patella lesion repair, microfracture & stem cell implant

[DreamRunner]

Hi all, I had an arthroscopy just over a week ago for a large, 2cm x 1.5cm grade ivb, osteochondral focal lesion on the articular surface of my right patella. The surgery record refers to the procedure as "scaffold augmented microfracture" and they also implanted stem cells taken from the bone marrow in my iliac crest in order to regrow the cartilage (if it is successful). They tidied and prepared the lesion, microfractured the exposed bone, then mixed the stem cells with collagen and fibrin glue and pasted this over the defect. pre-op I was given a 75% chance of success but this may have lowered now, as the actual defect was larger than first thought. The theory is that as the microfracture heals, the collagen and stem cells encourage the formation of new cartilage. Straight after the op I had an hour of CPM and was straight away allowed full weight bearing as pain allows but am needing to use crutches still due to pain & instability, and have to use a knee brace locked at 0 - 20 degrees for standing and walking. The procedure was performed by Professor Anan Shetty with Mr Ahmed assisting, at KIMS hospital in Maidstone where I was treated very well indeed and was allowed home the same day.
I am posting my progress here in case it helps anyone else with a similar condition and also to share the journey's ups and downs.
pain was quite bad the first few days but was not as bad as I had expected, I've had worse back pain in the past. Currently the knee is aching at times, is still a bit swollen and feels hot so am icing 3 or 4 times a day.
The biggest problem I am having is that the knee is completely unstable as the quads don't want to work. It's a problem that I had for the last five years and the knee was giving way when walking, and running and descending stairs in the usual manner, have been impossible. I wasn't expecting this level of instability afterwards though, it's currently much worse. I would not be able to stand or walk without the knee brace right now. I believe the quads won't engage due to the patella pain when I try to tense them. It wasn't a problem that was anticipated by the physio though, as he gave me a set of exercises which included straight leg raise and raising the foot with the towel under the knee - both which are impossible to do, at first the muscles were just going into spasm at any attempt to tighten the quads and now are still having spasms but are more jumping up and down as I try to tighten them, cutting in and out, has anyone else had this? Before the op I was able to do straight leg raises with heavy ankle weights no problem, it was just putting load onto the bending knee that was impossible. One thing that has pleased me already is that I can do the leg extension almost all the way, which has been impossible for five years due to the pain. Range of motion exercises are coming along well too. I'm seeing the physio in about a week's time. I would be very interested to hear if anyone else has had a similar procedure and how they got on  TTFN

[DreamRunner]

Just a mini update. I have been feeling really down the last few days and at times quite afraid that there was something else wrong with my knee that was causing the instability, which surely my physio or surgeons would've warned me about if it was expected?

The knee is still giving out as I walk, despite the heavy-duty locked knee brace and crutches. It 'slips' out as I try to put weight into it at anything beyond about 5 degrees, which is exactly the same as I have had over the last five years only now it's worse.
The giving way started when I was walking up a step (in 2012) and the knee very suddenly and forcefully gave way and buckled beneath me. straight away I had severe pain on trying to bend the knee and walking became extremely difficult - as difficult as it is now. I had a MRI and it was reported as osteochondritis on the articular surface of the patella, not OCD but 'healing' osteochondritis. I can only think that was the cause of the lesion which did not appear straight away, as I had thickened, hypertrophic cartilage and a 'cyst' within the bone on that area. The lesion with full thickness cartilage loss only showed up on last year's scan.

Anyway, I felt a little more cheerful and hopeful today when I managed to do some straight leg raises, although very wobbly ones, but it made me feel like I was making a little more progress because until now I have not been able to do these due to muscle spasms. Even on the morning of my surgery 11 days ago I was doing straight leg raises with 5kg ankle weights so I felt sure this difficulty couldn't be down to muscle weakness. I think it must be due to the area of damage on the patella which is relatively large, given the small size of my kneecaps. Professor Shetty said it was the largest (and deepest) of this type of lesion he has seen on a patella.
Anyway, I am feeling a little happier now for achieving this small step today, and my leg muscles feel a little more 'awake'. I have my first physio session in three days and have a follow up with the surgeon in four days so will update again after that

[DreamRunner]

Hi all,
just updating on my progress.  I had my first physiotherapy session this week. He's pleased with the progress I am making but said it will be a long process of trying to get the leg working again, it will be months as opposed to weeks of physio, which is pretty much what I was expecting given the level of dysfunction I have had for years now, being unable to do most exercise, even cycling and swimming were too painful, I couldn't even kick my shoes off! my vastus lateralis has gone completely and is hollowed in instead of curving out, my right (bad side) thigh had been 1 & 1/2 inches thinner than the other for years so I think it's going to take time to build that up, having said that I can feel that muscle is working again already, the day after surgery I noticed it felt sore and now realize that's because it's working again, it must have completely switched off due to the damage and pain. I had been able to do straight leg raises before so my VMO wasn't so bad.

