OATS Recovery Journal

[pds]

I recently did OATS in June 2018. I'm going to track my recovery here in case others are interested and considering the procedure.

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Background: Repetitive ankle sprains. 3x prior surgeries (#1 MF, #2 MF + B-G, #3 MF w/ Denovo).
Full history here: http://osteochondraldefect.net/forum/index.php?topic=371.0

Injury: 1 cm OCD on the medial talus shoulder (uncontained); secondary lesion on lateral talus; continued ankle instability

Surgery: OATS w. autograft from knee to repair primary OCD; Biocartilage + concentrated bone marrow aspirate (stem cells) from my hip to repair secondary OCD; Kaarlson Gould procedure to repair anterior talofibular ligament. Had to perform an osteotomy (surgical cut of the bone) on my tibia to get into the joint. Repaired the osteotomy with three 1.5" titanium screws.

Doctor: John G. Kennedy at the Hospital for Special Surgery in New York: http://osteochondraldefect.net/forum/index.php?topic=13.0

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Recovery plan from Dr. Kennedy is very aggressive:
2 weeks non weight bearing in a hard splint
2 weeks non weight bearing in a cam walker boot. Can do light touchdown weight of 10% body weight -- basically just resting the weight of the leg itself. Remove ankle out of boot for 1 hour per day for slow movement exercises up and down only.
At ~4 weeks, begin easing into weight on cam walker boot, doing 10% per day. Expand exercises to include light pressure upward against foot to increase range of motion. After getting to 100% weight bearing, walk on boot for 3 full days
At ~6 weeks, begin easing out of boot slowly. 1 hour out of the boot per day for the first day, 2 hrs the second day, and so on over the next two weeks. Begin physical therapy at 6 weeks.

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Recovery so far:
First 3 weeks were pretty tough. Much harder than microfracture surgery. Lots of swelling in the joint. Seems to be from the osteotomy where they cut my tibia and the screws they put in. Hurt a lot. Had to keep it elevated basically 24/7 and was still on lots of pain meds. Really disrupted sleep for the first 4 weeks or so. Began easing into more body weight on the leg (in the cam walker boot) starting at 4 weeks.

I'm at 5 weeks post-op right now and up to 60% body weight and no real problems. Doesn't hurt to put pressure on the leg, although if I walk around on it too much it starts to hurt after a while. Main problem is the swelling in the joint. I'm managing the swelling by elevating, icing, and soaking in epsom salts. Seems to all be effective and if I stay on top of it, it's manageable. I'm only taking tylenol as needed plus ibuprofen at night to help me sleep. Sleep is still hard, as if I don't keep it elevated then the ankle swells and the pain will wake me up. Main problem is that the swelling is limiting my mobility, as I need to keep it iced and elevated most of the time. Thankfully, I have a job where I can mostly work from home, as I can't be up on my feet crutching around for more than a 2-3 hours before the swelling is very painful. And the swelling is disrupting sleep. But it is getting a little bit better every day. I'll be up to 100% weight bearing within 4 days, then walk 3 days on the cam walker boot all day with no crutches. Then I begin easing out of the boot, increasing by an additional hour every day.

X-rays at 2 weeks and 4 weeks all look good and the incisions have healed up no problem. Wicked scar, though.

My knee (where they did the autograft) feels great. No problems. The knee hurt pretty bad only the first few days. I iced it and did range of motion exercises, and now I have no pain or stiffness and full range of motion. It's just a little sore if I kneel on it, is all, so I wear a knee pad if I'm going to be kneeling on things. The knee problems have limited me using a knee walker, which I got. I did it one day but after an hour or so my knee was pretty sore. Thankfully, I haven't had to do much scooting around.

Feeling very optimistic about the recovery. I'll post more updates as things progress.

[ocdnetadmin]

thanks for the detailed update pds. We're interested on your progress for sure.

how long is the Physical therapy scheduled for?

[pds]

6 week post-op update:

Transitioned off crutches to 100% weight bearing in the cam walker boot last week and now transitioning out of the boot over the next 2 weeks. 1 hr out of the boot the first day, two hours the next day, and so on. I'm up to three hours out of the boot as of today. I'm astonished by how aggressive Dr. Kennedy's recovery protocol is, but it seems to be working. I'm able to bear weight on it and can awkwardly walk short distances (~50 ft) in a halting, limited fashion. Range of motion is still poor and the swelling is tremendous, but slowly getting better on both fronts.

