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Author Topic: OATS and Medial Meniscus Transplant for 32 year old active patient?  (Read 4451 times)

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Offline badleftknee1

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Hey all,

I am being advised for OATS and medial meniscus transplant and this is horrifying. Let me explain:

I am 32 years old and have always been very active in sport. I first hurt my left knee at the age of 18, with a bucket handle tear of my medial meniscus. This was repaired. When I was 22 this was torn again, this time having to be removed, leaving my articular cartilage at risk. Alas, after 10 years of soccer, distance running, and telemark skiing, my life drastically changes 3 months ago when I noted after playing soccer that my knee felt internally swollen and was having major pains with cutting movements, and now even going up and down stairs is painful. I can walk and get around ok, but like I said, stairs are difficult which seems ridiculous for a 32 year old.

I went to see a local OS who specialized in sports medicine, trained in Boston and knows his stuff. He took X rays and found moderate-severe joint space narrowing on my left medial knee. We got an MRI which shows large full thickness chondral defects on the medial portion of my tibia as well as full thickness, more scattered and focal, defects in the femoral chondyle. His impression was that I was not a candidate for allograft/autograft/ACI due to the extent of the defects (probably up to 10 cm in total). His plan was for arthroscopy for visualization and clean up, lavage, as well as amniotic stem cells for symptomatic treatment (his thought is that cartilage regrowth is not realistic with stem cells and my degree of injury).

I went to Boston for a second opinion, where I was immediately offered an OATS (Allograft) in combination with medial meniscus transplant. I was told I was not "the most ideal candidate" but that it could be done, and they were optimistic given my age and fitness level.

In regards to my thoughts on activity and goals:  I am willing to give up running and cutting sports, but am unwilling to give up hiking, and some less aggressive skiing. At this current time I can probably hike although with some pain and some alterations in gait that doesn't allow me to get my thoughts off of my knee and is much less enjoyable than prior- I haven't tried skiing yet but I assume the same to be true.

So lots to think about, here are my major concerns:

1) OATS and Meniscal transplant literature and testimonials is very scattered literature. It is my best summary to state that it is a HUGE surgery and recovery, up to 2 years to really get back to anything in any comfort, and even when this does happen you may still be in pain and you really aren't looking at getting to anything better than walking, hiking, low risk skiing, cycling etc. The rates of success are quoted at 70-90% but this is at controlling pain, not stopping arthritis, and the better outcomes seem to be young patients (which I am) with smaller defects (which I am certainly not). If this were to somehow workout though, I least I could fend off a partial knee replacement for maybe 5-10 years, MAYBE? This is not to mention the cost, time off from my career, and potential complications which mean more time off and costs.

2) My other option is basically symptomatic treatment and waiting on a partial knee replacement, which is also scary as heck. My problem here is that my quality of life will be pretty crappy until I get the PKR- which seems to be encouraged at a young age (late 30s early 40s) by some, and discouraged by others. The problem for me is that if I get a PKR at at 38 for example (hopefully I can make it 5 years? maybe I can make it more?), and I am in the group that it fails after 5 years (rather than 20 years which seems to be the absolute longest), that means I need a revision to TKR at age 43- which leaves me completely debilitated ate 63 once that fails?

So my questions are these:

-Anyone out there in there early 30s 40s with similar decision making to do (or had to do)?
-Anyone with a combined OATS and Meniscus transplant by an expert in the field that went well? Didn't go well? What are you able to get back to? Would you do it again? Would you have waited it out and treated symptomatically?
-Anyone had a clean out, lavage type of scope that was actually helpful? Literature suggests otherwise but just curious.


Finally, I never could have imagined how difficult this is emotionally. I have found myself obsessive over trying to find solutions. I found this site to be very informative and in fact helpful with the emotional impact this has had on me. I am hoping that I can get some guidance from folks on my situation- my only request is that details be provided on your injury with a response as all injuries are not alike and I really want do my best to extrapolate from your situation!

Thanks so much in advance. Looking forward to some input.

Offline Vickster

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #1 on: October 22, 2017, 05:54:23 PM »
Look for posts by lateralmeniscusguy, he had similar done albeit lateral (in the UK)

He has a few posts in the meniscus forum e.g...

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=70076.0
« Last Edit: October 22, 2017, 05:56:26 PM by Vickster »
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 Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #2 on: October 23, 2017, 06:41:16 PM »

-Anyone had a clean out, lavage type of scope that was actually helpful? Literature suggests otherwise but just curious.


