OATS -MACI OATS, ACI, or What?

[nsirotta]

Hi all,

Im a a 33yo male with lateral femoral condyle lesions in both knees, and have been dealing with these defects (not due to injury) since I was 16. I've had 3 scopes (2 lft, 1 rt) to remove loose bodies, but ultimately the cartilage continues to deteriorate, and osteoarthritis has become apparent. When I was 23, I was able to run 3 miles a day to lose 40 pounds and ultimately turn my life around. I've been able to find short periods of time since then where my knees feel good enough to do light running for general fitness, but ultimately it always leads to the same place: debilitating pain and immobility for an equal period of time.

After my latest scope in Nov 2019 to remove 2 loose bodies in the left knee and smooth out the lateral surface of my knee, another loose body has broken off 7 months later and is now floating free in the knee. My surgeon said it would be pretty easy to remove with another scope, but ultimately this will keep happening and suggested either OATS or ACI as a more long term solution.

I've seen varying degrees of success with OATS, but it seems like I'd be a good candidate for my age group. I have a 6 month old daughter and want to be able to be active with her as she grows up. I'm not looking to do any marathons or serious contact sports, but I need to be able to kneel/crouch with ease, hike, bike, and if I'm really fortunate some light running/jogging.

Any insight on OATS or possible approaches to this problem would be appreciated - all your previous stories & accounts have been wildly encouraging & helpful.

 

[Celle]

@nsirotta
I have moved your post from where you posted it, because that's an old thread that hasn't had much on it since 2018. This is your thread now, so please continue to post here. We'll advise you here, too.

You probably won't like to hear this but, to be completely frank, I think you would be wasting your time and money with either Osteoarticular Transfer System, also known as mosaicplasty (OATS ) or Autologous Chondrocyte Implantation (ACI).

Both of these procedures usually only work if your knee cartilage is still in pretty good condition,, with only small, early signs of deterioration.

Your knees are already past that stage, with pieces of cartilage breaking off and osteoarthritis present. In addition, you have had several arthroscopic surgeries, to "tidy up " the cartilage and remove loose bodies.
It's becoming more and more widely recognised that these arthroscopic procedures to trim the deteriorating cartilage seem to hasten the deterioration of the knee.

I think your best choice is to stop wasting time on procedures that either won't work, or may be only temporary fixes, and to go straight to replacement of both knees.

This is what skigirl wrote, back in 2018

i had an OATS. Six weeks of crutches and then weeks of (continuous Passive Machine (CPM), which I had to give up on since it was killing my back. When I woke up from TKR and saw the CPM on my bed, I just climbed over it and asked the nurse to remove it!!

The OATS took a chunk of my life and the results were so-so. Less pain at first, but it seemed to wear very quickly when I began skiing again.

After my TKR, I was really sorry that i spent so much time chasing rainbows. The TKR was the final surgery---no knee pain, no knee thoughts. The only thing that is difficult for me is kneeling.

At 33, you probably think you are too young to have knee replacements, but ideas about that are changing.
With knee replacements nowadays lasting 30+ years, there's no longer any need to wait for a knee replacement until you are "old enough". That's old-fashioned thinking.

There only a few ways in which you are "too young":

• You are too young to be living your life in constant pain and needing multiple surgeries.
• You are too young to have your mobility so badly compromised.
• You are too young to be giving up the lifestyle you enjoy.
• You are too young feel so old.

Knee replacements have a very high success rate. There's no need to fear being non-ambulatory.
Have a look at these posts, to see what some people can do with their replaced knees:
Stories of amazing knee recoveries

Go ahead and get those knees replaced, so you can enjoy playing with your daughter.
You may have to find a different surgeon - one who will look at the state of your knees and not at your date of birth, but it will be worth it.

 

[nsirotta]

@Celle
thank you so much for this insight. i have been reading more and more that knee replacements for people in their 30s are becoming more and more common.

obviously you don't have my x rays or MRIs, but i've been reading quite a lot about partial knee replacements and am wondering if that would be a good option for me. especially since i've read that PKR are not very complicated to convert to TKR if needed down the line.

have you seen that people with TKR on both knees are able to be somewhat active? again, not talking long distance running or contact sports...but am i going to be able to run after my kid and hike?

