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Slowtwitch Forums: Triathlon Forum:
ACI vs. Microfracture

tandem

Oct 27, 09 3:58

Post #1 of 24 (250 views)

ACI vs. Microfracture	Can't Post

Does anyone have any thoughts on these two knee surgeries. Its been confirmed that I need the work done on my knee now I need to figure out the best way to fix it. From what i've seen the recovery is about the same as is the success rate.

Any reason to choose one over the other? Does anyone have any real life experience with recovery and post surg activities?

ride2eat

Oct 27, 09 5:28

Post #2 of 24 (242 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

What is ACI? I had my ACL repaired and it's nothing really as far as the procedure. The rehab is as challenging as any workout you will ever do and holding back is probably the hardest part. Gaining back mental confidence to push it was equally as difficult. Did you mean ACL?

dforbes

Oct 27, 09 5:32

Post #3 of 24 (239 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

I had microfracture because the success rate is higher, and my legions were extremely big. Plus, my surgeon didn't want to perform surgery again if the simplest technique may work. So he did the microfracture, and took samples for ACI incase I needed to come back. But, I thought the recovery times were a bit different. I had to be non weight bearing for a few months, then weight bearing with a non-load bearing knee brace for another few months. I was given the green light to run on a treadmill around month 8. For ACI, I thought you were non weight bearing for over a year? But, opinions vary I'm sure. It doesn't sound like this helped much, but my surgeon believes in minimal invasion, and decided that microfracture was the way to go because of the percentages. Good luck.

AndyPeterson

Oct 27, 09 5:38

Post #4 of 24 (233 views)

Re: ACI vs. Microfracture [ride2eat] [In reply to]	Can't Post

In Reply To:

ACI is autologous chondrocyte implantation. The OP has a chondral defect, not an ACL tear. Your story is not applicable.

To the OP: Our surgeons do them for different indications. Microfracture if the chondral defect is small or at a non-weightbearing site. ACI (we call ours an OATS - osteochondral autograft transfer system) for larger defects on weight wearing surfaces.

This is not a good topic for a "which treatment should I get" type of discussion. It really depends on what the surgeon thinks is going to most successful based on the technical aspects of the case. Trust your surgeon or see another one. PM me and I might be able to point you in the right direction if you want a second opinion.

Gfizer

Oct 27, 09 7:47

Post #5 of 24 (215 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

Not sure exactly what or where your injury is, so this may or may not be relevant. I had a substantial tear of the articular cartilage on the medial head of my femur. I know microfracture is an option for this type of injury. I had a "mosaic plasty" and have had great results. They can do a mosaic plasty by taking plugs of your own cartilage from the edges of your joint and plugging the hole, or by using synthetic plugs. The synthetic plugs were described to be like a coral reef - they are porous and will atract your own cartliage cells. I had the synthetic plugs. Non weight bearing for about 2 months. I was water ski jumping 180 feet 8 months after surgery (pretty hard on knees), have done two halfs this summer and am doing Ironman Florida. Gets a little tender if I am doing a lot of running, but no mechanical problems and no swelling.

mmrocker13

Oct 27, 09 8:22

Post #6 of 24 (211 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

How big is your lesion? Where is it? What other complicating factors do you have? Really, they are two different procedures, and apply to different cases.

MF is designed for smaller (maybe medium) lesions, with healthy subcondral bone. The return to athletics is generally faster than ACI or OATS (autologus chondrocyte or osteoarticular allo/autografts). It does NOT create real cartiliage, but rather scar tissue--which is inferior to actual cartiliage. Depending on what you read/who you ask, long-term viablility is somewhere around 50-75%.

ACI (autologus chondrocyte implantation) is a more involved process. In that, they surgeon harvests your own cells, then grows them in a lab (more or less...basically, it grows immature cartiliage cells, which are then implanted, with the hopes they mature into cartiliage, in a gross oversimplification). The advantage of this over OATS is it's your own tissue, so the risk of rejection is less. Also, since they atre lab grown, they don't have to harvest a chunk form your healthy areas. As well, it can cover a larger area than MF or even OATS. However, again, it's not TRUE articular cartiliage, and is still slightly different than regular AC. And, many insurance companies will not cover this procedure at all, or unless other options have been considered.

