Second-Generation Autologous Minced Cartilage Repair experiences

ACI=The two-stage process, where joint cartilage is taken and cultured in a laboratory, before re-implantation. MACI=similar but grown on a membrane.
gaoshanfelix
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Second-Generation Autologous Minced Cartilage Repair experiences

Post by gaoshanfelix »

Wondering that no one here has posted about Second-Generation Autologous Minced Cartilage Repair or other one step cartilage repair treatments excluding microfracture/nanofracture.
I guess they will replace a lot of ACI/MACI and nanofracture in the future based on the first results after 5 years (seems to be as good as ACI/MACI - but it's one step surgery instead of two step, and therefore faster recovery. MFX/NFX has fast recovery and good 2 year results but after 5 years degradation - while scaffold / matrix enhanced nanofracture should replace normal nanofracture in future but I personally feel minced meat will get better long term results - but this is really not proven yet).

This is AFAIK an alternative to CartiOne - it's an different approach based on the same scientific knowledge.


There is a lot of good information here about newest cartilage surgery methods in the webinars here: https://cartilage.org/webinarseries2021/
They are intended for doctors, but if you read into cartilage surgery because of cartilage damage - I think being up to date on methods is useful.
My surgery was down with Arthrex Autocart (by Stefan Marlovits in Vienna) - but those are mainly some tools to make the surgery procedure faster and more standardized. So some other good solutions exist. Some doctors add a scaffold like Hyalofast on top for protection, mine only uses Fibrin glue and not scaffold. Before such solutions the last years doctors would just cut up the cartilage by "hand" with tools instead of a mincing tool/machine. Some doctors may use nanofracture too below the minced cartilage - but the consensus seems to be it is not needed/recommended.


Well so I can write a bit about my process. I had 3x already my ACL replaced in my left knee after sports injuries - and my meniscus is more or less half missing two after tears and removals. Last time ACL replacment was 5 years ago - and I always returned to semi competitive sports - though I did not return to professional sports (before first ACL injury at age of 18) - and over time became more and more careful. My main sports are mtbiking, and snowboarding/skiing. So over time I did not take the biggest jumps in funparks anymore, then at some point let it be completely (was never my speciality, I was freerider) and didn't do jumps in powder from more than 7-8m height. Still riding pretty hard but kinda lost confidence in my knee over the years. For mtbiking I stopped doing drops over 2-3m and jumps over 8-10m length. Also after my last ACL tear my muscles in my left leg never fully recovered - I was only at 80-85% or so because my knee didn't feel too good doing heavy weights, and I got scared in general a bit more so used my right leg much more.
I therefore did a bit more trailrunning - not at a competition level - but I often ran like 2000m vertical up and down, 30km in like 4.5-5 hours or fastpacking with 3000-3500m vert up and down per day in the himalayas (40-50km per day). So I was ambitious but nowhere near a competition level outside of fun competitions.
Last year in March I was doing an interval training for trailrunning with a friend - where we ran entirely on wooden logs. Doing like 400m uphill in 20minutes - then short break. Fast pace down again and short break again, 2800m vert for that day.
In the evening my knee went big and next day I could not walk down stairs normally anymore. It recovered but became pretty painful whenever I did a bit higher impact sports. Had to stop playing badminton, and hiking 2-3 months later was max 2000m up/ 1000m down one day without pain. I had one more time where after 3 hours of kitesurfing I went for 1.5 hour soccer - and Bam after the soccer my knee went huge and I could not even drive a car with clutch for 3 days.

I looked up my MRIs over the years - and yes I had been kinda steadily progressing on cartilage problems after the first ACL / meniscus tear. I had kinda always known that at some point - I will need my knee fixed properly, doctors telling me I'm on path for TEP at some point or ACI/MACI - but no one would say when - I had expected it to happen some years later - not at 37 (19 years after first ACL tear). Due to moving around a lot as a digital nomad, I had not managed to get an MRI until August - when it showed that I have 2x1.5cm down to the bone no more cartilage on the femoral condyle, and grade 4 damage (less 1cmxc2xb2) on the lateral side. Likely wrongly decided to do the surgery in late autumn, because I did not want to miss the kitesurfing season and thought November is a perfect timing for surgery to fit my schedule. Actually after surgery the area replaced is 10cmxc2xb2 - 6cmxc2xb2on femur, 3.5cmxc2xb2on lateral - because they need more cartilage for the mincing - and it was too thin in the areas still covered a bit.

However even though I more and more reduced my activities - it got really bad. 1km walking barefoot in a small creek made my knee go berserk, so I decided I can only walk in very suspended shoes from now on. The last month before the surgery it got so bad I woke up at night with knee pain, and I could not sleep with extended leg anymore - else it would swell. Well pretty bad bone bruise on the femur, and small bone bruise on the lateral side.

I have always been quick to recover from surgeries - a lot ahead of schedule (ran a marathon 6 months after first ACL surgery for fun to see if I can do it), went skiing 5 weeks after my third ACL surgery on the healthy leg all day, and hiking 2000m up/down 3 months post surgery.