 

[Jaycey]

but i've been reading quite a lot about partial knee replacements and am wondering if that would be a good option for me.

The only way you can find out if PKR is right for you is from a surgeon looking at your x-rays. In some cases they may need to visibly assess the joint when they go in and do whatever procedure will fix the damage to your knee.

but am i going to be able to run after my kid and hike?

Definitely! Of course there will be time when you are healing . Read the thread on this link Celle left for you Stories of amazing knee recoveries.

 

[nsirotta]

@Jaycey

thanks for the link - seems like people have seen a lot of success with BTKR. i am definitely going to consider this as an option.

i am scheduled to get a 2nd opinion here in Portland in the next few weeks, so will report back on how that goes.

thanks again for your insight.

 

[Jaycey]

I'll tag my colleague @Roy Gardiner to come and chat with you. Roy had BTKR and is a an avid cyclist.

 

[nsirotta]

Thank you - I look forward to Roy’s insight.

 

[Celle]

i've been reading quite a lot about partial knee replacements and am wondering if that would be a good option for me. especially since i've read that PKR are not very complicated to convert to TKR if needed down the line.

Don't get too impressed with the advertising about a partial knee replacement (PKR). Some web sites say a PKR will give you a faster recovery or will feel "more natural". Unfortunately, recovery from a PKR takes just as long as recovery from a Total knee replacement (TKR). And both sorts take a while for your body to adjust, but can feel just as natural and give you just as much mobility.

Revision from a PKR to a TKR is just as much major surgery as having a TKR in the first place, sometimes even more.

My first knee replacement was a partial (PKR). That was back in 2000, when the idea that you had to be "old enough" was still prevalent. I waited for 9 years for that knee, my pain and mobility getting worse all the time. They were wasted years.

That PKR gave me back the active life I had wanted for so long. I travelled the world with it. In fact, I think I wore it out, because eleven years later the spacer broke (I had worn it too thin) and I had to have it revised to a total (TKR).

The revision surgery and recovery were about the same as my original surgery and my revised knee is strong and reliable. But when my other knee needed replacing I chose to go straight to a TKR, because I didn't fancy another revision surgery.

My PKR was a success and 11 years is longer than many PKRs last . Unfortunately, osteoarthritis tends to progress and many PKRs have to be revised to a TKR within just a few years, some even within the first year, because arthritis has invaded the other compartments of their knees.

When you find a surgeon willing to replace your knees, ask if a PKR would be suitable. If he/she says yes, be sure to check that he/she will be prepared to convert to a TKR during surgery, if there are any signs at all of arthritis in the other compartments of your knees. If there are, it would be unwise to do a PKR.

have you seen that people with TKR on both knees are able to be somewhat active? again, not talking long distance running or contact sports...but am i going to be able to run after my kid and hike?

Well, I have had a TKR in both knees for almost 5 years now. Once recovery was over, I returned to being just as active as I was with my one knee replacement. I'm getting old now and my body has slowed down, but I still travel, still play with my granddaughters, still do all my own housework and gardening. I think my knees are more fit than I am nowadays.

When Roy Gardiner talks to you, he will tell you he is still active in cycling.
I believe another member with two replaced knees went back to her job as a ski instructor, and several others are back into hiking.

So yes, once your recovery is over (and that does take quite a long time), I see no reason why you wouldn't be able to run after your daughter and return to hiking.

 

[Roy Gardiner]

Thank you - I look forward to Roy’s insight.

Hi. Yes, I went back to riding my bike after BTKR and now, many years later, my knees are absolutely not a limiting factor in any way. Indeed, my pedalling action is better than before because (a) I am no longer bow legged and (b) I'm not compensating for damaged knees.

 

[nsirotta]

Thank you - I look forward to Roy’s insight.

