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jedfsu 04-01-2013 12:57 PM

arthroscopy or straight for mosaicplasty?
I'm glad to have found this forum as I was dx w/a 12 mm x 7mm lesion on my right talus about 2 mo. ago. I'm 44 & have two kids (3 and 5 yrs) and stay home w.them. I'm mentally a disaster. The doc I see (am in Boston) says that we can do arthroscopy or go straight for mosaicplasty. I am not sure what to do. He says that there is no study to show which is better or for that matter what will happen if I do nothing. I'm not in a lot of pain and am going back to the gym soon. Prior to this, I was very active athletically and really don't want to deal with this clicking and popping and/or have this thing get bigger. Doc says that he has no data on what will happen if I do nothing. I'm going for a second opinion at MGH in May. The most frustrating thing is the time that the docs give you. I had so many questions and he basically cut me off and said he has to see another patient. He talked about using bone from my knees but when I told him about previous knee surgeries he then spoke about cadaver. He said that mosaicplasty is OATS but then it seems that it's not exactly the same. I saw a post that was from 2007 that outlined the different things that you can do surgically but saw no mention of mosaicplasty.

Also, has anyone suggested to this site that they have an "ankle" section?

Thanks for listening!

jmpt 04-01-2013 02:43 PM

re: arthroscopy or straight for mosaicplasty?
Hi Janet,
The big question is if the defect you have is on the medial or lateral side of the talar dome and how deep is the defect. The major blood suppy to the talus is on the lateral neck of the bone. If the defect gets too deep, it MIGHT, big Might afftect the blood supply to the bone and cause the bone to become necrotic. If you are not wanting surgery and not having much pain, then just monitor it with MRI or CT scan every couple of years. If pain increases- get it checked out. I know what it is like to have the craziness of kids. mine are almost 3 and 5. My husband had to take care of the kids in every way after my surgery for 6 weeks. After about 3-4 weeks I could help some but not much b/c I was non-wt bearing for 6 weeks.
If your defect is shallow , it might be a good idea to fix it now. Mine got deeper over time. I am happy I got the DeNovo graft. It has made such a wonderful difference. You might want to find a surgeon that has done the denovo graft before. (I personally do not want to be a surgeon's first) The one thing that made me do the denovo graft is the recovery time is shorter than the cadaver bone; less invasive and if the graft does not work (which it has worked)- I could go for the cadaver graft. If the cadaver graft fails, the only thing left to do is fuse the ankle.
I am confident it will not need anymore surgeries.
I hope this helps

jedfsu 04-02-2013 06:20 AM

re: arthroscopy or straight for mosaicplasty?
Thanks so much for your quick response!!! I live in Boston so I searched this board and found Dr. Johnson at MGH does the DeNovo. I have an appt to see her in May. The doc I saw yesterday did not mention the DeNovo at all. I also tried to get a # out of him on how many of these he's done (he is a foot and ankle guy at a Harvard Hosp so I'm guessing he's done a few...) but he didn't offer up a number but was more vague. He was just so short w/me & I had so many questions. It didn't help that my kids were off school and we had to wait over an hour for x-rays (one machine was down) and then wait another 1/2 hour to see him. There is only so much "Super Y" they can watch on my phone!

I've been looking for a live in nanny or au pair so that if I do go for the surgery, I can manage with the kids. My husband works full-time so is limited in how much help he can be. I was non-weight bearing for 4 weeks in the CAM boot to see if would heal on it's own. Looking back, I think that was a complete waste. I think my lesion is far too big to heal that way. I was able to drive taking boot off. But this time, the whole not driving thing has me very worried. I calculated out 8 weeks and if I have the surgery in July (we're taking a much needed vaca mid June to beginning July) then I should be driving again 2nd week of Sept. What worries me is that if I'm in too much pain to drive what am I going to do? I did find one caregiver who does not start back to school until end of Sept but I also don't want to be stuck w/someone here if I don't need them!

