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Old 06-13-2011, 01:30 AM   #1
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Overview of ankle OCD treatment options

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Overview of treatment options for OCD of the ankle talus

Based on my Internet research, conversations with doctors, and information shared by other members of Healthboards.com, I assembled a list of known treatments for OCD (Osteochondritis Dissecans or osteochondral defect) of the ankle talus. Many of these treatments also apply to OCD of the knee. More than half of this information was learned from other members here in Healthboards.com.

Disclaimers: I am not a doctor. This overview cannot tell which treatment(s) is best for any particular patient. Not all treatments are available in all countries or from all doctors. Not all treatments are covered by insurance. Some of the "Experimental" treatments listed below are not FDA approved. No treatment, surgical or otherwise, has a 100% success rate for fixing OCDs. All surgical treatments involve risk. This overview is not comprehensive--it does not cover all possible treatments nor does it include all relevant information about each treatment. This is not an endorsement of any of the listed treatments, doctors, or products.


PART I -- STANDARD TREATMENTS. These treatments are listed in approximate increasing order of complexity and from most conservative to most radical (and from least complex to most complex). Nearly all OSes and DPMs (podiatrists) are familiar with these options and most can perform them.
  • No treatment -- If they are not growing and not causing any symptoms, some small OCDs might not need any treatment. In very rare cases they shrink with no treatment.
  • Conservative treatment: Some combination of boot or cast plus NWB to see if defect heals or symptoms decrease. May include physical therapy, NSAIDs, and/or cortisone shots. It’s cheap, low-risk, and may relieve symptoms, but rarely heals OCD lesions in adults. Juveniles (skeleton still growing) occasionally see OCDs heal with conservative treatment.
  • Chondroplasty removes loose pieces of cartilage and cleans up rough edges. Usually done arthroscopically. Good at eliminating joint locking or clicking. Generally doesn’t regenerate any new cartilage.
  • Fixation: Fix loose fragment or flap of cartilage, sometimes with attached bone, back into place with pins, screws or other method, hoping it will heal in place. Can be done arthroscopically and in theory could be combined with experimental treatments like HGH or PRP. May not be an option if fragment is completely detached, doesn’t fit defect, or underlying bone is cystic.
  • Microfracture/drilling: A “marrow stimulation technique” (MST) puts holes in underlying bone to encourage bleeding and release MSCs into the defect, forming new fibrocartilage. Retrograde drilling means drilling from behind defect, through the talus, to avoid damaging articular cartilage.
    o Pros: Can do arthroscopically; fills defect with new cartilage
    o Cons: May not fill defect completely; new cartilage not as durable as original
  • OATS: Osteochondral Autologous Transplant Surgery takes a piece of your own bone (with attached cartilage) to fill in the defect. Most common source is a non-weight-bearing intercondylar notch of the femur (knee), but can be taken from iliac crest or lower end of tibia.
    o Pros: Fresh chondrocytes and live bone; high chance of fast bone integration; No viral disease risk; very low rejection risk
    o Cons: Can cause donor site (knee) problems. Usually requires osteotemy. Cannot use on very large lesions. Knee cartilage is different from ankle cartilage. Can be hard to get proper graft shape especially to fit “shoulder” of talus.
  • Allograft: Same as OATS but from cadaver talus instead of from your own knee/tibia. A fresh graft is 5-7 days old (to test for dieases) and has live chondrocytes but dead bone. If successful, your body slowly replaces the dead graft bone with new live bone.
    o Pros: No risk to your knee; can fill grafts too large to be done by OATS; can get better shape match for talus dome/shoulder
    o Cons: Small risk of graft rejection; small risk of viral disease. Bone is dead so may not integrate as quickly as autograft. Usually requires osteotemy and must schedule surgery around donor availability.
  • Mosaicplasty: OATS or allograft using multiple small plugs instead of one big graft. Body fills gaps between plugs with new cartilage, which might be fibrocartilage, hyaline cartilage, or a mix. Number of plugs can range from 2 to 14(?).
    o Pros: Better than simple OATS or allograft for repairing very large OCDs.
    o Cons: Surgery is longer and more complex than doing a single block graft.
  • Ankle replacement replaces the bottom of tibia and top of talus with an artificial joint. The bottoms of the tibia and fibula may also be fused together using plates and screws.
    o Pros: Can treat severe arthritis while allowing more joint movement than fusion.
    o Cons: Very complex surgery (more complex than fusion) requiring removal of some tibia and talus bone. Expected lifespan is about 10 years and revision (doing a second ankle replacement) may not be possible. May make doing ankle fusion later more difficult.
  • Fusion uses mix of screws, pins, and bone grafts to permanently fuse part of the ankle joint.
    o Pros: Typically reduces or eliminates pain from severe arthritis
    o Cons: Reduces ankle mobility and flexibility, eventually causing arthritis to develop in adjacent joints. Complex surgery. May or may not preclude later ankle replacement.

This is the end of part I on conventional treatments. Part II will cover experimental and investigational treatments.

Last edited by LivesNearStore; 06-13-2011 at 01:36 AM.

 
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Old 06-13-2011, 02:18 AM   #2
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Re: Overview of ankle OCD treatment options

PART II -- EXPERIMENTAL/INVESTIGATIONAL treatments.
(Please see disclaimers in post #1 of this thread. Most of these treatments are NOT FDA approved for ankle OCD treatment.)