Hi. Yes, I went back to riding my bike after BTKR and now, many years later, my knees are absolutely not a limiting factor in any way. Indeed, my pedalling action is better than before because (a) I am no longer bow legged and (b) I'm not compensating for damaged knees.

This is wildly encouraging. Thank you

 

[Roy Gardiner]

Good. You will have NO TROUBLE on a bike, trust me.

 

[Jockette]

Partial knee replacements are only good if the damage in the knee is limited to one area. I wouldn’t recommend a partial if the damage covers more than that.

And, if you find a surgeon who recommends a partial, make sure he/she does a lot of them, not just a few a year. It takes a special skill to do a partial so lots of experience is key!

 

[nsirotta]

Partial knee replacements are only good if the damage in the knee is limited to one area. I wouldn’t recommend a partial if the damage covers more than that.

And, if you find a surgeon who recommends a partial, make sure he/she does a lot of them, not just a few a year. It takes a special skill to do a partial so lots of experience is key!

it is primarily in the lateral condyle - i do have healthy cartilage in the other compartments of my knees. the lesions are in the lateral femoral condyle in both knees - left knee graded stage IV, right knee still unknown (but likely to find out in the next few weeks when i go get my 2nd opinion).

 

[Celle]

it is primarily in the lateral condyle - i do have healthy cartilage in the other compartments of my knees.

That sounds good, but when your surgeon is operating he/she should examine the articulating surfaces of the medial and patellofemoral compartments as well. If there is any sign of osteoarthritis at all, no matter how small, a total knee replacement should be performed.

 

[nsirotta]

update here:

went to get my second opinion. doc said there is healthy cartilage in the other compartments of my knees and said 99.9% of the problem lies in the lateral condyle in both knees. he feels strongly that OATS is the best course of action. since he only does about 1 or 2 a year, he is referring me to another surgeon here in the portland area who does them very regularly (2-3 per month) and specializes in these kinds of defects.

i inquired with this surgeon about knee replacement, and he ultimately said the problem isn't bad enough to warrant a knee replacement. it's not bone on bone (yet) and there is still some cartilage present in the affected area.

will report back when i see the new specialist at OHSU who specializes in OATS and chondral defects.

 

[nsirotta]

Hello, all. It's been a while since I've posted here, but wanted to update everyone on my progress.

I was able to finally connect with a surgeon here in Portland (Dr. Dennis Crawford) who specializes in osteocondral defects, and performs 50-75 allograft transfer surgeries per year. In fact, the donor bank sets 2 grafts aside for him every month since he performs so many of these procedures. He has published various reports and journals on the procedure, and is considered by many to be one of the top surgeons in the country for allograft transfer surgery.

He looked over all my imaging and history with failed knee scopes, and determined that I am the perfect candidate for allograft transfer surgery on both knees, given that the defects are isolated to the lateral femoral condyles and the rest of my knees are healthy.

I am now 1 week removed from the allograft transfer surgery on my left knee. Swelling and pain have diminished considerably, and I'm able to do at-home PT exercises (leg lifts, knee slides, etc) without a great deal of discomfort (each day gets easier). Dr. Crawford also advised me to be partial weight-bearing on the surgical knee to avoid atrophy and maintain strength, which was exciting to hear given all my research on OATS and similar procedures (6-8 weeks non-weight bearing). I go in for my post-op in 6 days, and am projected to be walking in a limited capacity at about 2-3 weeks out.

I will keep everyone updated on progress, but I am very optimistic about the results thus far.

 

[Celle]

Thank you for this update.
Best wishes for your recovery.

Please will you tell us your full surgery date so we can put it in your signature for you?
Thank you.

 

[Celle]

I have copied your post, above, @nsirotta , and used it to start a recovery thread for you, here:
https://bonesmart.org/forum/threads/nsirottas-allograft-recovery.62618/

Please post any further updates on your recovery thread. Thank you.

 

[Jascherm]

Thank you for your post! I just had my oats procedure on Thursday. This is a tough one. How are you feeling!?