Patellar cartilage tear, considering ACI/Denovo ?

[willrunagain]

Thanks for looking into this jjackish.  Let me know when/if you are able to get in touch with an Osiris sales manager. 

I too wish there was an independent study of at least 30 patients or so.  I was only Dr. Farr's 10th or 11th patient when it came to cartiform, but he is seeing good results in his subset of patients.  I sought many opinions before meeting with Dr. Farr.  They all suggested Denovo.  The decision to see Dr. Farr was easy because my insurance wouldn't even approve Denovo.  Since Cartiform qualifies as an osteochondral allograft, there is already an established insurance billing code (27415).

You are right to be worrisome in that Osiris is not publishing much.  I think it has more to do with the fact they are not an orthopedic oriented company rather than it being a poor product.  Zimmer being such a long standing powerhouse in Orthopedics is a big reason Denovo is still so popular.  The mere size of Zimmer is a big entry barrier for Osiris's Cartiform product.

Apparently there have now been over 600 cases to date from what I inferred from Dr. Farr.  That number includes other joints though and not just the knee.  I just recently emailed Dr. Phil Davidson who has supposedly done nearly 30 cartiform procedures.  I have not heard back from him yet, but he put together a powerpoint presentation on Cartiform.  One of the final slides mentioned he is putting together a registry of his patients.  He's done a few second looks and has stated that it resembles hyaline cartilage in firmness and appearance.  I will post if I hear back from Dr. Davidson.

[jjackish]

Cool good stuff willrunagain, you've done your research so kudos.  Sounds promising! 

I'll meet with an Osiris rep this Friday and let you know.

[willrunagain]

Dang... nice work jjackish.  I have to hand it to you for pulling off a meeting with an Osiris rep!  Please post what you can find out from this person in regards to Cartiform patient results!

[jjackish]

Yeah, I talked with someone who said a representative would be available this Friday.  I told them when I could meet and never heard back.

[poohray32]

Please, keep updating your findings and this thread.   

Ive been battling severe knee pain since April 2014.  My O/S took an extremely conservative approach and was completely honest from the get go and said there may be a lot of scenarios we have to pass first. 

At the time of my first MRI I don't think he realized the multiple things wrong with my knee and its surrounding areas.  I had a stress fracture of my tibia close to my knee.  So he treated that first.. Took off 4 months to heal, tried working out and was still in excruciating pain.  Went back and he mentioned how fissured and tore up my cartilage was from my MRI back in April 2014. 

Took a cortisone shot and Naxproxen Rx, nothing helped..

Did a Microfracture on my patella Nov 24 2014.  After a looooooong rehab tried exercising again, still in excrutiating pain going up and down stairs, squatting and still can't even jog to chase my 3 year old..  Did another MRI this past July 2015 said the micro fracture filled the defect in nicely and healed.. but that my pain is due to all the shredded/fissured cartilage under my patella.. 

Asked me to go on a special medical diet to lose 50 lbs I did!  He thought the extra weight I was carrying from post baby was making my knee hurt.. STILL IN THE SAME PAIN..

I have a SCOPE scheduled for Nov 15th to determine if I am a candidate for ACI.  He is afraid I am not because my micro fracture defect is a kissing legion he won't know for sure until he puts a scope in there.  If I am not a candidate for the ACI than he will do to the deNovo tissue graft at that time instead.  Either way I am getting cut WIDE OPEN over my knee.

If I am a candidate for ACI (which he says is better, and has a better success rate 80%) than he will take some healthy cartilage during the scope and send it to the labs.  I will then have my stage 2 surgery on Dec. 30th.       

Background; 34 female, athletic, prior D1 field hockey player.  Medial Meniscus tear when I was 17 that was repaired..  played multiple sports year round with ZERO resting.. BIG MISTAKE!!

[dal_knee]

Poohray
How did doc treat tibial stress fracture?  These are nearly impossible to treat. I'm assuming it was a weight bearing area.

I would immediately seek second and third opinions as ACI after micro fracture is recipe for failure. Are you not aware that the harvested chondrocytes do not include the necessary bony component that secures the new cartilage to underlying bone?  Is your ORTHO aware ?  Please ask.

As for Denovo. That is also another risky one at least for patellar defects.  The histological composition of it is subpar. You will find a lot of supporting info on this forum. 

[hopalong2]

Fascinating discussion.  I just wanted to chime in about something upthread.  OATs (allograft) is well-studied, and the 10-year success rate is roughly 82%.  (As someone who had that procedure, I got nervous when I saw the comment that they don't last for more than two years!)  Here is one of several reports that I found:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528935/

[jjackish]

poohray, let us know how you are doing.  Good luck!

hopalong, you had OATS and it went pretty well??

I am a physician too, FWIW, although not orthopedic so I don't know that I have much special knowledge apart from anybody here.  I will see if I can meet with Osiris rep again.  They gave me the cold shoulder after initially agreeing to meet.  As for myself, I haven't made any decisions yet.  I have no impairment with ADL's so there's no rush for me. 