Well not so this time. The first week after surgery was really painful - couldn't do much. Second week became better and at the end I was of painkillers. The third week was really good then. My doctor had told me to simply progress in small steps and I started walking around the house on one crutch, and swelling was pretty much down to pre surgery level. Pain was gone and the extension became better and better too (I was limited on flexion to 30 degrees first two weeks, then 60 degrees third week, 75 degrees forth week) wearing a brace. At the beginning of week 4 post surgery - I was doing some steps without any crutches - and it felt fine. My doctor told me around 90 degrees flex the implants are most vulnerable - so I made sure to only apply weight/force up to 45 degrees, a little up to 60 degrees. Now it could be I went too fast on the weight bearing, but I actually think I went wrong on forcing extension. I made the stupid error of trying to roll one legged with blackroll under my calves for forcing extension. It directly hurt so within a second or so I sat down because I felt it was wrong. 4 hours later my knee was back in swelling to levels like directly after surgery - and if tried to extend it for like 3-4 minutest it my foot would "fall asleeep" and pain got really strong. Well I tried cooling/painkillers but I was back to like day 3-4 post surgery pain. flex was no problem however.

After 5 days I decided to contact my doctor and he told me to get an MRI. Took the MRI I was shocked at the result - saying there is strong bone bruise on both sides, and a problem on the femur with the implant. I was really down. My doctor looked at the MRI in the evening and told me everything fine - the implants look like they should 4.5 weeks post surgery - but told me to go no weight for 2 weeks and slow it down.

It felt like I was thrown back 2-3 weeks. So besides more flex I started kinda the program again. 5.5 weeks past surgery visited my doctor for the 6 weeks checkup. He said it looks fine and I should go to full weight and within 1 week drop the crutches. Hell yeah - I felt I have no way to do so. Also from now on I can ride stationary bike with power. Well the bike part went fine - within 10 days I was at 100w for one hour. Well I guess 80% of work done with my right leg - but finally some cardio workout again. I would stop when I noticed my knee not to track well anymore - be powerless. But away with the crutches - impossible now (remember it was fine for a few steps before my mishap). Then as scheduled I flew to Taiwan where I plan to spend the winter. Which means 2 week quarantine and no way to keep on training on stationary bike (well I though I can get one after the first 7 days, but that went wrong)

I was supposed to be without crutches - on day 42. Well I finally made it again on day 54. Well I had decided to go really light on extension - as this had been my problem pre surgery, and I strongly believe was what cause my relapse. So I had been training my quads more with some flex - so funnily I managed to do one legged stand at 30 degrees flex 1-2 days before I managed it on day 54 for like 3-5 seconds without pain with more or less extended leg. Once I reached this step I decided to try to walk without crutches (but yeah confined to my quarantine hotel room).
On day 63 my quarantine ended and the first thing I did was try to walk some bit further without crutches. Well suffice to say - after 200m decided to turn around because my limping got much worse and I feared not getting back otherwise. Took a bicycle and rode 10km instead - going easy. Today - on day 64 decided to try a long bikeride. Mind though - I have not yet found time / chance to buy a proper road bike - so I have to use the rental citybikes here - which have the seat 5cm too low fully extended for my size. Plus I sit too far backward for my taste. Plus only 3 gears and you have to power the dynamo for the light the whole time... Anyhow managed 50km 500m up/down with that crappy bike. I was still afraid to stand up while cycling - and surely did 65% or so with my right leg - but it was a fine workout and 6 hours later my knee still feels fine. It did feel a bit tired right after riding, and a tiny bit unwell - but now it feels like before again. There was tiny swelling but went away with icepack. I think main problem of course too low RPMs with too low saddle.
Gonna get a proper road bike hopefully tomorrow - and start riding 100k 5x a week as main training.

I kinda feel I will not force the walking without crutches now - Just do what feel right and the more my muscles comes back - the better the walking will become. Will add swimming too in one week (not allowed into public swimming pool in Taiwan the first 7 days after quarantine - yeah they are crazy here). So actually for cycling and anything with more than 15 degrees flex I feel I am now again ahead of schedule.
After months 3 I am allowed to go running / hiking IF I have the muscles for it and IF my knee is not swelling from doing so. Well I don't see that happening so soon right now - but will just force the cycling plus coordinative exercises - and hope that this will get me hiking and walking safely for longer distances ASAP. If muscle and coordination and so on is at 85% after 6 months I am allowed to start all sports (meaning one legged jump to 85% of distance of other leg - landing on some foot as taking off) - if not I will have to keep on training before skiing, snowboarding or trailrunning downhill is allowed again. Anything of course gradually and only if no swelling occurs. I really wonder where I would have been without that mishap. It surely would have saved me a lot of time in building muscle back up. I don't expect to be there at the 6 months mark - but hope to reach it after 9 months. I think most of my pain is still from the bone bruises - so that should go away as the bone is now covered with cartilage again...
Right now the circumference of my right thigh is 9cm bigger than my left. Calves are 4cm difference. After ACL surgeries it was never down as much - but yeah the recover from ACL replacement is quicker in the beginning for sure.


