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Author Topic: OATS and Medial Meniscus Transplant for 32 year old active patient?  (Read 4449 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

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #15 on: March 11, 2018, 01:56:48 AM »
Just wanted to update on MRI results. So you canít actually see the chondral defect healed in, which I am being told (which seems reasonable) is because fibrocartilage is a different density than hyaline and wonít show up at around 4.5 months. What you can see, however, is that my subchondral bone edema in my femur is completely gone. I still have a touch of edema in the subchondral bone on the tibial side (which currently has grade 3/4 wear). This means that either 1) stopping high impact activities has helped the edema and/or 2) the microfracture was atleast partially able to fill in the defect. Really not too sure what to think of it. In the end I think it is really how I feel is what matters.

So hereís my new conundrum. I have a few months off this summer between jobs (would be about 8 months post the microfracture surgery) that I can think of a million better ways to use other than surgery- but if itís the best thing form my future this would be a nice time window to have an osteochondral allograft and meniscal transplant completed. I would need to start getting this set up soon. Although I have seen some benefit with microfracture I still feel like some really important activities would still be very uncomfortable for me (mainly hiking, skiing). Of course there are no gaurantees with the transplants, in fact itís a bit of a long shot with my cartilage status. So my biggest thoughts now are- is my microfracture going to keep healing and I am rushing the process? Is it worth going with the transplants, to begin with regardless of timing (eg is is realistic tho think I would be doing anything more than walking, which I already do fine with)? If the transplants fails am I ďfast trackedĒ to knee replacement? Decisions, decisions. I donít think there are good answers really. I think Iím going to start by getting a few additional opinions at this point.

Will keep the updates coming.

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #16 on: March 11, 2018, 09:30:30 AM »
If you function well in everyday life, walking/standing without limitations, no major pain/stiffness/swelling/inflammation problems with everyday activities, I would probably not go for another surgery at this point. Hiking and skiing might be difficult despite another surgery, and the fewer surgeries you do, the better. That's just my two cents. However, just as you plan, I think it is a good next step to a get few additional opinions. 

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 #17 on: March 12, 2018, 12:10:50 AM »
Brandon, would you count stairs as everyday activities? Still have a bit of trouble with those. Otherwise I do reasonably well at this point- no locking, minimal stiffness, no inflammation, occasional twinge, definatley will get sore after a half day up on it- but not too bad. Thatís about it.

Part of me totally agrees with you that I should wait this out- see if it gets better in a delayed fashion and just deal with my functionality as is- have also been interested in getting an unloader brace to see if that is helpful. Another part of me really wants the more active side of life back, even knowing itís a long shot. That and I am wondering if the transplant could offer me some less symptomatic years to come, even if the underlying arthritis progresses. Out of curioousity- what bothers you about getting a another surgery in my situation- the risk of it getting worse? The risk of scar tissue formation? The risk of altering the effectiveness of an eventual PKR?

Thanks for all your input.

Offline Brandon123

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #18 on: March 12, 2018, 03:51:07 PM »
Yes, I do count stairs as everyday activities. If you cannot climb stairs (up and down) without pain, then of course that is a problem. But one thing regarding stairs, before I had my scope in 2009, I could not climb stairs at all. After the scope, it took me 1-2 years until I could climb stairs without any limitations (like 7-8 floors in fast pace up and down) and see the full benefits of that surgery. So at least based on my own experience, I still believe you might see further improvement after your scope last year.

There is nothing in particular that bothers me about getting another surgery in your situation. Just that fact that you have had multiple surgeries on that knee already, and for every surgery there is an additional risk of scar tissue formation, accelerated arthritis progression, things going wrong etc. My thought was just that if you function well without any major problem/pain/symptom in everyday life, the safest route would probably be to give it another 6-12 months and see if you will improve further from your latest surgery.

However, of course only you can decide how comfortable you are at your current level of functioning, and how important additional activities like hiking and skiing are for you, and if it is worth trying to get even better with a new surgery. These things are not easy, I know.
   
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 #19 on: March 13, 2018, 01:43:17 AM »
Thanks again Brandon. Will keep you updated on my discussions- going to meet with one additional cartilage specialist over the coming weeks and also discuss my situation with my OS in a little bit more detail, see what he has to say. His major problem (not being a cartilage specialist, more sports med specific) with meniscal transplants (and the reason he didn't want me to jump to it right away) is that you are basically taking away any pivoting activity just by taking on the surgery in the first place. It truly is more salvage for the majority of us. My major problem with it is that I can't find any success stories out there to make me feel confident enough about it, and the fact that my wife may kill me if I take are long awaited 2 month break for recovery!