Yes, I had one for patella cartilage damage that worked well for approx. 6 years. However, I know it is a 50/50 gamble and I am thus hesitant to do it again, despite my previous success. 


Finally, I never could have imagined how difficult this is emotionally. I have found myself obsessive over trying to find solutions.


The mental game it really tough indeed, both regarding a) finding solutions when there are really no optimal treatments on the table, and b) recovery from surgery once you take the plunge.

I'm 35 and recognize the horror of these 'PKR/TKR-lifespan-until-total-disability-calculations'. Hopefully, PKR/TKR will not become necessary in your case for a long, long time, if at all. I think key here is that you do not rush in to something, get 2-3 opinions on what procedure to go with. Also, there has only been 3 months since your injury/flare up in symptoms, maybe things will settle down with time (despite your lesions) and it will be enough with a minimally invasive treatment.
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #3 on: October 24, 2017, 12:41:03 AM »
Brandon123 thanks for the info, it's greatly appreciated. I was hoping similarly that sometimes doing nothing is best, but I may go through with the minimally invasive scope and stem cells given that I really haven't seen any improvement in 3 months. I talked in detail with my OS, and he seems like he's a reasonable and experienced guy so I don't think he will be hacking away good cartilage in there. I can also stay awake with a spinal instead of general anesthesia if I want, and watch the whole thing. In that regard, I don't think I will be doing harm but MIGHT (probably not a great chance) that he finds something that may be irritable and remove it, and will get the stem cells which might help from an anti-inflammatory standpoint. Then PT, unloader brace, and see how things go. OATS/MTS ONLY if becomes debilitating I think, which I hope it will never become. Ah, life changed quick on me this year, that's just how it goes I guess- time for children? a boat?

Anyone out there living with severe arthritis (grade 4, bone on bone) and just get on with life with it? Would love to hear what you are able to do? how limiting it is?


Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #4 on: October 24, 2017, 09:01:17 AM »
I may go through with the minimally invasive scope and stem cells given that I really haven't seen any improvement in 3 months. I talked in detail with my OS, and he seems like he's a reasonable and experienced guy so I don't think he will be hacking away good cartilage in there. I can also stay awake with a spinal instead of general anesthesia if I want, and watch the whole thing. In that regard, I don't think I will be doing harm but MIGHT (probably not a great chance) that he finds something that may be irritable and remove it, and will get the stem cells which might help from an anti-inflammatory standpoint. Then PT, unloader brace, and see how things go. OATS/MTS ONLY if becomes debilitating I think, which I hope it will never become.

I think this sounds like a reasonable plan. However, an inflamed/irritated knee can take a long time to settle down, many months. So I would probably still give conservative treatment a few more weeks before the scope + stem cells.
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline Vickster

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #5 on: October 24, 2017, 02:23:36 PM »
To your question...
I'm older than you (45 now, 37 when I first injured my knee, was scoped twice the year after, lateral 25% lateral meniscus removed), but based on the most recent MRI (a year ago), I have a 2.5cm2 defect on the WB lateral condyle. This filled with fibrocartilage in response to the trauma (was bone on bone at that time, my knee did a diy microfracture essentially), but the fibrocartilage is now deteriorating as would be expected so long after it formed. Subchondral cysts and bone marrow effusion
Other mild changes through the lateral tib-fib compartment
Degeneration and fraying of the medial meniscus
Full thickness focal cartilage loss on medial femoral condyle
Fissures on apex and medial facet of patella

Despite all that, and potentially more deterioration since (and a diagnosis of possible inflammatory arthritis), I don't plan to do anything. I have hyaluronic acid injections every couple of years (had a series of three after that MRI)

I'm due another scan on the knee for another reason, see if that shows anything else

I know the endgame is a TKR for me, at one point it was just the lateral compartment and a DFO or PKR might have been possible but that ship sailed. I went down the MACI path about a year after the injury but the surgeon wouldn't do it as I'm mildly knock kneed. He offered a DFO, I wasn't going there.

I can still cycle, work, go on holiday, although I now have arthrtis in my foot on that side too so trying to manage foot pain (worse than anything the knee chucks my way). I can't kneel, I can't run, I can't really even bend the knee fully but nothing that stops my life ultimately.

