Hello everyone, newbie here. Starting a new thread because moderator moved my post and I couldn't edit the subject line. I read several of the OCD threads here and am impressed with all the encouragement, support, and information about treatment options.
Question: Should I get MF (drilling) or a graft, or push for something different like the BMAC or the juvenile minced cartilage? If I get a graft, which kind? Or should I just wait, since the symptoms are minor and I'm not a runner?
History: Male, age 41, 188 lbs, physically active but not seriously into running, dancing, horseback riding, basketball, karate, etc. Severe ankle sprain 21 years ago (volleyball) healed okay I thought. MRI in June 2010 (for different issue) showed talar OCD posteriomedial with cystic bone underneath, something like 5x7mm. I had mild or no symptoms. One DPM said drill, 2nd DPM said enjoy life and check again in a year to see if it grew. Nine months later (March 2011), MRI shows OCD slightly bigger, something like 6x8mm (9mm deep). Symptoms are mild with pain ranging from 0 to 3 (mostly 0-2) on a 10-point scale. Saw 3 docs and got 3 different recommendations.
#1 (DPM): Saw me 11 months ago, hasn't seen 2nd MRI. Recommended MF then 6 weeks NWB.
#2 (DPM): 9 months ago said "live your life"; 2 months ago said get MF because OCD is growing. For graft prefers cadaver for best shape match. If I don't get MF, said get another MRI in 6 months.
#3 (OS): I'm borderline between MF and OATS, and if graft he would get it from my knee for freshest graft. BUT given my low level of pain (no swelling, full ROM), he said I should wait until it prevents me from doing what I want to do. Said DPMs never recommend knee source because they can't operate on the knee. Also said even with successful MF or OATS, it's possible I could have more pain and less ROM than I do now, which is why he suggested waiting.
#4 (DPM sports medicine): Too far gone for MF because I have underlying bone damage. Autograft from tibia to avoid knee complications. If I get MF, I'll be back in a few years with a bigger OCD and need a graft anyway.
None of the doctors brought up ACI, BMAC (bone marrow concentrate), or the Zimmer D. I asked about these and they all said there is no solid clinical evidence that these procedures have better long-term outcomes than traditional MF or graft. It seems all 3 docs agree that regular running or jumping will make my OCD grow and decrease the long-term success probability of MF. I think they all agree that bone graft is more likely to be a long-term fix--they just have three different philosophies about where to get the graft.
I would welcome any thoughts about how to decide on the best treatment.
If it's not causing you any problems, I would not do anything. With surgery, you run the risk of having things get worse. I'd wait until it's preventing you from living your life, and then go to a reputable OS, not a DPM. I live in OC, too, but travelled to Santa Monica to have my surgery with one of the top surgeons in the country. (He's now in Sacramento, darnit!) The MF helped my problem immensely - not completely - and I'm not sorry I had it. (I'm a long distance runner.) You might want to get a 2nd - or 5th! - opinion wih Dr. Bertil Smith in San Diego. He's a top notch OS who knows what he's doing with OCDs.
The Following User Says Thank You to Calrunner For This Useful Post: LivesNearStore (05-04-2011)
Heinselrunner, Tzturbo21: Thank you for your advice. I might check out that doctor in San Diego.
If I had never had the first MRI, or if the 2nd MRI had shown no change, I could live with it for another 20 years because the pain is minor. Reading about other ankles on here--those who had OATS--it sounds like many experienced occasional pain levels up to 6 or 8 (out of 10) before getting surgery, while mine has never gone beyond a 3.
Actually I seem to have the most frequent pain right after seeing a doctor! Probably my mind focuses on my ankle after each doctor visit and amplifies the sensation. The last doctor (sports medicine DPM) did have me hop barefoot on each side to see if it caused pain. No pain while hopping but more pain than normal the next day.
Living with it sounds so much easier than arthroscopic drilling, which sounds much easier and less traumatic than a graft with osteotemy. I just worry that waiting will mean larger lesion and thus lower chance of success for either MF or graft. Then I get confused by the 3 different graft sourcing strategies: Docs 1&2 said cadaver ankle; Doc 3 said my knee; Doc 4 said my tibia. All of them had convincing arguments--only cadaver bone gives you the right shape; your own bone is the safest; fresh bone is more successful; knee cartilage is different from ankle cartilage; don't risk a pain-free knee to fix your ankle; and DPMs don't source from the knee because they can't. Actually doctor #4 said (after recommending using my own tibia for the graft) that cadaver talus bone is an "end stage" option if the autograft fails, or if the defect is above a certain size.