These are not yet accepted by by most doctors as proven/mainstream treatments for ankle OCDs. Many involve some form of stem cells. Some of these treatments are not FDA approved for treating OCD of the ankle (some are not FDA approved for anything yet). Generally insurance will NOT cover anything classified as "Experimental" or "Investigational," though if you and your doctor appeal claiming that no other treatment will work and conventional treatments have failed, your insurance company might cover it. In some cases, the experimental treatment can be combined with MF or OATS, and your insurance might cover the MF or OATS procedure but you will have to pay out of pocket for the experimental part. Procedures are listed in alphabetical order.
  • ACI = Autologous Chondrocyte Implantation. Bit of your own cartilage is removed and stored up to two years by a lab. If you decide to do ACI, the lab cultures your chondrocytes until they have 10 million then doctor injects them into the OCD defect under a stitched-on periosteal patch. Requires two surgeries; first arthroscopic and second open athrotomy or osteotemy. ACI using collagen membrane instead of periosteal patch may be a future option.
    o Pros: Uses you’re your own chondrocytes, which might rebuild more/better articular (hyaline) cartilage than MF.
    o Cons: Requires two surgeries; second surgery is complicated; periosteal patch can overgrow (hypertrophy) and require 3rd surgery. Risk of pain at periosteum harvest site. Must limit weight/motion until implanted cells have “set.”
    o Examples: Carticel by Genzyme; ChondroCelect by Tigenix. For examples of ACI with scaffold/matrix--see "MACI" below. As of today, Carticel is FDA approved only for knee OCD.
  • Articular paste graft--take a little healthy cartilage, grind into paste and smush into the defect site after microfracture. The MF releases marrow with MSCs but the paste adds chondrocytes and maybe helps convince the marrow MSCs to make hyaline cartilage instead of fibrocartilage.
    o Pros: Might lead to higher quality MF repair; can be done arthroscopically if doctor can get to the defect site with scope.
    o Cons: Few doctors offer this. Weak clinical evidence that it is better than normal MF. (That doesn’t mean it’s not better, just that there is no rigorous proof that it’s better.)
    o Example: Stone Clinic in San Francisco
  • BMAC (bone marrow aspirate concentrate)--Remove marrow from your iliac crest (pelvis), spin down to concentrate stem cells, then inject concentrate into joint. Not sure if inject into defect site or just into joint space and let the stem cells wander around looking for something to regenerate. Could be combined with bioabsorable scaffold, like synthetic bone.
    o Pros: Uses your own stem cells. Only one surgery (plus big needle to get marrow).
    o Cons: Big needle in pelvis; requires expertise/equipment to spin marrow.
  • HGH injections—Normal MF or OATS plus several injections of rHGH (recombinant human growth hormone) into joint. In theory promotes new vascular growth which releases more stem cells, generates better new cartilage, and leads to faster recovery.
    o Pros: Might lead to faster recovery and better quality repair cartilage. rHGH is FDA approved for other uses.
    o Cons: Few doctors offer this; requires multiple injections over months. Not FDA approved for joint repair. More success reported using HGH in knees than ankles.
    o Example: Dr. Allan Dunn in Florida
  • Juvenile minced cartilage from young cadaver donors should have more highly active chondrocytes and more MSCs than adult cartilage, leading to better repair. Glued into defect with fibrin glue. Sold by the packet; number of packets needed depends on defect size.
    o Pros: Only one surgery required. Might generate better cartilage than MF.
    o Cons: Can't be done arthroscopically. Likely requires more doctor skill than MF but not as much as OATS.
    o Example: Zimmer's DeNovo NT; Denovo ET/Neocartilage from Zimmer and ISTO Technologies (in clinical trials). This is not an endorsement of any of these products.
  • MACI = Matrix-induced (or assisted) Autologous Chondrocyte Implant. Second generation of ACI, it seeds chondrocytes in an absorable scaffold or matrix (typically collagen, fibrin, or hyaluronic acid) glued into the defect with fibrin glue.
    o Pros: Does not require periosteal membrane cover
    o Cons: Not FDA approved (clinical trials)
    o Examples: ChondroCelect, BioCart II, Cartilix, CAIS, Verigen MACI, NeoCart, Hyalograft, and Cartipatch. AFAIK, none of these are FDA approved.
  • MSC (Mesenchymal stem cells) are multipotent stem cells that can differentiate into several cell types including osteoblasts (bone building) and chondrocytes (cartilage building). Bone marrow contains MSCs, so both microfracture and BMAC attempt to recruit MSCs to do cartilage repair.
  • PRP (platelet-rich plasma) is blood plasma with the RBCs/WBCs removed and the platelets concentrated. It doesn’t contain stem cells but releases growth factors and is traditionally injected into muscles or tendons to improve healing. Some studies suggest it could improve cartilage regeneration.
  • Synthetic bone. A synthetic bone substitute (paste, powder, granules, strip, or plug) acts as a scaffold to convince body (we hope) to make the right kind of new bone and cartilage. Can be soaked with ACs (autologous chondrocytes), PRP, your own blood, or BMAC prior to implantation.
    o Pros: One surgery, no disease risk, does not require bone harvest, and might regenerate better cartilage and/or new bone. Can be combined with stem-cell type treatments. Plugs are FDA approved for backfill of OATS harvest sites. Powder/paste/granules are FDA approved for other bone repair.
    o Cons: Not FDA approved for OCD. Plugs probably cannot be implanted arthroscopically on talus. Powder/paste/granules do not seem to be used much for OCD repair.
    o Examples: Tru-fit plugs/TRUKKOR system from Smith & Nephew; Osteoset from Wright Medical Technology; NovaBone from NovaBone; VITOSS from Orthovita; Pro-Osteon from Biomet; and Bi-Ostetic from Berkeley Advanced Biomaterials. Several other synthetic bone products exist. This is not an endorsement of any of these products.

Last edited by LivesNearStore; 06-13-2011 at 02:20 AM.

 
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