OATs treats small to medium-large defects by taking a plug of healthy articular cartiliage from either your knee or a donor knee, and then implanting them in the defect. Obviously, the size of lesion that can be covered is limited by the size of plug they can take from elsewhere in your knee without causing arthritic symptoms over there. Donor cartilaige can be used, but then you run the risk of rejection, etc.

Both ACI and OATS have higher long-term success rates than MF.

All of these depend on size and location of lesion, as well as whether your alignemnt is good, and what the rest of yoru joint space is liek (meniscal injuries, etc).

If my surgeon said "Hey! You pick one!" I'd be a little concerned, b/c they are nOT in terchangeable.

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This country has far too many special interest folks who think that every human is just one hug away from redemption - when the fact is that some humans are just a burden to society. --R10C

tandem

Oct 27, 09 8:54

Post #7 of 24 (205 views)

Re: ACI vs. Microfracture [mmrocker13] [In reply to]	Can't Post

chondral defect at the medial femoral condyle (.6cm transverse/ 1.5 cm AP). Other than that the knee looks clean. My surgeon did provide options, but was leaning towards ACI. His rational was that with ACI I can go back in 10-15 years and still have success with MF or OATS. If I choose MF first then then my future success rate with the other options are decreased (at least thats how I understood it)

I was told the recovery time and success rates are about the same. I've also read that the recovery is not lots of fun. The one advantage to ACI was keeping my options open for the future, The advantage to MF was a single surgery. I am getting a second opinion later this week but have already scheduled the scope for ACI. Any opinions?

dforbes

Oct 27, 09 9:32

Post #8 of 24 (196 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

Try to read as much as you can. After reading fine print, I found that ACI was about 25% successful (back to athletics) and that there is not a huge number of studies (2yrs ago) and most reports were from abroad.

mmrocker13

Oct 27, 09 9:57

Post #9 of 24 (188 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

There is absolutley a difference in success rates, esp. in a return to running (which will be contraindicated by almost every doc you talk to--and, usually, for good reason).

Plus, ACI is relatively new, and not done in a lot of places, so the number of success stories on it are, obviously, limited to a degree. (And again, there is the insurance issue) And, there are also studies thatsuggest that long-term, the cartilage developed in ACI is not all that different from the fibrocartiliage done in a MF.

Frankly, and this is anecdotal, of course...but ask around a bit and see what you come up with... these are not procedures that you go in for repeatedly. If your MF fails or your OATS fails in a couple of years, you run the risk of being a one-and-done. Esp. with runners, who t end to ignore pain until it's too late. Eventually you will get to a point of no return where NONE of these are an option. So you definitely want to choose wisely the first time around. Your lesion is fairly small, def. try and keep it that way. You also have intact meniscii and ligaments and good alignment, which further helps your cause.

I'm not sure why, as a whole, ACI v. MF v. OATs would be different long-term for your next option, should one fail (except for maybe if you do an AUTOgraft, as opposed to ALLO in the OATS). You will be left with a defect. Which may or may not have healthy bone underneath. I was a candidate for OATS and ACI following my MF failure. I do know that insurance prefers you have a MF failure before it gives the approval for ACI/OATS (or at least the three providers I have had recently do).

Honestly, I'm not sure which one I'd go with. Probably OATs, actually. Real cartiliage is best, assuming it works. That or MF, although I know a lot of folks would poo poo it. But with a smallish defect, and intact meniscus...that would be my choice. It's one surgery, it's done arthroscopically, and it's covered by insurance, and compared to procedures that could come down the road, not a bad recovery time, esp. these days. In this situation, I don't think I would want the hassle of ACI.

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This country has far too many special interest folks who think that every human is just one hug away from redemption - when the fact is that some humans are just a burden to society. --R10C

dforbes

Oct 27, 09 10:01

Post #10 of 24 (185 views)

Re: ACI vs. Microfracture [mmrocker13] [In reply to]	Can't Post

Yes, I'm waiting for the day that knee replacements are good enough to last longer than 10 years and you can do anything with them, I'd have both knees done!!!

mmrocker13

Oct 27, 09 11:02

Post #11 of 24 (172 views)

Re: ACI vs. Microfracture [dforbes] [In reply to]	Can't Post

Over the course of a lot of reading, I have found that people DO continue running and playing tennis and soccer (typically the three they tell you NOT to do) following PKR/UKRs, as well as after osteotomies. The numbers are low, and the mileage is as well... but they are out there. But there's almost ZERO data on it. (and DUH, b/c what doc/insurance company is going to okay it.)

