Transcript Slide 1

CHONDROCYTE TRANSPLANTATION / IMPLANTATION
VERSUS EXISTING TREATMENTS
NEWSLETTER
July 2008
Welcome to our second newsletter for patients in the ACTIVE trial. For those of you who have
recently joined the trial, the first newsletter is on the website under “Your participation”
www.active-trial.org.uk We will send out a regular newsletter and would greatly appreciate any of
your stories, news or pictures suitable for sharing and helping others with a similar knee problem.
Please keep in touch…
If your address is going to change please let us know so that we can collect the information which
is vital to the trial. A change of address form is enclosed. Most of your assessments are in the
first 12 months (pre-op, 2-3, 6 & 12 months, then 3, 5 & 10 years post-op) but we also send you a
questionnaire by post at 2, 4, & 6-9 years follow-up. Whether or not your knee is still causing you
problems we need to know about it so please attend assessment and complete the forms.
Your stories following ACI surgery
The Lee’s knees
Lee Williams from Abertillery in South
Wales provided these photos of his scar
after ACI. Lee’s surgeon here at
Oswestry said his knee had healed well
though somewhat tethered. I think Lee is
trying to show that is gets rapidly better,
and not to be too alarmed when you first
see it! Thanks Lee for the thought.
(Apologies to anyone who’s squeamish!)
It takes more than surgery….
In this edition we are featuring the stories of two ACTIVE patients who have shown a great deal
of determination. Firstly, Debbie Holmes provides an insight from the perspective of patient,
physiotherapist and ACTIVE Trial assessor. Our second story comes from Conor O’Donovan
from Ireland who describes his rehabilitation under the guidance of a private physiotherapist.
Debbie Holmes
My own knee injury came as a very unwelcome surprise back in 1997. I had always been
active in most sports so at the age of 31 I did not consider my injury to be anything
particularly serious that would curb my activities for long.
And so, while I was limping around at work at the Derbyshire Royal Infirmary (I should
perhaps mention that I am a physiotherapist), I was spotted by one of our orthopaedic
consultants and sent for urgent tests. When the x-ray revealed nothing, an MRI scan followed
but there was still no obvious cause of the huge swelling in my knee. Three days later I was
being wheeled into the operating theatre for exploratory surgery, still protesting that I really
did not need an operation and that my knee would surely settle down by itself. My surgeon
Mr Rowles fortunately knew better.
He discovered that I had sustained damage to the articular cartilage that covers the end of the femur leaving a hole
about the size of a ten pence piece. He had tidied up the area and carried out microfracture to encourage new tissue
to grow over the area where the strong articular cartilage was missing.
Over the past ten years my activities have been restricted due to the painful area in the knee. There would be
periods when the knee would allow me to carry out some sports but to a lesser standard than before injury. Every
year or so, I would suffer bouts of swelling and pain which would often continue for a few months before settling
again. I was fortunate only to return to theatre once more, whereas I know that many other patients have endured a
variety of procedures aimed at trying to improve things.
Continued overleaf
There were periods of devastation as I was often unable to do the things I loved. Working as a physiotherapist is
very difficult when you are on crutches more often than your patients. There were often spells when I would be
confined to deskwork; always with the underlying fear that I could lose the job that I loved should the hospital
declare me unfit to fulfil the role. Fun activities with my young family were often impossible or frustrating and I have
to confess that I was probably not all that easy to live with at times.
It was during one painful flare-up that I began to look into the current work being done on chondral injuries. Some
of the operations that are being tried and tested throughout the world are not available on the NHS as there is not
yet sufficient evidence to prove their effectiveness. This was certainly the case at my own local hospital where I had
a surgeon willing to try a different procedure but no funds available from the local authorities to pay for it.
My only option was to seek treatment from a centre that had funding to carry out the surgery as part
of a research trial. I discovered that such a trial was about to start at the RJAH Orthopaedic Hospital near
Oswestry and was delighted when they agreed to see me and accepted me into their ACTIVE trial.
I was informed a few weeks before my surgery that I would be having Autologous Chondrocyte Implantation.
This procedure involves two operations, one to harvest the cartilage cells for growing in the laboratory and then a
larger operation three weeks later to insert the new cells into the knee under a membrane. I underwent surgery in
May of 2006, my knee swollen from a flare-up that had lasted the previous seven months and had shown no signs
of settling. I was more than ready to surrender to any surgery that might provide some relief.
It is now two years since my operation and I am progressing well. I do walk with a slight limp due to
some minor discomfort but I have not had swelling or a flare up since the operation. I have not returned to
many high impact sports but I am able to walk unlimited distances and participate in high energy cycling
classes at the gym. I think in terms of sport my priorities have changed and I am no longer prepared to risk
further devastating injury when I can at least keep fit by doing lower impact sports.
More importantly, I am back at work and carrying out my full duties on the wards. This is not to say
that the process has been an easy one. Autologous Chondrocyte Implantation has a difficult and lengthy
recovery period requiring hard work and patience. I am fortunate to have a sympathetic employer who afforded me
all the time I needed to recover and has graded my return to work so that I do not endanger my knee. It is thought
that it takes as long as 12 to 24 months for the new cells to mature and reach their maximum potential. Other
procedures have a quicker recovery but until the much-needed research is complete there are many unanswered
questions as to the most effective way to treat these injuries.
Conor O’Donovan’s story
Ever since I can remember I played all kind of sports - golf, soccer, rugby, badminton, Gaelic football and hurling.
As I got older I began to concentrate more on hurling which is a contact sport played in Ireland and is the fastest
field game in the world. During my hurling career I injured my right knee three times. On each occasion I was able
to resume playing hurling following several weeks of rest and rehabilitation without having to undergo surgery.
