the AMZ- so it's as if I didn't even have it done.

I know the ACI has failed. So my question is, should I try for the ACI again with a revised AMZ (assuming that is the cause), or do I try a different approach like DeNovo, OATS or something else (not real familiar with all options)? Obviously an AMZ is necessary for a successful ACI, so can I assume the ACI failed because of a poorly done AMZ? I would so appreciate and desperately seek any opinions.  I have an appointment on the 14th, so I need to be prepared and knowledgeable about all options.

Thank you so much for the input!
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #1 on: August 05, 2015, 11:05:35 PM »
Any experience with failed ACIs or general knowledge about other cartilage transplants/implantation procedures? Can another technique be done now? Someone has to have experience!
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Online Vickster

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Re: Failed ACI...now what? Try again or something else?
« Reply #2 on: August 05, 2015, 11:25:52 PM »
The availability of other techniques will depend to some extent on what country you are in and your access to healthcare/insurance cover

There's a section of the forum for cartilage repair which may shed some light on other possible options
Came off bike onto concrete 9/9/09
LK arthroscopy 8/2/10
2nd scope on 16/12/10
RK arthroscopy on 5/2/15
Lateral meniscus trim, excision of hoffa's fat pad, chondral stabilisation
LK scope 10.1.19 medial menisectomy, trochlea microfracture, general tidy up

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #3 on: August 06, 2015, 02:33:53 AM »
I'm in the US (Indiana).  I need to know specifically if there are procedures that can or can't be done after an ACI.  I know some are contraindicated once certain procedures have been done- like no microfracture after an ACI. So I really need to know not about the procedures, but rather what to try after a failed ACI (or if I could try another ACI).
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline RGrelsamer, MD

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Re: Failed ACI...now what? Try again or something else?
« Reply #4 on: August 10, 2015, 03:28:07 AM »
If you're in Indiana, go see Jack Farr, MD (unless of course he's your surgeon to begin with. In fact, even if he is).
R Grelsamer MD
 www.KneeHipPain.com

Due to time and legal restrictions Dr. Grelsamer can respond just once to queries on the Bulletin Board. Thank you for your understanding.

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #5 on: August 10, 2015, 04:24:36 AM »
Hi! I have heard of Dr. Farr, but he is not my ortho. I'm about three hours from Indy, so I would rather not travel that far.  I was going to Dr. Cole (he did my AMZs), but with a change in our insurance, unfortunately, I can no longer go to him. Dr. Farr is my back up choice if my current ortho (he did my ACIs) is unable to help.  My current ortho is a wonderful dr., but his practice isn't quite as advanced as Dr. Cole and Dr. Farr.
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline willrunagain

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Re: Failed ACI...now what? Try again or something else?
« Reply #6 on: August 11, 2015, 02:49:59 PM »
I am getting cartiform on my patella defect by Dr. Jack Farr on Sept. 8th.  This is a procedure that came out in 2014.  It is a cryopreserved chondral allograft.  It has a very limited bone portion, so it won't burn any bridges like osteochondral allograft does.  Dr. Farr even published a study alongside Brian Cole showing how superior the repair tissue was when comparing it to Denovo.

If your surgeon is Dr. Cole, then I am positive he has performed some cartiform implants because he has a demonstration video on the arthrex website. You should google it.

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #7 on: August 15, 2015, 12:09:31 AM »
So, it looks like I'll be seeing Dr. Farr, as well.  Today I saw the ortho who did my ACIs.  I now have bone damage and a large bone spur.  I'm so upset.  I could tell right after the AMZ on my left knee that it was not right.  The crepitus continued and my patella started to get stuck on the trochlea when I bend it (subluxation).  He said he has no doubt that the ACI failed. He also said with the bone damage, I may not be a candidate for another ACI, or similar, surgery.  He thinks I will need a PKR- I told him I'm 38 and not ready to have anything artificial in my body yet.  He's setting up an appt. with Dr. Farr in hopes that he will have more options. I'm so upset! I brought my concerns to Dr. Cole's attention (he did the AMZs but not the ACIs) that I thought something was wrong very early on after the AMZ, and they were dismissed. I just can't help but think that if I had stuck with my gut feelings and gotten this taken care of sooner, I wouldn't be as bad off as I am now. Sigh...
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #8 on: August 15, 2015, 12:23:39 AM »
Ok, so I think it would be a PFJR not a PKR.  We didn't really discuss this much other than that may be the direction I'm headed. PFJR would be done on the petello-femoral joint.  Either way, it's a scary thought!
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #9 on: August 15, 2015, 04:54:13 AM »
Willrunagain (and any others who have gone to Dr. Farr), did you have to wait a long time to get in with Dr. Farr for your initial appt.? I'm hoping since my ortho is setting it up, I'll get in a little quicker.  I'm just so ready to get this ball rolling.
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline willrunagain

