In 1998, Justin Hamilton was 20 years old and on course to graduate from the University of Northern Colorado in Greeley when he hit a major bump in the road.
The road in this case was some stairs Hamilton was negotiating downwards with some furniture. He took a misstep. His right leg buckled, and his femur (thighbone) and tibia (shinbone) slid out of position at the knee joint. The knee popped back into place, but the trauma broke his patella (kneecap) into several pieces.
Surgeons repaired the damaged kneecap with screws, but Hamilton needed three subsequent surgeries to clean up scar tissue and floating fragments of cartilage, the smooth, buffering tissue that covers the ends of the bones in the joint. He says he managed the injury fairly well through his 20s, but admits it severely limited the life he’d led as an active native Coloradoan.
“The break was life-changing,” Hamilton said. “I used to go snow-skiing and water-skiing and played high-impact basketball. After I hurt my knee, I was too unsteady, even with a knee brace. It was a big loss.”
Persistent knee pain
The bad knee didn’t stop Hamilton from building a good life. He met and married Jill, and they had two daughters, Leelah and Violet, now 13 and 10, respectively. He’s had a successful, two-decade career in database marketing. But the injury continued to take a toll, physically and emotionally. He had more surgeries, but the remaining cartilage continued to wear away from his kneecap. He resigned himself to good days and bad days, but about a year ago, the knee pain went from intermittent to constant.
“It hurt to the point that on a daily basis, the pain was a 6 or 7 out of 10,” Hamilton said. “It was a sharp, stabbing pain that would not quit.” He relied on a cane constantly, even with daily icing and doses of Aleve. Walking up and down stairs was “truly a nightmare.” The damage limited his ability to take part in his daughters’ sports and other activities, a loss he felt keenly.
Hamilton knew he was headed toward a knee replacement, but at 42 he wasn’t ready for that. He wanted to find someone to “think outside the box” and present an alternative treatment that would restore, at least for a few more years, a chance to “live a comfortable life.”
A biologic alternative
He found that person in Dr. Rachel Frank, an orthopedic surgeon and associate professor of Orthopedics with the University of Colorado School of Medicine. Frank is director of CU’s Joint Preservation Program and practices at UCHealth CU Sports Medicine, UCHealth Steadman Hawkins Clinic Denver, and the UCHealth Orthopedics Clinic on the Anschutz Medical Campus.
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Jill attended a presentation by Frank that highlighted her work with Dr. Brian Cole, an orthopedist at Rush Medical Center in Chicago who specializes in a procedure to transplant healthy cartilage to damaged areas of joints, including shoulders, elbows and knees. The procedure involves procuring undamaged tissue from the patient’s own body (autograft) or from a deceased donor (allograft) and using it to rebuild the joint, much like fixing a pothole in a road, as Frank put it.
Jill told Justin about the procedure and Frank’s experience, and they met with Frank late last summer to discuss it. The discussions led to another life-changing turn for Hamilton, physically and in his appreciation for the gift of donation.
Understanding the patient perspective
Frank comes by her expertise in cartilage transplant both personally and professionally. She developed her expertise in the procedure during her Sports Medicine and Shoulder Fellowship at Rush Medical Center in Chicago with Cole and has been practicing it at UCHealth since she arrived in 2017. But Frank also received a total of three cartilage and meniscus transplants after injuring her left knee playing soccer. Her last transplant surgery as a patient was in 2010.
“Surgeons often don’t know what it’s like to be a patient, and they forget about the daily struggles that negatively impact patients and their families,” Frank said. “I truly think about being a patient in addition to being a surgeon.”
Frank said cartilage transplantation, which makes up about a quarter of her total practice, isn’t for everyone. She bases her assessment of the joint on five criteria: the extent of damage to the cartilage; the location of the damage in the joint; the effect of prior surgeries in the area of the damage; the depth of the lesion and whether it involves underlying bone; and other problems in the knee, including meniscus or ligament damage, as well as malalignment.
Frank said she performs autografts for relatively small injuries, but more extensive damage requires donor tissue. “With those patients, there is not enough healthy cartilage to give away,” she said. “We can’t rob Peter to pay Paul.”
For example, cartilage transplant is not a good option for people with moderate to severe arthritis because the damage is too extensive. “We can fix potholes but not the whole gravel road,” Frank said. At the same time, she doesn’t recommend cartilage transplant for people who don’t have many symptoms and can still run, ski and generally be active. Patients who are not candidates have many other surgical and non-surgical options.
Managing expectations with cartilage transplants
Justin and Jill Hamilton discussed all of these points with Frank, who also asked him to define his goals for surgery. She emphasized that cartilage transplant does not turn a diseased knee back to normal or reverse the tides of time.
“It’s not a teenager’s knee anymore,” Frank said. She noted that patients have to have “reasonable expectations” about what cartilage transplant surgery can and cannot do.
“The main goals of the surgery are to get people back to their activities of daily living, with minimal pain, high levels of function, and minimal or no swelling,” Frank said. “If we get back to climbing stairs, walking the dog, or participating in light activities with kids or grandkids for another 10 years, that’s a big win.”
Within those parameters, Frank said the procedure has an 80 to 85% success rate. “Understanding patients’ expectations is critical,” she said.
At 42, Justin Hamilton was toward the end of the age spectrum for cartilage transplant. Frank performed an arthroscopy in October 2019 to assess his prior damage – correcting problems like malalignment of the knee and damage to ligaments or menisci is also critical to surgical success – and pronounced him “borderline” for the procedure. The cartilage transplant could get him another five to 10 years of activity, but it would likely be a bridge to knee replacement. Was it worth it?
After taking time to discuss the options with Jill, Hamilton decided it was. His goals were relatively modest, but essential to his life.
“I have young kids,” he said. “I want to be active in their lives, whether that’s kicking a soccer ball or throwing a softball around, hiking in the mountains.”