Had my first PT visit today and I'm at 5 degrees of dorsiflexion. Need to get to 20-25 degrees in order to run. Based on the PA's guidance I've been doing ankle pumps and dorsiflexion with some light pressure for the past two weeks, but now I'm cleared to do heavy pressure to stretch it out. My gait is awkward now but I assume that will improve over the next two weeks as I start walking more.

I suspect that in the long run the big hurdles will be getting back to full dorsiflexion range of motion so that I can run and dealing with what I imagine will be some continued swelling for awhile. I complained about the swelling enough that the PA sent me a scrip to get an ultrasound to look for a fluid collection, but there isn't a pocket of fluid anywhere that might indicate infection. The fluid is all distributed throughout the tissue, likely just the result of the osteotomy and surgical screws. The flipside of the aggressive rehab protocol is that the OATS recovery so far has been much, much more challenging than microfracture or even a Brostrom-Gould reconstruction. I think this is principally because they have to break the tibia to access the talus to do the OATS, which is what I think has led to the intense swelling. I doubt it is the OATS bone plug directly causing all the pain and swelling, since they effectively did one at my knee using it as a donor site for the ankle and filling the hole with a cadaver allograft and my knee feels basically fine.

Alan -- The doc didn't give an end date for PT. My PT and I agreed to meet 2x per week for the next three weeks then 1x per week for three more weeks after that. With three prior ankle rehabs under my belt I'm a pro at the therabands and balancing on one leg and all that jazz. I just need someone to give me guidance on what exercises to do at home as I progress. We'll continue as long as I need it, probably a few months at a reduced level. I have a good PT practice (after years of searching) and I don't think they'll kick me out prematurely, as I have had other physical therapists do. Apparently according to the doc I will be cleared to transition to sports-specific PT at between 8-10 weeks, but to be honest that seems hard to imagine at this point. That's only two weeks away and I can only barely walk right now, so we'll see.

Now that I'm up and moving around more, I'm feeling much better about how things are going. The first 3-4 weeks were *rough* with a lot of pain and swelling that kept me off my feet. I'm able to be up and about much more now, which is nice. More updates to follow.

-Paul

[marcif]

Paul,
That's great to hear you are doing so well!! I am starting to lose hope. Next week will be 16 weeks and my dorsiflexion is at 3. I am also still walking only very short distances without at least 1 crutch. According to Dr. Kennedy my MRI looks great and my pain and lack of ROM is related to excessive scar tissue which I have had a problem with after all of my surgeries.
If anyone has any suggestions for how to break up the scar tissue I would love to hear. In the past I have tried Shockwave Ultrasound (very expensive and not helpful), lots of PT (I do probably over an hour daily of exercises outside of 2 PT appointments a week), Cortisone injections (2 different times it broke off a piece of cartilage and I had a loose body) and I had surgery to clean up the scar tissue before my most recent OATS.
wishing you continued fast healing!
Marci

[pds]

Marci,
Oh no, that sounds awful. What about deep tissue massage or cupping therapy to try to break up the scar tissue? Have you tried those?

Have you done any joint distraction to increase mobility? I went into PT yesterday with my ankle at 5 degrees of dorsiflexion and after some distraction we got to 10 degrees. It felt better too.

Sending you healthy vibes,
Paul

[marcif]

Paul,
I actually talked about your dorsiflexion in PT today. I started today at -2 degrees and made it to 3 degrees after distraction. The most dorsiflexion I have had since my first surgery seems to be about 5 degrees (looking back at PT reports).  My problem for the most part right now is scar tissue. I have a significant amount of scar tissue according to Dr. Kennedy in the front of my ankle. I have had the same problem after each surgery. Surgery #3 was just to remove scar tissue. My ankle felt good for about 3 weeks after. I have tried deep tissue massage and acupuncture. I haven't done cupping on my ankle but that might be a good idea. I will ask my acupuncturist about it tomorrow. I am also meeting with a chiropractor tomorrow that is supposedly very good at working with scar tissue.

Dr. Kennedy wants me to do Shockwave treatment. I tried it after my first OATS procedure and it didn't work but I am willing to try anything non invasive at this point!