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Re: Failed ACI...now what? Try again or something else?
« Reply #10 on: August 17, 2015, 03:05:59 PM »
Hi mknmaa,

I did not have to wait long at all to get my first appointment with Dr. Farr.  They had something available within 1-2 weeks if I recall right.  I have United Healthcare for insurance.  Not sure if that made any difference.

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #11 on: August 17, 2015, 08:30:13 PM »
I have an appointment this Friday already! I couldn't believe how quickly they could get me in!  I also have United Healthcare. I switched from Anthem about six months ago.  Anthem was great as far as paying for my previous procedures. My ACIs were on the patella, so I thought they would put up a little fight.  Thankfully, I didn't have any problems with them. I'm a little nervous with UHC- never having been through getting patellar defect surgery approval with them.  Did they fight coverage for the cartiform? Do you have any bone damage? Thank you so much for your help!
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline willrunagain

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Re: Failed ACI...now what? Try again or something else?
« Reply #12 on: August 17, 2015, 09:15:17 PM »
My UHC plan approved the cartiform procedure within 3 weeks of the request.  I was very pleased with the turnaround because I thought for sure I would have to fight it. Cartiform falls under UHC's Osteochondral Allograft billing code, so it should always be approved if the surgeon deems it necessary.  Especially if you're too young for a knee replacement. I think it's also important to mention I haven't had any prior surgeries to repair this defect.  This will be my primary procedure.

Dr. Farr told me that he has had much more luck with his patients getting approval for cartiform vs. ACI and Denovo.  I think he rarely performs ACI or Denovo anymore.  Cartiform is the most innovative treatment on the market now and the clinical studies prove it. 

As far as I know my bone damage is very minimal.  I think the MRI showed a small edema under the patella, but Dr. Farr didn't seem to be too worried.  He thinks it will heal just fine once he implants the cartiform.

Offline mknmaa

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Re: Failed ACI...now what? Try again or something else?
« Reply #13 on: August 20, 2015, 12:49:57 AM »
Thank you for your reply! That definitely makes me feel a little more optimistic, as far as UHC's coverage.

I had my MRI done yesterday. It was definitely worse than I thought. I don't think I will be a candidate for cartiform, or possibly any allograft/autograft procedure. I have moderate thinning of cartilage in the petallofemoral compartment, the lateral trochlear facet and the femoral condyle.  It is all the way to the bone in areas and greater than 50% everywhere else.  There is also joint effusion and subcortical degenerative cystic changes (I'm assuming this means osteoarthritis). In the past, only my patellar cartilage had defects; I can't believe all of the new damage.  I'm definitely a little less optimistic about the type of surgery I can have now.

I guess I'll find out on Friday. 
 
8/91 L & R chondroplasty
12/94 R chondroplasty w/ lat. release
9/99 L chondroplasty w/ lat. release
5/10 L chondroplasty and ACI biopsy
7/10 ACI
12/10 chondroplasty and ACI biopsy
5/11 R ACI
10/4/11 L AMZ
4/27/12 R AMZ
9/1/15 L scope- exploratory- prep for PFJR
9/29/15 L PKR- PFA
2/28/17 L TKR

Offline willrunagain

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Re: Failed ACI...now what? Try again or something else?
« Reply #14 on: August 20, 2015, 03:17:50 PM »
Sorry to hear about the additional damage.  On the bright side, you are in good hands with Dr. Farr.  I am positive he'll put together a plan and find a solution for you.















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