Currently, my exercises are progressing still, the straight leg raise is still jumpy and wobbly, leg extensions are slowly strengthening but I have noticed there is a strong click in the kneecap as it passes a certain point and then it clicks again as I lower the leg back down. There is also some pain in the patella bone at the region of the defect when I do this exercise, which worries me in case it is damaging the repair.
I have now just about regained full ROM, which pleases me because it helps when turning in bed etc. I still have swelling but it's 50% improved since the first few days when it was like a grapefruit, I can now nearly see my kneecap again. I am getting quite a lot of stiffness too.

I also saw the surgeon this week. He told me it will take 18 months for the cartilage to fully regrow and that it should be 25% grown after 6 months (I think that's what he said). At 6 months, which will be around Christmas time, I will have another MRI and it's then that we'll see if the repair has worked and if it is re-growing. He also explained that the clicking is caused by the line around the edge of the repair and that it's common because it's not possible to get it perfectly smooth. I am guessing this may be permanent as the new cartilage will grow into the filler matrix and there will always be a 'join', I can live with it though, it's nothing compared to extreme pain and loss of mobility.  Best wishes to fellow stem-cellers! Will update again as things progress

[stevew4270]

Dreamrunner Fascinated buy this never knew it even existed!! Can I ask you please where are you and where did you get this surgery? Secondly I have lesion's on both the pack of the patella nd also the femur. Is it possible to get this treatment on  two surfaces opsite eachother ??

Cheers and great news, long may it continue!!

Thanks Steve

[stevew4270]

Sorry missed your location. I see it now, were you private or NHS please and can you get this treatment on the NHS or private only please?

[DreamRunner]

Hi Steve,
I got it done on the NHS! I was preparing to have it done privately as my GP didn't think it would be covered by NHS but it was, including all scans, consultations and physiotherapy. Before the op the surgeon thought they may find damage on the femur too and said that he would also repair that at the same time, so yes, you could get both lesions done. It turned out I just had the patella lesion so that simplified things. If you have the two lesions opposite each other then you have to go non weight bearing or partial weight bearing for the six weeks, which I imagine would be tough, but worth it to get your knee back!

Are you in the South East? I think Professor Shetty has been training orthopaedic surgeons from other areas in this technique so there may be someone near you who is doing it. I think it is all relatively new so not been publicised much. They said there was a 75% chance of mine being successful, though that may have dropped a bit because the lesion was half a centimetre bigger than first thought. I really wanted to try it though, my other option was to have it resurfaced with a plastic button insert, and that was going to be at a private hospital in London because that wasn't available on NHS, so I am thrilled to have got it done, and close to home too which mad it easier on the day.
Do keep us updated if you decide to go for it. Good luck with it 

[stevew4270]

DreamRunner

This really is enlightening to hear. I m going to see my surgeon one last time begining of next month and think there saying par knee replacement which with my job and age I m not really comfortable. If stem cells from them is not an option I m going to pay to get stem cells private. Will definatley keep you updated and thanks for alerting everyone on here to this new technique Has lifted me quite a bit to know there are a few options out there. If I get stem cells as planned I would like to know regardless of money and time which is the best option to go for, I m well aware theres no garuntee with anything but need to give it one last go before I resign to getting a part knee as theres no going back once I go down this avenue. Hopefully the lesion only being on your kneecap has been a big help to your success and long may it continue. Must feel great now having beeen through so much pain!!! Rock on Babby!!! I m going to try to research the difference between getting bone marrow stem cells and cartilag stem cells as this is brand new to me its best I have a basic understanding before I go and ask someone to give them to me. Thanks Alot VERY VERY Grateful for this post!!

[DreamRunner]