I am trying to do as much as I can physically to stay positive - hot yoga (most days), pilates, weights and biking on a stationary bike.
Thanks for the healthy vibes! Keep up the great progress!
Marci

[pds]

Marci -- Glad to hear the distraction is helping. It seems to get about 5 degrees worth for me too. Interestingly, I saw a different PT and they gave me a totally different number for my degrees. I think they don't all count the degrees in a standardized way, maybe. So now I have no idea what any of these numbers mean.

I'm glad you're able to stay active -- that's so key. Best of luck to you!

-Paul

[pds]

8 week post-op update:

Transitioned fully out of the cam walker over the past two weeks. Now I'm walking around in shoes (low-top hiking Merrells). Lots of issues still but every day I think it's improving. I'm pushing myself, but trying not to get carried away. I spend several hours each day massaging, icing, elevating, and soaking in epsom salts. I can walk without the boot, but to be honest my gait is messed up, my foot is weak, and I can't go very far. For longer distances (like 2 blocks) I have been breaking out the walker boot. But it's still improving every day so I'm very optimistic.

ROM: Range of motion is still limited in dorsiflexion, but improving. One issue seems to be that my arch is collapsing and for whatever reason that limits my ability in dorsiflexion, like the foot is at the wrong angle or something. When I try to flex the foot upward or lean into it, the main point of resistance seems to be my posterior tibial tendon right below the knob on the ankle. I have a ton of swelling in that region and the tendon there is sore. My PT explained that because my arch is weak it is dropping and that means the posterior tibial tendon has a longer way to go around the bone. I saw Dr. Kennedy's PA for a follow-up and she said the same thing - my arch is collapsing and my foot is turning outward because of a weak posterior tibial tendon. This isn't really a surprise, as I've had longstanding issues with posterior tibial tendonitis for years predating the OCD, but good to know. I need to step up the PT there.

Dr. Kennedy's PA also connected me with an orthotics specialist in the office (who was amazing!) who gave me a slight heel lift on the inside to help angle my foot back to neutral and correct the collapsing arch. I walked on it all over NYC Penn Station after the visit and it feels great! 1000x better than my ankle felt this morning traveling up to NYC. So that seems to be helping. Hopefully over time as the posterior tibial tendon gets stronger I should be able to hold my foot in the right position without the lift, but this is helpful for now. My ROM is also improved with the lift and I can begin to get a normal stride.

Distraction (separating the joint) also seems to help with the ROM. My PT does it manually by cranking down on the foot while flexing it. It hurts but seems to work. I also have an inversion board at home where you hang by your ankles and I tried that to get some distraction. I think it helps. I can't measure the ROM afterward but the joint feels better and easier to walk around on.

Swelling: The other biggest problem I have in addition to somewhat limited ROM is that the swelling in the joint is pretty bad. Whenever I don't have it elevated, iced, or in epsom salts it swells up a lot and starts hurting from the swelling alone. Dr. Kennedy's PA agreed that the swelling looked bad. (This is my fourth surgery on the ankle so not a total shocker that this might be the case.) The PA recommended compression socks and the orthotics specialist in the office actually hooked me up with a light pair to take home and I can already see it's helping. I'm probably going to buy a heavier compression online though, which the PA recommended. I'm hopeful this will help the swelling.

Weakness: Less significant than the swelling or ROM is the fact that all of the muscles in my foot are just super weak. Like my big toe is weak and I have to be really deliberate in pushing off and getting a normal stride when I walk. This is already starting to improve the more I walk, so I'm sure it will be fine but it is somewhat ridiculous how lazy the body is. 6 weeks off and my foot muscles decide to go on a permanent vacation. Uncool. Everything is also super tight and sore, especially the plantar fascia, but probably not more than one would expect post-surgery. I rub my arch on a golf ball and it hurts a ton but helps loosen it up.

Overall, I'm feeling very positive. There's a ton of swelling and my muscles are weak and I'm hobbling around and can't go far but it's only 8 weeks post-op, and I'm actually amazed by how well I'm doing for how soon it is. I credit this to Dr. Kennedy's aggressive recovery protocol. I also went on an anti-inflammatory diet to help the healing, cutting out sugar, carbs, and dairy, but I'm not sure how much credit this deserves since I can only make it a few days in a row before caving and eating an entire pizza. I had this grand scheme to lose 15-20 lbs to make it easier to recover and get back into running and I've lost like half a pound, haha. But ankle still is doing well. More updates to follow. 

