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Author Topic: Patellar cartilage tear, considering ACI/Denovo ?  (Read 13016 times)

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Offline jjackish

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Patellar cartilage tear, considering ACI/Denovo ?
« on: September 18, 2015, 10:24:32 AM »
Hi there, i play ice hockey and took a hard fall to the ice a few years ago and tore a piece of cartilage 12 x 5mm  or so on the medial portion of knee.  It is still in place but torn. 

I have pain when doing running for longer periods (for instance greater than a few miles can get fairly stiff afterwards).  Jumping is difficult.  Deep bends especially (squats, etc) are the worst.  I used to love leg workouts and any deep bending particularly with weights will get pain and stiffness later.

I also have some mild medial quad VMO weakness that has been hard to eradicate as it's a little difficult to fully strengthen.

Am considering arthroscopy, and then assuming that likely won't work.  ACI with autograft or Denovo.  Denovo would be covered bc it would be part of a study.  That would be in Minnesota.  The autograft ACI I could do with Dr. Cole at Rush-Chicago.  He could get that covered through insurance reportedly.  He seemed nice but also seemed a little rushed sometimes.  I was leaning towards MN Denovo guy.  Dr. Cole mentioned he may consider a micro fracture on arthroscopy depending on how it looked inside my knee.

Anyhow, looking for anyone's thoughts on this surgery.  My defect is not huge, but I am 39 and like to be quite active and this is a bummer.  Played 2 college sports so it's a big part of my life.  Any help is appreciated!!  Be well.

JJ
« Last Edit: September 18, 2015, 11:39:49 AM by jjackish »

Offline dal_knee

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #1 on: September 18, 2015, 03:55:55 PM »

I would suggest asking your physicians how close is the generated cartilage (histologically) to normal hyaline cartilage.   Real cartilage is critical to outcome.   

Don't accept microfracture, it's unethical due to the subchondral bone damage it creates.

I have heard (ortho assistant) that with DeNovo they were seeing overgrowth as a common complication.  So ask your physician about that.   

Also since you are looking at ACI & DeNovo, you might want to consider Cartiform.   User willrunagain just had his procedure, you may want to take a look at his posts.  I'm seeing 85-90% matching to hyaline for Cartiform.

Another option would be Dr Saw in Malaysia or Dr Broyles in Baton Rouge, if affordable.    Dr Saw claims 95% matching to hyaline.
2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline jjackish

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #2 on: September 22, 2015, 03:55:51 PM »
Thanks for your advice.  I actually work at a hospital and surprisingly one of the authors of a Denovo patellar article is right at my institution so I talked with him.  He thinks it is maybe the best procedure for the patella based on the contours and other matters.  However, he did not feel that it was totally normal cartilage.  I don't know that there is anything that is.  I have not heard much about Carticel. 

Given everything will go for arthroscopy and then DeNovo likely if that does not work. 

He also agreed that micro fracture is not a good idea. 

Thanks again, JJ
« Last Edit: September 22, 2015, 04:01:05 PM by jjackish »

Offline willrunagain

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #3 on: September 23, 2015, 09:11:11 PM »
jjackish,

Check out this video starting at 4:59.  They directly compare the Cartiform repair tissue to Denovo repair tissue.   The study was done by an independent pathologist.  The science has made it pretty clear. Tissue morphology rating when compared to healthy cartilage is 91/100 for cartiform and a dismal 25/100 for Denovo.

http://www.arthrex.com/resources/presentation/BY488mDq0U2FywFLmQZS0g/cartiform-cartilage-restoration-using-a-novel-cryopreserved-viable-chondral-graft

Offline jjackish

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #4 on: September 30, 2015, 07:05:09 AM »
Thanks guys for your replies.  Carticel, while appearing encouraging in that it has good apparent hyaline cartilage matching, doesn't seem to have much of a track record.  I looked through some older posts and there were other mentions of overgrowth and failure, but I don't know if the procedure had been well perfected back then.  I may go see this Dr. Farr and get an opinion.  I don't have trouble with ADL's really so would hate to mess it up with a procedure that went the wrong way.  I will look forward to seeing your progress willrunagain!

Offline dal_knee

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #5 on: September 30, 2015, 03:51:48 PM »

jackish,

I think you are confusing Carticel and Cartiform.   Carticel is same as ACI and is prone to failure.  One problem I'm aware of is that the cartilage that's regenerated doesn't have the needed bony component, and is prone to non-adherence to the underlying bone.    With that being said, I'm certainly not pushing Cartiform.  Just wanted to clarify for everyone's benefit.
2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline jjackish

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #6 on: September 30, 2015, 11:32:24 PM »
You sir are correct. I didn't realize I was conflating the two. Cartiform!

It'a odd that a search for Cartiform here reveals nothing but crickets.  I actually called Osiris pharmaceuticals to see if they had any follow up studies on their product.  The cartilage restoration market would be huge so I'm surprised there aren't more studies on this?  It just makes me slightly leery that it is as good as advertised. If they thought it was that good I would imagine that they would be doing larger-scale studies to demonstrate its effectiveness?
« Last Edit: October 01, 2015, 01:34:57 AM by jjackish »

Offline dal_knee

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #7 on: October 01, 2015, 03:02:59 AM »

And you should be leery, these cartilage restoration products tend to come and go, after 2 to 5 to 7 year data becomes available.  First, orthopedists will perform the procedure and then follow up analysis begins, all the while having been approved for general market use, somehow.   I'm not an expert in the way these things get released without controlled trials.  Look at microfracture, for example.   How did this technique ever get widely publicized and then implemented as a cartilage restoration procedure?   What about OATS?  My doc says it's only good for 2 years and the 5 year outcomes are not acceptable. 

