Looking to treat severe knee medial compartment OA

[ubercool]

silver_maple that’s what I was afraid of. But maybe I should still try LIPOGEMS to help postpone a TKR. Here’s what I found out about the company. The patent holder and founder of LIPOGEMS is Carlo Tremolada (https://www.linkedin.com/in/carlo-tremolada-b0913522/). He also heads up Image Regenerative Clinic in Milan (https://www.istitutoimage.it). I will have a friend of mine in Italy contact him to request a telehealth consultation to see if it’s worthwhile to fly to Italy and have him perform an MFAT procedure. I think you will agree that it would be great to get the scoop directly from the horse’s mouth.

Thanks for the Dr. Vangsness recommendation. I checked out his site and he does look remarkably accomplished. Unfortunately, UnitedHealthcare will likely consider him an out-of-network doctor, which will make a TKR at $30,000 to $50,000 an onerous burden.

Ubercool,

I have good news and bad news. The good news - Lipogems is available in the U.S., you do not need to travel to Europe. Lipogems has not explicitly been approved for arthritis, I'll spare you the legal details. But the procedure is legally available and you can find a provider off Lipogems' site.

The bad news - based on the radiology report you shared, your medial compartment appears to be too far gone to expect anything meaningful from MFAT.

Recommend seeing a knee surgeon who also has a sideline doing regenerative, like Dr Vangsness. This type of physician will not push regenerative if they think it's meaningless, given they have a mainstay surgery business. If you go to a "stem cell clinic" (tend to have "regenerative" in their business name), some of the better ones may turn you away but I suspect most will be happy to take your money, possibly arguing that you don't know if it'll work until you try it.

Best!

[silver_maple]

Yes, Ubercool, Dr Tremolada is the driving force behind Lipogems. Have not dealt with him directly. There are parallels in some respects to Dr Centeno in that one needs a major entrepreneurial drive to translate research into practice. Dr Centeno has had his critics, he's taken flak in this forum, too. I haven't seen similar attacks on Dr Tremolada. A lot of good research is done by pure academic types, languishes in journals, and gets nowhere fast. And then there is the not so good research.

If you consult with Dr Tremolada it would be great if you let the forum know of what he says in your situation. I am open to trying MFAT even though I hold no high hopes. A lot of people spend $3-4K on a beach or cruise vacation, basically eating and lounging around. I am willing to spend that kind of money on my knees. May not work but I would sooner kick myself for not trying. I am at an earlier stage of this disease where any supposed benefit is more likely. Otherwise I am trending in your direction and in 15-20 years may well be where you are now, if not sooner.

[ubercool]

Hi silver_maple, thanks for the feedback. Dr. Tremolada just shared a LinkedIn post about an OS based in Post Falls, ID, right outside Spokane, WA, lauding her MFAT presentation at OrthoSummit:

https://www.linkedin.com/feed/update/urn:li:activity:6877407671088152576/

Dr. Joanne Halbrecht’s presentation was entitled: “Painless Adipose Harvest In The Office: Ignore My Colleagues.” She also participated in a panel entitled, “Final Jeopardy: Two Answers Only - Preservation Or Replacement - Time To Stand Your Ground - Lightning Round (Medial & Lateral Narrowed Joints, Non-Narrowed Joints With Bone Edema).

Dr. Joanne Halbrecht would be a good US-based resource for Lipogems:

https://halbrechtorthopedics.com

BTW, doctors participating in the Executive Education Committee might be a good barometer of their interest in keeping up with state-of-the-art techniques. I only recognized Dr. William Bugbee:

https://orthosummit.com/wp-content/uploads/2021/11/361015-OSET_Program-v2.pdf

I’m with you in trying to find out if Lipogems could be useful at this stage of the game. Having more time on the biological clock certainly helps.

Yes, Ubercool, Dr Tremolada is the driving force behind Lipogems. Have not dealt with him directly. There are parallels in some respects to Dr Centeno in that one needs a major entrepreneurial drive to translate research into practice. Dr Centeno has had his critics, he's taken flak in this forum, too. I haven't seen similar attacks on Dr Tremolada. A lot of good research is done by pure academic types, languishes in journals, and gets nowhere fast. And then there is the not so good research.