At least in Europe minced cartilage to me sounds like the best option. OATS with bone-cartilage allograft implants seem to be hard to get in Europe but are in America seemingly if money is no problem - the method of choice for many if you want to recover as quick as possible (bone heals in much faster than cartilage). In general it seems like Germany/Austria are amongst the cheapest places to get this surgery (from 4000-5000€ if paid privately, but most health insurances will pay for it - which was no help as in my countries of residence - Taiwan and Cyprus it's not offered so I had to pay it fully private - 6500€ for the surgery and visits to the doctor afterwards with 30 hours in hospital. Excluding the 2 MRI or the brace or painkillers - altogether another 1000€ paid privately). In USA surgeries are way way more expensive but there is more choice of modern methods. I guess in 5-6 years if the 10 year mark in studies is successful - ACI and MACI will be phased out because it is around 3 times as expensive as single step fully autologous cartilage repairs. Insurances will not pay for it if the single step repairs are as successful (which looks like it at the 5 year mark). Plus recovery is quicker (especially if you consider the 6 weeks between first and second surgery too - but even without)


But yeah - really hard to find experiences of other patients with 2nd generation minced cartilage on the internet. No one else on here with similar surgery? I will try to remember to post in 3 months again on the results then - even if no one replies.


Oh yeah - anecdote about the MRI. I've read in quite a few places many doctors are not good at reading MRIs - so when I got the MRI pictures with the text of problems after surgery - I was like okay let's try learning reading MRI pictures myself. Really useless if my doctor, Marlovits is not a world known surgeon, but is world known for reading MRI (Co-inventor of the MOCART / MOCART 2.0 score which is now widely used). So if he says the MRI is as expected - I should be able to trust him. I chose this doctor because I have family in Vienna - and he seems to be the leading, or one of the leading cartilage experts in Austria. Does mostly cartilage surgery over the last years. But with the recovery which is hard in the first few weeks, really try to get an expert within 1-2 hours driving by car - no further. It will be horrible to drive a longer distance the day after surgery, or 2nd day after surgery. Here is a good website to google for research your doctor has done - use search function on: https://www.aminer.org/ or https://pubmed.ncbi.nlm.nih.gov/
but - I am sure there are also many good surgeons without an extensive research career. Not every doctor loves to do research. It's a good info - but will not effect your personal result. And surely most of the work is done after the surgery - not before or during (many famous surgeons say physiotherapy and recovery work has much more importance than a top surgeon or an average surgeon).
Last edited by gaoshanfelix on Sun Jan 16, 2022 6:58 pm, edited 1 time in total.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

Post by Elce »

Hi, hope you doing well? What is arthrex autocart? Dehydrated minced cartliage? Is that what you had for your knee? There have been post for Cartiform which is similar. When they do Oats with allograft transplant do they have to find match? From what I understand when you have osteochondral allograft transplant they have to find match and also is very expensive but I have no information on cost.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

Post by gaoshanfelix »

Elce wrote: Hi, hope you doing well? What is arthrex autocart? Dehydrated minced cartliage? Is that what you had for your knee? There have been post for Cartiform which is similar. When they do Oats with allograft transplant do they have to find match? From what I understand when you have osteochondral allograft transplant they have to find match and also is very expensive but I have no information on cost.
Cartiform is a similar concept - but is far from identical - Cartiform is an allograft while Autocart is Autologous (huge difference). The cartilage is not dehydrated - it is simply a one step, fully autologous minced cartilage surgery, without using scaffolds and using fibrin glue.
I don't think Arthrex is pushing Cartiform anymore - they results for Autocart seem to be way superior.

3 months post surgery: I am very slowly starting hiking - but downhill is still very problematic. So 300-400m altitude max per day. My cylcling the last 4 weeks has amounted to around 1100km and 20.000m uphill. I'm slowly picking up a somewhat decent cycling form. My FTP is a little below 3w/kg I guess, if my left leg would be same strong as my right leg I guess I would be at 3.5w/kg so not too far of a decent 4w/kg form but yes the last 6 months before the surgery and the 6 weeks after I did next to no sports - so to be expected that it's a hard way back into shape.

Cylcing I right now feel most comfortable at around 85-90RPM cadence - on high intensity around 100 RPM. Need some training for hitting 100 on normal intensity and 110-115 on high intensity.

I'm still fighting with extension and pain on extension - so I am not actively working on getting my extension back. I'm too afraid of that way getting my bone bruises worse. So walking still looks a bit bad. And yes need at least another month before I can think about starting running or serious hiking. I think I could start on a crosstrainer and may do so soon.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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btw here are pictures of my knee - and a video showing me hiking 3 months post surgery (actually 2 months 29 days to be exact):
https://photos.app.goo.gl/5dthaqFA9ikf1wGK6
I really hope to start all sports 6 months post surgery. If my assioma Duo powermeter pedals are correct my power balance while cycling is 47/53 for longer rides or 70% FTP activity. Below 50% FTP I am at 50/50 while above 100% FTP it goes to 55/45 and for sprints maybe 42/58.