Offline Vickster

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #20 on: March 13, 2018, 07:55:31 AM »
Have you read this diary? Lateral meniscus plus OATS (donít think it was a big defect which will obviously impact success rates ?)

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=70076.msg671476#msg671476
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 #21 on: March 13, 2018, 05:27:07 PM »
Will keep you updated on my discussions- going to meet with one additional cartilage specialist over the coming weeks and also discuss my situation with my OS in a little bit more detail, see what he has to say.

Sounds like a good next step!
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 #22 on: March 13, 2018, 07:28:42 PM »
Vickster, I have been reading that blog- its fairly promising - we will need to keep following him for 3-4 years to see whether or not it was worth it. The major difference in my case that worries me is cartilage status- mine is more severe.

Some recent studies below: basically, bipolar cartilage lesions do benefit from meniscal transplant but are more likely to tear over a 5 year period (this is with concominant treatment of cartilage injuries). Also, lateral meniscuses seem to do better than medial. Unfortunately, the cards are seemingly stacked against me a bit more.

https://www.ncbi.nlm.nih.gov/pubmed/28075154
http://journals.sagepub.com/doi/full/10.1177/2325967116663185



Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #23 on: May 07, 2018, 04:02:31 AM »
Hi all, some updates.

I haven't improved any since my last update, and maybe slightly worse, going on 7 months now. Despite that, I think I am in a better place mentally than I have been prior. I still get around for the most part without major difficulties, although I have noted more twinges with say every 10th step or so. Prolonged walking, say through the city, is doable, but I find myself constantly adjusting my gait and after some time look forward to a chair. I have learned my knee is now very reactive to activity, for example a hard session on the bike or in the pool may feel great, but will be increasingly tender the next day. Stairs are hit or miss with discomfort, and I still couldnt pull off any sort of sustained uphill. Even any significant weight on the bent knee, around the house, will cause a quick twinge.

So, basically, I have arthritis.

I've had several discussions with loved ones, physicians, and several folks who have undergone meniscus transplant and OATs since I last posted.

I was able to see a cartilage specialiast out in Chicago while I was out there for a wedding, one of pioneers of meniscal transplant, I'm sure many of you know the name. He felt I would benefit from OATs and MTS, despite having bipolar/kissing lesions, and that he recently published a paper stating that by establishing femoral cartilage coverage, despite grade 4 tibial lesions, significant benefit is seen. In addition to femoral OATs and MTS, he would try microfracture of the tibial plateeu, to see if some additional tissue growth/protection could be obtained. Talk about a bioknee! I was actually able to speak with an individual who had the procedure done and with very similar cartilage status to myself (grade 4 "kissing" lesions) - she isn't perfect now but is able to bike and swim competetively, hikes to some degree, and has no challenges with basic ADLs (stairs, etc), this 8 years out. She does not run, or ski, or do additional high impact activities. I spoke with another ex-D-1 cross country runner who had the procedure done, unclear cartilage status but presumably fairly advanced, who 5.5 years out has a similar functional status to me at the current time. He had little to no benefit, in the end, although he will never know of course if he slowed progression and at this point, without the procedure, possibly would have pain with every step. Finally, I found this blog, http://kealohathoughts.blogspot.com/, which is a very recent ACI and MTS story well detailed and seemingly having success returning to pain-free ADLs. Of course the great story by Lateral Meniscus Issues on this site is also very well detailed, and clearly having success although he was one of the smart ones whom caught his disease progression early on prior to extensive cartilage loss.

In addition to the doc in Chicago, I spoke with a doc in California, who does free imaging review, whom concurred that trying something was necessary, offering a cartilage graft paste technique rather than OATs, along with meniscal transplantation. I'm sure many of you know the name there as well. For several reasons this wouldn't work for me- much of which lies in cost given that the payment is made up front and then potentially reimbursed by insurance.

There is also a new clinical trial for a device by a company called Moximed I thought I would update folks on, previously called "kinespring" but now has been repackage as "atlas", which is attached (outside the joint capsule) to your femur and tibia and separated by a joint unloading spring- and can absorb around 30 lbs of pressure. The idea is to unload the joint in a "non-invasive" fashion, and without shifting the weight to the lateral compartment as in HTO (device is marketed only for medial joint arthritis). The thought is that it would become another bridge to prolong the inevitable joint replacement. It seems intuitively like a good idea, and I believe around 90 patients have trialed it with good results, even up to 5 years. Be wary though, there are rare reports of "metallosis" (local metal shedding that gets into the blood stream), joint capsule infiltration, and persistent joint instability after removal of the device. Check it out.

