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Author Topic: Patellar arthroscopy and illiac crest aspiration  (Read 2645 times)

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Offline BezProblemów

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Patellar arthroscopy and illiac crest aspiration
« on: March 24, 2017, 02:33:01 AM »
Hi Everyone,

My procedure was on the simpler side, but I wanted to post it here in hopes that it will help someone as much as you all have helped me.

On 3/21/17 I had surgery with Dr. Farr in Indianapolis.  He performed an arthroscopy on my left patella.  He also drew bone marrow aspirate from my illiac crest (pelvis) and injected the aspirate into a bone marrow edema in my patella.

Brief background:
30 year old male, was highly active in soccer, skateboarding and distance running.  I began having problems 3.5 years ago that began as mild pain along the top of my patella while descending stairs.  The problem morphed into substantial crepitus and pain during flexion at about 60-45 degrees.  I stopped all rigorous activity 3 years ago.  I stopped biking about a year ago as even that was causing pain afterwords.

Knee medical history
I first saw a sports doctor who recommended inserts and PT to strengthen the VMO.  He said I had a patellar tracking issue.  I adhered to the boring home PT for months and went back because I was still having pain.  The doctor said my tracking had improved, and then suggested meeting with their in-house PTs.  I did that a bit and then took home the exercises and continued putting in effort with no results.  They also analyzed my running gait and found no major problems. 

1.5 years ago I saw an OS who did an MRI and then recommended subchondroplasty after spotting a bone marrow edema.  As it was an experimental procedure and seemed temporary at best, I did nothing. 

Last summer I went to another OS who poo-pooed the subchondroplasty idea and instead wanted to do a scope.  He mentioned ACI and said he might even do an osteotomy while he's in there.  A shoot from the hip kind of surgeon...  ???

In the fall I did a phone consultation with Dr. Dye in San Francisco.  He said it was idiotic that I was still driving a clutch (can't disagree, but the clutch motion was not in my painful range of motion) and that I should baby the knee, take 800 mg of Advil liquid gels, ice daily, take stairs one at a time, and check back in a few months. 

After a couple months of babying the knee, I started having a swollen/stiff sensation when rising from a seated position.  So instead of seeing progress, it felt like a step backwards.  I was concerned that a rogue piece of cartilage or my fabella was charting the vast expanse of my posterior knee for progeny. 

Finally I saw Dr. Farr in January.  He had me do another MRI and saw that I had full thickness delamination of my patellar articular cartilage.  He also saw the beginnings of a cyst in my bone marrow edema.  He also noted that bone marrow edema is a misnomer and it really is a stress fracture if viewed microscopically.  He recommended a patellar allograft.  But in order to do that, he first needed to do a staging scope for insurance authorization purposes.  I tried to fight that with insurance but quickly came to the realization that I would get nowhere and just waste time.  So I agreed to the staging scope.  He also wanted to inject bone marrow aspirate into my knee cap to try and promote healing.

The procedure
The OrthoIndy clinic is very nice and they are a well oiled machine.  I stayed overnight at a hotel the night before as I am a 3 hour drive away.  I arrived at 8 a.m. for my 10 a.m. surgery.  They promptly did paperwork with me.  I had brought along some WalMart crutches that I wasn't crazy about (still in the packaging) and asked if I could get crutches from the OrthoIndy store, even though it doesn't open until 8:30.  That was no problem and soon I had a better set of crutches waiting for me. 

They took me back to the staging area and weighed me and asked my height.  They took me to a room with a hospital bed, a few chairs, and a TV.  We did more paperwork and they did my IV.  I also changed into the gown and put a compression hose on my non-operative leg.  They shaved my knee (weird) and made sure my crutches were adjusted correctly.  They also put an anti-nausea patch behind my ear to help me with the anesthesia.  Then I had about an hour or so until surgery.  I just took the opportunity to lie there and reflect on life.  At about 9:55 the manager came in and said Dr. Farr was running a little behind.  So at 10:30 they came and got me.  Dr. Farr had poked in around 10:15 and asked if I had any questions.  He had said in an appointment that this procedure would not help cure my problem but may provide some pain relief.  So I was thinking that the surgery was basically just a pre-requisite and wouldn't really help at all.  But I asked him there if there's a chance it could help, and he said 30%.  It was a welcome surprise to think that there is a slim chance that I might not actually need the more invasive allograft.  But we'll see...