When you asked Osiris for their latest data, what was the result of that?  According to Dr Farr in video referenced above, approx 200 Cartiforms have been implanted but I cannot find the publicized data on it. 
2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline willrunagain

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #8 on: October 01, 2015, 03:11:41 PM »
The cartiform search results in crickets because with FDA regulations and other obstacles it is very difficult in the USA to come out with new innovative products that can be used on humans.  Let alone market them.  In Europe and Asia, the cartilage repair market offers much more innovative products.  In the US, we still have to use first generation ACI, while in Europe they are onto 4th/5th generation ACI.  If you look back at posts from 2007-2010 most everybody on kneeguru was getting ACI, even though Denovo had been out for 3 years by 2010.  My point is it takes cartilage products quite a bit of time for a new product to gain market share because they require long term studies of up to 5 years for patients to feel comfortable going through such a major surgery.

You can remain skeptical of Cartiform, but remember the procedure is only 2 years old now.  It is the first of its kind where they have figured out how to get mature hyaline cartilage alone to heal to the bone.  Arthrex the leading distributor of orthopedic products signed on only 18 months ago with Osiris to help market Cartiform.  It usually takes up to 5 years for a good cartilage product to make its way into the mainstream market.  And if you look at Arthrex's track record, they are not a company to sign on a product if they don't believe it has potential.

Although there aren't long term studies, every cartilage specialist agrees that the more closely the repair tissue resembles hyaline cartilage the better the outcome.  And cartiform is true hyaline cartilage. There is no denying that.

Offline LauraB12

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #9 on: October 02, 2015, 01:45:28 PM »
(forget it)
« Last Edit: October 02, 2015, 01:50:02 PM by LauraB12 »

Offline jjackish

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #10 on: October 03, 2015, 08:46:16 PM »
Great discussion.

Willrunagain, you may be absolutely correct, I don't know.  It's hard to judge at this stage because there doesn't seem to be a tremendous amount of data.  I sent my query to an Orthopedist I know who authored an article on outcomes of DeNovo juvenile allograft.  He does not work for pharmaceuticals however or get paid by them to my knowledge.

Here's what he said:
"If it really can achieve the results that Osiris, or Arthrex, claims, that would be fantastic.  The problem at this point is that none of those claims have been validated with any independent study.  Certainly in the case of Arthrex (who sells the product), they are a great company, but also happy to put exciting products out there without good data...that always is a red flag for me.  So, my opinion at this point is that it is an interesting idea with no data to support it; perhaps there will be, perhaps there won't be.  I have not really looked into using it at this point because of lack of info.  One of my partners has used it, but I don't think he has enough patients nor are they far enough out for him to really know what to think of it.  Jack Farr is a great surgeon, but also very happy to try new things without data.  Since he (or someone like Brian Cole) is the end of the road for many patients, he has some liberty in being able to try new things."
« Last Edit: October 03, 2015, 08:49:19 PM by jjackish »

Offline jjackish

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #11 on: October 03, 2015, 08:48:10 PM »
I called Osiris, have not heard back from them.  They didn't seem to indicate they had an ongoing study or a registry of how these patients are doing though from what I could tell.  I am not sure though, will have to wait to see if they get back to me.

I will try to get more information on it, because if it can produce more hyaline like cartilage and with no more downsides, I'm all for it.  I just want to see more numbers, more studies. 

Thanks everyone. 
« Last Edit: October 03, 2015, 08:49:55 PM by jjackish »

Offline willrunagain

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #12 on: October 04, 2015, 01:14:30 AM »
Well I don't know how you're going to find the studies you're looking for on cartiform when the registry only has 600 patients so far. An independent pathologist with no monetary affiliations to arthrex or Osiris graded the repair tissue of cartiform. I still think anyone going with Denovo over cartiform is making a serious mistake. Zimmer makes Denovo and there are far more surgeons in bed with zimmer than there are Osiris. Not to mention zimmer makes the majority of knee replacement parts while Osiris is strictly a biotech company. When it comes to cartilage repair patients are sort of at the mercy of the market and the surgeon, but if you do your research you don't have to be.

Offline willrunagain

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #13 on: October 04, 2015, 01:48:05 AM »
There have been in vivo goat studies and a clinical human case. Both studies graded the cartilage at over 85% true hyaline cartilage. That was enough for me to make an educated decision. I wasn't going to wait around in knee pain for 5 years to see long term studies. If someone wants to wait for long term studies that's great, but I feel the few studies out there are enough to prove it's a lot better than Denovo.

Offline jjackish

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Re: Patellar cartilage tear, considering ACI/Denovo ?
« Reply #14 on: October 10, 2015, 05:20:06 AM »
Yeah, I heard back from Osiris but the person who contacted me via email had no further information other than to direct me to their website.  Bottom line is they don't have any large studies and they don't seem to be monitoring it in any specific way which makes me a bit leery.  It may be a great product, but if so, they would probably want to do bigger studies.  If it showed efficacy they'd be selling this stuff like crazy. 

Here is the link
http://www.arthrex.com/orthobiologics/cartiform

I may schedule some time with Osiris' biologic sales manager to see if I can get more information. 

Best!

Willrunagain, wish you the best on a full recovery.  Let us know how you are doing!!
« Last Edit: October 10, 2015, 05:23:04 AM by jjackish »