If you consult with Dr Tremolada it would be great if you let the forum know of what he says in your situation. I am open to trying MFAT even though I hold no high hopes. A lot of people spend $3-4K on a beach or cruise vacation, basically eating and lounging around. I am willing to spend that kind of money on my knees. May not work but I would sooner kick myself for not trying. I am at an earlier stage of this disease where any supposed benefit is more likely. Otherwise I am trending in your direction and in 15-20 years may well be where you are now, if not sooner.

[ubercool]

Happy New Year! The holidays took a toll on my posting time, but I’m back! Just to let you know, I spoke to Dr. Purita’s assistant who informed me that Purita recommends the $6,000 stem-cell and PRP therapy. She tells me that Purita is “not worried about my meniscus damage” but definitely concerned about my OA. I don’t exactly know what that means but I can speak to Purita directly to have him explain his diagnosis.

The reason I’m hesitant to engage him directly is because of what was recommended here and also because I’m about to schedule a call with both Dr. Kevin Stone and Dr. Carlo Tremolada to get their inputs on my MRI. Hopefully, those consults will take place in the next few weeks, so stay tuned.

[silver_maple]

Ubercool, thanks for the update and Happy New Year to you, too. It is good to get 2-3 recommendations and then decide which one to take up. I'd be all ears as to what Dr. Tremolada says, you certainly aim for the top players globally.

An interesting study was published last year on the efficacy of MFAT in cases of advanced knee OA (such as yours) and the ability to delay total knee replacement. One of the authors is Dr. Adrian Wilson, who, as far as I know, enjoys good reputation in the UK - local posters could confirm.

The study's results and conclusion:

Results: MFAT injection provided a statistically significant improvement in the quality of life (EQ-5D) at 24 months in patients with a baseline OKS of 39 or less (p value: <0.001) as well as those with OKS of 27 or less who are deemed suitable for a knee replacement (p value: <0.001).
Conclusion: MFAT injection improves quality of life in patients with KOA who are deemed suitable for the knee replacement. MFAT is a low-morbidity alternative biological treatment and can delay the need for total knee replacement in suitable patients.

The question then is, are you suitable? If you can delay TKR by 5 years I'd say it's worth it. Could you hope to avoid TKR altogether? A long shot, up to the docs to say, I don't know.

The whole study:
https://pubmed.ncbi.nlm.nih.gov/34211557/

[vickster]

Prof Wilson is a regular contributor to the Learning Portfolio on the site, couple of links about him/Lipogems

https://www.theregenerativeclinic.co.uk/teams/professor-adrian-wilson/
https://profadrianwilson.co.uk/knee-treatments/adipose-tissue-therapy/

[ubercool]

Thanks so much for the info @silver_maple and @vickster. I downloaded the PDF and will keep Prof. Wilson in mind.

Good news, I spoke to Dr. Carlo Tremolada this morning and his assessment was that if my meniscectomy had happed today, it would be considered malpractice. He said that most of the meniscus was removed, which ended up damaging a major part of the adjoining bone, leaving a few holes.

This confirms my MRI report, which states “There is a truncation of the inner free edge of the body, anterior, and posterior horn of the medial meniscus over a 3.5 cm segment with small severely macerated remnant portion of the meniscus suggesting prior arthroscopic partial medial meniscectomy. Medial compartment articular cartilage shows severe full-thickness cartilage loss central weight-bearing region medial femoral condyle medial tibial plateau with exposure of subchondral bone and moderate subchondral stress response.”

His opinion is that a Lipogems treatment will help stave off a TKR for 3-5 years just like you said silver_maple, but that another procedure will be needed in 2-3 years.

I'm looking at flights to Milan around March 1. Dr. Kevin Stone's assistant is now also asking for x-rays, which I have scheduled for Monday.

