8 hip surgeries and now bilateral grade 4 CMP - fed up - when will it end?

[slink123]

Hello all, I dont usually moan but i'm having a bad day!   I had a waterskiing accident 6 years ago and tore the labrum and ligaments in both my hips.  When they scoped me they found out i had hip dysplasia which led to 6 failed scopes.  I ended up with a double hip resurfacing at the age of 37. After that op my psoas tendon was catching on the joint, so i've just had to have that released.
Anyway, about 5 months after the accident I started getting knee pain, I never really looked into it as was only going up and down stairs.  Fast forward to this year, 1 month after my baby was born a pilates class shredded my knees and have had problems since. MRI reveal I have CMP (chondromaelca patella) grade 4 on both knee caps, 1cm size, on the lateral side and also have patella Alta.  Ive had 5 rounds of PRP, 1 stem cell injection and intense physio but not getting much better.  One knee is kind of responding the other isn't.  Just walking around the house inflames it (I  have no stairs).  I cant get out and walk my baby.

Anyway, now looking at surgical options, so many options is scary. I want to go the biological route (cartilage regen) but think I need some patellar re-alignment  stuff too.

Anyway, 6 years in and I just want to be able to walk pain free.  I had such a bd experience with my hips that I am very surgery shy, but at the same time i cant go on like this as have two kids to look after.

Any words of encouragement appreciated!

[Brandon123]

Hi,

Sorry to hear you have gone through a lot with your hips and knees. I saw your other posts regarding which surgery is best etc. I'm in a bit of a similar situation, CMP grade 3 with patella alta. Having difficulty walking, standing, a lot of pain. Tried to get better with all sorts of conservative treatment for the last 3-4 years without any real success. I have also researched all the different surgical options.

Without getting into all the details and getting lengthy, what is still positive in your case is that your patella cartilage lesion is on the lateral side, and may thus respond much better to a Fulkerson type of osteotomy (that might also be distalized to address the alta), than if your lesion was anywhere else under the patella.

The answer to the question whether you should leave biomechanics alone and just fix the cartilage, or just fix the biomechanics and leave the cartilage, or do both, will differ a lot depending on which knee surgeon you ask. What makes most sense surgery-wise also depends on your age. I can give you some more info at a later point if you want.

[untitelhar]

  Yes, it is a good idea. And I have the same opinio

I agree with this opinion.

[slink123]

Hi there I only just logged back into see the posts.

I’ve consulted with three surgeons and they all say I need the Tibial transfer osteotomy.

I’ve recently had three rounds of prp and it’s takem the heat/swelling out of my knees so much that I can walk around the house.  I’m thinking of one last effort on rehab. I’d stopped because they had flared and was unable to get it under control.

Brandon 123 how have you managed to avoid surgery?

[Brandon123]

Hi there I only just logged back into see the posts.

I’ve consulted with three surgeons and they all say I need the Tibial transfer osteotomy.

I’ve recently had three rounds of prp and it’s takem the heat/swelling out of my knees so much that I can walk around the house.  I’m thinking of one last effort on rehab. I’d stopped because they had flared and was unable to get it under control.

Brandon 123 how have you managed to avoid surgery?

Well, basically by limiting my activities a lot and taking it really easy. Using crutches when needed, avoiding stairs etc. But I'm not getting any better and have a lot of functional limitations and pain. So must consider surgery options soon. Did your surgeons mention more specifically what type of tibial transfer osteotomy they want to do on you? Fulkerson with distalization? Or just a distalization?

[slink123]

Hi brandon123, that’s not good sorry to hear that.

I’m trying to decide if I go ahead or give rehab one last effort. My knees flared a year ago, I had prp and did intense rehab. I got to the point of being able to walk for an hour over a six month period, but then overdid it and they flared badly for a few months and rehab stopped, I had another round of prp, cortisone to no avail. I booked in for surgery this month then had another round of prp last few weeks and that has settled them down (the crazy synovitis) so I may be able to start rehab again (however if I just walk around the house they are sore at end of the day but settle overnight). I’m wondering if I’m just wasting time or I’ll have a real shot at avoiding surgery. .

Anyway, I’ve been recommend the modified fulkerson, no distalization but with lateral release.  I think one knee I have a bit of patellar Alta so that one may be with distalisation but I’d need to check which surgeon said what. I’m not sure whether I should go somewhere where they do cartilage restoration at the same time. I’m currently in South Africa and the surgeon of choice does not microfracture at the same time.

Do you have the same intensity of problem with both knees? What surgery are you looking at?

Thanks!

[vickster]

When are you moving to the UK? There's a patello
femoral specialist Consultant physiotherapist in SW London, might it be worth seeing her for an opinion before going down the surgical route if rehab is a viable alternative?

