No Cartlidge on Talar Dome Lesion- what is next?

[sead]

Hi I just had surgery 2 weeks ago(Brostrom to tighten ligaments and a scope) An MRI looked at by two different surgeons showe a small and what they thought to inconsequetial talar dome lesion. When the docor did the scope 2 weeks ago he dicovered the joint to be ragged and the lesion to have NO cartilige at all. He told me that he did some microfracturing to attempt to stimulate sub standard cartlidge though 14 year olds had a better success rate. I am 54 and VERY active. He told me I will not be able to do impact sports - sad as I run. When I asked him what grade of lesion it was he said grades were for radiographs and that the lesion was as bad as it possibly be. I asked if I would be able to ski or hike and he said I hope so.The best I could hope for he said was for the substandard form of cartlidge to grow then he left the room. He is supposed to be an excellent surgeon but I really do not know what this means? Is this why you are getting a cartlidge transplant? Can you tell me does no cartlidge basically mean arthritis will occur? Does this mean a fusion will be needed? Do you know if the chances of this kind of cartlidge growing is very possible? Iam in shock a bit and really would appreciate any kind of input or insight. My doctor did not talk to me after the surgery and yesterday which was 2 weeks after the surgery I found this out while they were takingout the stiches and putting on another cast for another 5 weeks of no weight bearing. I am wondering why he bothered doing the ligament surgery.

[Tamsin]

Hi Sead

I had microfracture in a two lesions on my talar dome - both near the front where the ankle pivots forward and back. Both were completely down to the bone, and I think about 1-1.5cm at their widest. I was 30 or 31 when I had the operation done about 4 years ago. It was keyhole surgery here in the UK.

I don't know anything about cartilage transplant as it was not recommended for me (or even for ankles at the time, if I remember correctly). I can tell you about the success of the microfracture though if that would help and will try and answer your questions from my experience.

I think the 'sub-standard' cartilage you talk about is also known as fibrocartilage if you wanted to google that to find out more. Your body makes it like scar tissue when the bone is drilled with tiny drills. This is completely different to a cartilage transplant which involves growing some new for you and then attaching it into the joint somehow. Very tricky, but there are people on this board who have had it so they might come and give you more information.

You asked if you have arthritis. I already had it, and it included lesions, bits of joint hanging around in the joint cavity and several growths impinging on the ankle joint around the front area. All these were removed by surgery which helped a lot with the pain as I think my ankle was being pushed into an incorrect walking position by the combination of the holes and the impingements and the bone chips - ouch! So you may have arthritis there as by definition I think holes in the cartilage is just one symptom of it? Probably worth discussing with your surgeon, but at the end of the day its just a term for the degeneration of joints - or at least that is my understanding.

Fusion is very much as last resort for treating arthritis as I understand it. You don't say how much pain you are in and how far you would go to be pain free. Again, there are plenty of people on this board who have been through it who can tell you about it.

I had the option of keyhole surgery which I had and was successful, followed by having the ankle cut open to do a full clean out and remove all the impingements followed by fusion if none of that worked.

As it turned out, the keyhole surgery with micro fracture was a success - at least by my definition. I am almost completely pain free these days, although I had modified the activities I do to minimise stress on my ankle. I want it to last another 50 years at least so am being careful. So no running or football for me. Or snowboarding. However, I do find that hiking with walking poles is completely fine. Your ankle is very well supported with boots anyway, softer ground is very forgiving, and the poles mean that all your joints are under less pressure. I can walk up to 20 miles with poles - much further than I can walk round the streets of London in my trainers!
It took me around one year to recover from the operation, by which I mean return to 'normal' activity levels - but I was only on crutches for about 4-5 weeks.

I don't know how much of the fibrocartilage I have - but judging by results I have enough to lead a normal active life (admittedly I led an abnormally active life before, but hey ho - that's partly how I got my ankle where it is!) and so I can only assume that it did grow and that it is surviving the daily grind. My surgeon did recommend that I gave up running as this is the worst type of loading for my kind of injury.

Happy to answer any other questions you have. And I totally understand your feeling of shock - I couldn't believe it when I heard how bad my joint was. i just thought it was a bad sprain. As it turned out the ligaments were all fine.

[sead]

Thanks so much for your post- it made me feel a little better.
My ankle does get sore but I have been downhill sking, cross country skiing and hiking all along. Actually went on a back country ski trip the day before the surgery. Running was quite painful especially if over 10 km- all activity made my ankle somewhat sore.i had been going to doctors and physios for years talking about my sore ankle but xrays alwyas looked good finally after training for an running 8 half marathons in a year my ankle became so sore i could not weight bear and the investigation began. Without my insistance nothing would have been done and even this surgeon was not sure that anything had to be done other than optional ligament surgery.he said he was very surprised to see what he found no cartilige.
Is downhill skiing and cross country skiing also considered high impact? I knew that snowboarding was pounding.
Do you know how long fibrocartilage is supposed to last for? Are you in pain still? do they repeat the surgery if it gets worse again?
Did your lack of cartlidge show up on the MRI?

[sead]

Not to say my ankle wasn't sore but pan is realative - what concerned me was the pain after a long run and occasionaly a catching or locking of the ankle with extreme pain. That gradually subsided into morebof a dull ache

[Tamsin]

Hi Sead,

To answer your questions, I would guess that skiing (if you do it well) would be quite low impact but I'm not sure as I was never that good at it so there was a lot of twisting and falling over!

Fibrocartilage can last a lifetime as I understand it, but there are no guarantees, and its not as 'good' as cartilage in terms of its performance.

I am not in pain any more, but as I said I have really modified my activities so that I don't do things that irritate my ankle, or that would damage the joint in the longer term. I would be in pain if I took up running, football, snowboarding etc but I have chosen not to restart all that.

They definitely can repeat the surgery, but I'm not sure about the microdrilling part of it. You can have arthroscopies often if the impingements grow back to remove them, and to clean out any stuff that accumulates from the arthritis.

My MRI showed areas of thin cartilage, but the Surgeon was surprised as in the two thinner areas from the MRI, the cartilage was not there at all when he opened me up - I guess its not a perfect picture of your joint, just and indication. SO the operation was more invasive than I had expected and the recovery time longer.

Anything else you want to know?

[sead]

Thanks so much . I have to wait until april 11 th before i see him again and get my cast taken off so other than the pics of the scope i have no idea about sizes etc and i will have to wait and see i guess- ibreally do feel much better having heard from you thank you so much- it is hard to have no idea- my one minute conversation while the stiches were being taken out left me with a lot of questions.

i did have one more question- how did you know that the fibrocartilage grew? Did they take another MRI or were they structly relying on how much pain you reported?
Thanks again

[Tamsin]

They didn't check with an MRI, no. My impression is that its a diagnostic tool that tells you more than an X-ray, but that its not like a photograph of the inside of your joint. The improvement was enough for me anyway!

I did have an MRI about 2 years after the op, as I had a slight relapse and was considering further surgery which I didn't need in the end. They couldn't relate the two holes that had been treated to any of the damaged joint surface.

(for some reason my replies are't getting posted - this is my third attempt!)

[sead]

Do you know how long the fibrcartiludge lasts?
What is your next step?

[Tamsin]

It can last for life!

My next steps are to enjoy a pain free ankle and try not to do it any more damage. I've been discharged by my surgeon.

[sead]

Well it is 7 weeks and my cast is off- unbelievable that i am supposed to be off crutches in 2 weeks and then start physio.
I can barely stand on the foot- it is much smaller than the other foot now
My doctor said that we should know how successful surgery is in about 3 months when i see him next. I guess the hard work starts now.