A friend of mine who was until recently a doctor is dealing with her own cartilage defect of the knee. She is looking at the ACI option and I checked it out but the vendor's web site seems to say it's only FDA approved for fixing knee cartilage damage, so while a doctor could use it off-label on an ankle, it's unlikely insurance would cover that. Plus that option requires two surgeries, one to harvest the chondrocytes and a second to implant them after culturing. (Of course maybe more than one vendor can culture the chondrocytes.)
Seeing doc #2 next week to seek more details on why some of his OCD patients did well with MF but others didn't.
Asking doc #4 (sports med) for full copy of his paper about talar OCD treatment (I only read the abstract)
Someone here pointed me to the Stone Clinic in San Francisco, who embeds a paste of your own cartilage and bone into the MF site. This is like ACI without the double surgery, chondrocyte culturing, and periosteal patch. Info on his web site is about knee OCD, but heard he does this on ankles too.
My doc friend is now leaning towards cadaver graft instead of ACI (Carticel). But that's for the knee, not ankle.
If I don't get surgery this summer, I'm wondering when to get the next MRI to see if the "pothole is growing" or not. Should I wait 3, 4, 5, or 6 months? (Doc #2 suggested another MRI in 6 if I don't get MF.)
I emailed 6 questions to Doc #4 last week. Yesterday he called me to answer them. For whatever reason he doesn't like to answer questions over email. He said...
I am not a candidate for MF because I have cystic bone under my OCD lesion
If my pain is not bad and I'm not doing impact sports, okay to wait and see, but there is a risk the OCD will grow
If I want to be a runner or basketball player, I need a bone graft
The biggest risk in his experience is non-union of the tibia (10%)
After graft surgery, you never get back to the full ROM as before surgery, but if you are a flexible person you might reach 95% of prior ROM
Didn't directly answer about risk of internal scarring, except by answering ROM question
Was surprised to hear single biggest risk of medial maleolar osteotomy (in his experience) is not infection, graft failure, or nerve damage; it's 10% risk of non-union in the tibia end (possibly higher risk in smokers), in which case they go back and put in a plate. I had assumed the tibia pretty much always re-integrates and the biggest risk was graft failure. Maybe the graft risk is more of an issue with allografts.
Saw Doc #2 again and he patiently answered my questions, plus put both MRI's side-by-side for me. Told me most of his MF patients were very happy but a few had failed MF and had to get a graft. In his experience, most MF patients either have very good results or failure, and there are very few "tweeners" who have mediocre results. Showed me an X-ray and photo of a talus mosaicplasty allograft. The photo of the talus graft didn't look so bad, but the X-ray scared me just because the tibia screws looked HUGE.
In the end he gave the same recommendation as in March: if it were his ankle (or his friend's ankle), he would MF first. Like doc #3, #2 said my lesion size is borderline between MF and graft, but do the MF because it's an easier procedure and recovery, and if it doesn't work I can always do the graft later. If I don't do anything, he said get another MRI in 3 months (6 months after last MRI).
Something new for me, he said in my case the cystic bone was NOT caused by avascular necrosis, but by hydrostatic pressure of the joint fluid forcing its way past the damaged cartilage (OCD) into the bone, causing the cyst(s).
Scheduled microfracture for July 8th. Decided to delay until July for four reasons:
1) Wait until my daughter is on summer vacation
2) Allow time for 3rd MRI
3) More time to think, possibly consult another doctor
4) Pre-paid for a track day (tomorrow) where I drive around a racetrack with an instructor and try to go faster without pooping my pants
Reason #4 is probably a dumb one. My only excuse is after surgery I won't be able to drive for a while and probably not drive on track for several months. Had 3rd MRI yesterday. Afraid of the results. If they come tonight I might avoid reading it until Saturday so I won'think about it while at the track. Wandering mind can lead to wandering car--not a good thing.