Good luck with whatever you decide. I'd only have major surgery if I was pretty sure I'd be better after recovery. And probably not two or more years of rehab
« Last Edit: October 24, 2017, 02:28:52 PM by Vickster »
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 badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #6 on: October 25, 2017, 12:15:07 AM »
Vickster,

Thanks for the reply. Very helpful.  How long are you gonna hold out on the TKR? Any way you could have monitored more closely (as to be a candidate for the PKR) and not let the ship sail? Are you able to hike still (if that's an interest of yours)? Thanks again.

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #7 on: November 01, 2017, 02:25:25 PM »
Hey all, went for my scope yesterday and a few surprises but overall is what they they thought it was. I knew I had extensive medial 1/3 tibial plateau cartilage loss (grade 4) as well as focal grade 4 lesions of my medial femoral chondyle from the MRI- the scope confirmed this but they also found a more acute flap or articular cartilage in my medial femoral chondyle, which they ended up doing a Microfracture on as they thought this may be the pain generator that was more acute for me (the thought is that the tibial plateau lesions may be more longstanding)- they also found a decent amount of shredded meniscus that they thought could also be contributing. So the big surprise is that I now am partial weight bearing for 6 weeks, and recovery to sports (if it works out) looking like 6-8 months. The doc thinks it went well and is hopeful for me to get back into sports, with some pain of course but to a lesser degree. For now, Iím in absolutely no pain and already flexing 90 degrees so the hardest part of this is gonna be mobility around work and the house! I will def keep updating on my recovery and let you know if I can get back to some more high impact activity as I go along. This is, fingers crossed, a good enough bridge to get me another decade without a PKR. If it doesnít work, I will need to consider the riskier allograft procedures.

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #8 on: December 27, 2017, 03:51:12 AM »
Brief update, for anyone out there following, or will follow. I'm now through my 8th week post microfracture. I started bearing weight in the 6th week, at first just toe touch, then 50% weight with two crutches, than 75% weight with one crutch for a week, then off completely just today! The progressive weight bearing is absolutely needed- I consider myself fairly fit and I worked hard to keep my muscles from atrophy during the non-weight bearing portions of recovery, but I definitely needed to progressively come off crutches. Today, I was happy to be able to walk relatively pain free- my biggest concern was that I would have sharp pains emanating from the microfracture site with each weight bearing step, which I don't have. I do have some general instability and easy fatigability and I have to focus on steadying my knee. Also, I have noted that if I stand for too long I seem to stiffen up, seems to be coming from the patellas ability to mobilize; partially I think due to some minimal swelling that remains (particularly apparent with full flexion of the knee where you can feel bulging in spaces around patellar tendon).

So all in all, I'm slow and still a little stiff/swollen in the knee at this point but am seeing steady improvement. For anyone out there who is getting a microfracture, be warned that you get a multitude of odd symptoms and pains from the site- do your best to ignore it (don't obsess over it like I do) and move on as they go away!  The real test is gonna be weighting the knee with a bend (e.g. stairs, squats, cutting motions) as ultimately these deficiencies were the reason I went for this procedure in the first place.

Updates to come.

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #9 on: December 27, 2017, 09:38:00 AM »
Glad to hear that your recovery is going well, looking forward to your updates!
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline fro60ol

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #10 on: December 27, 2017, 04:28:41 PM »
badleftknee,

i just saw you response to my post thanks again.... i am glad everything is going well for you post-op
what do you do for work and are you back to working?

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #11 on: December 29, 2017, 02:37:06 AM »
Fro, I am in medicine myself. I took a week of vacation for my surgery (disability not a real option for me), and then set it up so that I was working more of a desk job role for 2 months post op. I will be back on my feet, on the job, starting after the new year. I think I will be ready! The weeks directly following surgery were tough at work, even in a desk job. Mainly, this is because I wanted to either to be icing, elevating, or to be doing constant leg motions and working leg muscles to prevent atrophy which is hard to do when you are focused on tasks. I still managed to get a lot of passive motion movement in (I was not given a CPM, was told to do a TON of passive ROM instead). My thought on this is that if its an arthroscopic surgery you would be best taking 2 weeks (maybe more) if you have a desk job. I think if it is an open surgery you should plan on 4 weeks + off. If you have a job where you need to be active, that's a whole different story.

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #12 on: January 24, 2018, 02:07:59 AM »
About time for the 12 week post surgery check in. Some good, some bad here.