[hopalong2]

Yes, I had an osteochondral allograft in July 2014 and am pleased with the outcome.  To be clear, however, I am not back to where I was before my injury.  My repaired knee is still noticeably weaker, sometimes stiff and sore, and certain ways of moving, including descending stairs normally, remain challenging.  But overall I feel strong and healthy, and I can walk, hike, and cycle for hours at a time.  Feel free to message me if you have any more specific questions.

[willrunagain]

I just wanted to add my 2 cents to this board.  I am 16 weeks post op from cartiform to the patella.  Some of you may be already following me in the post op diary section. 

I had an MRI at 14 weeks and the cartiform was already of equal thickness compared to the rest of my patella cartilage.  It is also well integrated to my subchondral bone which is perhaps the most important thing.

Although I am still in the early stages of recovery, I am very happy with the results thus far.  I just biked over 80 miles last week and wasn't even reminded of my knee problem.  I even cheated a little bit and jogged through a crosswalk last week pain free.

I've been saying this since I've been on this website and I'll say it again. Cartiform is one of the best treatments out there for focal defects.  Denovo and ACI are 3rd class treatments at best.  They do not have the required bony component to ensure good integration to your subchondral bone.  Not to mention the repair tissue does not maintain the normal 3 layered architecture of hyaline cartilage like cartiform does.

[psny]

I just wanted to add my 2 cents to this board.  I am 16 weeks post op from cartiform to the patella.  Some of you may be already following me in the post op diary section. 

I had an MRI at 14 weeks and the cartiform was already of equal thickness compared to the rest of my patella cartilage.  It is also well integrated to my subchondral bone which is perhaps the most important thing.

Although I am still in the early stages of recovery, I am very happy with the results thus far.  I just biked over 80 miles last week and wasn't even reminded of my knee problem.  I even cheated a little bit and jogged through a crosswalk last week pain free.

I've been saying this since I've been on this website and I'll say it again. Cartiform is one of the best treatments out there for focal defects.  Denovo and ACI are 3rd class treatments at best.  They do not have the required bony component to ensure good integration to your subchondral bone.  Not to mention the repair tissue does not maintain the normal 3 layered architecture of hyaline cartilage like cartiform does.

It is indeed a wonderful treatment and seems to be the best option right now. The only other competing treatment would be the modified microfracture plus weekly BMAC + PRP + HA injections that known on this forum as the Dr.Saw / Dr.Broyles protocol. It would be really nice if Cartiform was done arthorscopically. It is indeed done arthorscipically for the ankle, not sure why it is not done this way for the knee. I guess it would be difficult to get under the patella.

[ArmstrongK]

I wonder if you could get Cartiform if you don't have a full thickness defect.  I have a grade 3 patella cartilage defect so I'm kind of in no man's land. 

[dal_knee]

These are purely my own thoughts, but would think the decision making tree would go something like this:  If grade III defect has intact hyaline cartilage, go with Cartiform only.  But if the grade III cartilage is found to be fibrocartilage ( as a response to normal, yet sub-par, healing due to prior injury), than it's ok to rip out that fibrous tissue, apply subchondral drilling (improved version of microfracture) + Cartiform implant.   I think that the Cartiform needs a normally hyaline & intact scaffold to adhere to.

[canyonking]

I'm with willrunagain on this debate. I had cartiform almost two years ago (in March) and I have loved it. I have no pain in my patella where I used to. I had it scoped about 4 months ago and in the pictures you can see where there is definitely cartilage where there didn't used to be any before. I took a risk getting the surgery done as I was maybe Dr. Davidson's 5th patient at that time for cartiform. I have liked it so much I planned to get it done on my left knee. The problem was I had damage in the trochlear groove and the cartiform would probably have gotten torn up. Insurance wouldn't authorize both cartiform and ftg arthrosurface inlay at the same time so the plan is to get the inlay now, then have the option of getting cartiform in the patella down the road. Although going through two major surgeries on one knee would positively suck. And that's only if my new insurance company will even cover cartiform.

[psny]

I'm with willrunagain on this debate. I had cartiform almost two years ago (in March) and I have loved it. I have no pain in my patella where I used to. I had it scoped about 4 months ago and in the pictures you can see where there is definitely cartilage where there didn't used to be any before. I took a risk getting the surgery done as I was maybe Dr. Davidson's 5th patient at that time for cartiform. I have liked it so much I planned to get it done on my left knee. The problem was I had damage in the trochlear groove and the cartiform would probably have gotten torn up. Insurance wouldn't authorize both cartiform and ftg arthrosurface inlay at the same time so the plan is to get the inlay now, then have the option of getting cartiform in the patella down the road. Although going through two major surgeries on one knee would positively suck. And that's only if my new insurance company will even cover cartiform.

How good is it? Can you do sports? Can you lift weights? Or does it only allow basic human activities such as walking, etc.