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.
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.”
Cartilage transplant considerations
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.”
Giving cartilage transplant a try
Frank performed the surgery in December 2019. Prior to that she ordered a donor graft from the Joint Restoration Foundation in Centennial, Colorado, which looked for a suitable match for Hamilton. Frank ordered the whole end of a femur and its associated kneecap to ensure enough material to transplant cartilage to Hamilton’s kneecap and the trochlear groove in which the kneecap sits.
Time is of the essence for a fresh cartilage transplant. The donor tissue must be procured within 24 hours of the donor’s death, and then transplanted within 15 to 28 days, before the cells begin to deteriorate, Frank said. Once there is a match, the tissue is tested to ensure it is free of disease.
Frank performs the outpatient surgery with the patient under general anesthesia. Through a small incision, she clears away any damaged tissue, and creates a socket for the donor graft. She and her team then make a plug from the donor cartilage and bone that matches the socket and presses it in “like the last piece of a puzzle,” Frank said. In Hamilton’s case, plugs from both the donor’s kneecap and trochlea were custom-fit to the defects in his knee. Patients typically go home the same day in a knee brace and with crutches.
Arduous recovery after a cartilage transplant
Hamilton readily admits the surgery was the most painful of the seven he has had on his knee. Under the direction of Frank, he soon began physical therapy at the UCHealth-Steadman Hawkins Clinic in Denver. For the first three months or so, he rode a rollercoaster of emotions.
“Steadman Hawkins is an amazing facility and so are the staff,” Hamilton said. “But there were days going in there that were a challenge. There were good, bad and very bad days.”
One day he was excited by his progress; the next he was discouraged when his knee swelled and hurt. He persevered with encouragement from Frank – she gave him her cell phone number – physical therapist Anthunee Galvan and physician assistant Kevin Shinsako.
“It felt like I had a team supporting me,” Hamilton said.
Hamilton took personal responsibility for his therapy during the height of the pandemic, and stayed in close touch with the team at Steadman Hawkins Clinic in Denver when it had to temporarily close in March because of COVID-19 He began work on an elliptical machine in July, while continuing exercises to improve his range of motion; strengthen and stretch his hips, quads and calves; and manage his pain.
“I’m still in PT mentally,” Hamilton said.
Cartilage donor debt
There is a deeper reason for his commitment. When Hamilton met Jill, she worked at Donor Alliance, the Denver-based organ procurement organization. She now works with a company that provides donor cells and tissue for allografts.
“Donation is a big part of our family’s life,” Hamilton said. “But I never imagined that I would somehow need it one day for me.”
Just as that single misstep 22 years ago sent his life on an unwanted detour, an unknown donor has put his life on a new, more hopeful path. Six months after the cartilage transplant surgery, he felt his knee getting noticeably stronger. He’s jogged and run up the stairs with his kids with no pain. His walks have steadily lengthened, up to 7 miles in a day. With more work, he can envision a day when he hikes mountain trails with some incline – something he hasn’t been able to do for quite a while. He’s set his cane aside.
“When I look back a year ago and compare it to where I am now, this gift changed my life,” Hamilton said. “I need to take responsibility for that. I could still be walking with a cane. That’s why I’m doing all this PT, to put this gift to good use.”
He’s taken his resolve a step further. He plans to write a letter expressing his gratitude to the family of the anonymous donor and give it to Frank to pass on.
“It’s hard to know what to say,” Hamilton admits. If the chance arrives, he adds, “I would meet with the family in a heartbeat. The donation completely improved my life.”
Frank understands. “None of this would be possible – not me having transplants in my own knee, nor me being able to give cartilage transplants to other patients – without the donors and their families. We are truly very thankful to them,” she said.
Hamilton continues to make the most of his recovery from the challenging surgery with the ongoing support of his medical team, his family and his friends.
“It’s gotten me a few more years before knee replacement,” he said. He recalled Frank telling him that from a baseball perspective, the transplant aimed to hit a single, not a homerun.
“The idea was to get me back to a comfortable life,” he said. “I say I think we hit a double, it’s worked so well.”