The good: I have transitioned nicely into full functioning at the job, around the house, etc. I feel I have made some gains in that I don't have as many sharp pains with small movements and turns compared to pre-surgically), and I also don't have the constant swelling sensation in my knee (although with a hot shower the swelling/sensation of swelling does come fleetingly). The swelling is nearly completely resolved.  My walking is nearly limp free, although when I walk quickly I can still feel a slight hitch in my step (and fleeting pains) although I am not sure the limp would be noticeable to others. I transition well from chair to walking, in and out of the car without any pain. I have been able to bike 30-40 minute clips on high resistance, do squatting exercises, and generally get around the gym just fine. Hoping I am cleared to swim soon which I am sure will go fine. The "sticking" I was having (primarily around patella) with initiation of movement has improved a great deal, likely with continued control of the inflammation. I am able to take the dog for 20-30 minute trail walks.

The bad: Stairs are still an issue. I do think there has been just the slightest improvement from pre-surgically in that I can bear weight on the uphill leg and push through some pain in order to get up stairs. BUT, it still is tender and my knee buckles in in a reactionary form to try and offload the medial joint space with every step (unless I slow down and really concentrate on activating muscles around the knee). Similarly, weighting the leg when the opposite foot steps down the stairs is troublesome- my leg seems to want to just drop the leading leg down as to avoid weight. I did have some improvement in these challenges, possibly around the 10-11 week mark, but have seemed to plateaued over the past week or so. Even offloading the joint the slightest makes it pain free, so it feels so close to being a pain free endeavor, but unfortunately not there yet. I am going to get an unloader brace soon hopefully, I would imagine this would be helpful given that even the slightest touching of a railing offloads my medial joint space enough to make it pain free. Any form of athletic movement still seems a ways off (although I haven't tried), I am sure it would cause some jolt of pain. I can very well localized where the pain is with my exercises, typically with all weight on slightly bent knee (20-45 degrees), exactly where my surgeon describes the microfracture site to be.   

I know its still "early" at 12 weeks out but I can't help to wonder if it is going to get better than this. I think only time will tell, and I know its important to stay optimistic.  I think at 6 months, with continued rehabilitation, it is safe to say that perhaps improvement would plateau. I am still hoping for continued improvements at this point. Even if its not perfect, but with wearing an unloader brace makes it so I can hike, etc, I would probably be happy (assuming it could get me to 40 or so before a PKR). I start a new job in September of this year, and at that point it wouldn't be acceptable to take 4-6 weeks off for another NWB recovery session (I would probably have to wait 1-2 years into the position before asking for something like this).

I think if there isn't continued improvement I would at least seek out a few more opinions on what to do, but I think it would likely be allograft and meniscal transplant vs. early PKR (given my neutral alignment not a candidate for HTO). Allografts are just tough given that you have to be ditch out your life with minimal notice when the transplant is available. The effects on my career would be my biggest hold, not fear of surgery/recovery, etc.

Alright, that's all for now. I will probably check in once monthly or so, and definitely at the 6 month mark.

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #13 on: February 21, 2018, 01:22:58 AM »
16 weeks/ 4 months post op:

This will be a shorter post today. Mainly, because there hasn't been much change.

The good: I am now walking around, limp free, at full speed. I rarely get twinges in my knee with day time functional movements, but they do occur. My swelling is completely resolved, and my patella no longer catches after prolonged standing. I can bike, swim, lift, and just started to use the elliptical without issues. I can walk for rather long periods (several miles) without issues. It does feel good to have uninhibited freedom with daily life again. I have improved from my post-injury, pre-surgical level in that functional movements (e.g. just getting around the office, pushing the clutch in the car), and swelling sensation in the back of the knee are now improved.

The bad: Stairs (down, more so than up), steeper inclines, and any degree of athletic movement are still not happening pain free. Read my prior post for the details here but I really have plateaued over the last 4 weeks regarding these issues. As an example, I went for a 5 mile light hike (rolling hills) a few days back, it was uncomfortable though not outright painful (uncomfortable enough to make it far less enjoyable than it should be). 

My OS is still optimitistic, noting that my edema has resolved and ROM is perfect, though he is surpised that I am stil having activity related pain in the medial compartment after microfracture. Without my request, he recommended we repeat an MRI to take a look and see if the defect has filled. At this point I would be lying if I didn't admit to having serious doubts on the effectiveness of the MFX procedure, despite this still being "early."

Will update after the MRI. Happy healing all.

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #14 on: February 21, 2018, 08:49:00 AM »
Sounds really good that your daily functioning has improved a lot! It will be interesting to see whether the MFX worked. If it didn't fill that lesion, maybe it is still contributing to your pain with more strenuous activities.
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment