Surgery details: Part 2, ACL repair and MACI procedure

Ok, the rest of the surgery details for those interested...

Part 1 talks about the meniscus transplant and is the previous post. 

So the above picture is a healthy knee looking at it from the front. This is a right knee but my busted knee is my left one. 

The remaining details of the surgery involves the medial articular cartilage (above the medial meniscus), and the anterior cruciate ligament (ACL) which is one of the pink bands behind the kneecap in the picture.

This picture (above) is my ACL, well, not mine actually. It belongs to a cadaver donor but has been in my left knee for 7 years now. 

I had an acute tear of my original (the one I was born with) ACL while planting for a kick in martial arts. My surgeon back then (Dr. K) used cadaver tissue to replace the torn ligament and told me good luck getting back to running (he was not a fan of runners).  Had I not been the mom of two very young boys and the only income source as a full time nurse...had I been smarter, I would've looked around for a doctor that I connected with, and one that I felt really wanted to get me back to the activity I loved. I didn't want to be off my feet any longer than I had to so I went with the first doc I could get an appointment with. I don't think he did a bad job, but I don't think he did anything great. 

He attached the graft where everyone has always attached the graft. Now they know that's not a good place to attach grafts because it can damage the articular cartilage on the medial side of the knee. He also removed more of my meniscus in that surgery (which I didn't know until my current surgeon, Dr. Z, read me the old operative report). I'm not blaming Dr. K for my troubles, if anything I'm placing the blame on myself for rushing to get the surgery and get back to mom/work life as fast as I could. 

So the picture earlier that Dr. Z took of my 7 year old ACL graft shows that there is a significant tear in it and very little stability left in my knee. It was hanging on by a thread. Literally.

 I'm 99.99% sure that I've completely torn it since then. 

So in addition to the meniscus transplant, I will be getting a new ACL graft.  


Above are pictures of various cadaver grafts that they use for repairs. Sometimes they braid several tendons together to make a "super graft." I'm not sure how Dr. Z does it. A question to add to my list, more for my own curiosity than anything else. He will attach it in a particular location that is now considered best practice. Ironically, once I get a Total Knee Replacement (TKR), I won't need an ACL, or meniscus either.

The final step in the surgery is called MACI (Matrix-Induced Autologous Chondrocyte Implantation). 

It's the coolest step in the surgery.

It's part of some incredible technology that is giving people better options for their bodies! 

It's also the most important part, and without it the meniscus transplant and ACL repair are pointless. 

The picture above was taken during my diagnostic surgery in August. It's a view of part of my articular cartilage on the medial side. It's ugly looking!  It is supposed to be white and shiny and smoothe. This is a full thickness osteoarthritis and is one of many like it on the medial part of my knee. 

It's a result of my faulty ACL graft rubbing on the cartilage and wearing it down over time. Apparently "cartilage is very strong when it comes to impact forces (like pounding from running) but is extremely fragile when it comes to shearing forces (fragments of tissue waving across it parallel to its surface)." 

That was quoted from my surgeon Dr. Z, I'm not just making this up because I love(d) running!

 So fragments of the ACL graft wore down the cartilage in several areas. 

Bummer...

If left as-is, the gnarled up bone and cartilage would destroy the transplanted meniscus in a year. Guaranteed. 

So....this is where the MACI procedure comes in!

Hold onto your hats because this is cool stuff!

When I had my diagnostic surgery, Dr. Z took a small piece of my cartilage and sent it to a lab. He also mapped and measured the areas of cartilage that were damaged. 

 That lab is now growing and multiplying my own (autologous) cartilage cells (chondrocytes) on top of a porcine (pig) membrane. After 3-5 weeks the cells on the membrane will be delivered to my doctor. When he is operating in November, he will make patches from this membrane that fit the damaged bone areas.

 He will place the patches cell side down and micro-sew them in place. And then I will have a smoothe bone that won't eat up the transplanted meniscus. 

The company that does this is also doing this with skin...literally growing skin for people who have had previous burn or injuries and are scarred, using their own healthy skin cells. 

My insurance company denied this part of the procedure initially and I was devastated. This is time sensitive and I felt like there was no way we could get it overturned and still have time to grow the cells (we are 5 weeks out from surgery now). Thankfully Dr. Z insisted on an emergency "peer to peer" appeal to plead my specific case, and in less than a week the denial was overturned (heard the good news yesterday!). 

Why does insurance not want to pay??? 

Well, just the part that happens in the lab (growing the cells on the membrane) costs at least $30,000!!!

So yeah, cool stuff!