[marcif]

Paul,
Great to hear you are doing so well! I am trying not to lose hope but am really frustrated! According to my PT since the beginning I am hovering around 0% dorsiflexion. Some days it gets up to 3% but some days are at -3%. I tried Shockwave treatment today for the excessive scar tissue. I did it after the first OATS also without success but hoping this time it will be effective.
Compression socks - huge! I didn't wear them or really know much about them after the first 3 surgeries and they really help with swelling and pain. Still wear them a good part of the day. I bought 2 expensive pairs - around $45 that weren't great from a running store. The $12-15 ones I found on Amazon are better. A heating pad also helps with some of the discomfort.
One thing I never did in PT before this round is Intrinsic Muscle exercises. Really helpful and sounds like it may help you - google it and ask your PT.
One thing you haven't mentioned is if you have ditched the crutches or scooter? According to Kennedy's plan I think I was supposed to be done with them around 8 or 9 weeks but still use 1 or 2 crutches and my scooter at home about 60 or 70% of of the day.
Continue to keep us all posted. Your posts are so thorough!

[pds]

Marci,
Thanks for the tip on the intrinsic muscle exercises in the foot. That does sound like that would help a lot. A big part of what I have going on is that my foot muscles are weak and my arch is collapsing, which is messing up all this other stuff. Most of this predates the surgery -- I've been dealing with ankle issues for 10+ yrs now so lots of things to fix. We're doing some of that now with exercises like arch lifting, but probably more we could do. I'll ask my PT tomorrow.

I'm 100% off the crutches and walker boot, but that doesn't mean I can make it through the day super easily. I'm definitely limited in what I can do. I don't think it's a problem with the OCD, just general weakness in the joint and swelling. I took a trip to Home Depot today and halfway through got really worn out as I was wandering up and down aisles trying to find caulk. The compression socks help a lot, though! I got the 20-30mm ones and they're a big help.

That's a bummer that you still are using the scooter and crutches. Is it getting any better you think?

Best,
Paul

[marcif]

Paul, so great that you are doing so well. I totally get the Home Depot thing. amazon prime and amazon now are my best friends. You couldn’t pay me to go to Target - my favorite store or any store the size of Home Depot. Not that I have much money left to spend after paying Kennedy . The intrinsic foot muscles are all about supporting the arch and strengthening foot muscles by isolating them. Interested to know if your PT agrees.
I finally had the opportunity to speech with Dr Kennedy this week. He did not like some of the things I was doing in PT. I had an exceptionally bad week last week and my PT wanted me relying on 2 crutches for a week but continuing to push thru with the excercises to try and get on top of the scar tissue. At the moment, according to my MRI from 2 weeks ago the gray is not incorporated with the bone. Kennedy said it should have been incorporated at 3 months but he expects it to incorporated by 5-6 months. I was doing a lot of lunges with my foot on a chair with a towel under my toes. I was pretty sure that it was increasing the pain but didn’t hurt much while doing it. Kennedy said it was putting way to much force on the joint and I should be focusing on distraction rather than compression. I have laid off them and am doing better. He also wants me focusing on walking unsupported. Opposite of what my PT instructed.
Hopefully the new plan will help. I’m also doing Shockway treatment for the scar tissue.
I would love to know what types of things you are doing in PT in addition the distraction.
Thanks
Marci

[pds]

Marci,
Glad to hear the new plan seems to be helping. I've definitely been down that path before where you're doing PT and the exercises seem to be making it worse. It's frustrating. Glad you have a new approach and it's promising. I think very highly of Kennedy.

The main issues I'm dealing with right now (9 wks post-op) are weakness in the foot, range of motion, and swelling.

