DeNovo NT graft done on 1/15/2013

[jmPT]

Hello All!
I previously posted 5 months after I had Micro Drilling on the medial dome of my talus. I have now had more surgery and thought it would be good to start a new post since the last surgery is "new" to the community. I cut and pasted some of my previous post for background information on my journey.

13 yrs ago I had a chip that was about 1/3-1/2 of the medial dome of my talus pinned.I was pretty much pain free for 9-10 years with a increase of pain in the past 3 -4 years. I had an MRI 6 yrs ago b/c of some minor aches but it was "arthritis" per the dr. Since then the chip became necrotic and has erroded away and I now have a 8mm x 17mm rectangle defect that is about 8 mm deep. On april 11th I had arthroscopic surgery to "clean up" my joint and microfracturing/drilling of the defect in hopes to decrease my pain and stimulate fibrocartilage growth in the defect. Initally it felt great and my pain was reduced dramtically. I actually had some pain free walking! But, as I increased my standing time and ambulating the pain returned and now has increased to my pre-surgery status. I try to limit my weight bearing exercises because it just hurt so much I start significantly limping. Even using a stationary bike hurts.

My surgeon mentioned prior to the 1st surgery the next step would be placing a cadaver talus bone plug in the defect. I know I am going to be placed on the bone donor list. My surgeon does not use frozen bone due to the rejection rate is too high and he already told me he does not want to take bone from my hip because the defect is too big.

I have heard about the zimmer DeNovo grafting but still researching and don't know if I am a candidate for it since my "hole" is so big. I see my Dr in 3 weeks and definitely will have my research with me on the Devo procedure. I am just nervous about the cadaver bone and if it will actually take.

 Funny part is I am a physical therapist and know I will be out of commission after surgery for a good 5-6 months (if all goes well). I have treated pleanty of post op surgeries but no OATs or deNovo zimmer grafts. Since I am on my feet for 90% of my day and work in multiple clinics (in-patient and out patient) I need to be able to lift patients. Right now I am barely able to handle the in-patient schedule because I am on my feet so much and lifting other people. I have to work as much as I can so I can afford to be out for the next surgery and still pay the bill. It is a total catch 22.

Well..... My surgeon in Columbus Ga thought I was a candidate for the DeNovo NT graft but does not do them. He referred me to Dr. Nicholson in Savannah Ga. I saw him in mid November and was scheduled for the DeNovo Graft for Jan 15th 2013. My new dr said he has had great results with the graft. He usually sees active duty military and I was his "first" non military DeNovo graft patient. He said one of his military patients is back to jumping out of airplanes and deployments without any problems. I will be out of work for about 4 months.
   
1/17/2013--Update on my right ankle. 2 days ago (1/15/2013) I had the DeNovo NT graft done. The dr had to cut off my medial maleoulus (osteomy) to get to the defect and then fixated it back on with 2 screws. He said he took a bone chip/bone marrow from my heel to fill in the bone portion of my defect and the graft lay on top. My ankle hurts like hell since the nerve block wore off, but i feel it is b/c of the osteomy that was done. I am in a cast like splint all wrapped up like a mummy. I am non weight bearing for the next 6-8 weeks depending on the healing of the medial maleolus. I can feel how swollen I am and I hope the graft takes. I see the dr on 1/28 for my 2 week fu and get my stitches out.

1/19/2013: My pain is getting better. I am now only taking pain meds every 6 hours instead of staring at the clock and counting down 4 hours. I feel the swelling is under control as long as I elevate my leg... basically, I'm stuck in my bed. Once it put my leg down, I can feel my ankle pulsating and swelling. I am hoping not to be taking any pain medications by the time I go back to she the dr on the 28th.

[mhop]

Please keep us posted.  I would really like to know how that works out for you.

[jmPT]

No problem on keeping everyone posted!!
 I see the dr on monday 1/28, but I would LOVE to post that I have not taken ANY pain medications since monday night---- today makes 5 days with no pain meds. Only Ibrophrin (sorry can't spell). I am very surpirsed by this because the dr had to cut off my medial maleoulous (part of the tibia) and then use 2 screws to put back on after fixing my defect. I have some soreness but it is LESS than the pain I had prior to surgery.

I LOVE MY DR!!!

I am excited to get the stitches out on monday and get this splint/cast off.

