This little piggie..... helps in knee surgery?

There was one interesting question from my last appointment that I had to research before I could answer. I was asked if I wanted the doctor to use a Bio-gide patch. I had no idea what that was, but it turns out to be a pretty cool little bit of piggie.

A key part of the surgery is that the new cells are implanted under a little flap that holds them in place. That flap has in the past been typically taken from the surface of your bone in another part of your leg, just below the knee. That meant another incision was needed to harvest it, which meant more time under anesthesia and more required healing.

With this traditional method, by far the most common complication leading to more surgery was overgrowth. In other words the cells wouldn't stay in their little pocket, but would continue to grow and start getting in the way of knee function. Overgrowth would require that subsequent surgery to clean out the joint and allow it to move freely again.

Okay, now to get to the point. Bio-gide is a little flap of tissue that is harvested from a pig, instead of your leg. Right there one benefit is obvious as the use of Bio-gide means no second incision and a shorter surgery. However it gets even more interesting. For some reason using the Bio-gide instead of your own tissue patch significantly reduces the occurrence of overgrowth. In the study done on this, the comparable rates of required subsequent operation for the original method was 25.7% (77 of 300 patients) and the Bio-gide group was 5% (5 of 101 patients), with no significant difference in the overall ACI success rates. That is an 80% reduction in the occurrence of the most common cause of needing more surgery! Studies done in Europe are seeing similar results.

There is an important caveat that patients should understand. While the FDA has approved the use of Bio-gide in other surgical procedures (mostly dental), it has not been approved for knee surgery. As most people know, government agencies can move slowly. However, the benefit is so significant that surgeons don't want to wait at the expense of their patients.

So, thanks little piggie.

Answers

Well, I had my last appointment with my OS before surgery. I got all my questions answered and two pieces of good news. First, I don't need an osteotomy! Second, my insurance approved the ACI after the peer-to-peer review! It's actually going to happen. I am getting more nervous, but unfortunately it is still over a month away. I just want it over with.

If you are curious, here are the answers to the questions I listed last time.

- 24/7 care really isn't needed, but it would be good to have my husband off work and around for the first week. He still asked off for two weeks since recovery is different for everyone and it would be better for him to return early than have to stay out longer than planned.

- Again, no osteotomy! The 51" long leg X-ray showed good alignment in my knee. This is very good news as an osteotomy would have increased the chance of complications, increased the pain, and put more limitations on my rehab protocol.

- As for what hardware I will need, the answer was yes, yes, and yes. I knew the CPM machine would be needed, but that was the first time we discussed the Bledsoe brace. It's huge! The ice machine will be nice since it means I will have continuous icing and not need to refreeze ice packs.

- Regarding the post-surgery meds, they have a pharmacy in the hospital so my husband can just take the scripts down there while I am still admitted. That's not so bad.

- I will have to stay in the hospital for a day or two, depending on so many things that I don't think he wanted to narrow them down.

- He used Google Scholar to print out the research for me. I have not had occasion to use that before, so I didn't think of it. I think I will be looking up some other research as well.

- I don't need to arrange for an in-home physical therapist. The hospital will take care of that. They apparently only brought it up to see if I already had someone I wanted to use.

- I can take the Ryzolt up to the day before. I plan to reduce how often I take it from twice a day to once a day for three days before so I don't stop suddenly.

- He said the drugs he was planning on giving me after surgery shouldn't interact with Rozerem or Lunesta so I should be able to take them if needed. My reasoning for thinking I might want them is because I am a light sleeper but I was really hoping to use the CPM machine at night. I am not sure if I can sleep through the motion and sound without help.

I still have some more things I need to do to get ready, but I can't help but feel like this appointment was a major milestone. The treatment is now defined and approved so there aren't any big questions remaining open.

Questions

I wanted to write out and share the questions I am accumulating, both for the benefit of organizing my thoughts and as a reference for others.

- How long is 24/7 care recommended?

- What type of osteotomy are we talking about?

- What hardware will I need to use (i.e. CPM machine, Bledsoe brace, ice machine)?

- Can I pick up the post-surgery medications (pain killers and blood thinner) before the surgery so they will be waiting for me? I don't really want to have to stop at the pharmacy on the way home.

