OATS -MACI MACI vs autograft OATS for post haematological transplant patient

[beng5124]

Hi everyone! I at a loss here so hopefully someone who's been in a similar position can help! I'm a 33-year old female about 52kg and am a post haematological transplant patient (transplant in 2016). As part of the transplant process, I was on long term steroids. One of the side effects of that was an infection in my femoral condyle that caused osteonecrosis in that area. The osteonecrotic area was treated with a subchondroplasty (done in 2018) as the rest of my knee structure was still intact. Fast forward to a few months ago, I found out my cartilage with the same diameter of the subchondroplasty is essentially gone. It's about 1.6 - 2cm in diameter. I've narrowed down to 2 options: (1) autograft from the iliac crest + MACI or (2) OATS from the posterior femoral condyle. An allograft or PKR are out of question because of my immunological condition and age. Both options have pros and cons, in terms of success I can't tell the difference from this standpoint. But from what I've gathered, hip autograft + MACI would be more joint preserving but with longer recovery time. OATS would provide a more robust structure but might compromise the donor site of my knee, especially since I probably don't have much bone to start with. Would appreciate some insight comparing the two options from this community! Thank you in advance

 

[Layla]

Hello, I'd like to welcome you to BoneSmart and thank you for reaching out here. Regretfully, I don't have anything to offer, but hopefully a few member's will stop by to share some insight. Your post has been brought to the attention of Administration and while often quite busy, it is a possibility they may have some thoughts to share with you. Thanks for joining us!
@beng5124

 

[Layla]

Following is a link to members that have experienced OATS - MACI

 

[Jamie]

Hi, and welcome. Since you have such a specific issue, the best opportunities for information from our forum are probably within some of the member posts that Layla provided for you. I've added a prefix to your thread title to make your thread a bit more visible to any of our currently active members who might see it.

You might want to get some additional medical opinions from one or more surgeons. I'm assuming you've discussed your questions with your current doctor as well. What was his or her opinion? Someone who could actually review the details of your case (and you, in person) would likely be the best way to help you reach the right decision for you.

While I understand the possible reason behind ruling out an allograft, I'm not understanding why a PKR might be off the table. Since the rest of your knee is healthy, this might be a good thing to at least consider. PKRs can be a bit tricky, but if you had a surgeon who was very experienced with them, it is possible for you to get a lot of years out of the implant.

 

[beng5124]

Thank you for the links and the advice above! I've seen about 11 orthopaedic doctors and surgeons in total. I have 2 doctors that can give me unbiased advice on which road to take but unfortunately they're also baffled! Although one has advised me to do MACI as it burns less bridges.

I think the hesitancy for PKR is based on the level of activity I'm looking to have (dance and pregnancy/raising kids) and the general fears around PKR - for me mainly knowing that my leg gets stiffer with every revision and that it's irreversible in a sense. I think most doctors I've seen want to try all the options before the last resort. Although it is very tempting to just go for it! I think it's the not knowing about the future (what levels of activity I might have) and irreversibility that anchored my decision to rule it out too.

As for OATS vs MACI, from what I've learnt both have pros and cons. One doctor is confident to do OATS and two doctors, graft + MACI. But I think with the shape of the osteochondral lesion I have I'm leaning towards the graft + MACI. As the cylinder from OATS might not correspond to the shape of the lesion? This I'm not entirely sure about. But at least with the graft + MACI, perhaps the graft gets packed in nicely even if the cartilage implant doesn't take? Maybe someone that has experience in both can comment on this.

 

[Peter Mac]

I've had a MACI procedure, but I'm confused by your question. I've never heard of an auto graft from the Iliac crest being combined with MACI.

 

[beng5124]

I've had a MACI procedure, but I'm confused by your question. I've never heard of an auto graft from the Iliac crest being combined with MACI.

Thanks for your comment! What was your experience like? In terms of recovery and your condition now? In regards to the autograft, I have an osteonecrotic area just above where the cartilage defect is. So in total a whole area of 20×25mm needs to be filled in. The solution to that is to fill in with bone graft and patch the MACI on top.

 

[Peter Mac]

I'm about 9 months post op. MACI requires some time non weight bearing and lots of time on the CPM machine.
I am still working through a lot of scar tissue from the mini arthrotomy. Maybe I wasn't aggressive enough early on so I grew too much scar tissue. Maybe I was worried about protecting the MACI graft too much. It was also really difficult to find physical therapists who had a clue about the proper MACI PT recovery. Had I known there are so few MACI trained therapists, I would have spent more time getting physical therapy advice before surgery. Physical therapists have a lot of attitude as well. They want to tell you what to do instead of finding out what the proper MACI protocols are.

Anyway, my surgeon seems to think the MACI graft is doing well and says I've passed all of the tests to determine if the graft properly took. I'm a skeptic though and told him I won't get my hopes up until I see my MRI. At one year post op I will have an MRI. I can't really tell how much I've improved because I have so much scar tissue pain. Giving MACI the benefit of the doubt, even if the MACI graft grew perfectly I still need to work through all my scar tissue before I can see if I'm pain free. If I regrew all my cartilage, but I'm still in pain from scar tissue, I haven't exactly reduced my pain levels

Is your surgeon planning to bone graft and patch with MACI in the same surgery? That seems incredibly aggressive to me. If you had one surgery to graft the bone and then MACI a year later I think the chances of success would be higher. Granted, I'm not a surgeon so I would ask both doctors about the success rate of graft plus MACI at the same time. You are asking your body to successfully grow new bone and cartilage at the same time.

I'm also a skeptic. I'm a victim of two scam knee surgeries so I'm extra skeptical of what any surgeon tells me anymore. I need to see hard evidence before I'll believe anything. Even a simple MACI procedure has a lengthy recovery time period. I think my recovery could have gone twice as fast if I had a clue about what to do or if I could have found a MACI trained therapist. If I had to do it over again, I would have spent a lot of time pre-op with a competent MACI trained therapist even if it meant I had to fly to another state to get quality care. MACI is a relatively new technology and Vericel needs to make a strong effort to get more PT's trained on its protocols.

 

[Peter Mac]

beng5124, I noticed you never responded to my last post. Do you have any follow up information?

 

[beng5124]

beng5124, I noticed you never responded to my last post. Do you have any follow up information?

Thank you so much for reaching out! So sorry for the late response, it's been a hectic month coming to a decision. Thank you for your advice, I went back and forth between the 2 options and finally decided to do the graft + MACI. My orthopaedic doctor assured me that it's vital to get the bone graft in, whether or not the MACI works. So I just had the cartilage retrieval last Monday and it's now in a lab as we speak!

I think my concerns regarding the MACI and graft failing were addressed by the surgeon. He said he's done it before and he believes that it will work. And if it fails, they can do the minced cartilage option. Which was one of the options I was researching but since it's only a few years old and isn't yet strongly evidence-based, I decided I would go the gold standard route of MACI. So fingers crossed all will work out!

I will definitely learn from your experience and do my best to find a MACI trained physiotherapist. I imagine with the pain in my hip and my knee I'll need plenty of rehab! How long did your cartilage take in the lab? They've advised me it would be about 6 to 7 weeks from retrieval. And how are you on your progress of recovery?Thank you again for all your help!