I'm going to call today and find out more about my lesion. I just know it's 12mm x 7mm. I've not yet had a CT scan just MRI so maybe they don't know the depth? Location they did tell me but I forget. I think it's on the inside of my ankle but also will double check. I really have no pain, just annoyance of the clicking and popping. BUT, I've not been working out at all. I'm going to start back shortly at the gym but not do any high impact which really bums be out. I really love some of boxing classes which have a lot of jump roping. The doc yesterday told me to do activities where my feet don't leave the floor like spinning and elliptical. BORING!

I'll repost when I get more info and thanks again!!!!!

jedfsu 04-02-2013 06:26 AM

re: arthroscopy or straight for mosaicplasty?
Here is my MRI - there is no mention of depth!!!! Maybe you can see something that I'm not seeing?

Signs/Symptoms: Pain/tenderness in Rt ankle

INDICATION: Pain, tenderness. Intermittent pain, localized
medially and anteriorly. Concern for osteochondral lesion of
medial talar dome.

TECHNIQUE: MRI of the right ankle was performed without
administering intravenous contrast, according to standard
departmental protocol.

COMPARISON: None available


Bone: A 12 x 7 mm (4: 16 and 5: 17) osteochondral lesion is seen
within the medial talar dome, with marked underlying bone marrow
edema and some subchondral cystic changes within the talar body.
Minimal fluid is noted along the inferomedial portion of the
osteochondral lesion, but none along its superolateral margin.
There is heterogeneous high signal of the cartilage of this
osteochondral lesion, suggesting impaired integrity.

Tendons: The anterior extensor tendons (tibialis anterior,
hallicus longus, and digitorum longus) are intact. There is
tenosynovitis of the posterior tibialis and flexor digitorum
longus tendons. The flexor hallucis longus and peroneal tendons
are intact.

Ligaments: The deltoid ligaments (anterior and posterior
tibiotalar, tibio calcaneal and tibionavicular) are intact. The
lateral collateral ligaments (anterior and posterior talofibular,
and calcaneofibular) are intact. The tiofibular syndesmotic
ligaments are intact.

Miscellaneous: There is a mild amount of subcutaneous edema about
the ankle and a small joint effusion. A focal 9 x 3 mm fluid
collection along the dorsal aspect of the talonavicular joint
likely represents a ganglion. Loculated fluid adjacent to the
posterior subtalar joint may reflect reflect early ganglion
formation. The tarsal tunnel in is normal in appearance. Edema in
the sinus tarsi may reflect early sinus tarsi syndrome.

1. Stage 3 osteochondral lesion of medial talar dome, with
incomplete circumferential fluid around lesion, marked underlying
bone marrow edema and small subchondral cystic changes of talar
2. Tenosynovitis of posterior tibialis and flexor digitorum
longus tendons.
3. Loculated fluid adjacent to posterior subtalar joint and
smaller fluid collection along dorsal aspect of talonavicular
joint may reflect ganglion formation.
4. Edema of sinus tarsi may reflect early sinus tarsi syndrome,
in the appropriate clinical context.

FLIN21 04-02-2013 10:24 AM

Re: OATs vs DeNovoNT for osteochondral defect in talus 17x8x8mm
JEDFSU, good luck with your appointments. I can't tell you how much I have learned through this process. It is absolutely so importatnt for you to be your own advocate and continue to educate yourself on all of your condition and your options. For me, i needed to know that I was choosing an option that provided me the best chance of having the most normal ankle possible, without limiting my future options. I have had many recommendations from microfracture ( my lesion and cysts are too large for this to work), to a fresh osteochondral allograft (too risky for me, leaving me with no future options if the procedure were to fail). Utlimately through my exploration, I found that there was in fact a more moderate approach that provides the chance for my ankle to remain in tact, repair the bone, and have potential for cartilage regrowth, all without risking future options should I need them. I will keep you in my prayers and look forward to hearing how you progress.


LivesNearStore 04-02-2013 01:13 PM

re: arthroscopy or straight for mosaicplasty?
JedFSU: I think the radiologist can see the depth on the MRI but either didn't want to guess at the depth or simply forgot to measure it. MRIs tend to show fluid, inflammation, and activity better than bone, so it's possible the radiologist can see the depth of changes around the lesion but doesn't want to guess how much of that is damaged bone vs. merely irritated bone.