My knee would have a tendency to feel a little bit uncomfortable at times, especially during the close season. I
continued playing hurling until 2003. During that year though for no obvious reason my knee began swelling each
time I played, even though I didn’t experience any pain.
In 2003 I had keyhole surgery and the surgeon told me there was considerable wear and tear to the cartilage. It
was not possible for him to do any real repair work and all that he could really do was a tidying up job. Then his
next remark metaphorically pulled the rug from under my feet when he said that I probably would require a knee
replacement in ten to fifteen years time. I was gutted. Even though I was 41 at that time I had hoped to continue to
be active well into my later years. But this news brought my hopes to a shuddering halt.
A year or so later I returned to light, low stress sports activities such as jogging, swimming, golf and cycling just
to be active. Then on one occasion as I was playing a fun game of tennis I had to reach for the ball. In doing so my
weight transferred onto my bent knee and a searing bolt of pain shot through the knee joint. It was obvious to me
then that there really was a serious problem with my knee. To continue to stress the knee joint in this manner would
be detrimental to its condition and would mean that a replacement knee would be inevitable.
Around this time I became aware of a procedure which involved a knee cartilage transplant and wondered could
this work for me? My surgeon informed me that this type of surgery was not carried out in Ireland but he gave me
the name of the RJAH, Oswestry where Autologous Chondrocyte Implantation (ACI) was carried out.
During my consultation with Professor Richardson I was asked if I would consider participating in the ACTIVE
trial. I was delighted to accept this invitation and was later informed that I was randomly selected for ACI.
The ACI treatment is a two stage surgical procedure. In January 2007 I had the first stage which was keyhole
surgery in my right knee to extract some healthy cartilage tissue from which new cartilage cells were then grown in
the laboratory over the following three weeks. The following month I had open knee surgery when the newly grown
cartilage cells were implanted into the defect in my right knee. The cells were sealed in by a patch over the defect
made from a strip of membrane taken from my shin bone, called periosteum.
After my discharge from the hospital I knew I was facing a lengthy period of rehabilitation. I learnt that it is vitally
important to have a good physiotherapist, that you fully adhere to the rehabilitation protocol set out for your
recovery, and that you have good support at home.
Continued on next page
My first physiotherapy appointment was in March, a week after arriving home from the operation. I was very
fortunate that this particular physiotherapist had previously treated a patient who had ACI surgery in Australia and
was familiar with the rehabilitation requirements.
From March to May I attended the physiotherapist on a weekly basis, dropping down to every other week from
June - July, then every three weeks with my final session in November 2007. During this period my
physiotherapist adapted the rehabilitation protocol to enable me to do all the necessary exercises in the comfort of
my own home (with the exception of going to the swimming pool).
With the benefit of hindsight I could have been more proactive in planning my recovery as this would have
enabled me to manage it a lot better. I should have contacted my physiotherapist a couple of weeks prior to my
surgery and put him in the picture. That way a post-operative management plan could have been devised in
advance of my surgery. The first part of that plan would have been to have my first post-operative physiotherapy
session already pre-booked rather than waiting until after the surgery to book it. Also by informing him well in
advance the physiotherapist would have had time to compile a list of items I would need to assist me through the
rehabilitation period and that I could have these items already in place prior to my surgery.
The following is a list of items I ended up acquiring during my recovery period to assist with my rehabilitation:
•KNEEHAB (this is an electrical muscle stimulation product to treat thigh muscle wastage)
•Inflatable Roller Ball
•Medical Stocking to reduce swelling in foot and calf muscle
•Bio Oil to help the surgical scar to heal.
•Exercise Bike
•Cryo-Cuff (to help reduce knee swelling)
•Ankle Weights
•Step-up block
•Aqua Belt (for jogging in swimming pool)
•Air Disc/Wobble Air Cushion
•Mini Trampoline
Conor (left) playing golf in 2006
At various stages during a long physically and mentally demanding recovery period I used each of the above
items. Each item played a vital part in the recovery process. However it would have been much more convenient
if I already had them in place prior to the commencement of my rehabilitation programme. My wife was a great
support and she did a lot of running about the place getting things for me.
While the recovery was slow and demanding almost every day brought some degree of improvement. Because
I work in an office I was able to return to work in April 2007, nine weeks after stage 2. Another milestone was
April 19th when I finally discontinued using the crutches. The 19th July 2007 was a significant milestone in my
recovery as I played my first round of golf following my surgery.
It is now sixteen months since I had the ACI surgery. During this time I have been able to resume all forms of
normal activities including quite an amount of heavy lifting, owing to renovations to our house. I am playing golf
on a regular basis without any pain or problems in my knee. It is also satisfying to be able to draw a kick at my
son’s football when I feel like it. I have done some light running without any pain or problems. But the ‘litmus’ test
is in being able to put my weight on the bent knee without pain.
In order to reap the full benefits of the ACI surgery it is vitally important that one commits to doing the
rehabilitation work in a serious and dedicated manner. I still need to do a little bit of maintenance work once or
twice a week in order to keep the knee strong. It is very likely that I will have to continue indefinitely with this
maintenance work. However, it will be a very small price to pay if it prevents my needing a new knee in the future.
Thanks Debbie and Conor for your stories. I’m sure there are many more stories we can
feature so please contact me if you’d like to share yours. In particular, we’d like to include
stories from patients who have had microfracture or one of the other non-ACI treatments in the
trial. We could also have a helpful tips column where you can share little snippets of
information to help other patients, or to help staff working on the trial. I look forward to hearing
from you.
Best wishes,
Heather
ACTIVE Trial Office, ARC, RJAH Orthopaedic Hospital, Oswestry. SY10 7AG
Trial Manager: [email protected] Tel: 01691 404142 website: www.active-trial.org.uk