I today ran 10km equivalent on a crosstrainer... Maybe in 1 month can start running on a treadmill? Yeah recovery is much harder than from ACL. With ACL I did multi day hiking at the 3 months mark (2000m uphill/downhill per day).
As I switched to cleated shoes while cylcing I had some pain post cycling. Will have to work on the cleat position a bit more or maybe go back to flat pedals for some more weeks. I'm living in 14 floor and decided to skip the elevator now - so its 13 floors up/down each time from now (3 months 7 days post surgery). I always think most important is good fitness - so I continue to put in as many hours of cycling as possible, and weather permits (not possible next 5-6 days which really annoys me). But my resting average heartrate already dropped 10 beats the last 5 weeks to low 50s. 6 months goal is 4w/kg FTP, runinng 15-20km without pain at 12-13km/h in heart rate zone 3, or 10-11km/h in zone 2, and picking up trailrunning. Then I would feel fine for staring kitesurfing and soccer over summer - and skiing/boarding next winter again. But that means I need to be able to hit the gym with my leg soon - which is not possible yet. Cycling a lot is good but it builds up muscles rather slowly.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

Post by Elce »

Thank you for your update. I don't think this procedure is available in UK, at least I can't find any information!
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

Post by Elce »

Hi Vickster, Do you know if this procedure is available in UK? I did look at the brochures that you posted but can't find any information for UK!
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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I don't know I'm afraid. I think you'd need to reach out to the big centres in cartilage repair like RNOH and Oswestry. It might be trials only.
Or email the company (Arthrex? Geistlich?) even.
Think only standard 2 stage MACI, possibly one stage AMIC (not sure what offered on NHS now).
These surgeons in Cambridge seem to offer a few options privately (among other surgeons discussed elsewhere). No knowledge of them but they are in the forum specialist database
https://www.thecambridgeknee.co.uk/cart ... lantation/
Last edited by vickster on Mon Feb 21, 2022 11:59 am, edited 1 time in total.
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

Post by gaoshanfelix »

Actually I would really oppose any two stage procedure. The one step procedures seem to provide as good if not better results - and you lose a lot more of muscle with the two step procedure - which besides those 5-6 weeks between surgeries, will take time to rebuild.

I really think I should have done the surgery 3-4 months earlier because those bone bruises only got worse - and they cause me now in recovery still problems (I guess it's them).
Today in the gym I tried a bit on the leg press - however sadly they only have an 45 degrees estimated angled one. So you kind have half your body weight besides the weight you put on.
I actually improved quite quickly from set to set - getting more confident.

While on my good right leg I was fine doing 3x20 on 68kg (so I guess that's 67+33 (half my body weight) - I could just do 24kg on my left leg (so 24+33), at the begiining I had trouble using the leg press with minimal weight - which is 6kg (+half bodyweight so 6+33) plus I could not go into full extension on my left - starting at 90 degrees. While on my right I didn't go into full extension to have better training effort. Well actually on my right if I start at 45 degrees I could put on 100-120kg or so. I remember after my last ACL surgery my doctor then (Austrias most famous knee surgeon for skiers) told me to really load the press but do little knee angle to get the muscles back - well not possible this time. But yeah I guess this is a bit ski racing specific - as you hold most weight on your outside leg in a turn - which is nearly extended. So moving 6-7 times your body weight between 30-10 or 30-0 degrees on a single leg is pretty sports specific and something which you cannot train kinda outside of leg press or speed disciplines on skis.

So I guess barring the bone bruise region - my left leg is now around half strength of my right leg.

If the weather is somewhat okay I will try some springs on my bicycle tomorrow - and maybe a 20 minute FTP test. Otherwise I'll do it in the following days.


Oh yeah - I researched a bit more about Cartiform and Cartione. I think Arthrex phased out Cartiform because more and more surgeons now want to avoid anything involving MFX/NFX. Cartione is a bit closer to Autocart/minced cartilage than Cartiform but still involves drilling. So maybe you find that available. Seeing the experts on ICRS more and more saying to avoid any kind of drlling/microfracture/nanofracture which was previously the one step procedure - I would think Autocart has better prospect than Cartione (by Orteq which is another of the big companies involved) - which includes drilling for the bone marrow to mix with chondrocytes. I can kinda find a good logic in Autocart - from the point that it is known that the minced cartilage/chondrocytes get activated by the mining - held in place by the glue and don't need any bone marrow or other things to grow into new cartilage. From a non doctor education it makes sense that minced cartilage is the closest to actual cartilage - and as it's known to profilerate that way - avoid anything else.

My surgeon Marlovits, who is kinda only treating cartilage damage (plus associated problems like ligaments, Osteomie, Meniscus and so in combination) told me he since one year exclusively uses Autocart - and stopped using ACI/MACI/MFX/NFX that he used previously. I don't know if he previously used Cartiform - I guess no because he doesn't list it on his homepage, while he does list the others. OATS and similar allografts are hard to get donors in Austria - so maybe he still uses that occasionally - I just know he stopped any drilling/MFX/NFX and any two step procedures.

Actually in Austria and Germany Autocart will be much easier to be paid by insurance than ACI/MACI because it's unregulated as it's fully autologous. As the tools required are pretty low tech, and for a single defect site the surgery will take like 1 hour - insurances should be pretty happy to pay for it. In Austria at least one public hospital announced doing it too - however it could still be mainly available only for people with private insurance or paying the surcharge themselves. I guess it will spread fast - if insurances see a new procedure that is much cheaper (than ACI/MACI) - I would guess 10-20 minutes slower than MFX/NFX so only marginally more expensive than those - but results on par with ACI/MACI or better - they will soon not pay for ACI/MACI anymore. This is happening already in Germany and Austria - however they seem to push also for things like MFX plus scaffold. As Arthrex removed Cartifrom from the website, is pushing Autocart, I guess the spread will only speed up.