You can ask your doctor to show you the MRI in the office and break out the electronic ruler in the viewer, or if he isn't willing to do that, request a copy of your MRI on a CD and look at it yourself.

If your defect is on the inside of the ankle I think that's the medial side.

I would say a mosaicplasty is essentially the same as OATS except it uses multiple small grafts instead of one piece. Mosaicplasty is used if the lesson is too big to take a one-piece graft from your knee/tibia/iliac crest/calcaneous, or if using several pieces is the only way to fit the shape of the lesion. For this reason mosaicplasties tend to be for autograft, since with a cadaver ankle the doctor can usually trim the graft to fit in one piece.

jedfsu 04-02-2013 02:38 PM

re: arthroscopy or straight for mosaicplasty?
Wow - thanks for the emotional support! I spoke to the PA today who told me that depth is not apparent on MRI but rather CT scan, which I've not had as of yet. I asked if doc that I saw yesterday does the DeNovo and she said yes but wasn't 100% sure and was going to talk to doc and then call me back. Maybe he uses for other procedures but not ankle? The doc said we could do arthroscopy and see how that takes but I just don't understand how that can help. PA said that by drilling it may stimulate some bone growth. Really? How can that be? he said my lesion was "large". I thought he said stage 5 but the MRI says stage 3....

I guess what is most frustrating to me is the lack of data to support anything! I'm a strong believer in studies and the doc said that there is just not that much out there yet.

Can someone explain the DeNovo better? It's called DeNovo NT Natural tissue graft, right? I just read the Zimmer brochure on how to implant but what I don't understand is why everyone mentions using their own bone, too. My doctor said that he'd use from my knees but then when I told him that I had previous knee surgeries and have need for additional reconstructive surgery on my left knee, he then said cadaver. Would he use both the DeNovo and cadaver? Why woudn't he suggest other places to get the bone like others have mentioned (hip, heel etc)? I know these questions are probably better suited to the doctor but he was very short with me.... I may ask PA when I talk to her again.

I am going for 2nd opinion w/MGH doc Dr. Johnson that others have mentioned on this thread. I'm eager to meet her and talk to her but alas, the wait time for an appt is long. I did have earlier appt but they had to reschedule.

The PA did tell me by 9 weeks I should be ok to drive. Can anyone comment on that? My older son starts school on Sept 4 and I can probably arrange for someone to bring him home (husband does drop offs).

Thanks to all!

jedfsu 04-02-2013 06:01 PM

re: arthroscopy or straight for mosaicplasty?
just spoke to surgeon - he called me at home at night! Gave me probably as much time as he gave me in the office. He said that he doesn't think I'm a candidate for DeNovo because my lesion is a "contained defect off to the side". He also said that he would not use knees because of my issues and that the hip and heel don't contain cartlidge so he can't use them. He said cadaver is the best because he can get the size just right.

We also talked about my pain level which is relatively low, especially now since I've not been working out. Can anyone tell me how high their pain was when they had the surgery?

FLIN21 04-02-2013 09:50 PM

re: arthroscopy or straight for mosaicplasty?

I found it helpful to think about the injury/diagnosis as 2 seperate issues. Please keep in mind, I am not a doctor, so this is my own simplified understanding that I have gained through my own experience. The first issue is that of cartilage, your injury has resulted in a portion of your talus's cartilage to die, I believe this is what is referred to as the lesion. The second issue is the underlying bone. Due to the damage done to the cartilage, the underlying bone has cysts that have formed, likely resulting from fluid being able to penetrate and wear into your talus bone. In order to correct this condition, both the underlying bone structure and the surface cartilage need to be repaired. In more minor cases, especially those without the cystic changes, people are able to recieve micro fracture (tiny drills into the bone), that promote the bone growth and a cartilage like material to form on top. For larger defects, docotors often need to fill in the defect with bone from another part of your body, utlizing areas such as your knees, where the bone has cartilage on top. This approach allows the bone and cartilage defect to get repaired using bone from your own body. Some defects are too large to take bone from these areas where cartilage is contained. In my case, the defect is too large to take from my knees to correct botht the bone and cartilage issues. When these defects get too large, there is a lot of debate on what the best course of action is. Some doctors will recommend doing a cadaver bone, where you recieve a donor talus bone matched to your size, and the doctor can replace the damaged portion of your talus. Another option, like what I am having done, is to do a bone graft using bone from your own body to fill in the cyst then utilizing the DeNovo for the cartilage graft over top. Essentially 2 procedures in 1. Because the deonovo is used for the cartilage graft, we are able to take bone from places such as the hip or heel where the bone does not have cartilage. I hope you find this helpful.