So I am at a bit of a stand still. I have decided, as many of you advised, to take a breath and have finally stopped frantically looking for a solution, which is much healthier. My wife was becoming exhausted with the process, I don't blame her. I start a new position in September and will likely focus on my career for atleast several months, more likely a year to two, before revisiting a possible solution. I am becoming crafty with ways to get a good workout in, and my upper body and core is as strong as its ever been. Although of course I would absolutely love to get back uphills as to hike with family and friends, this remains a tough pill to swallow.  I am hoping I don't have a rapid progression of my cartilage loss between now and my readdressing of a possible solution, although I honestly feel that by cutting out high impact stuff it should steady out. By the time I re-visit this, I will likely need new MRIs, X rays. That will put me around 34-35 years old dependent on timing, still much too early for a resurfacing procedure- so I will likely try the long-shot OATs and MTS if I can ever get work to let me off. One additional concern I have is that there is some literature out there about OATs worsening outcomes of eventual resurfacing joing replacement surgeries. I actually asked one of the cartilage specialists about this and the response I got is that it shouldn't alter the resurfacing procedure from a technical standpoint, and that perhaps low pain thresholds were to blame (e.g. those folks were destined to fail with any procedure).

I did try an Ossur One unloader brace, without succes. It seems to unload the joint well in full extension of the knee, but in flexion does not really give that much relief (exactly where my problem is) unless I really crank the degree of unloading- but I am fearful I will stretch/tear my MCL with this- as others have described on this site. I may try a compression knee brace next.

I will keep the updates coming, perhaps a bit more spread out now than previous, but will certainly update with any major breakthroughs.

Thanks for letting me rant!

Offline LateralMeniscusIssuesGuy

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #24 on: May 08, 2018, 08:41:37 AM »
Hi badleftknee,

I'm sure I know who your specialists are, I spoke to them too despite being in the UK, luckily I found a surgeon domestically who I found I trusted more, seemed as competent, honest, and covered by my UK insurance.

It seems I absolutely have smaller articular cartilage legions, but despite that it hasn't been plain sailing, am obviously still mid rehab, and my current conclusion is surgery vs doing nothing is still a very difficult decision in my eyes, despite my living through it in (so far) a positive way, luckily.

With regards to knee unloader braces, I'm planning to be fitted for a CTI OA custom in the next fortnight.  I have been advised that it provides unload through full ROM where other braces are only designed for unload through the first 15 deg of flexion, you may try to find that information somewhere online, although I struggled through online information, instead I got it from the UK's seeming most respected fitter of Occur and Donjoy products (Dave Fewster).

You seem very balanced and appreciate it is refreshing to have a change of focus and not be constantly searching for solutions, instead just getting stuck into the grind of incremental gains.  I recommend you look into blood flow restriction training (BFR) as a way of doing minimal load work for your lower body, but maximising muscle gains.  Perhaps you want to desist from lower body work entirely but I can't imagine that atrophy will be helpful to your joint preservation.  There's lots of information on it all over the web.

Even if it is far less frequent, still be great to hear how you continue to progress, and I obviously wish only good things for you.

Good luck
JT
Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #25 on: May 10, 2018, 01:29:21 AM »
Lateralmeniscus Issues,

Thanks for the reply, much appreciated. Very helpful on the unloader brace, I will see if I can get a script from the OS too have that covered by insurance and give it a try- you said Ossur CTI custom? I have heard from others with medial arthritis that they have also had luck with compression braces, so may give one of those a go too.

I will keep tracking your progress, its very exciting and certainly hoping you can get back in the game.


Offline LateralMeniscusIssuesGuy

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Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?

Offline LateralMeniscusIssuesGuy

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #27 on: June 01, 2018, 02:16:51 PM »
How's everything going badleftknee?
« Last Edit: June 01, 2018, 02:25:54 PM by LateralMeniscusIssuesGuy »
Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #28 on: June 02, 2018, 06:22:40 PM »
Hey there, this past month was actually a pretty good one. It's all relative of course. Prolonged walking is now much more doable, and for 95% of the time my left leg feels like my right. Uphills require a slight adjustment, but my mind and body seem to be doing it in a more automatic fashion, as to let my mind let up thinking about it a bit. I did a moderate 1 hour hike with my wife, which I tolerated well. Again, steps require adjustment which is not ideal; but, I am just happy to be out there again. Swimming and biking remain pain free, for the most part that's even with pushing hard out of saddle, and my knee seems to be reacting better meaning I don't feel tender the day following. I rarely ice anymore unless I really over do it. I'm certainly not out of the woods given that weighted knee bends at certain angles can cause pain, as well as any form of cutting movement or attempts to run.

