Advertisement - Hide this advert





Author Topic: Best cartilage repair option in Europe for patellar?  (Read 423 times)

0 Members and 1 Guest are viewing this topic.

Offline slink123

  • MINIgeek (20-50 posts)
  • **
  • Posts: 24
  • Liked: 0
Best cartilage repair option in Europe for patellar?
« on: March 10, 2019, 04:35:09 PM »
What is everyoneís opinion/research on the best cartilage repair options for the patellar?

Are there any good one stage options?

Some doctors are telling me none are good, whereas US doctors are suggesting MACI.

I need a tto, Iím just figuring out if I should push or travel for cartilage restoration at the same time.

Offline Vickster

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #1 on: March 10, 2019, 05:02:40 PM »
Unfortunately, the evidence shows that they're all a bit hit and miss and very variable from patient to patient. I think it's been said before that you should try the TTO and see if that helps after the year of rehab that'll be needed. Cartilage repair is also expensive (and most if not all public health systems won't fund especially for overseas patients due to the sketchy long term outcomes)

The only thing you can do is talk to several experts and get their opinion and then its down to you to take a punt or not. That's assuming they're prepared to do both procedures at the same time.

How big is the grade 4 defect on your patella and whereabouts is it, lateral, medial, central? Has it been operated on before? Microfracture? Chondroplasty?

The cynic in me says the US docs like MACI due to the $$$

This gives an overview of the options (from UK cartilage repair centre of excellence)
http://www.kneeclinic.info/problems_articular_cartilage.php
Which is this surgeon's site https://www.nuffieldhealth.com/consultants/professor-vladimir-bobic
« Last Edit: March 10, 2019, 06:04:12 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 slink123

  • MINIgeek (20-50 posts)
  • **
  • Posts: 24
  • Liked: 0
Re: Best cartilage repair option in Europe for patellar?
« Reply #2 on: March 11, 2019, 09:03:20 AM »
Hi vikster, thanks for your thoughts.

My cartilage defect is on the lateral side of my patellars, not very big (1cm??). So I know that the tto may be enough.

I guess I donít want to be in a situation where I have one surgery then need another one as it wasnít enough. Iíve just had ten hip operations so want to make sure I do the best option from the outset with my knees regardless of cost..

Do you know if insurance companies in the uk cover cartilage repair? Iím currently in a country where my insurance may cover an overseas surgery of this kind, Iím moving to the uk soon hence why Iím askimh about Europe.  I will also have private  insurance in the uk but will have a two year wait period.

I hear what you are saying re the US surgeons. I had a long dialogue with jack Farr who  said that having Maci would increase outcome by 10-20%. He also recommended guys in Europe - Peter verdonk and Tim Spaulding so I didnít get the feeling he was talking his own book..  However from what I read they do two stage ACI. 

Iíd like to be convinced a tto would be enough as I have a good surgeon in capetown that can do that ang Iím covered insurance wise :)


Offline Vickster

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #3 on: March 11, 2019, 09:50:20 AM »
Itís unlikely any UK insurer would cover a repair to a pre existing condition. I know Bupa (the biggest insurer I think) no longer covers MACI after NICE decided that the outcomes werenít good enough unless v specific conditions met
https://www.nice.org.uk/guidance/ta477/chapter/1-Recommendations

I had a massive battle in 2010 to get MACI (femoral consume) funding agreed and that was part of a trial and before the NICE ruling (didnít have in the end due to mild misalignment). Youíd likely have needed to try something else like microfracture first in order to get cover for a much more costly proocedure (even if the evidence now suggests otherwise).
AMIC was a complete no no for the insurer.
Why arenít you considering 2 stage? Itís a simple scope which Iíd say is sensible anyhow if not done before so the surgeon can actually visualise whatís going on

Itís worth talking with the surgeonís secretaries about feasibility and costs though. Theyíre all too familiar with battles with insurers. They even needed teams of info for my recent scope! Tim Spalding has long waiting lists even for private.
I think Anan Shetty in Kent does something similar to Dr Saw and is a patella specialist so might be worth researching
« Last Edit: March 11, 2019, 10:39:10 AM 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

  • Forum Faithful
  • ****
  • Posts: 404
  • Liked: 42
Re: Best cartilage repair option in Europe for patellar?
« Reply #4 on: March 11, 2019, 03:26:49 PM »
I had a long dialogue with jack Farr who  said that having Maci would increase outcome by 10-20%.