[silver_maple]

Ubercool, thank you very much for sharing this! I wish you a successful and effective MFAT procedure. To the best of my knowledge no one in this forum has reported Lipogems experience with the doctor who invented it. You are going to the top!

With respect to repeating in 2-3 years, par for the course I would say. This is not a miracle shot by any means, no one-and-done here, even at earlier stages of the disease, much less so in advanced KOA cases. The June 2021 study that Dr. A. Wilson co-authored also states, on p. 13 "There may even be utility in repeating the injection in order to “top-up” the effect in those who have return of symptoms at 2 years."

There haven't been recent MFAT post-op experience reports in the forum. If time allows you could go into the archives and read razuzin's posts (he had Lipogems in Nov. 2015 in New Jersey). MDAL and psny also had adipose stem cell cocktails (2014-2016) although theirs were collagenese-digested, not microfractured.

If you can stave off TKR for 5 years, that would be a success. Anything beyond that would be gravy. I know it takes time and effort to write so up to you if you want to update us post-procedure. I for one would be interested to learn how it went and how you feel. Best!

[ubercool]

silver_maple I too was all excited to get treated by the inventor himself then I read this report published last May that brought me back to earth (Autologous Micro-Fragmented Adipose Tissue (MFAT) to Treat Symptomatic Knee Osteoarthritis: Early Outcomes of a Consecutive Case Series https://pubmed.ncbi.nlm.nih.gov/34064010/). Specifically:

• Inflammatory flare – During the first 2–4 weeks after MFAT administration, an inflammatory reaction (flare) was observed as shown by the presence of at least one inflammatory sign in 79% of injected knees. Unfortunately, since I plan to be in Italy for only 10 days (the study reports a reaction on average within 16.6 days), I could end up with an inflammatory flare while traveling back, which would be uncomfortable to say the least. Also, was not planning to stay in Milan the entire time, so I would have to drive back from who knows where to see Tremolada.

• Injection area pain/stiffness – As suggested by Barfod et al. [18], patients eligible for MFAT should be properly informed about abdominal discomfort after lipo-aspiration and significant flares (pain, swelling, or stiffness) during the first 2–4 weeks, as found in this study. Of note, arthralgia after MFAT injection in this study was assumed to be part of an inflammatory reaction, although it could also be attributed to a mechanical volume effect of MFAT (8–10 cc). So, you have a lot of pain and stiff knees (Tremolada is treating both) and can’t take any NSAIDs because they’re discouraged. Since I’m planning to travel with my GF (for emotional support ), that might make her first Italy experience a big downer.

* Effectiveness – But what really concerned me was this conclusion: “The study demonstrated an early clinical improvement but a mediocre response rate of 45% at 12 months after a single intra-articular injection with autologous MFAT.” I had been grappling with how to interpret TRR (therapeutic response rate) until I read this sentence. So, only 45% effective after 12 months but that could improved: “Assessment of bone marrow lesions on MRI can be helpful to increase the therapeutic responsiveness of MFAT up to 70% at 12 months.” That suggests that a U.S.-based follow-up treatment would be helpful.

I will pose these observations to Dr. Tremolada and see what he says. Thanks for reading.

[SuspectDevice]

This thread has been a very interesting read.

Useful to know that 'regenerative' options are still pretty sketchy.  Knee replacements seem like the only 'proven' solution.

My surgeon warned me (in 2012, age 49) that my partial (1/3rd) medial menisectomy may well lead to arthritis later on.  The fact that I continued to cycle hard before the menisectomy with the loose piece flopping around did me no favours at all, as it caused chaffing on my femur cartilage which still gives me grief today.

My approach now is to work on strength & balance issues, try to manage my weight (increasingly harder in middle-age) while still training/racing shorter triathlons in an attempt to stave off replacement, and still do a little of the sport I enjoy (Ironman aspirations are on hold - maybe I'll have a crack at my one and only in my late 60's or 70's if I'm lucky). 

But it is a very fine line that I sometimes stray across = medial pain.