Hi Steve,
I am so glad I did this post now hearing that it has helped you and given you more information regarding your options, whichever way this goes for me I hope it offers information to you and others with similar injuries. I had a look through your posts to see how you got to this stage, and one of the best things is that you've had your tracking and alignment corrected as maltracking is a big factor in the failure of patella repairs - as i'm sure you know! They checked mine before the op with a series of CT scans that shows how the patella tracks and if it tilts when bending the knee. My patella sits laterally but tracking was ok so they didn't have to do lateral release, which made it more straight forward.
I don't know much about MACI, but what I have gleaned in the past is that the main problem with patella repairs is the shearing forces on the patella which most repairs (standard microfracture) cannot withstand. With the treatment I have had they use fibrin glue in the mix which is really hard and protects the repair until the new cartilage has grown, which takes around 18 months. After that the glue and collagen it's mixed with is gradually absorbed and disappears. This is the way I understand it - I may have misunderstood but I think that's how it works, so I think that's what makes it a more successful repair for patella lesions.
I agree with you about knee replacements, I am 50 and still feel I want to keep that as a last resort, that's why I wanted to try to re-grow the cartilage with stem cells, and if that's not successful then move onto knee replacements.
Good luck with your upcoming consultation. If they don't offer you what you are looking for, Professor Shetty also works at the Spire Alexander privately if you can't get your GP to refer you on NHS (I don't know how it works with referrals). I too was prepared to go privately to have this done, with it being a 'simple' arthroscopic procedure it was going to be much cheaper than the resurfacing anyway, but fortunately I didn't need to. Best wishes and good luck! 

[stevew4270]

Cheers DreamRunner

LOL its fantastic I phoned Professor Shettys secratery today but think it was his NHS secratery to get an idea or price but she never answered, will try his private one in the morning cheers. I phoned a surgeon who I have herd great reviews about who works alongside the Mr Skinner (Gent) who did my last MACI stem cell implant. His secretary said they are no longer doing the MACI and now using the Bone marrow stem cell implants (I m guessing this is the same as what you have had) as its cheaper and only one op so quicker. She said its £16000 ish as opposed to 21k for the MACI. I have found this all out through your prompt so If I have to go private then wont be as painful.

Its uplifting to hear all this!! WOW About the glue if your right that means it has a far better chance of success last time I had it only lasted 6 months though I put this partly down to the out of alignment.

REALLY REALLY Lifted me Thanks

[DreamRunner]

Update:
Hi folks! It’s 6 weeks since the surgery. I am free from the knee brace now and dropped the crutches a couple of weeks ago. Still have some pain in and around the patella and occasional slight swelling and hotness, and still using ice for that. I am managing to gain strength in the quads, the muscles are now larger and stronger than they have been in years, HOWEVER, they are not working when I walk and the knee is still very unstable or “wobbly” as I call it, and it is painful to walk as the leg either remains straight, straining the back and inside of the knee, or the knee gives out.
I saw the surgeon this week and he explained to me what is happening. He says the Instability is called “pseudo-instability”, and is caused by the affected area of the patella riding against the edge of the femur (the lateral condyle, I think), and the pain of this has caused “quadriceps inhibition”, which is where the proprioceptors in the tendons that join the patella send messages to switch off the quads muscles. It’s good to finally have this explained after having this giving way problem for over 5 years, but it is very worrying as it will be very difficult to get them firing again, especially while the patella is not fully healed.
The surgeon also gave me a little more information about the repair, which I had not been told about before, he said that the repair ‘gel’ mix, which was full thickness (same as existing cartilage) at the time of surgery, would now be much narrower and lining the bone within the hollow of the defect. This, he explained, is because the fluid/moisture content from the gel will have seeped out into the joint fluid after about 2 weeks post op. The stems cells, though, are still contained within the remnants of the gel and will (hopefully) have grown back 25% of the cartilage within 6 months.  Also, interestingly, he told me that as the new cartilage grows, it is shaped by the trochlear groove as the patella glides against it, and this is why it’s so important to strengthen the VMO as much as possible to keep the patella where it should be within the groove, if there is constant catching of the defect area against the femur, then that area of the new cartilage will end up with a dent in it, which is not ideal!
Before the op, at the initial consultation, I was told I would have another MRI at 6 months to see if it has begun to regrow, but now he is saying there’s no need unless I am having significant problems (pain and instability I presume?), so now it’s just a case of be patient and wait and see. I will post again before the 18 months is up, though, with news of how the quads are going. 
 

[ayoung555]

Hi all,
just updating on my progress.  I had my first physiotherapy session this week. He's pleased with the progress I am making but said it will be a long process of trying to get the leg working again, it will be months as opposed to weeks of physio, which is pretty much what I was expecting given the level of dysfunction I have had for years now, being unable to do most exercise, even cycling and swimming were too painful, I couldn't even kick my shoes off! my vastus lateralis has gone completely and is hollowed in instead of curving out, my right (bad side) thigh had been 1 & 1/2 inches thinner than the other for years so I think it's going to take time to build that up, having said that I can feel that muscle is working again already, the day after surgery I noticed it felt sore and now realize that's because it's working again, it must have completely switched off due to the damage and pain. I had been able to do straight leg raises before so my VMO wasn't so bad.