BTW - found a report of Autocart patient 4 months post surgery back to playing basketball: https://www.hindawi.com/journals/crior/2021/9501039/
So if my process seems quick, it's really slow in comparison. Basketball is surely a highly demanding sport because of the erratic way you run. I really hate myself for stressing that extension now even more. Maybe I could already be back to hiking without that mishap. Or better should have had the surgery much earlier when the bone bruise was still minimal. But yeah 18 vs 37 years must make a difference to.
Last edited by gaoshanfelix on Mon Feb 21, 2022 6:10 pm, edited 1 time in total.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

Post by Elce »

https://www.forbes.com/sites/stevensalz ... 60dcf26950 This is interesting article. If you read the article Dr Robert Marx ( he is in New York ) says this therapy already exist but not yet approved for cartliage repair but you could ask your ortopedic surgeon whether he will try it. Sound too good to be true!

Gaoshanfelix, the cartliage taken for your procedure came from your knee? Is it only suitable for single cartliage defect in the knee?
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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Elce wrote: Gaoshanfelix, the cartliage taken for your procedure came from your knee? Is it only suitable for single cartliage defect in the knee?
It's taken from the spot they repair or around it. Usually just clearing up the damaged area and using the cartilage should be enough. Could also be taken from non load bearing places in addition. But yeah you really have to hope it doesn't fail - otherwise afterwards your left with a much larger hole of missing cartilage.

Gian Salzmann in a video on ICRS said that he lost a bit hope that we can just inject stem cells into the knee and they will heal it (like PRP/Hyaluronic acid but of course that would be the ultimate goal) but for sure evolution with better methods will progress. The problem without surgery is that how should the stem cells know where to attach/grow and how far to grow. That's in short the theory behind scaffolds. As someone with knee damage now, I would not give much importance to that New York study but yes I hope they do a proper study on it with humans.
Maybe those proteins work. From my point right now I would trust more that minced cartilage is the better alternative for a treatment right now. Once they have 2 year results on humans with actual check of the new cartilage on camera not MRI it will get interesting. Before it's rather ask your doctor to add it into the MFX procedure if that's the only thing available to you.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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Well last week I overtrained a bit so to say (putting it gently). 1500 minutes of sports in 6 days.
On my third visit to the gym I only had 100 minutes time or so. Warmed up on the elliptical at my usual Zone 2 heart rate (that is step 12 out of 25 of that machine). Then did some one legged exercises on a half ball and some single legged leg press. Felt my leg was done for today and as it was a 5 day rain period (day 5 of it) I decided to get on the stationary bike as there was no way to throw in any outdoor rides. Damn those bikes are weak (Matrix - seems the most common in Taiwan). After 20 minutes at 20/25 setting (supposedly 330 watts but it must be lower - my FTP is now around 240) I thought let's try to ramp it up and see where my max heart rate is, so I cranked it up to max and after 2 minutes they bikes engine gave up, overheated and it switched of. Haha I'm at 66kg and this bike cannot handle it. Supposedly 550 watts which is impossible - may have been 400 but rather 360 or so. Still hit 187 beats not bad for 38 years.

Well next day my legs were stiff as f**k and my muscles burning. Well the weather was great so I decided to go on a quick 50km ride with 1000m vertical and even though my legs were aching I went quite fast. So 10% faster than 4 weeks earlier at 20 beats lower heart rate.
Next day kinda the same just decided to go a bit faster and do some intervals. Yeah my legs were still stiff, actually hard to get my legs over the saddle. Then perfect weather and nothing to do - so next day in with 5:30 hour bike ride at 110km/2000m altitude I planned as recovery ride. Well those climbs were too steep so I grinded away at low RPM. But I planned a rest day next day. Overtraining started to hit me couldn't sleep much at night with burning leg muscles. However girlfriend calls me she has a day of let's go hiking so there I go on an "easy" 400m uphill/downhill hike. The problem is - I found out the way to go downhill for me without pain is to never extend my legs. Stay at 100-45 degrees degrees flexion all way. That seems to be a way for me to get down stairs without handlebar and pain too. However that burns the quads like crazy.. Then next day bike ride with friends if only 1 hour but at high speed needless to say my sleep deficit due to aching muscles had gotten even worse. Still somehow my wattage was decent. Then yesterday 50km biking, 500m uphill and 500m uphill/downhill hiking. I managed to do it all without ever stepping over heart rate zone 2, but my power on the bike was dismal. 20% lower for same heart rate as before. Finally today called it a rest day cancelled my bike ride with friends in the evening. Really need to recover because otherwise my hormones will go crazy.
Hope by tomorrow my legs feel fresh, so I can start another round of training.

I kinda guess my FTP on bike to be around 3.5-3.6w/kg by now. After being at 1.5w/kg when I started on the stationary bike 6-7 weeks after surgery (well and my heart rate then was actually quite high, so my FTP for sure below 1.8w/kg - though a lot must have been adaptation of my knee driving my heart rate up).

I hope to hit 4w/kg FTP in 4 weeks or so. That's when I plan some bigger bike rides - like 3000m vertical up/down and 200km days.

However I don't seem to improve at all for normal walking, still limping around as I simply don't manage to get from fully extended to say 30 degrees with body weight on. Also training in that range with less than body weight causes the same pain as the last 3 weeks. So while I have found a way to walk down stairs, or walk up (same game, simply do not extend leg fully) my knee doesn't improve the way I hope for. There is no way I can start running anytime soon this way. Another way to walk down for me is backwards.

