I just consulted with 4 different ankle specialists on surgical options, weighing between Denovo and OATS (along with a few other options). I know other folks may be in a similar position, so I thought I’d post some observations on how the doctors talked about the options, in case it’s valuable. In the course of these discussions, I’ve learned quite a bit about how some of the top docs on the east coast think about OATS vs. microfracture(MF)+Denovo for OCD repair.
Background: 3 prior OCD surgeries. Surgery #1 (MF) was successful, but never repaired the ankle instability and I reinjured it. Surgery #2 was a modified Brostom-Gould to repair the instability and MF to repair the OCD. The B-G worked; instability fixed. The MF to repair the OCD failed. Surgery #3 was MF+Denovo to repair the OCD. It kinda sorta worked for a while, then rapidly deteriorated 5 years post-Denovo.
I now have a 1 cm OCD on the medial talus. Saw four different ankle specialists:
John G. Kennedy (New York City)
Daniel Cuttica (Falls Church, Virginia)
Daniel Lahr (Rockville, Maryland)
Stuart Miller (Baltimore)
John G. Kennedy (New York)
Far and away the most positive about my prospects for a full recovery. Said I had an “uncontained” (aka shoulder) lesion that was >1cm and so MF was out and it had to be OATS. He also said that my ankle is still unstable and that the ligament repaired by the B-G has stretched out over time and that is contributing to my problems. He said that he would do a “hybrid” repair, which consists of slicing out a piece of the peroneal tendon – about 1/3 of the tendon – and using that to reinforce the joint. (Technical term for this is: “Anterior Talofibular Ligament Reconstruction via Hybrid Procedure with Peroneus Longus Autograft”). He also said there were two smaller lesions – a small kissing lesion opposite the main one on the talus and a small one on the lateral part of the talus. He recommended we *not* do MF for these since the lesions have not yet gotten so bad to damage the subchondral plate, and we don’t want to damage that by doing the microfracture. Instead, he recommended Biocartilage with stemcell seeding with Concentrated Bone Marrow Aspirate (CBMAC).
Kennedy said that for the OATS we should do an autograft from my own knee vice an allograft (cadaver). He said that for years they thought the outcome was the same, but recent research he’s done which is not yet published has shown better outcomes with the autograft. He said the risk of knee pain afterward has historically been 4%, but recently they’ve come to better understand what causes knee pain (he says it was wrapping the wound too tightly and causing scar tissue), and they’ve adjusted their approach. If there are knee problems, he said they can do a one time cortisone injection that will fix it, bringing the risk of knee pain down to 2%.
Kennedy said that with this surgery I should be able to return to full activity – sports, running, etc. – in 6 months. (Note: Given my age (39), this timeline seems aggressive. But I am hopeful about the return to sports.) He said for someone with my condition if this was the first surgery, the odds of a full recovery were 96%. He said for secondary surgeries, the odds drop to 90%. He said they didn’t have good data on the odds for someone for whom it is a fourth surgery, but I could use that as a ballpark estimate.
(Aside: These docs below are all good, but I like Kennedy the best by far. My comments on him here:
http://osteochondraldefect.net/forum/index.php?topic=13.0.)
Dr. Stuart Miller (Baltimore)
Recommended some kind of treatment that I didn’t fully understand where they would shave the bone back and then put in some “bone grafts” (not OATS) to regrow the cartilage. It’s possible he meant concentrated bone marrow aspirate. I’m honestly not sure. I asked him about it but it didn’t make much sense to me. He agreed that MF with Denovo and OATS were also options, although his recommendation was the first one, whatever it is. Although he made clear that none of these were really good options and that there simply weren’t good options to regrow/repair/replace cartilage for someone in my position, with three prior surgeries. I said I was leaning towards OATS at this point in time, and he said that was a reasonable choice. One of the things that we discussed was my lifestyle (I skydive) and I expressed concern that the fibrocartilage created by the Denovo may not be able to handle the impact of an occasional rough landing. He said it seemed reasonable that OATS may make more sense in my case.
He said that *if* my ankle was still unstable he would tighten it up using a “rope” (I think he means a checkrein procedure). But he didn’t think my ankle was unstable and thought it was fine. He did not think that the risk of knee complications from OATS was significant. I asked what a bad outcome for the knee looked like, and he said he’s had some patients complain of a clicking sound in their knee when they walked up stairs. No pain, weakness, or trouble doing stairs. Just a clicking sound. I said I would love that to be the worst problem I had and he agreed.
Miller said I should give up running and try biking instead. (I have a bad hip. Haha.) Was also not very keen on skydiving and gave a short speech to his fellows about how impactful skydiving was on the joint.
Dr. Daniel Lahr (Rockville, Maryland)
Recommendation was MF, given that the lesion was ~1 cm. When I asked about whether that meant MF+Denovo, he said we could add the Denovo and called it the “gold standard” but said that it didn’t really add much in terms of odds of recovery. If greater that 1.5cm, he would have said OATS. He agreed that it was an uncontained shoulder lesion but said that didn’t matter. He also did not think my ankle instability was a problem requiring me to redo surgery. He agreed OATS was an option and was comfortable doing it if I preferred it. He said at the end of the day that the odds of a successful recovery were basically the same going with Denovo or OATS, about 85%. His inclination was for the one that was less involved for my body. One of the concerns he raised was that the osteotomy (surgical cut of the bone) required to do the OATS to access the region meant he was cutting through the cartilage in the joint and that could contribute to arthritis in the long run. This was interesting, as I had not heard this raised before. I expressed concern that the Denovo would fail again as it has the last time, but he said the data shows that a prior failed procedure does not negatively affect the outcome, only the size of the lesion. (Note: this may be for second surgeries, but I am doubtful that they have sufficient data of fourth surgeries to make that claim in my case. And given my experience and lifestyle I think it’s highly likely that if I did a Denovo, I would be back in this same boat again in a few years.) Lahr said in any surgical option, my long-term outcome was only going to be modest and I should give up on running. He was crystal clear about this – I would not run again. (I hope he’s wrong but I appreciate his honesty. I would rather a surgeon not paint an overly rosy picture.)