Honestly though, with things like arthrosurface now available...really the only thing they tell you to avoid is running. I hope that company gets up and going here in the US more, b/c it seems really promising.

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This country has far too many special interest folks who think that every human is just one hug away from redemption - when the fact is that some humans are just a burden to society. --R10C

dforbes

Oct 27, 09 11:18

Post #12 of 24 (164 views)

Re: ACI vs. Microfracture [mmrocker13] [In reply to]	Can't Post

The problem is that runners like me are numbskulls and will still do it, that's why they had surgery, for a second chance! Of course they tell you not to, or recommend it, but we do it anyway and complain!

weenis

Oct 27, 09 11:21

Post #13 of 24 (164 views)

Re: ACI vs. Microfracture [mmrocker13] [In reply to]	Can't Post

I am going to defer to others who may have had one or both procedures ( I was too far gone for either) but if I had to pick one, I'd go for the real hyaline cartilage over the fibrocartilage and for that reason take the ACI. As far as recovery and rehab my sense is they are very similar (every knee procedure other than my diagnostic scope has had the same rehab), although your return to "full activities" (shitty euphemism for running) may be lengthier with the ACI. Even so, if I had a chance to get it right, I forsake a few more months of running.

Rocker - What is arthrosurface?

mmrocker13

Oct 27, 09 11:42

Post #14 of 24 (154 views)

Re: ACI vs. Microfracture [weenis] [In reply to]	Can't Post

Arthrosurface HEMIcap is a new (in the states) resurfacing hardware (they do knees, ankles, shoulders). They had a brochure on it at my PT office (wierd, b/c as far as I know, no one here does it yet--at least no one I'd go to :p).

It's typically outpatient, and is billed as a "middle treatment"--as in between first-line treatments and total arthroplasty. Basically, it's a titanium screw, with a cobalt plate. They can get the plate size pretty close to the actual lesion size, so the amount of damage elsewhere in the joint/bone is minimal. For the knee, they have a partial resurfacing (meniscal sparing, so it only covers the actual defect size--this would be similar to what the OP needs). They have a patellar/femoral one, as well, and a femoral condyle one. My problem is, the femoral one is still not yet FDA approved in the US. (All of the other ones are).

http://www.arthrosurface.com/

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This country has far too many special interest folks who think that every human is just one hug away from redemption - when the fact is that some humans are just a burden to society. --R10C

(This post was edited by mmrocker13 on Oct 27, 09 11:43)

weenis

Oct 27, 09 12:49

Post #15 of 24 (141 views)

Re: ACI vs. Microfracture [mmrocker13] [In reply to]	Can't Post

Yes I just spent a little while on their website. Cool product. I missed the part where knee is not yet FDA approved. Also confused by the term "meniscus sparing." I assume this means thery don't remove it as in traditional TKR/PKR? Also, what if you don't have a meniscus? I wonder if not having one cuts down on the useful life of the device?

Also did not yet see info on which activities (running) you can and can't do.

I'm going back into the website now.

onboost91

Oct 27, 09 13:10

Post #16 of 24 (134 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

As others have noted the rehab time-line of the MF is really going to depend on the severity of your knee issues and whether there is good surrounding cartilage that can help bear weight after the surgery.

I had MF surgery at the end of June in conjunction with a Lateral Release. Luckily the site of my MF was surrounded by good weight bearing cartilage so I was encouraged to start rehabbing it almost immediately. I read some nightmare stories about people who had to stay off the leg for months and then had to deal with major muscle atrophy and long difficult recoveries. I was hobbling around on 1 crutch with in days. After my 1 week follow-up I was told start self rehab (no PT) beginning with spinning on an exercise bike (opposite leg driving and the injured one just along for the ride for ROM which the LR swelling made extremely difficult). At 6 weeks I was biking for 45 minutes a day and was told I could start on an elliptical. At 8 weeks I was able to start on a treadmill. At 10 weeks I quit the treadmill and started on a rubber track. Each phase of the recovery from bike to running has been a slow incremental build where I was only adding a few minutes per week. I am now running 2-3 miles most days, mostly on the rubber track but sometimes on pavement and I have no noticeable problems biking or swimming. I am doing leg strengthening exercises 2x a week. I still have a way to go though because I cannot comfortably do anything that completely isolates my knee and applies major force to it (lunges, 1 leg jumps, 1 leg weighted extensions, even the full weight bearing knee bend while going down stairs is iffy). Kneeling, squatting on the floor to play with my children and being able to touch my heel to my glut are things I only fairly recently have been able to do.