My left calve look less muscular than my right, but the size is now nearly identical (missing max 1-2cm circumference). My upper leg is still missing quite some volume though.
I do know that muscles don't grow at training but at the rest after training. So have to be more stringent in cancelling friends asking for a hike or ride together.
Most of the hiking is on a wooden logs trail, with a handlebar and wearing the brace. The steeper the better, little gradients are worst. And I don't see when I can hit proper hiking tours or if I can actually kitesurf by June which was my plan.

Many doctors say, biking is the best thing to get back in shape after ACI/MACI whatever knee surgery actually. So I may have to stick to it even longer than anticipated. Stronger muscles and better fitness should be the number 1 way to relieve knee pressure at other sports. It's so devastating - you wake up and want to run around, your muscle feels like it could do it while on a bike or elliptical - but there simply is now way at all if the 0-30 degrees flex range is not working. That is usually the easiest range for the muscles - but for me it's now the opposite.
Also as my muscles tired from day to day I noticed that the power phase arc on my Assioma Duo Shi pedals got smaller too. I really need to be careful to ramp it up slower. 6 months of more or less no sports have taken it's toll, though my fitness is coming back the recovery times seem to be much bigger than what I'm used to.
gaoshanfelix
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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Well, after resting 32 hours I decided to go out and do a 20 minutes FTP test. My legs were only slightly sore and I had been able to sleep quite normally again. After 25 minutes warm up I did 3 minutes at 300 watt, 2 minutes break, 5 minutes at 140 watts and then the 20 minutes all out which I started around 280 watts (on assioma pedals, so 99 percent correct not like those fitness center garbage measurements). At the 10 minutes mark my average was down to 270 watts while for 5 minutes my heart rate was at 95-97 percent. Kinda forced myself to just keep on and by 20 minutes my average had fallen to 265 watts. So ,251 watts FTP or 3.8w/kg...
This was uphill and uphill I'm always better than flats and only for 5 seconds I had to take out speed to dodge a red traffic light.
Next morning I was tired but motivated so I decided to go on a big ride.
3080m uphill, 160km, 8:30 hours riding time and few breaks (total time 9:30 hours).. this was essentially a 3000m in one go climb, with a 200m downhill after the first 600m altitude ending up at 2666m for the highest point after starting at 80msl and then return (road not in good condition so downhill rather slow, Taiwan has very few roads where you can let it fly downhill, too many potholes and gutters for rainwater to drop in, besides many switchbacks...


Next day my knee felt a bit warmer than usual, and some pain so I did absolutely nothing except 5km bikeride to a testament and back. I feel that long ride with little breaks was asking for it a bit....

Then in Sunday decided again on hiking with my girlfriend, but she wanted a departure place where I don't feel secure in leaving my own bike. So hat to take one of those rental city bikes which are way too small for me and 3 gears are a massacre on the 450m altitude climb to the trailhead. Basically my heart rate was peaking but my speed was only 60% of my normal road bike pace up the 6-15 degrees climb. At the top my knee hurt so I needed a 30minutee break before hiking.
I really right now cannot hike small inclines. That's very painful. But as soon as it gets steep I'm fine. So 400m altitude up in 50 minutes, First time some decent hiking speed uphill. The downhill again very slow as my knee wasn't too comfy. My girlfriend means there is progress and is becoming afraid how long she can keep up, knowing that once I'm fit again my speed will be twice at least.. So maybe after all even though I feel quite stuck on progress, there is progress all along.

In 1 week it will be the 4 months past surgery. And in 10 days I told friends to go on a 2 day hiking trip up a river and back down. I'm most afraid about carrying a backpack with the camping gear, as I really notice as soon as I have more than 6-7kg on my back my walking really deteriorates. Well may just take crutches with me as precaution even though I think I last used them over a month ago.

I'm still icing once or twice a day, but I take the ice pack from the fridge, not freezer, with a small pack from freezer to keep the temperature lower a bit longer.

My Fenix 6x calculated my vo2max after the long bikeride at 53. Up from 44 on 13 February when I first used my power meter pedals.
It feels a bit crazy, my biking speed/, Vo2Max is at around the 3 hour marathon mark now, so getting towards the point where I can consider myself sportive again instead of a sofabum. But I still cannot walk down stairs without discomfort...

I hope to hit 4.5w/kg FTP in 2-3 months and keep on upping my vo2max. But gains are getting harder and harder now. I maybe just drop my weight a bit more, 2-3kg lower I can still do safely (body fat right now maybe still 10-11 percent) and that will make things easier too. The leaner you are the better for the knee.

This week I'm non a business trip for 3 days so have to scale down training a bit. Will have to do with the hotel gym and a hike...I'm really waiting for this breakthrough moment where suddenly I can flex my knee with load through this 20-30 degrees flex zone. My muscles are strong enough now already.

Oh yeah while hiking I wear the brace. I got myself a cheap knee soft brace whatever for around 10 USD at decathlon, hoped it sucks down my knee cap a bit but it doesn't seem to help at all. Will give it a try for some more days...