Currently, my exercises are progressing still, the straight leg raise is still jumpy and wobbly, leg extensions are slowly strengthening but I have noticed there is a strong click in the kneecap as it passes a certain point and then it clicks again as I lower the leg back down. There is also some pain in the patella bone at the region of the defect when I do this exercise, which worries me in case it is damaging the repair.
I have now just about regained full ROM, which pleases me because it helps when turning in bed etc. I still have swelling but it's 50% improved since the first few days when it was like a grapefruit, I can now nearly see my kneecap again. I am getting quite a lot of stiffness too.

I also saw the surgeon this week. He told me it will take 18 months for the cartilage to fully regrow and that it should be 25% grown after 6 months (I think that's what he said). At 6 months, which will be around Christmas time, I will have another MRI and it's then that we'll see if the repair has worked and if it is re-growing. He also explained that the clicking is caused by the line around the edge of the repair and that it's common because it's not possible to get it perfectly smooth. I am guessing this may be permanent as the new cartilage will grow into the filler matrix and there will always be a 'join', I can live with it though, it's nothing compared to extreme pain and loss of mobility.  Best wishes to fellow stem-cellers! Will update again as things progress

can you email me directly if possible or send your email address? Love to know more about your procedure and progress. [email protected]

[mjeffrey]

Better to post here rather than start a private conversation. I'm following this thread and I think a lot of other people would be interested as well.

[DreamRunner]

10 weeks post op now. progress is slow. It looks like there won't be substantial differences in my leg function until the repair is largely healed, which might take the whole 18 months. I still get bone pain in the patella like I used to, which worries me in case it is not healing. The physiotherapist keeps me positive but also says it is going to take a long time. The knee swells easily and goes wobbly - quads inhibition - with the smallest amount of walking, which then continues to be unstable for days. The other day I slowly walked about a hundred yards and it went wobbly and the knee had swelled to double it's size. At least now I understand why this keeps happening - swelling leads to quads inhibition and therefore 'instability'. This vicious cycle is to be avoided in order to make progress, according to the surgeon, but that's easier said than done. He also said ice is very important to prevent this, which I am still doing most days.
An interesting thing started happening about a month ago, when I completely straighten the leg and tighten the quads, as when doing thigh squeezes, the knee cap gets stuck then releases with a visible jump and an audible crack, presumably the edge of the lesion is getting caught up against the femur. for a while it started doing this when I was walking, which was mildly irritating, though fortunately it doesn't hurt. At my recent physio appointment he got me doing light squats (deep squats, along with running and jumping, are forbidden for 18 months) and this seems to have helped prevent the clicking, except for when doing thigh squeezes. My guess is that the VMO is strengthening and is correcting the tracking to keep it from catching so much, which is good.
I have gained a little more bulk in the muscles, which is great, any progress is welcome, but I have to say I was expecting to be better than this at this stage, and the slowness of progress keeps me from getting excited. It would be nice, though, to think that in a year's time I could be going for a walk somewhere...   

[Brandon123]

Thanks for the update! Try to stay positive, and keep in mind that you are only 10 weeks post op and this is a marathon. I wouldn't be surprised if progress is slow in the beginning (first months post op) and then speed up.  Can I ask if this method has some specific name that is searchable online? There are so many different cartilage restoration techniques out there, and it is difficult to understand the difference between all of them

[DreamRunner]

Hi Brandon123,
Thanks for your words of support, that really helps! It's a really up and down journey physically and emotionally and I suppose that comes across in the diary. I also have ME/CFS and Fibromyalgia so that drags me down too and probably casts a shadow over the progress I am making. But thanks again for your words of encouragement as it really helps put things into perspective, and the marathon is a good analogy, I will try to keep that in mind. Ultimately though, what I am trying to do here is give a true account of my journey after this procedure, whatever directions it takes.
I was not given a specific name for the procedure and I, too, have tried to search it online but not found much other than a similar procedure called Cartifill. The consent form I signed called it "Scaffold Augmented Microfracture", but that didn't yield much in a Google search. The operation note I was given on the day of the procedure said:
"Procedure: Bone Marrow Aspiration Illiac Crest, right knee arthroscopy, repair osteochondral lesion." and further on says: "Lesions Pat 2x1.5cm, lesions debrided to subchondral bone, microfracture done, CO2 insufflation, lesion treated with BMAC/HA/Fibrin gel.
Hope that helps explain the method a little. Perhaps they'll give it a more common name in the future, it is quite new, Mr. Ahmed (who I saw on the follow up) told me they had only been doing it 5 years or so. The nurses and physiotherapists don't even know much about the procedure.
I have got some pictures taken during the arthroscopy, but I'm not sure about posting them as they are a little graphic!!