[jmPT]

I saw my ortho yesterday. Cast off and stitches out. My ankle looks like it went through war. It looks worse than it feels. The dr wanted to place me in another cast but after some pleading, He agreed to place me in a boot. I am still non weight bearing and have to wear the boot 24/7 except for showers. I even have to sleep with it on. I am not allowed to move my ankle when it is out of the boot. My dr has me in the boot b/c of having to cut the medial maleoulus off and then screwing it back on. He wants to make sure it is completely healed before I place weight on it and start moving it. This is the second time it had to be cut and fixated back on so integrity is the key to keeping my joint stability.
In 3 weeks I will be allowed to perform ankle dorsiflexion/plantarflexion (move up and down) 3 times per day 10 reps each. I will see the dr one week later for my 6 week post op visit.
He told me at 6 weeks (if everything is healed) I will start to be able to place a little weight in my foot and progressive weight bearing from there. By 3 months post op I will be able to start to ramp up my weight bearing activities. He was not specific but I am hoping that means working on agility and progressing speed walking to .... possibly jogging in the future. ... a girl can dream. I have not been able to go jogging in more than 5 years. it is a true dream to do this.

[ocdnetadmin]

That's an ambitious surgery. Kudos to you for going through with it. I wish you the best of luck, and really hope you can go jogging again someday.

Just wondering, is that an alternative to OATS?

[jmPT]

I was not eligible for the OATS procedure. My OCD was on the medial side and VERY close to the medial wall of the talus bone. My original ortho in Columbus Ga said the medial wall of my talus was too thin b/c of the defect and would most likely collapse from the  OATs. My only other option was either try the Denovo graft or cadaver bone. With the cadaver bone, he would have to cut off the medial shoulder and alot of the dome of my talus and replace with cadaver bone. Basically a huge chunk of bone needed to be replaced. With the denovo graft, my new ortho did have to take some of my medial shoulder of the talus off secondary to it being sclerotic bone and he filled in my defect with bone from my calcaneous/heel and then was able to place the Denovo graft on top. In a way, I opted for the less invasive procedure. Plus, there is a less chance for rejection with the DeNovo graft than with Cadaver bone.

[jmPT]

Hello All!
I saw my ortho 2 days ago and I'm happy to report my medial maleoulus is healed and I can FINALLY weight bear!!! Insert happy dance here  . I have to wear my boot for one more full week while progressively increase my weight bearing with crutches. Next week I can start wearing a lace up brace 50% of the time and wean myself from crutches all together. I stop wearing the boot in two weeks. I have to wear the lace up brace with all weight bearing activities until I see the dr on March 25th. I am allowed to move my ankle in all directions too when I am sitting in the recliner. I can also finally not wear the boot when sleeping. (that is one of the most awesome things- I had alot of trouble sleeping in the boot) My ankle was very stiff in the beginning but after 2 days, it is getting better.
At the dr appt I saw my x-rays and the dr pointed out how well the bone grafting is adhering and I can actually see a full joint. I have not had that in a good while.
I was able to walk around the house with one crutch today (with the boot on, of course) but now a little sore.... once again I pushed myself.. I should really know better but it feels so good to "walk". Tomorrow will be a 2 crutch kind of day. One good thing is that I'm sore at the medial maleoulus where the screws are.... not the joint. NO PAIN IN MY JOINT!!!! once again, insert happy dance!
I am so happy I made the choice to have the Denovo graft.

[Alpharetta]

Hi Jim,
So happy to hear of your wonderful progress and especially "no pain in the joint".

[DanDaMan]

Hey jm - this looks like wonderful progress.  Really intense decision you made, but as a PT you have an advantage since you'll know what your limits are and when to push as part of this longer recovery period.  It looks like you will get a chance to jog again at some point too!  Thanks for taking the time to chronicle your journey on this forum; it's so helpful to learn from others' situations.

I'm still dealing with ups and downs from my MD ... I'm 6 months post-op.  I've decided to stay away from running for now and have moved to road cycling.  So far so good, so hopefully my MD repair will hold up.  I'm in GA so I'll have to see if your doc is in network; just in case.   Your decision to move forward with the DeNovo graft is inspiring.

Keep it up!

[jmPT]

Hey All!
Well it has been about 2 weeks since my dr said it was OK for me to wt bear. I was able to wean off the crutches in the first 6-7 days (while walking in the boot). This week I was able to toss the boot aside and walk in the lace up brace    I am happy to be out of the boot but it gave me so much support and actually easier to walk in it. The lace up brace give pretty good support but it pushes against my scar. I have been having some pain at my upper part of my scar and a little bit in the joint. It appears I have some popping in my joint with some movements. I think it will get better with activity/time. The scar pain is b/c of the extra scar tissue I have. The Dr had to cut on my previous scar. I believe I have some some adhiesions to the underlining fascia and bone. I am doing scar massaging and starting Thermal ultrasounds to loosen up the scar. My range of motion is doing better (at about 50% of normal limits) but then again, I have only been able to move it for the last 2 weeks.
I am still limiting how much I walk b/c it actually starts to hurt some when on my feet too much. I do push myself too much and have to remember on tuesday it will only be 8 weeks post op. Overall even though I am having some pain, I am staying positive and know I will keep getting better if I progressively walk and not do too much too soon.