Edit - evening same day. Today in the gym decided to go a bit harder than before. Well last time in Gym was 6-7 days ago as first I had too much sore muscles, then the weather was just motivating me more to go bike riding and hiking with handlebars...
I today decided to go a bit harder on the leg press. My right leg alone I could do a set of 5,4,3 times with breaks of 2 minutes at the max load of 400lbs. Damn Taiwan gyms machines are really for people without any strength... My operated left leg I kinda could do the same only at 200lbs. I tried 220 but it I felt insecure and dropped back down to 200lbs.Yes at 200lbs I'm only close to max weight, but it doesn't feel like I can go any harder without my knee still tracking fine. If I would put on the brace I likely could do a bit more. Left I only did like 90 degrees to 45 degrees and back. No way for me with more than 100lbs or so to go 90 degrees to full extension without really feeling shitty - so I won't do it. That's really a bit crazy as muscle wise it should be much easier.

Been training a lot on a wobble board too. One legged and two legged.

Oh yeah - why am I attacking it so hard? Most studies have shown better results for people rehabbing aggressively. E.g.
https://pubmed.ncbi.nlm.nih.gov/20051508/
Now of course this was for MACI but I think minced cartilage should follow a similar progress just maybe a bit faster.
Also the following is IMHO a must read for anyone having cartilage surgery in the knee:
https://www.jospt.org/doi/10.2519/jospt ... %200pubmed

Also first time went on the treadmill. Max speed I can walk while limping as always is around 6.2km/h. I tried supporting my weight with my hands and go for 10km/h - didn't feel ready at all. I think in 2 weeks I switch the gym for the only one I found around here with Precor machines and go on the Precore AMT. That's way closer to actual running, actually you can set it to more or less 100% running just without the shocks. Other ellipticals are just crap compared with Precore AMT, never seen adaptive motion trainers of other brands that are nearly as good... I don't think I will be running in the next 3-4 weeks still. But if I can use Precor AMT to increase stride length to running stride length that would go a long way of getting closer to running.

I am sure you should do as much as possible without pain, and as much as your fitness permits. Every week 15-20 hours should really be the bare minimum in the rehab process once you can start on a fitness bike. Invest in a fitness watch (like Garmin Fenix 6/7) so you can go as hard as possible without maybe not noticing overtraining. I think without a reliable watch (sorry no Huawei, Apple or whatever that really outputs random fitness numbers) tracking resting heartrate, sleep patterns and training load - you cannot go nearly as hard without risking overtraining. Even with a watch your enthusiasm may get you down like me last week. But noticing I really did too much and cannot train through it was just like a 72 hour break for strenous activity. You want to push your body as hard as possible as that way you get the right hormonal mix for growing muscle and that surely helps your chondrocytes bed in better too. Well having access to Human growth hormones is expensive and not possible for me. So training as hard as possible sets free as much HCG and testosterone as possible too. That helps healing.
People being afraid of going hard are IMHO making a mistake. Yes please train only things without pain, but train as much as your body can handle. All studies show that early and aggressive rehab is key after cartilage surgery (except MFX/NFX which is a disgrace and not proper surgery anyhow).
Last edited by gaoshanfelix on Mon Mar 07, 2022 1:38 pm, edited 1 time in total.
gaoshanfelix
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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Yesterday chose to do kind of extended VO2max training on the bicycle. I'm really a bit on my loss as in regards to my heart rate vs power zones. I more or less correctly did the FTP test - but if I train by FTP my heart rate on endurance activity is clearly too high - also I can hold pretty high heart rates for way longer than most people. So is my FTP result too high vs reality? Or am I part of those people with simply higher heart rate and my lactate kicks in later? I think I can only tell by doing a lactate test in a lab. The strange thing is - all my performance/health markers are way better after hard but rather short (for me that is 2 hours!) training vs long stead training (4-8 hours).


Why do I write about this? Well maybe for my current form in the rehab right now I should much more focus on high aerobic activity than low aerobic activity - making quite a big difference in when it comes how to get back muscle - and how to get my body in the most productive state hormone wise for the graft to heal up (I am sure that is identical - at the phase 2-6 months after surgery you want to build strength/muscle as much as possible to make your body incorporate the graft and let it grow/harden to the best state).
My doctor has been very vague on how much I can train. He wrote me one month ago when I asked for advice for walking down stairs (saying it hurts): I am cleared for all activities as long as I increase to them slowly, they do not cause pain, and they do not cause swelling - and wait 1-2 more weeks before starting to walk down stairs or train walking down.
He knows I'm very ambitious on my way back but he still wrote pain not discomfort.


My problem is - yesterday after the demanding training, which was like 5x 8minutes at or above my FTP threshold, at around 80-95% max heartrate (while accidentally hitting 99% max heart rate - if my max heart rate hasn't moved up by the training since 2 weeks ago when I did a max heart rate workout test) I didn't have any pain - but my knee was markedly warmer and I had to ice it quite a lot plus it got a bit stiff. Say uncomfortable. I don't have this so much after long steady workouts (4-8 hours). The actual workout was nothing new, the max power I excerted is much lower than during those short 5-10 second yellow traffic light sprints I tend to do since 6-7 weeks (350w max, highest 10 minute average at 298 watts vs 600-700w for 5-10 seconds), well I did do about 1/3 of those intervals standing not seated (pedals can track this nicely).
So is this only woes of adaption or should I not yet do such training? For my fitness/general health I really have to do them - Yesterday night had the best night sleep since many weeks (subjectively as well as according to my sleep tracking on my Fenix 6x Pro). This morning my knee feels fine - a tiny bit warmer than usual (maybe 0.5 degrees C, hard to actually notice, or 1.5 degrees warmer than my right knee).
Garmin connect tells me my optimal load range right now is 1000-2100 minutes of sports per week. That's a really high range but I feel at least for 1-2 weeks I should aim for the low end but go for very intensive activities.