But why bother with a 3rd MRI? (I could turn this into a navel-gazing blog, "OC about my OCD in the OC.") We already know my OCD grew from 2010 to 2011 so another MRI shouldn't change anything. Want to know it got bigger. If not, getting surgery won't feel so urgent. If bigger, I might ask for the boot and crutches early. If much bigger, will switch to OATS.
Got my 3rd MRI results with radiologist notes and a short email from my podiatrist. Good news is my OCD is not growing, but I have been avoiding running or jumping. Radiologist notes said it looks the same as the last MRI. Podiatrist email says it actually looks better, as in same size defect but less marrow edema around it. For first time, radiologist notes say there is likely a 3mm loose fragment sitting in the OCD. This ankle had some locking last year, which went away after about 6 months. Maybe the fragment came loose but later settled down in the defect.
For whatever reason, this MRI had more extensive radiologist notes than the other two MRIs. Microfracture still scheduled for July 8th.
My doctor friend (ex-doctor actually) had a donor come up and is scheduled for allograft next week. But that is for her knee.
That is good news about the MRI. Well, I guess as good of news as you could want, other than them telling you the OCD disappeared. At least you are able to give MF a go around and don't have to jump right to OATS because of the increase in size. I am very curious to hear about how your surgery goes and how you deal with the post-op process. I am probably going to be a few months behind you. I have to wait until the summer is over for my microfracture surgery because I used up the majority of my FMLA from my last surgery. My work was not very happy to hear that I will be out for a while for a third time because of my ankle.
I'll definitely be watching to see how your recovery goes. I certainly don't blame your for putting it off a bit. Might as well get everything done you'd like since you don't know how long it will be before you'll get to do it again.
I've emailed my Dr. that I too would like to go with MF also. Maybe we'll be recovering together if I can get on the schedule next month.
__________________ Microfracture drilling for OCD Jan '12
Mrs. Heidi, thanks for the support. I hope you get the surgery date you want. I'm seeing my doc again tomorrow to discuss latest MRI results. He's gone from "if it were my ankle, I'd do the microfracture" to "maybe you should wait on the surgery." My friend with the knee cartilage defect is scheduled for cadaver graft tomorrow, so I phoned to wish her luck.
Yesterday the doc (#2) showed me the latest MRIs side-by-side, and lo and behold the cysts do look a little smaller, and the amount of edema (inflamation) in the talus appears to be less. The cartilage defect appears to be the same size, though again it's hard to even be sure how big that is because it's a MRI, plus I have no experience reading MRIs. The radiologist wrote that there was no change, but my DPM made a convincing case that the bone beneath the defect looked a little happier. His recommendation has changed. In March it was "You should have surgery; I would in your situation, and if you don't, it will probably continue to get worse." Now it's sort of "You could have surgery. If you don't, the cystic bone might continue to improve, or it might get worse."
Picked up crutches and was practicing in the office, where I got lots of sympathy until I explained I was just practicing; then I still got some sympathy. One coworker urged me not to have the surgery if the symptoms are manageable. Another revealed she had a OCD of the ankle many years ago and had it fixed with a graft. I'm still planning on having the MFx in 2 weeks.
As an experienced OATSer, I can say, if it doesn't hurt you. Do nothing.
Mine hurt, a lot. I couldn't walk, plus I had torn peroneal tendons and needed a Brostrom repair. I started with Microfracture with the peroneal tendon repair, plus the brostrom repair, plus the peroneal tendon subluxation repair. Which led to-
Surgery #2 OATS, Brostrom #2, microfracture #3 (first time I had microfracture on 2 ocd lesions) so this time it was OATS (actually mosaicplasty) on one and microfracture on smaller one, revision brostrom, more peroneal tendon repairs.
Then surgery #3, scar tissue clean up, microfracture #4 on smaller (but now quite large ocd) and repair of posterior tibial tendon
Which led to surgery #4 and then #5 DIstraction arthroplasty and microfractures of who knows how many spots in talus.
Which led to surgery #6 debridement of osteomyelitis in tibia
which is leading to surgery #7 ankle replacement and possibly surgery #8 spinal cord stimulator for complex regional pain syndrome thanks to a fall with ex fix and spread thanks to surgery #6.