Then I got whisked away on my bed into the recovery area where I talked to a nurse about world travels and got my mind off of the surgery.  Then the anesthesiologist came in and they sedated me, which felt nice, and they also did some poking and prodding on my surgical sites.  At this point I was peachy and barely remember being rolled into the OR.  They asked me to hold my arms out, which I was able to do until I forgot and they had to remind me, and then I scooted onto the table and I was out.

I came to in a private room and asked the groggy idiot's question:  "Am I all done?"  They went over a few things with me, I went to the bathroom, and then I was out of there in no time. 

Gritty Details
I am now 2 days post-op.  The day of the operation was a pretty fine ride home.  I thought it would be much worse but I was in a good mood because the surgery was behind me.  I got home and was pretty sleepy, so I took a nap.  I ate some crackers, chicken noodle soup, and had ginger ale and water that day.  Thankfully, they didn't put a catheter in so I didn't have that burning sensation while urinating. 

The 1st day post-op was a lot of time on the bed reading old Wall Street Journals that had piled up.  I was able to shuffle around on crutches and put a bit of weight on my left leg.  I ate cereal for breakfast (high fiber), leftover soup for lunch, crackers, ginger ale, almonds, and muffins for snacks, and chili for dinner.  I tried to keep the fiber up as they warned of constipation with the opioid pain killers.  I also pounded the water.  I tried to ice as much as I could remember, and also did my exercises.  In the evening I took off my gauze as instructed, but then had a hard time getting the clear adhesive bandage on.  I ended up using both of the ones they gave me to cover the 3 holes on my knee.  My knee was pretty swollen.  I also had a bandage on my upper waist from the aspiration.  I had asked a nurse earlier what to do with it and she said it's just a needle hole and you don't need to protect it from getting wet after 24 hours.  But when I took off the bandage, I was surprised to see stitches.  It did end up getting wet, so hopefully it'll be okay.  The aspiration site is a bit sore, but nothing too bad.  I had a headache this day that grew worse into the evening.  I never get headaches so I was a bit concerned.  I decided to rip off the patch (even though you can wear it for 3 days) - and I think that was the cure.  No poops day 1.  I took a shower but it was quite awkward as I couldn't really lift my leg into the shower and had to support myself on one leg the whole time.  Still, better than many surgeries I'm sure.

Day 2 I began to stretch out my pain meds.  I have only taken 2 pills all day today.  The meds make me pretty drowsy, so I'm not crazy about them.  But I did notice some pain creeping in in between doses.  I continued my exercises and icing regimen.  I hobbled around a bit more today.  I had a big bowel movement finally after focusing on high fiber and even supplementing with metamucil.   I worked from home today.  I notice that my knee is warm to the touch.  I don't think it's anything to be concerned about at the moment, but I'll keep an eye on it obviously.

Tomorrow I plan to go into the office, but we'll see.  Maybe I can ditch the crutches over the weekend.  My follow up appointment is Friday the 31st. 

I had an appendectomy in August and this one has been easier on me so far because the knee doesn't affect my breathing or moving my upper body. 

That's it for now.  Please let me know if you have questions and I'll be happy to answer!

Offline dal_knee

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #1 on: March 24, 2017, 03:03:53 AM »
Hi
What kind of patellar allograft are you getting with Dr Farr in the 2nd stage? Sounds like it would be ACI??