She also works closely with a team of orthopaedic surgeons (private)

http://clairepatella.com

[Brandon123]

Do you have the same intensity of problem with both knees? What surgery are you looking at?
Thanks!

No, only very minor problems with left knee, but major problems with right knee. So, I would only consider surgery for the right knee. I'm looking at a tibial transfer osteotomy to fix my patella alta and unload damaged cartilage (distalization or fulkerson+distalization) with or without cartilage repair. Unfortunately, patella cartilage repair/regen seems to be quite much of a hit-or-miss procedure.

It sounds like you have gotten your knees to settle down enough to function quite well a few times, so maybe worth giving conservative treatment a few more months before surgery? E.g. visit the UK specialist Vickster suggests.     

[slink123]

Thanks Brandon.
What do you make of combining cartilage repair at the same time? I’m trying to figure out if I push for this, will mean lots more money and travel potentially.
I’ve actuslly written to dr fulkerson and dr Farr in the states for their opinion. I just have to cough up 250 dollars to get their response 😬

I’m going to give myself another 6-8 weeks of rehab and if still painful just around the house will go ahead with right knee first.

[vickster]

Not the patella but I discussed combining MACI to a weight bearing defect and a distal femoral osteotomy with an eminent knee surgeon back in 2010. His view was that it would be ‘too much surgery to have in one go’. Might it be that offloading / removing malalignment with the osteotomy and full rehab is sufficient to decrease the impact of the cartilage defect (bearing in mind the patella is not weightbearing?)

Is Fulkerson still practising given his age?

[Brandon123]

Thanks Brandon.
What do you make of combining cartilage repair at the same time? I’m trying to figure out if I push for this, will mean lots more money and travel potentially.

As I've understood it, osteotomy and cartilage repair are basically two separate surgeries. So the recovery and rehab would be much tougher for the two combined, than osteotomy only. Also, there is probably a chance that an osteotomy alone could fix your problem, as indicated by Vickster. Of course, this is something you need to discuss with an OS. If your OS (whoever it will be) thinks there is a good chance of fixing the problem with an osteotomy only, I would probably try that first. It will also be much cheaper If an osteotomy doesn't solve the problem, you can always go for cartilage repair as a next step.   

[slink123]

So I’ve had Dr Farr advice and he thinks I definitely need the AMZ with lateral release and one stage MACI.  I also think the surgery is a bit easier/less invasive with the new MaCi??
He says getting the cartilage restoration procedure will improve my odds of a good outcome by 10-20% and I should do that at the same time.

I am looking into the AMiC procedure in uk/Germany to see if it’s better as will be much cheaper. There is also gel ACI which is one step also I believe. Still lots of research to do.

Have you guys done much research into the AMIC procedure? That’s microfracture with a membrane.

Thankw

[vickster]

It was suggested to me about 8 years ago, never went ahead as couldn’t get funding (my surgeon had done a few, I don’t know if he has since). In the time I’ve been on the forum about one member has posted about it and I think with a very poor outcome (use the search function).
It’s rarely done in the UK at least so do lots of research to find an experienced surgeon. Best starting place would be the orthopaedic centres in Stanmore and Oswestry and then find a private surgeon. I doubt it’s even funded through the NHS since the trials ended a few years ago.

Info from the manufacturer here
https://www.geistlich.co.uk/en/patients/cartilage-bone-regeneration/cartilage-regeneration/
https://www.geistlich.co.uk/en/orthopaedic/therapeutic-area/cartilage-regeneration/general-information/

To complicate matters you also need a patella specialist, finding one who does AMIC will be doubly hard.

Prof Shetty in Kent is also doing cartilage repair to the patella as part of multiple procedure ops.

See posts here by reflex nl
https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=69981.msg693756#msg693756

[slink123]

Hi vikster. That’s not ideal. Dr Farr says MACI in the US is better than AMIC

To your knowledge are there any other good cartilage restoration procedures available in Europe? 

Dr Faa suggested Peter verdonk in Belgium is doing cutting edge cartilage restoration.

I’m a bit overwhelmed! I’m not sure my insurance will approve the US costs (60k for Maci plus 30k for surgery!)

[vickster]

MACI is pretty new in the US, last couple of years. I’m Europe, been around probably for 15 in trials and then post trial. AMIC was one if the arms of the ACTIVE trial but just no one on the forum has posted from my memory. A few MACI / ACI though. MACI is two stage (cell harvest/implantation) not one like AMIC

Unfortunately none of the procedures are great for the patella although better possibly when everything is properly aligned

This is a good resource for understanding the options

http://www.kneeclinic.info/problems_articular_cartilage.php

Prof Shetty uses a paste called Cartifill. Another option is Dr Saw’s microfracture plus stemcelks (also done by a Dr Broyles somewhere in US)

There’s a surgeon list here which might give you some names to research

https://www.kneeguru.co.uk/KNEEnotes/primers/whos-who-knee-surgery