[silver_maple]

Ubercool,

I had read this study in Sep. 2021 and now re-read it so I can comment while fresh. I won't dwell on the fact the study design is a prospective case series, i.e. lower level of evidence (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124652/). The study was good in that it tried to answer an important question - what baseline characteristics of KOA make for a better or poorer response to Lipogems MFAT.

The good news for you is that age was not an issue at 12 months - younger patients (<=50 y.o.) responded more quickly at 3 months but by 12 months the older ones had caught up.

The bad news is that the presence of bone marrow lesions (BML) is a huge negative for effectiveness. I can't recall if you had BML but you have osteophytes and these tend to be correlated (https://pubmed.ncbi.nlm.nih.gov/28115233/). Also, medial meniscus damage, esp. to the posterior horn, is a negative, at least at 6 months. (I am in this camp too with a complex medial meniscus tear involving the posterior horn).

Don't worry too much about the initial inflammatory flair. Such a flair was actually associated with a stronger 12 month response, you'd want some early inflammation. The study also briefly compares against other injectables and notes such flairs are common after PRP, too. I have had 6-7 PRP shots and I found the inflammatory flairs quite manageable (no medication needed).

Some discomfort at the adipose harvest side is well known to occur and some clinics advise the wearing of a compression belt for 24-48 hours. Eventually this resolves. Could lead to minor cosmetic changes, e.g. a dimple. Not sure whether you can "iron" these out eventually through nutrition, in any case minor stuff compared to the knee.

You have to be fully prepared that you are not the ideal patient. Responder/non-responder is not a boolean division, see the chart on p.4. Quite possibly you could end up a "low responder".

As previously discussed, the alternative is TKR or maybe unicondylar KR. Please see ref [5], Evans et al in the Lancet about how long these last. You may be ok if you go straight to TKR/UKR now but if you live long and need a revision in your 90s I am not sure how many docs would do revisions in patients 90+, that's something you could explore. If docs won't do revisions 90+ and you are in pain, then you could be on opiates until the end of your days.

Yes, effectiveness of stem cells is sketchy. Because there is no going back from TKR, if cash is not an issue trying a stem cell treatment seems defensible to me given lack of serious complications. If it doesn't work, well at least it's been tried and then a TKR/UKR could be done knowing full well there is no other option left (not seriously counting joint distraction, https://pubmed.ncbi.nlm.nih.gov/28618871/). If there is some effectiveness from stems then, of course, this is good news. If the effectiveness is low, maybe not bother with repeats - start making plans for TKR/UKR. If the effectiveness is moderate then repeat shots could be worthwhile.

Best!

[ubercool]

Thanks for your post, SuspectDevice. I’m currently plowing through a host of PRP studies Centeno has graciously collected for us. There is a remarkable similarity between the results of MFAT, PRP, and even HA. These treatments all work better for a short period of time on people who, as the MFAT study says, are “well-selected patients with symptomatic knee OA.” Well-selected means younger patients with less severe OA and meniscus damage.

My goal here is to avoid TKR as long as possible. While I’m not an optimum patient, I can walk normally and I’m not in severe pain, as long as I don’t try any Ironman stuff.

But may well have to eventually admit that it’s the only solution.

This thread has been a very interesting read.

Useful to know that 'regenerative' options are still pretty sketchy.  Knee replacements seem like the only 'proven' solution.

My surgeon warned me (in 2012, age 49) that my partial (1/3rd) medial menisectomy may well lead to arthritis later on.  The fact that I continued to cycle hard before the menisectomy with the loose piece flopping around did me no favours at all, as it caused chaffing on my femur cartilage which still gives me grief today.

My approach now is to work on strength & balance issues, try to manage my weight (increasingly harder in middle-age) while still training/racing shorter triathlons in an attempt to stave off replacement, and still do a little of the sport I enjoy (Ironman aspirations are on hold - maybe I'll have a crack at my one and only in my late 60's or 70's if I'm lucky). 

But it is a very fine line that I sometimes stray across = medial pain.