So, the doc injected BMAC directly into patellar bone at the site of the bone marrow edema/stress fracture??   I imagine that you would pay separately, outside of insurance, for that?  Just curious.   I think that's interesting as I do think he is a regular "user" of subchondroplasty with synthetic calcium phosphate. 
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 BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #2 on: March 25, 2017, 02:58:45 AM »
Hi there Dal,

The allograft is an osteochondral allograft where they take a core of cartilage and subchondral bone from a cadaver and graft it into my knee.  That procedure isn't really two-stage like ACI is; rather, the insurance approval in my case (as a virgin knee) is two stage because authorization of an osteochondral allograft requires "inadequate response to prior surgery."  YMMV based on insurance.

I am not sure if it was BMAC because I don't know if it was concentrated or not.  Yes, he injected it right in there from what I know (I will get more details at my post-op appointment).  It is considered fracture treatment, as the bone marrow edema is technically a stress fracture.  They gave me one billing code for the whole surgery (an arthroscopy code), and my insurance said it was covered. 

Dr. Farr told me he used to do subchondroplasty on patellas, but has stopped doing so as he didn't have great results.  He said the patella as a seismoid bone doesn't handle subchondroplasty as well as other joint surfaces.


Day 3 Post-Op:
My ROM is slowly improving with my exercises.  I iced every other hour for an hour (or until the ice pack got warm where it touched my warm knee).  Interesting that even after icing my knee was still warm to the touch.  I think it's probably normal but just fascinating.  I think the swelling went down slightly today and I put a bit more weight on it a couple times.  The pain has subsided quite a bit, especially when doing leg lifts (I had some pain/pressure in the patella before).  I did not take any painkillers today.  On day one when I tested the ROM, I could hear a little liquid pressurized noise when putting my leg back down into the relaxed straight position on the bed.  Those sounds are gone now.  I am curious to see how/if the crepitus has changed once I can do more with the knee.  I took a video of my crepitus the night before as a benchmark so I can compare to that and remember what the last 3 years have been.

Offline dal_knee

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #3 on: March 25, 2017, 03:45:55 AM »
When is the 2nd stage?  Then the osteo-chondral allograft will be placed?  Not yet clear on the timeline. 

And thanks for the commentary that Farr is getting less than "acceptable" results from patellar subchondroplasty, generally speaking.  There have been a couple inquiries on this forum about subchondroplasty in patella, and there is not much clinical info to pass on. 

Happy healing, but as stated above, I'm not sure where you are in the surgical process??     



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 BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #4 on: March 26, 2017, 01:48:32 AM »
Thanks Dal!

The timing of my next potential surgery is to be determined.  It will take 2 months to know whether or not this surgery was sufficient (likely won't be with only a 30% success estimate - plus I'd like to be more active again and even if the bone marrow edema in my patella heals, I will still have a missing chunk of cartilage).  Then it will take some time to get pre-authorization for the allograft.  That could take a month or two.  Then, it depends on donor availability.  Dr. Farr said he has pretty good access to donors, but again, it could be months.  So I think the earliest possible would be July, but more likely late summer or early fall. 

I think one of those patellar subchondroplasty inquiries you are thinking of was me.  My first OS recommended one even though he was a bit shaky on it and mentioned it wasn't FDA approved.  He had never done one on a patella before.  Then my second OS (same clinic) said he wouldn't do it.  And then Dr. Dye of course wouldn't do it as he as all about letting the knee heal itself.  Dr. Farr was my final stop and again he won't do one now.  So 3 out of 4 OSs in my case were not willing to do one.  That should paint the picture.


Day 4 Post-Op
My ROM is improving and I was able to bear more weight today.  Again no pain meds today and no major pain to speak of.  The knee is still quite swollen and I have limited use of it, but I came close to walking on it without using the crutches much.  I tweaked my back today which was a setback, but not a surprise as I've probably been doing more with my back than I normally do and also a lot of lying on the bed in various positions.