Interesting discussion! Can I ask what was Jack Farr's opinion about TTO only? Did he mention any estimate for chance of success with TTO only? And would MACI increase chance of success by 10-20%, or did he mean that you would get a 10-20% better result with MACI? 
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 slink123

  • MINIgeek (20-50 posts)
  • **
  • Posts: 24
  • Liked: 0
Re: Best cartilage repair option in Europe for patellar?
« Reply #5 on: March 11, 2019, 04:06:43 PM »
Thatís interesting to know about the insurers, if they donít fund AMIC or MACI then that answers a few questions. I will see if my insurer in South Africa will as Iím still currently insured here..  The reason why I donít want to do a two stage is Iím 39 and want another baby so I want to minimise my time taken up doing this.  You are right re insurers, they will insure preexiating only if I donít have any claim or symptom for two years. This might work out if I postpone surgery until after I have a baby as that will take up two years, although if I wait that long I guess I can use the nhs.. A miserable two years with knee pain though!

Iíve looked at Anan shetty but someone on here has bone growing instead of cartilage after his procedure  which worries me slightly, any thoughts on this? I also see on google that RHOH in London are doing a similar procedure to dr shetty so I will phone them to find out if available on nhs or insurance.

Jack Farr said 60-70pct chance of successful TTO which increases by 10-20pct with MACi or AMIC. He prefers Maci as one stage. Iím not sure if 10-20pct as a discrete number or as a pct of 60-70.

One option is I do the TTO and if not successful I then go to Dr saw for cartilage, his approach gels with me the most and has less chance of complications.

Good idea re phoning the secretaries to find out information. I will do that tomorrow.

Offline Vickster

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #6 on: March 11, 2019, 04:13:24 PM »
Overgrowth is also a risk with other cartilage procedures and osteophytes can develop in response to any insult to the articular cartilage

A few posters have previously posted decent results with Cartifill. I wouldnít be put off by one unfavourable outcome. These procedures often are only 50/50 especially on the patella and thatís with a perfect scenario and rehab

Most cartilage repair isnít available on the nhs beyond microfracture

Maci isnít one stage, you need the cells harvested to be seeded on the matrix as I understand it (at least MACI in U.K.) Thatís AMIC

I donít think all insurers will cover pre existing after 2 years, can be 5-7 years
« Last Edit: March 11, 2019, 04:16:18 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 slink123

  • MINIgeek (20-50 posts)
  • **
  • Posts: 24
  • Liked: 0
Re: Best cartilage repair option in Europe for patellar?
« Reply #7 on: March 11, 2019, 04:48:41 PM »
Is cartifill availAble in the uk?

I think he was talking about MaCI in the US as one stage.

Bupa has a two year rolling moratorium. So if you donít claim for two years on pre existing then covered. Although it doesnít sound like insurers offer much benefit to nhs if you can wait.

Have you seen this? They talk about a cell carrier, Iím womdering what they use.
https://www.rnoh.nhs.uk/our-services/joint-reconstruction-cartilage-transplantation/cartilage-transplantation-stem-cell-project-sscp

Offline Brandon123

  • Forum Faithful
  • ****
  • Posts: 404
  • Liked: 42
Re: Best cartilage repair option in Europe for patellar?
« Reply #8 on: March 11, 2019, 04:51:30 PM »
Jack Farr said 60-70pct chance of successful TTO which increases by 10-20pct with MACi or AMIC. He prefers Maci as one stage. Iím not sure if 10-20pct as a discrete number or as a pct of 60-70.