- How long do I have to stay in the hospital? I will have to climb two flights of stairs when I get home in order to get settled and that might need to be taken into consideration. Actually a better question might be to ask what conditions I need to meet in order to be released.

- Can they get me a copy of the relevant published research? The STAR study appears to be the biggest applicable effort that has been performed. Here is the information about it if anyone wants to find it, but it requires either payment or a subscription as it is a professional research paper. I figure my doctor probably has access and might be able to let me read it.

Kenneth Zaslav, MD, et al. A Prospective Study of Autologous Chondrocyte Implantation in Patients With Failed Prior Treatment for Articular Cartilage Defect of the Knee Results of the Study of the Treatment of Articular Repair (STAR) Clinical Trial. In The American Journal of Sports Medicine. 2009. Vol. 37. No. 1. Pp. 42-55.

- Do they have an in-home physical therapist they would recommend? My physical therapist does not have a recommendation for anyone local.

- When do I need to stop taking the Ryzolt? My pain management doctor mentioned that it is common to get nasty withdrawal effects if you stop it suddenly, so it is a good idea to step it down to once a day for three days before stopping entirely.

- I have some Rozerem and Lunesta left over from trying to sleep while the pain was out of control. Can I take that with the post-surgery drugs? After I step off certain drugs can I start taking them if needed?

A Few Things

There are a few things going on right now. First, the Mid-Atlantic area is experiencing a crippling series of snowstorms, so I have been stuck inside even more than usual. The new office is taking shape and I do really appreciate how I can physically separate phases of the day by just changing my scenery. It makes my world seem a tiny bit bigger.

Second, my insurance company provided an initial assessment and denied coverage for the ACI. This understandably freaked me out, as my research indicates I am a perfect candidate for it (BMI under 35, far too young for a knee replacement, damage contained to a limited area, failure of previous methods). I called Dr. Trice's office and spoke with his personal admin, Denise. She has been very kind and I am so grateful that she always seems to have time to answer questions. She said that the initial denial is not uncommon, but once the treating physician has a "peer-to-peer" review with the doctor making the insurance assessment, that it is usually approved. She said they had attempted to do that review, but were only able to leave a message. The crazy weather might be causing problems where the insurance doctor is located too.

It's funny to me that the reason the ACI was denied is that it is an unproven procedure. That makes no sense as it has been performed widely for years, has had multiple extensive studies (including a big one published last year), and it is routinely covered by insurance companies. I guess for something so expensive the insurance company must try denying it first to get the full picture of whether you really need it. Being a patient is awfully hard sometimes. Insurance makes me feel like I am following breadcrumbs in a forest and am always on the verge of getting lost and abandoned. And I have really good insurance!

The third thing going on is that I have another appointment with Dr. Trice on Monday. I believe we will be discussing the osteotomy and it will be a chance to ask questions about the ACI. Wish me luck!

So fast... so slow

I feel like I am in a time warp. March 24th seems so far away and I want it to hurry up, but when I look at all the things I need to get done before then it feels like I have no time at all. Anticipation and dread do funny things to your head.

I have ordered some new furniture and am setting up a dedicated office in my house. I have been just kind of working wherever was comfortable or setting my laptop next to my home computer, but there are distractions and I want to be more productive. It is also kind of an admission that I will be stuck working at home for a while after the surgery and I need to plan for it.

We have a room that is not being used for much, so I will be setting up a desk and other office furniture in there. I also ordered the tallest ottoman I could find to prop my leg up. Most are pretty low. I had a lot of issues with my foot swelling up after the microfracture, which prevented me from doing anything where my foot had to be down for more than two or three minutes. The same thing will probably happen, so I want to be prepared this time.

Note from after the surgery: It turned out that low ottomans worked just fine. I ended up using a low one with a big pillow on top.

Dead Leg

I ordered a leg lifter this morning. I don't know if I will need it or not, but I saw it on Ray's Checklist, and it seems like a good idea. It does seem to be the height of helplessness to need it, but I can totally see that happening.

I am still managing and getting by. I have good days and bad days, but it seems like the bad days are coming more frequently lately. My cat woke me up early this morning by standing directly on the spot on my knee that is most sensitive. A moment later she flew through the air as I bolted upright! Thanks, kitty.