I do notice the hard training is paying off. Yesterday I walked down staircases for 2 floors and only very lightly used the handlebar and my knee felt just fine. It was stable.
I have also been reading up many many topics on here on ACI, sadly most people seem to have ACI on the patellafemoral joint, not on the femoral condyle like me - and there seem to some differences in rehab. However most patient handout recovery advice - doesn't make much of a difference in timeline. They much rather make a difference on how many spots you had the ACI, and size of graft. The more/bigger the slower the rehab AND on general fitness - the fitter/younger you go into the surgery - the faster your recovery schedule (only the weight bearing first 8 weeks really differs). And in general to me I think those who started to train early had way better results. This is also evident from medical papers.
I think minced cartilage may grow in a tiny bit quicker vs ACI/MACI because the minced pieces are a bit bigger than just stem cells. The main advantage however rather being that you don't keep on losing muscle/fitness between the two surgeries, plus one surgery instead of two is simply less stress on your body. I am quite sure Denovo NT protocols and minced cartilage protocols should be pretty much identical. Denovo NT is not available in Europe, but minced cartilage and Denovo NT should be quite comparable with the huge difference of course autologous vs allograft.

Today I will hit the gym again for 90 minutes, plus at night go for a 140minutes group bikeride (45 minutes high intensity). Will be my first bikeride on a group with many competitive cyclist, two of them very high level. So I will rather draft along. Those two have FTP well over 6w/kg, the rest of the group rather 4.5w/kg to 5w/kg but I want to challenge myself a bit and ride with people that are at my pre injury/surgery level. I know from Strava they are still much faster, but it's way too easy to fall into mediocracy so always aim to compare yourself with the best. This weekend I have some business meetings/work so I will only hit the gym and maybe take short hikes - have to go to Taipei. So more time to recover and then next week hit back training with full strength.
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Re: Second-Generation Autologous Minced Cartilage Repair experiences

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I think I found a main reason why my gait sucks, and why I still have so big problems while riding bike pretty well. My Hamstring is gone gone gone. Kinda none existent anymore. When I first went on the Hamstring curl machine it felt like the machine is stuck or my leg forgot how to use... After some repetitions on minimum weight I got to 17kg or so, nothing at all so to say!
Maybe that's a problem of doing the rehab all by my own - but then on ACL rehab so far with physiotherapeutic support they never focused on hamstrings either - maybe because my physio was only up to 2 months or 2.5 months post op, and the doctors always only looked at functional numbers or how big your quad is.

With most exercises that involve the Hamstring like squats or lunges not recommended at proper weights/intensity, actually the only way is to get to a gym and work with the hamstring curl machine (besides fixing a theraband and working against it - I actually did this in the early stages, like week 2 to week 6 or so, but with theraband it is really hard to see monitor your process). With the hamstrings in general a weak muscle, problem for many healthy people, I think after minced cartilage surgery or ACI you really wanna focus on your hamstring curl machine and work out on it every second day from 8 weeks mark to full recovery. Before you can use a theraband.

Oh yeah - I seem not to be alone with Flexor deficit - and seemingly this is highly related to return to normal activity:
https://espace.curtin.edu.au/bitstream/ ... sequence=2
https://doc.rero.ch/record/332304/files ... e_2964.pdf

So actually for many people flexor return to strength coincides with the greatest improvements felt. Now of course the inverse relationship is not proven, I state that if you want to be back to normal activities and no pain, getting your flexor strength back must be the first goal! Why? Easy achieving decent flexor strength after cartilage surgery isn't too demanding, and it won't happen during a normal recovery protocol but only after being cleared for all sports. So get ahead of the game and invest at least 1/5 of the time you spend on your quadriceps on your hamstrings. Quadriceps will be strengthened by countless activities - and if you miss strength here - it is very obvious. If you miss hamstring strength - it is not obvious why you are stuck in your process - but it is likely even more important for pain free activities. You can ride bicycle, run on treadmill, elliptical virtually without any hamstring - but it won't be nice. So put in every day 10-20 minutes minimum working on your hamstring. Actually running backwards on elliptical could help a bit but you really want to hit the hamstring curl machine as soon as possible - while squats and lunges are forbidden the first months. I didn't do it and definitely suffer from this mistake.

Oh yeah on flexion, I now slowly approach levels were I actually flex my muscle a bit, and not only feel it stuck inside my knee - As I only miss 6-7 degrees vs my right knee, and my right knee is super flexible for my age, I will not work into any discomfort. There is not much need in those last 6-7 degrees - and I can still work on that if it doesn't come back on itself with time.


Oh - and I found a really accelerated protocoll here:
https://www.connecticutchildrens.org/wp ... otocol.pdf
Stationary bike by week 4, starting to run by week 12 to 6 months, return to sports from 6 months onwards. That's about the most radical program so far that I found.
Last edited by gaoshanfelix on Wed Mar 09, 2022 9:53 am, edited 1 time in total.
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