Ok thanks for the info :)
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

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #9 on: March 11, 2019, 04:55:33 PM »
Cartifill is what Shetty uses (or used)
Cartiform is what Jack Farr uses if I recall (couple of posters historically, one had a good result and one a very poor experience). You can do a search for posts about each

Not familiar with what youíve linked

Iím not sure thatís the case with all Bupa policies so do check. You canít be waiting for treatment when you sign up or transfer from another policy, even if youíve had no treatment
« Last Edit: March 11, 2019, 05:07:16 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 Vickster

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #10 on: March 11, 2019, 04:57:51 PM »
Oh and this is the post I recall on Bupa not covering MACI. Itís old though so may have changed

https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=59407.msg581605#msg581605

Prof Briggs mentioned heads up the RNOH team
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 slink123

  • MINIgeek (20-50 posts)
  • **
  • Posts: 24
  • Liked: 0
Re: Best cartilage repair option in Europe for patellar?
« Reply #11 on: March 15, 2019, 03:26:04 PM »
Thanks Vikster.

So I've had a busy week consulting and getting info;

Tim Spaulding - doesn't do cartilage restoration any more/at present - some problem with licensing and lab costs
Jonathan Eldridge UK - doesn't believe in cartilage restoration ACI/MACI for the patellar as poor outcomes.  Would do realignment/chondroplasty first.  Crazy waiting lists on NHS of 12 months. 8-9k GBP privately.
RHOH - do do something like cartifill plus realignment together and can get on NHS - 4 mo wait list.  Not a bad option but wouldn't be assured of which surgeon I'd get for the realignment.
Lars Blonde - i consulted with him for 150 euros, was very helpful and sent me post consult summary with all my angles etc.  Thinks I don't need cartilage procedure as well, would only increase odds by 5-10% - so marginal in my case.  Recommends distilization/medialization plus lateral lengthening. He thinks I shouldn't wait to get this as my damage is already bad and will only spread if I don't address this. Will cost about 8-9k euros if I pay privately.

So after all these opinions (!) I think I am feeling ok that realignment without cartilage restoration will give me an OK shot at things - this is in line with what my local surgeon recommends (Spike Erasmus who is well known in South Africa).


Offline Brandon123

  • Forum Faithful
  • ****
  • Posts: 404
  • Liked: 42
Re: Best cartilage repair option in Europe for patellar?
« Reply #12 on: March 15, 2019, 05:15:59 PM »
Thanks for sharing all the opinions! Have you decided yet where you will have the surgery? 
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

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #13 on: March 16, 2019, 10:37:54 AM »
Thanks for sharing all the opinions! Have you decided yet where you will have the surgery?
The surgeon in South Africa it sounds like?
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 slink123

  • MINIgeek (20-50 posts)
  • **
  • Posts: 24
  • Liked: 0
Re: Best cartilage repair option in Europe for patellar?
« Reply #14 on: March 16, 2019, 04:15:47 PM »
Yes Im going to go ahead with Spike Erasmus in South Africa.  Feel good to make a choice! 

I am considering asking him whether I can get both knees done at the same time - do you think thats crazy and do you think its possible?

My left knee isn't as bad as my right but its still pretty bad. I don't have such bad dysplasia and am borderline patellar alta, grade 4 arthritis.  I got pretty far in my rehab last year like 2 hours of walking was ok but then my right knee stuffed up, then had surgery on my right hip so I compensated a lot and it started hurting again in November.  Ive had cortisone and PRP and back doing lots of rehab but still get sore from walking about my house (no stairs). I'm on week 6 of an intense program so not sure if it will come good.

Offline Vickster

  • Administrator
  • SuperKNEEgeek
  • *****
  • *
  • Posts: 4614
  • Liked: 371
  • Neelie knee!
Re: Best cartilage repair option in Europe for patellar?
« Reply #15 on: March 16, 2019, 04:27:23 PM »
Personally I would never have elective surgery on both knees at the same time. Do the worst, recover, see how you are. Especially as I think you said youíve got a small child, so presumably using a wheelchair wonít be practical
« Last Edit: March 16, 2019, 04:58:49 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