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #5 on: March 29, 2017, 03:56:55 AM »
1 Week Post-Op
Today was the first day where I did some walking without the crutches.  I still took them with me to work, but at home I got around pretty well without them.  There is still some instability in the knee but each day is better.  The swelling has subsided to the point where I can start to see the definition of my knee and leg again. 

My mind often wanders to the more intense recovery I'll have with the allograft in my future.  I can't imagine 6 weeks in an immobilizer and using a CPM.  What I'm going through now is pretty insignificant in comparison.

I have a follow up on Friday.  I'm excited to hear more about how the procedure went and hopefully see some images or video.

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #6 on: April 05, 2017, 03:41:19 AM »
2 Weeks Post-Op

I ditched the crutches on day 8 post-op.  So far so good but I still am far from 100%, with my knee feeling stiff and still slightly unstable when walking.  But every day is a small improvement.  I am still icing in the evenings a bit.  I have some pain in the kneecap if I try to do leg raises when my knee is already stiff from being on my feet for a while.  When I lie for a while and then try to do leg raises, no problem. 

I made the haul back to Indy last Friday for my post-op follow up.  They showed me the images from the surgery, which was very fascinating for me after 3+ years of guessing what my knee must look like inside.  I could not believe the sight of the defect.  It reminds me of a nuclear bomb mushroom cloud.  Holy Jellyfish, Batman!  Pics attached.

The defect was around 16 mm x 16 mm and that is apparently about the size where it is considered medically necessary to pursue something like an allograft.  Thankfully the rest of the knee was in good shape and the trochlea was not damaged by the defect.

They said my ROM was about 120 degrees in the knee, so it's not far off from my other leg.  They said I could return back to the gym in 2 weeks, but the joke's on them because I wasn't going to the gym before.  Also they said to keep avoiding stairs until I'm at least 1 month out from surgery and even then it seemed like stairs were not highly encouraged.  I'd be curious if anyone else has experience with stairs post-op with a patellar defect debridement procedure.  Maybe they are being cautious due to the bone marrow aspirate work done.

Apparently Dr. Farr did one injection of aspirate into my patella and then a 2nd into the general joint capsule, or the open space within the knee.  The hope is that the 2nd aspirate injection will encourage healing of the cartilage defect, which I find pretty far fetched seeing as it is just floating around diluted in the joint fluid (at least in my imagination - maybe I didn't understand completely).  There was no microfracture or anything done to the defect other than debridement, so I doubt that even fibrocartilage would form.  Since I have a hole in my cartilage, I don't expect my bone pain to go away long term, even if the edema/stress fracture in the patella does heal.  It would likely just come back without the cartilage there to absorb shock.

They want to see me back in 6-8 weeks.  I'm not sure that one will be necessary as I'll either be feeling good and not want the allograft (unlikely) or I will know that I need it - not sure what else they can accomplish by seeing me once more.  Plus, this time I only saw the PA and she didn't even look at my chart before coming in the room and had to ask me what Dr. Farr did to me...not exactly what you want after driving almost 3 hours to get there and taking the day off work. 

The insurance process is already underway for authorization of the allograft.  That should take a few months.  It does look like everything with the 3/21 surgery so far has been covered by my BCBS group PPO plan.  There are always so many bills though with surgery that I am sure there are more incoming.

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #7 on: April 12, 2017, 03:04:59 AM »
3 Weeks Post-Op

Every day is a little bit better.  My knee is really starting to feel good now while moving around.  It is less stiff, more stable, and I think about it less and less.

I tested out the portion of my range of motion that used to cause severe crepitus and occasional pain.  There was no sound, no ratcheting, nothing.  There was some pain and it almost felt wrong to test it - maybe because I have been trying to avoid it the last few weeks and because my mental pathways expect crepitus/pain there.

I will post again once I try stairs or when I start to mull whether I want the allograft procedure.