With that in mind I will say its definately tougher to get a solid workout in now. Requires more time and more thought. I used to be able to throw my shoes on and go for a long run at any time from my front door. Now I have to abide by pool or gym hours, have a solid lifting workout plan and make sure I don't slack off to keep my heart rate up, etc. There are worse things of course but at times it is less convenient and I can see how if working out was never your thing, how arthritis could further discourage any form of movement leading to further health decline.

So all in all, I remain in a tough situation given my hopes for higher activity levels. But, I am very thankful where I am at, given my degree of cartilage deficits. I do, of course, hope that things keep improving.

I still have to get that custom knee brace set up, I hope to get the script this week. I spoke with my local ortho on the phone last week and updated him on my endeavors with seeking out cartilage specialists opinions (which he has encouraged)- after I explained everything to him he though that the best thing to to do is keep waiting it out and rehabbing rather than jumping into anything too quickly. I do respect his opinion, but am unsure if his opinion is the right one either (symptomatic management for as long as possible followed by partial knee replacement).

Thanks for checking in LateralaMeniscusIssues. Looking forward to your updates as well!

Offline badleftknee1

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #29 on: September 30, 2018, 12:50:46 PM »
Hope everyone is doing well. Figure I could check in at the 11 month mark s/p MFx of MFC.

So, things are ok, though not perfect.

What I can do: Stairs- no longer an issue at all unless a major misstep occurs, this is both going up and down. I can take longer walks now without the knee becoming irritated, probably up to 2 miles or so, then I may feel it a little but I can still can continue in relative comfort- nothing that will ultimately stop me. From a higher level of activity standpoint- I have done a few hikes, moderate to severe terrain, though not extended (4 mile round trip is the most), and it is certainly not perfectly comfortable, but it has become doable, which I am grateful for. I am still biking, swimming, lifting weights, and actually did my first HIT class the other day- just making sure to let our trainer know that I still recovering from surgery and that I preferred to avoid cutting or high impact moves- I was still able to pull off a sled push, deadlifts, etc. Very slow going, overall. Please don't mistake this for complete success, I feel my knee being different than my good one for almost all moments of the day, even when just walking around the house barefoot- although it might not be agonizing pain, it is just enough of a difference to constantly remind me its a bum knee.


What I can't do- Very prolonged hiking and walking irritates the knee, it stinks to have to plan around realy prolonged walking- like full day hikes etc, but for the most part walking around the city, say on vacation, requires many breaks etc so just being on my feet for a long time is very doable. I definately do not feel comfortable going for a run, doing cutting moves, or jumping moves. Part out of fear, although I have jogged comfortably for 10-20 steps, its with quite compensation and a giant jolt of pain has stopped me on a few occasions. My biggest hope is to ski this season, though I will have to give up the tele sticks- which hurts the moral a bit.


Other stuff: It seems when it rains it pours. I have had some irriation in my right hip (my good leg). This occurred while moving in early July. At first it was a twinge in my hip with rotating, or bending over. It escalated to a point where prolonged walking and any sort of bending were quite painful. Luckily, over the past 3 weeks the pain has lessened greatly, barely noticeable. I did see a new orthopod (as I relocated for a new job), and he thinks I may have suffered a very small labral tear of the right hip- I am actually due for an MRI in mid-Oct, although I hope to cancel if I continue to trend in the right direction. I am taking this as more incentive to keep rehabbing and training the left leg, as I am sure whatever issue it is arose from compensation.


Thats it for now. My other focus is my new job, for the moment. Trying to be as patient and diligent as possible, and to not cry myself a river of pity, which is sometimes hard to do! Happy healing all.

Offline LateralMeniscusIssuesGuy

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Re: OATS and Medial Meniscus Transplant for 32 year old active patient?
« Reply #30 on: October 10, 2018, 08:15:27 AM »
Thank you for sharing your progress badleftknee.

For what it is worth, I recommend Functional Range Conditioning as an accompaniment to any rehab, it seems to be resulting in better quality of movement, and less pain for me.  Its all over the internet, and the pioneer is Dr Spina, again lots of youtube content.
Partial Lateral Meniscectomy (2/3 removed), pristine articular cartilage...2013
Return to impact sport, continual responsive swelling ever since
Mild pain onset..2016
Arthroscopy reveals grade 2/3 articular cartilage damage lateral compartment behind kneecap
What now? Allograft / brace / nothing?