[ubercool]

silver_maple, thanks for pointing out that the study is a prospective case series. Not familiar with that nuance, however, I did notice that one unidentified author is a paid consultant for Lipogems. Then again, the lead author, Peter Verdonk, has published more than 90 peer-reviewed papers. ([Verdonk Peter | ICRS Main Site](https://cartilage.org/member/verdonk-peter/))

I did see the results improvement over time among older test subjects but that was before I understood what TRR meant, so thanks for emphasizing that point.

My MRI report does not mention bone marrow lesions (BML), so that’s good news. Your post-op experience feedback is very valuable. I will take that into consideration.

As you conclude, giving a stem-cell therapy a try before TKR would be a logical thing to do, even it works for only two years. By that time, I will have been able to do far more research into state-of-the-art total knee arthroplasty. And since my mom lived to be 90, and I will be dabbling in other futuristic anti-aging science, I must take possible knee revision surgery into strong consideration.

Then again, I reviewed your earlier posts and those of @vickster which seem to suggest that I’m too far gone for anything but a TKR.

I’m also more inclined to revisit your earlier recommendation of consulting with Dr. Thomas Vangsness, since he’s intimately familiar with the entire spectrum of possible therapies.

Thanks again, everyone, for helping me on my knee journey.

Ubercool,

I had read this study in Sep. 2021 and now re-read it so I can comment while fresh. I won't dwell on the fact the study design is a prospective case series, i.e. lower level of evidence (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124652/). The study was good in that it tried to answer an important question - what baseline characteristics of KOA make for a better or poorer response to Lipogems MFAT.

The good news for you is that age was not an issue at 12 months - younger patients (<=50 y.o.) responded more quickly at 3 months but by 12 months the older ones had caught up.

The bad news is that the presence of bone marrow lesions (BML) is a huge negative for effectiveness. I can't recall if you had BML but you have osteophytes and these tend to be correlated (https://pubmed.ncbi.nlm.nih.gov/28115233/). Also, medial meniscus damage, esp. to the posterior horn, is a negative, at least at 6 months. (I am in this camp too with a complex medial meniscus tear involving the posterior horn).

Don't worry too much about the initial inflammatory flair. Such a flair was actually associated with a stronger 12 month response, you'd want some early inflammation. The study also briefly compares against other injectables and notes such flairs are common after PRP, too. I have had 6-7 PRP shots and I found the inflammatory flairs quite manageable (no medication needed).

Some discomfort at the adipose harvest side is well known to occur and some clinics advise the wearing of a compression belt for 24-48 hours. Eventually this resolves. Could lead to minor cosmetic changes, e.g. a dimple. Not sure whether you can "iron" these out eventually through nutrition, in any case minor stuff compared to the knee.

You have to be fully prepared that you are not the ideal patient. Responder/non-responder is not a boolean division, see the chart on p.4. Quite possibly you could end up a "low responder".

As previously discussed, the alternative is TKR or maybe unicondylar KR. Please see ref [5], Evans et al in the Lancet about how long these last. You may be ok if you go straight to TKR/UKR now but if you live long and need a revision in your 90s I am not sure how many docs would do revisions in patients 90+, that's something you could explore. If docs won't do revisions 90+ and you are in pain, then you could be on opiates until the end of your days.

Yes, effectiveness of stem cells is sketchy. Because there is no going back from TKR, if cash is not an issue trying a stem cell treatment seems defensible to me given lack of serious complications. If it doesn't work, well at least it's been tried and then a TKR/UKR could be done knowing full well there is no other option left (not seriously counting joint distraction, https://pubmed.ncbi.nlm.nih.gov/28618871/). If there is some effectiveness from stems then, of course, this is good news. If the effectiveness is low, maybe not bother with repeats - start making plans for TKR/UKR. If the effectiveness is moderate then repeat shots could be worthwhile.

Best!

[Dave33]

I've been biting my tongue pretty hard reading most of these posts. Glad to see it changing direction.

[ubercool]

I've been biting my tongue pretty hard reading most of these posts. Glad to see it changing direction.

@Dave33 I have not forgotten your early advice not to waste my time and money and just go for a proven TKR.