[jmPT]

Hey Y'all!
I say my surgeon this past monday and he said everything is going really well!  I am 10 weeks post op and walking without a limp!!!!! This is the first time in years I have been walking "normally". I do get sore in the morning but after walking around for a little bit in the house, it resolves. I still have to wear a flexible ankle brace for the next 3-4 months to be on the safe side. I have noticed some popping in the joint occationally (1-2x/day) but only when i'm non weight bearing - when i'm doing ROM in the recliner or in bed. My Dr said as long as it is not painful, i'm fine. I have had 2 pops that were uncomforable but I'm just going to monitor it. When I'm walking, I don't have pain or popping-- it does puzzle me. I am allowed to start progressive walking distances. I have been going to stores like Walmart and the grocery store and have only minimal or no pain afterwards. I went for a walk outside yesturday for 30 mins (felt great to do some sort of exercise!!) and did not have any pain. I think the weather is playing a part in my soreness. It is in the 30's in the AM and then 60-70's in the PM.
 The dr said he does not want me doing any higher impact exercises for another 2 weeks. (eliptical or speed walking) NO Jogging for for atleast another 6 months. He said the Denovo graft is still growing into the bone for the first 1- 1.5 yrs after the implantation. I don't want to mess this up, so i'll be good. The dr actually said I am ahead of schedule on how well I'm doing at 10 weeks. I am very positive about this but he warned me not to do too much to risk the vitality of the graft. I shoudl be starting PT in the next 2 weeks (awaiting insurance approval). I can't wait!!!
I am not a religious person, but I just thank God for guiding me to my Dr and allowing him to take my pain away

[jmPT]

I am officially 4 months post op and feel great!!! I saw my dr about 2 weeks ago and he said I am cleared to go back to work on may 15th. I have to wear my lace up brace for work until august and then..... BYE BYE brace!!! I can start trying to slowly progress with jogging as log as it is pain free. I am planning to try to wear my 2 inch healed boots this fall. It will be the first time in 3 years I have been able to wear them. Any girl would understand where I'm coming from on this one    I don't wear my brace when I am out and about on flat surfaces but am still careful with grassy areas and wear my brace. I see my dr on 2 1/2 months and then at my 1 yr anniversary. I'm excited to go back to work but am going to miss being home. Overall I feel great. The only thing I worry about is an occasional painful pop when I'm sitting up in the recliner and doing ROM. It feels like there is a rough spot that catches iin the joint. It doesn't happen more than 1x every 3-4 days and not in a consistent motion I do. The dr said there might be a rough edge due to the bone growth or possibly a small cartilage loose body. but either way the rough edge will smooth out or the loose body will be absorbed naturally. He felt it was not a big deal b/c it is not all the time or consistent. Plus I am still pain free so that is the best indication on how the graft is doing.

I feel I can say I'm a success story and THANK YOU Dr Nicholson for finally making me pain free and able to play with my kids unrestricted again!!!!!

[ocdnetadmin]

jmPT, that is great news. Please be careful while jogging. Maybe start with very short distances and see how it goes.

Keep us updated!

[jmPT]

Alan,
I plan on it! I have not been able to jog due to pain in over 5 years. I was never a big runner, b/c of ankle issues since I was 13. I plan on speed walking first and then try a light jog for short distances only. I think a block would be my starting distance. I am so scared of messing up my ankle that I am being very cautious. I might even wait until august. So far I have been working for almost 2 weeks and was only sore the first day. I'm on my feet all day so I'm happy I have been pain free for the most part. I still swell at the end of the day but by the next day it is back to normal. My popping has even decrease. 

I see the dr in July for my 6 month fu.

[jmPT]

HEY ALL!
Well its been 6 months since my surgery and I feel great! I saw my dr today and he said everything looks great. He did a weight bearing x-ray and the bone looks almost like new. It was amazing when he put the 6week post op x-ray next to todays. The grafted bone looked almost like the rest of the bone. I am so amazed on the difference in my life since the graft. I am walking without pain and able to run after my kids again!! I have not "ran" more than a short distances to grab my kids from doing something dangerous. (they are 3 and 5 yrs old) I was told next month I could try jogging short distances but remember the graft take 12 to 24 months to fully adhere to my bone. I don't want to mess this up so I may wait a little longer than August to try jogging. 
I see my dr again at my one year mark (January)