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #8 on: May 13, 2017, 04:12:56 PM »
8 Weeks Post Op

Within the last few weeks my knee has really felt 100% normal again while walking.  I am still not really going up stairs on it but have tested it out a bit and it seems decent.  The crepitus is still staying away aside from a small click - nothing compared to the terrible velcro sensation I had before.  As for pain, it remains to be seen whether this surgery will solve my pain issue.  I haven't tested the knee much, but did have some pain yesterday after a 45 minute walk the day before. 

I have a follow up scheduled for 2 weeks and am debating going or not as it's a 6 hour round trip and I probably won't get much out of it.  My plan for now is to test the knee out a bit more and see if my pain returns, and if it does, I'll pursue the allograft most likely.

Offline Mark100pudov

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #9 on: June 08, 2017, 09:01:38 PM »
Glad to hear about your progress. How is your healing going on now?

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #10 on: June 17, 2017, 07:58:45 PM »
Thanks Mark.  I am about 3 months post-op now and things are pretty good.  I can go up and down stairs and don't have any crunching and no significant pain so far on stairs (but I've been pretty careful).  However, there is still a dull pain sometimes when I extend my leg or flex the knee.  It feels like it probably won't fully heal, but maybe I'm wrong.  I do need to test it out more too.  I am going to give it some more time but will seriously consider doing the allograft in the fall if I am still feeling some pain. 

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #11 on: July 01, 2017, 04:00:48 AM »
3+ Months Post-Op

I did some cycling this week (probably 2-3 miles, low gears) and the knee seemed to react well to it.  The knee felt good and relatively smooth during, and then didn't have any pain flare ups after.  It was encouraging and felt so good to be back on a bike after over a year.  I would like to test it a bit more and ride to work some time, which is about 4 miles one way. 

I do still feel the dull pain during my ROM, even without a load on the knee - just a simple extension will do it.  So that dull pain + the idea of keeping my trochlea intact for the long run are making me consider the allograft procedure.  It almost feels like Icarus.  I have seen quite a bit of improvement and maybe I should be happy with it, but I do fear that things will slowly degrade with time if I leave the cartilage pothole on my patella.  Plus, I don't think I'll be able to run in my current state, and I would love to run again some day. 

Offline Mark100pudov

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #12 on: July 06, 2017, 12:05:01 PM »
Thanks for the update. I'm not sure you've mentioned it (sorry if you have) but do you know what exactly the doctor did on your patella other than injecting the knee with bone marrow aspirate?

From what I've read, athroscopy is indeed only about temporary relief, so it's surprising your doctor said there's a 30% chance you won't need another surgery. Maybe it's just your particular case.

I really hope it works out well for you.
« Last Edit: July 06, 2017, 12:06:59 PM by Mark100pudov »

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #13 on: September 17, 2017, 01:17:42 AM »
Sorry for the delay Mark and thanks for the kind words!  Dr. Farr removed the delaminated cartilage from my patella and then injected the aspirate.  That's all he did.

6 Months Post-Op

My knee feels really good overall.  I have no pain while walking.  I have been taking stairs probably since about the July timeframe and generally have no problems.  Sometimes there is some slight pain while descending, but not much.  If I am on bigger stairs and do some decent dipping down, then I feel the pain.  I have ridden my bike to work without any pain. 

I feel very happy that the surgery was able to eliminate so much of my knee problem.  Since I am no longer athletically active, this simple surgery has alleviated almost all of my symptoms.  However, I have still not tried to run on the knee or jump on it. 

I have tried a few small things to push the knee a bit:
  • Getting in a car normally (i.e. on one leg) - this hurt my knee like in the past
  • Going up a step backwards on the bad leg (the ultimate test for me as it caused a lot of pain previously) - I had a fair amount of pain during this test
  • Climbing a ladder - Not too bad, probably more psychological at this point than anything

Clearly I still have the underlying stress fracture/edema, and there is now 0 cartilage in place to cushion that area.  In my mind I just imagine the rough edges grinding down my trochlea over time.