jmpt 05-12-2013 09:18 AM

re: arthroscopy or straight for mosaicplasty?
jedfsu: I know it is confusing with all the different procedures. I hope this helps:

Microfricture (MF) or micro drilling (MD): Arthroscopic surgery where the dr cleans up the area and then drills small holes in the defect in hope fibrocartilage will grow and decrease the pain. sometimes if there is left over cartilage covering the defect, the dr will elect to take it out/sometimes they leave it there. ---- I had this surgery but did not work-- pain actually increased for me

OATS: dr takes a piece of bone usually from your knee or iliac crest (if knee is not optimal)- this is call a bone plug. They use something that looks like a round cookie cutter to take this bone out. the dr then takes the same cookie cutter thingy and places it over the defect (the size of it is bigger than your defect so it will fit the entire area correctly) and takes out the extra area. He then takes the plug and puts it in the newly enlarged defect and it fits perfectly. recovery is usually 8-12 weeks non weight bearing and then slow progression with wt bearing and exercise. all depends on your age and pain ----- I was not a candidate for this b/c my defect was too close to the medial wall of the bone and 2 ortho surgeons (in different practices) said my medial wall would collapse and the procedure would fail if they did it. My integrity was compromised due to the depth and location of the defect.

Cadaver bone: you get placed on a bone donor lost and wait. your dr would have you get a CAT scan / MRI to map you ankle for the exact size/shape. When a person with your size bone and blood type dies and has consented for bone donation, you would get a call that your surgery will be within the week. The dr has about 12 days to get the bone in you before too many of the bone dies. It is not a "planned surgery" You know it will happen but not when. Studies have found that frozen bone does not take well and often rejected by the recipient. So fresh is the way to go. the recovery for this is about 4 months non-weight bearing and then a very slow progress with wt bearing. total recovery time without any problems arising about 8-12 months. rejection rate 10-15%

Zimmer DeNovo NT graft: juvenile cartilage (10yrs old and under) is donated when a child passes away. (I know it is sad but these are organ donors too). It is minced up and placed in a solution. Juvenile cartilage is used bc it is not done growing and the is more likely to naturally grow to the bone. When the defect is into the bone, the dr will elect to take bone from another region (for me it was my heel/calcaneus) to replace the missing bone and then places the graft on top. the bone grows to your bone and the graft grows onto the graft.... kinda cool. recovery depends on the location. if the defect is on the medial side, the medial maleoulus (part of the tibia) is removed to get to the region. then screwed back on after the procedure is done. if on the lateral side, all can be done arthroscopic. With the medal maleoulus ostomy done, 6-8weeks non weight bearing and then progressive wt bearing for 1-2 weeks and then progressive walking from there with boot on and progress to a lace up brace..... and so on. With the lateral defects done arthroscopic, 2 weeks non weight bearing and then progressive weight bearing in a boot then to the brace. --- I had this done and my dr had to incorporate some of my shoulder fo the bone with the graft. I had to have the medial maleoulus ostomy done too. I am doing great and recommend anyone talk to a dr that has experience in this procedure before you discount it. My dr told me he has done only about 12 of these with all great results. I was full weight bearing without crutches at 8weeks. My pain is gone and I am looking forward to a normal life running around with my 3 and 5 yr old children.

I hope this helps

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