For weakness, I'm doing a whole bunch of exercises every day but also just walking unsupported, mostly in shoes with orthotics but sometimes bare feet for a bit around the house. The exercises I'm doing are really all focused on arch strengthening:
- Toe scrunches on a towel. Scrunch and hold for 10 sec. (My foot is so weak it shakes when I'm holding.) I do these with both feet (separate towels) under the theory that the muscle memory may be aided by me simultaneously doing the good foot. Also, I'm hoping that shame at its poor performance will spur my bad foot to keep up.
- Arch lifts, both seated and standing. This is where you keep your foot flat and just lift up the arch a bit. It took me a while to get the hang of this but it's getting easier.
- (This is hard to describe) An inward-turning theraband exercise where I am seated and my foot is flat on the ground, knee bent forward over my toes, and pushing my toes and ball of my foot into the ground. The idea here is to keep my foot entirely flat in the same position it would be when standing and just move my foot inward in the same plane, without turning it. The intent here is to isolate my posterior tibial tendon and focus on the muscles in the foot instead, since that's what is weakest for me.
- Just started exercises on a wobble board, one-legged. Other leg is on the floor and my hands on a table leaning forward. I probably only have ~30% of my weight on the board. Towels under the board on the sides and front so it doesn't go all the way. I'm doing circles each way and then left/right and up/down. All with my knee bent to isolate the posterior tibial tendon, a particular problem area for me, and take it out of the equation. These are just stupid hard. My PT told me to do 30 each way and I just laughed. It's killing me to do 5. But I'm working on it.
- I'm also doing a standing exercise that is almost impossible to describe that is focused on restoring strength and muscle memory to my weakened left hip and core after years of walking imbalanced due to the recurring injury. If you're interested I can try to describe it, but it's about the hip muscle complex.

For ROM, I'm doing a similar lunging thing, but on the ground, leaning forward into the bad leg. I can't tell if it's helping. That's an interesting point Kennedy made about the compression, though. I am also doing distraction to help the ROM. The PT basically yanks on my foot and pushes down and away on the foot while flexing it, and that seems to help. I get a few more degrees every session. She does it really hard and a lot, though. I saw another PT just to get a second opinion on what I should be doing and the other PT didn't nearly do the distraction as hard. I think it's helping. On my own, it's nearly impossible to apply distraction. I do have one of those upside-down hangy bat things (inversion table) and I've tried that a few times. I think it helps. I'm going to step it up and try it several times a day for a week and see if that makes a big difference. I feel like I'm making progress on the strengthening but the ROM isn't improving as fast. After I've been sitting for a while the foot swells and gets stiff and my range of motion is limited and I hobble around for a bit until the joint loosens up again.

For swelling I've added compression socks to the ice, elevate, and epsom salts regimen. They're helping a ton. Still lots of swelling but it's no longer as painful or as limiting.

Best of luck to you and I hope your new plan keeps showing improvement.

-Paul

[pds]

Marci,
What did you mean by "the gray is not incorporated with the bone"? The gray is the OATS transplant into the bone?

Best,
Paul

[marcif]

Sorry that was a typo. I meant graft.  The arch lifts and towel excercises are very similar to what my PT called “intrinsic muscle exercises”.  In PT in the past they had me doing towel scrunches as well as picking up marbles with my toes.  This time I’m lifting just my big toe and holding it alternating with lifting just my 4 smaller toes and holding. Also spreading my toes and holding and lifting my arch and holding. Also for strength, balancing on just my bad foot for as long as I can and lifting up on my toes until fatigue. Also the same Theraband exercises.  You motivated me to order a wobble board. I’m also doing hip strengthening excercises. I understand too well about the body being lopsided. They also said it would be good for my knee. Are you doing anything to rehab your knee?
What is the inversion thing called that you have? My husband has been distracting my ankle for me which is probably as effective but I’m curious.
Keep up the hard work. So jealous that your dorsifexion is improving every time you go!
Marci

[pds]

Marci,
Thanks. Sounds like very similar PT exercises we’re doing.

Here’s an inversion table. This isn’t the brand I have but it looks just like this:
https://www.amazon.com/Exerpeutic-Inversion-Table-Comfort-Backrest/dp/B005P4NV3E?ref_=Oct_BSellerS_3408421_2

I can’t be sure if it’s actually helping add dorsiflexion but it does put a lot of force into distraction and the joint feels better after I do it. Kennedy/Rebecca didn’t tell me to do this. I just had one in the basement and thought I’d give it a whirl.

Did Kennedy have any suggestions on things that would help the graft take? I’m taking calcium pills and am walking on it. I wonder if there’s anything else one can do?

Best
Paul