In terms of knee complications from OATS, Lahr said they’re rare and he’s never seen them in any of his patients.
Dr. Daniel Cuttica (Falls Church, VA)
His first surgical recommendation was simply to do a debridement and cut away the flap of torn cartilage that was showing on the MRI. (Note: Miller thought this option was “stupid” given my MRI.) *If* things seemed really bad in terms of the remaining cartilage, Cuttica said he would add a layer of Denovo. He said he would *not* do MF, because there is some evidence showing that the blood that comes out can make the Denovo graft slip around. (Only person I’d heard mention this.)
When I said that Kennedy thought the OCD was “uncontained” making MF not an option, he said that he agreed that *if* it was uncontained then MF wouldn’t work, but that he thought he saw a sidewall on the MRI making it contained. But, to his credit, Cuttica said we should do a CT scan to get a better look and that if it was uncontained he would change his mind and recommend an OATS. When the CT scan came back he agreed it was uncontained and said OATS was my only option.
He agreed the ankle was unstable and should be fixed. He said he recommended doing another Brostrom-Gould and supplementing it with a checkrein procedure, so basically doubling up. He said he used to do the hybrid procedure with the peroneal tendon autograft and got good outcomes, but has switched more recently to the checkrein because it doesn’t require cutting into a perfectly good tendon and he preferred that.
In terms of long-term outcome, Cuttica said that I should be able to run a little on an OATS, but that I shouldn’t make running my full time source of exercise and be running marathons or something. An occasional 5K, maybe. He agreed the knee pain from the OATS was very rare and, if it happens, not generally that bad.
Points of agreement among all doctors:
- I have a ~1 cm lesion on the medial talus shoulder
- OATS was a reasonable option on the table for repair
- If doing OATS, the risk of knee complications is low
- The existence of two smaller lesions
Points of disagreement among the doctors
- Whether Denovo + MF was even a viable option to consider (all docs initially thought so except Kennedy, but Cuttica changed his mind after seeing the lesion was uncontained)
- Whether OATS was required. Kennedy (and eventually Cuttica) said that was the only option for me, given the size and that it was uncontained. The other two docs thought it was an option, but not required.
- If we did OATS, whether an autograft or allograft was better. Most docs didn’t seem to think it mattered in terms of outcome. Kennedy said that was not true and recommended the autograft.
- Odds of a successful outcome with OATS. Kennedy was more bullish on a successful outcome.
- Whether my ankle was still unstable or not. Docs were split 50/50. (Note: My left ankle clearly turns more than my right. The docs seemed split on whether this mattered. It didn’t cross the line to clinically “unstable” in the minds of Miller or Lahr. Cuttica didn’t notice this at first either, but he agreed it was an issue after I pointed it out. Kennedy’s point was that because it turns so far over, the talus is hitting the tibia and that’s what’s causing the two additional small lesions. It is also no doubt contributing to additional stress on my prior OCD repair. Given the existence of the two smaller lesions, I think he’s right and I’m surprised that Miller and Lahr don’t agree. That seems shortsighted in my mind.)
- If my ankle was unstable and needed surgery, the best surgical option. Two recommended checkrein procedure. Kennedy recommended hybrid with peroneal autograft. No one seemed to think the hybrid procedure with peroneal autograft was unreasonable, though.
- Value of biocartilage. Kennedy is using it. Miller thought it was junk. I interpret this to mean that it’s new and of questionable value so far.
- The significance of the two smaller lesions and whether they demanded some kind of treatment. Aside from Kennedy, the other docs thought they should be ignored.
Observations
With the exception of Kennedy, who was all about the OATS, it was not the first choice for any of the other three doctors. They all agreed that it was a reasonable option on the table, but all pushed for something different to try to regrow the cartilage instead. All the docs were willing to do it, but with everyone except for Kennedy I had to push for the OATS. I had some long discussions with a number of the docs on why they’re so reluctant to do OATS and I think there are a couple factors. For one, I had only a 1 cm defect. The fact that it was uncontained pushed Kennedy to OATS and eventually Cuttica as well, although he was reluctant to go there and only switched his mind after I explained Kennedy’s reasoning and Cuttica confirmed it was uncontained with a CT scan. For Miller and Lahr, the fact that it was uncontained didn’t matter. 1.5 cm was threshold for OATS for them and I wasn’t there.
The prior surgical history of failed MF+Denovo did not seem to be a major factor for most docs. I’m not even sure if it was a factor for Kennedy, to be honest. I think his main driving factor was the size of the lesion and whether or not it was contained.
Kennedy was the only one who thought that a full return to sports was possible. I hope he’s right.
Decision: I’m going with Dr. Kennedy to do OATS (autograft) plus the hybrid tendon autograft to repair the instability. I will follow up with post-surgical updates as I recover.