Whatever you decide good luck. I hope everything works out.

DavidC

Oct 27, 09 13:14

Post #17 of 24 (134 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

PM me if you want to talk about my experiences returning to hawaii ironman level competition (9:46 IMLOU, 10:16 Kona in 2009) after microfracture (lateral femoral condyle). I'm one of the success cases, still going strong 3.5 years after procedure. 47 years old.

weenis

Oct 27, 09 14:12

Post #18 of 24 (125 views)

Re: ACI vs. Microfracture [DavidC] [In reply to]	Can't Post

David you did a kneeguru diary on your return to IM after MF, correct?

mmrocker13

Oct 27, 09 14:17

Post #19 of 24 (122 views)

Re: ACI vs. Microfracture [weenis] [In reply to]	Can't Post

In Reply To:

I actually have an e-mail in to their medical research guy, seeing what they anticipate the device will and won't be able to do.

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This country has far too many special interest folks who think that every human is just one hug away from redemption - when the fact is that some humans are just a burden to society. --R10C

weenis

Oct 27, 09 14:22

Post #20 of 24 (117 views)

Re: ACI vs. Microfracture [mmrocker13] [In reply to]	Can't Post

In Reply To:

I actually have an e-mail in to their medical research guy, seeing what they anticipate the device will and won't be able to do.

DavidC

Oct 27, 09 15:02

Post #21 of 24 (112 views)

Re: ACI vs. Microfracture [weenis] [In reply to]	Can't Post

That was me over at kneeguru, yes. Still don't know of anybody else who's done an IM at that level after microfracture. Planning on Kona next year.

Buckeye

Oct 27, 09 15:52

Post #22 of 24 (106 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

I had my ACL reconstructed and MF last year. My doctor didn't know if he was going to do MF or OATS until the surgery and he ended up doing MF on one cartilage defect but there was a 2nd defect that was too large for MF or OATS. I spent 4 weeks on crutches and was back riding my bike after 5 weeks - although only short distances, flat roads and being really careful (doctor's a triathlete too..). The doctor recommended that I give up running but i wanted to try it any way so he prescribed an unloader brace. It was still too painful to run with it and so now I have switched to aquabikes and time trials. I miss running but am glad there are still other outlets available for competing. Good luck with your knee - hope everything works out well.

johnpostmd

Oct 28, 09 12:55

Post #23 of 24 (70 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

Tandem - lots of helpful information here but as was pointed out, ST'ers (me included), while well intentioned, don't make the decision, you and your surgeon do. But you can help him immensely by being open about your post-op plans, keeping your weight down, and maybe putting the career as a ski jumper or dirt track M/C racer behind you.

You also want to know what the doc feels he's best at. More OATS are done than ACI's but MF frequency exceeds both. How many OATS and ACI's has he done in the last year? I always consider it a compliment if a patient asks to speak to some one I've done the procedure on and gladly share that.

In the end though, I think it'll be the surgeon's best judgement at the time of surgery, after evaluating all the findings, that pushes the final decision. With your keen level of interest and involvement, I'm certain you'll do well. Good luck.
John Post, MD
Medical Director, Training Bible Coaching
www.trainingbible.com
http://johnpostmdsblog.blogspot.com

boomersb

Oct 28, 09 15:18

Post #24 of 24 (54 views)

Re: ACI vs. Microfracture [tandem] [In reply to]	Can't Post

I've had two ACI's, in two different areas of my one knee. While a doctor is best to advise you on the best alternative based on your specific situation, there are a number of points to consider. First - - my suggestion is to approach the decision on the surgeon you consult very cautiously. There are many different experience levels. I saw Gillogly, the Atlanta-based surgeon (who is also the team dr. for the Atlanta Falcons). He is highly experienced in sports-focused surgery and recovery, and is one of the early pioneers in the states for the ACI surgery. Second, you must fully understand the recovery period and effort required. My first steer to people is that if you're not fully committed to the PT, you shouldn't have the surgery as it can't be successful without that. That being said, although I'm still in process of recovery, my knee is well on its way to being very successful, and in fact, is being highlighted in some medical seminars. If you want to really talk in more detail, PM me and I'm happy to step you through the experience of a runner, now cyclist.