Now, could I have continued with the pain I was in before surgery #1? No, not at all. But if I was pretty pain free, I would have waited. If I could have been closer to 50 when I did all this, instead of mid 30s when this started, then I may have avoided some of this and gone right to ankle replacement instead of trying to buy time. Or maybe I would not have been so active and I would have just been able to deal with it longer, I don't know.
I do know that after getting a few opinions from various foot and ankle specialists, the zimmer product has not been proven yet and that is why I did not go that route, that, and I had too much area on my talus to cover.
The microfracture for me, at the beginning, really worked the best. After the OATS, it was all downhill. The first surgery got my 1.5 yrs of some activity back. I never went more than a year after OATS without another surgery.
As another experienced OATser (is that a word?? Lol) I too can say if it doesn't hurt don't do anything.
I had micro fracture in 2007 because I couldn't walk at all without pain. That led to OATS (actually mosaic plasty) 10 months later, ankle distraction 2 years later and ankle distraction and subtalar fusion 1 year later and tarsal tunnel release as well.
So 5 surgeries, actually 7 procedures in the OR since 07. Think long and hard if you are going to do this if it is not necessary now. I am 42 and have lost the last 4 years of my life and feel like a snowball going downhill until just recently.. And I am only 5 weeks out from the last surgery above.
No, this might not happen to you but if something isn't hurting you, why risk it?
K. Lana and Kimberp: Thank you so much for your perspectives and advice. I am rethinking whether to get the Mfx now. If I had a crystal ball saying Mfx would lead to a string of surgeries like you've had, I would run, run run away from my doctor. My challenge is there are two different approaches to treating low-pain cases like mine.
Philosopy #1 is don't have surgery if you don't have a lot of pain. I am not pain-free, but it's very managable right now. At the current level I could live with the pain for 10 years or more, if it doesn't get worse.
Philosophy #2 is fix it early while it's small enough for MFx rather than wait until OATS is the only option. If the cysts get a lot bigger, the cartilage above will collapse, putting more pressure on the remaining cartilage, making the defect bigger.
Over the last 3 months it's not getting worse, but I have been avoiding all running or jumping and cut back on the walking. I'm living in fear. My PPO has great coverage but expensive premiums, and might need to change it to a less expensive HMO or PPO in August, which will cover much less of either MFx or OATS. Though if I need OATS in 2012 or later, by then I will be on a different insurance anyway (even possibly back on the same PPO I have now). To complicate matters, even a "successful" MFx which has good results at 2 years out is no guarantee it won't get worse in the future.
If you promised me MFx would give me 10+ years then I'd need OATS, I'd happily do MFx now. If you told me MFx would last <2 years, I'd just get OATS now. If you told me taking it easy would shrink the cystic bone area, I'd probably delay surgery. But as my doctor said, nobody can predict the future. The bottom line is I have to gamble which is a bigger risk: MFx surgery now or chance that the cartilage defect will grow if untreated.
Mrs.Heidi: Hope you got a date convenient for you. My surgery date is today. Trying to remember if I have everything I need... ice packs, crutches, handicapped parking card, prescription painkillers, magazines I haven't had a chance to read, extra movies from NetFlix, etc. I'm sure I forgot something. Maybe next week I'll decide I need crutch pads or a knee scooter.
So in the end the answer was "Drill", or technically pick, since I guess it's hard to get a drill in there arthroscopically.
Surgery done. Don't remember a thing after shuffling myself from the gurney to the OR table. Lay down, next thing I know, woke up in recovery. Don't remember having them inject the anesthetic, though there were like 2 nurses and an anesthesiologist in the room and my arm already had an IV in it, so they might have put it into the IV when I wasn't looking. Or more likely the anesthesia causes memory loss starting a few minutes before it's given. No pain yet, but they also injected a long-lasting local anesthetic (not nerve block) which hasn't worn off yet.
Doctor took a lot of color photos for me and explained some in recovery, but I don't understand them all yet. He removed a loose body and cleaned up some rough cartilage somewhere else in the ankle. Will have to get the surgery notes and ask more questions at the follow-up appointment.
Now icing, elevating, snacking, and of course on the Internet.
I was about ready to write goodluck with the surgery and then saw that you already posted again! Glad to hear there is no pain yet... Be sure to keep posting about your recovery if you are willing to do so, as I will be following it. This is coming in my near future, so it is great to read about other peoples experiences... even though everyone is different. Happy Healing!