Thus, I am still planning to have the osteochondral allograft procedure on my patella, even though many of my symptoms have improved.  I called the office in July and found out that the paperwork had not been submitted to insurance for pre-authorization (you've got to be kidding me!).  They made up for it though because within a month and a half I had my pre-authorization letter stating that I could have the surgery done anytime in the next 12 months.

The plan for now is to target a late November surgery and hope for the best.  I am dreading the recovery already, but I really have great confidence in Dr. Farr after the last surgery and do not want to miss this opportunity to prolong the life of my knee.  I am banking on the fact that while I feel pretty good now, I will have a better chance at feeling really good for a very long time by having the surgery.

Offline BezProblemów

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Re: Patellar arthroscopy and illiac crest aspiration
« Reply #14 on: May 06, 2018, 08:28:32 PM »
1 Year+ Post-Op

I visited Dr. Farr in October of 2017 to discuss an osteochondral allograft.  He felt that at that time my symptoms were not bad enough to warrant an allograft.  He recommended I test the knee some by jogging in the spring and then coming to see him and getting an MRI.  So, I left that visit feeling optimistic, but I soon started to come back down to earth, thinking that my knee still causes me some problems and that maybe I painted too rosy a picture during the visit.

Over 6 months later and here we are.  Last week I went jogging on grass for the first time in about 4 years (wow, I felt alive again for about 9 minutes) and my knee was sore while running.  So much for that.  In general the knee has pretty much been the same - slight pain with stairs at times, pain getting in the car with one leg, but much better than before.  There have been some slight crepitus changes and the knee seems to be a bit less smooth while extending than it was about 6 months ago.

I visited Dr. Farr again 2 days ago.  I got an MRI.  The results shocked me:  the cyst in my patella was gone, and the bone marrow edema was gone!  He also said I had about 50% cartilage thickness in the defect area.  I reminded him that he originally said my defect was full thickness, and he checked the MRI from 1 year prior and confirmed that it was full thickness.  So it appears that in much of the defect area I have some cartilage coverage (probably fibrocartilage).  There may still be an area that is full thickness, but he wasn't sure based on the MRI.  Overall, these were great MRI results and far better than I had expected.  I honestly thought the BME was still there since I do still have some pain sometimes.

Based on the results, Dr. Farr could not recommend an allograft.  He said that he can't do anything to make me better at this point because my symptoms are just not severe enough.  He thinks that the risk of the allograft procedure and the recovery time do not outweigh any potential marginal benefit I would receive.  I really appreciated his candor.  He also said that since I no longer have a bone issue, the allograft would not be his recommended procedure anyway.

The current plan is to avoid activities that cause pain (no running and no exercising on stairs but taking stairs as part of daily living is okay).  If my symptoms get worse to the point where they start interfering with my life (intense pain and swelling/effusion), he wants to see me again and do another MRI.  They would then do another scope and potentially cartilage restoration (MACI). 

Here are some more interesting tidbits from the visit:
  • Anthem (Blue Cross Blue Shield insurer in 14 states) is no longer authorizing osteochondral allografts.  That severely limits options for surgeons in these states.  Dr. Farr recently had to do a kneecap replacement on a late 30s patient due to inability to proceed with allograft.  He said he is trying to get a group of surgeons together to fight Anthem's new rule.
  • It sounds like there is some work being done on variations of MACI, but these may not be better solutions, just different

That is all.  This post might be the last one for me on this surgery thread.  I'm very pleased with the results of my surgery.  I'm not 100%, but I know I am fortunate to not have major knee issues like some on this board.  I think I'll need another surgery someday, but I am optimistic that it will be a less invasive procedure than allograft, and that technology will continue to improve treatment options and outcomes.  Best of luck to all and let me know if you have questions - I will occasionally check in.



« Last Edit: May 11, 2018, 02:35:09 AM by BezProblemów »