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Ankle pain after OATS procedure

My daughter has had 3 surg on her ankle. It stated 6 years ago with a sprain that broke 3 bone fragments off. They screwed them back into place and a few months later one of the fragments died and needed removed. Now 7 months ago they had to go back in because she broke the top layer off and it could not be repaired. They removed the bone and replaced it with tissue from her knee. 3 months after surg she began to walk after 7 long months and was doing great up until a few months ago. increased pain and swelling. She was injected with a cortisone injection yesterday for they feel that its scar tissue causing all this pain. I cant remember her having this side affect previously.. I am reading how painful these shots are and a lot of people here are being told the root of the pain is from scar tissue and i guess I never knew how much pain this could cause.. She just wants to be able to walk without pain and be able to enjoy her senior year. Anyone have any suggestions?
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First Helper User Profile Gaelic
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replied October 12th, 2011
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asowers1,

Unfortunately, your daughter has had a significant injury during her growing years, and has had to have three surgeries. This is a lot of trauma for a young, developing ankle.

As to scar tissue, every time soft tissue is damaged, it heals with scar tissue. So, she has had the original injury, in which the bones were fractured, but the soft tissues were injured also. Then this is followed by surgeries, which also damages the soft tissues. So, it is no wonder that she has a significant amount of scar tissue around the ankle.

To have had on OATS procedure done, also means that she has had significant damage to her articular cartilage in the joint. This cartilage lines the bones that make up the joint surface.

The OATS (osteoarticular transfer system) takes plugs of cartilage with underlying bone from the edge of the knee, and transfers them to somewhere else that needs to have cartilage replaced. The bone on the plugs, then heals to the bone in the bottom of the defect into which it was placed. The plugs are round in shape, so there are little areas around them that have to fill in as they heal. This fills in with fibrocartilage, which is not quite as good as articular cartilage, but is better than bare bone. And it takes time for all these plugs to heal and the area to fill in.

Again, this is a patch for the defect in the cartilage, it does not make original articular cartilage. In a way, it is just another type of scar.


So, again, unfortunately, your daughter has had a lot a damage to the ankle. It can sometimes take as much as 12 to 18 months after the last surgery to get to a final endpoint.

The cortisone was administered to try to control the inflammation in the joint (manifested by the swelling). If it can be calmed down, then the pain may decrease also. if the cortisone takes care of everything, great. Another thing with cortisone injections, is that it is not uncommon for the patient to actually feel an increase in pain about 24 hours after the injection, up to about 72 hours. Then this subsides and the antiinflammatory property starts to work. So, we usually tell all of our patients to actually expect to hurt a little more after the injection, but then begin to feel better. This "flair" doesn't occur in all patients, but if it does, the patient is not surprised by it.


However, there is one thing that you should keep in the back of your mind. Since she has so much scar tissue around the joint, it can sometimes get in between the bones of the joint, and get pinched. This can cause sharp, intense pain, as you can imagine. With time, as this tissue gets pinched over and over, it becomes thickened and fibrotic. Thus, it is like a little piece of grissle, and it can become lodged in the joint, causing pain.

This was first described by a surgeon named Dr. Wolin. One of the impingement syndromes in the ankle still bears his name, the Wolin lesion. If your daughter has one of these lesion (also called a meniscoid lesion), that may be causing some of her pain.

If the cortisone injection doesn't help significantly, you might ask her surgeon about the possibility of a Wolin lesion (meniscoid lesion). An MRI should be able to pick this up, if she has one. The MRI can also look at how the OATS cartilage is doing.



So, your daughter has significant scar tissue around the joint, with the addition of significantly damaged articular cartilage. Though the damages have been "fixed", they are still not the way they were before the original injury. A teacup that has been broken can be glued back together, but it is still a glued together cup, not a new one. Again, this ankle is never going to be a "normal", but hopefully, it will be a functional.


Wishing you and your daughter the best. Hope you find a reason for the new symptoms and it can be treated. Good luck.
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replied October 12th, 2011
Thank you for your information. I have been reading a lot of people who have had the same injury as my daughter were getting ankle joint replacements verses fusion.. If this injection doesnt work i'm afraid they will want to fuse her ankle. I know that she prob would not be a candidate for replacement since she is only 18, but what is your thoughts?
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replied October 12th, 2011
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asowers1,

You are correct in that she is a bit too young for a joint replacement. That is not to say that they have not been done, but it usually raises a lot of eyebrows in the orthopedic community when they are done at that age.

There are a couple of big problems with total joint replacement (total ankle joint - TAJ) in an extremely young patient: activity restrictions and the prosthetic implant wearing out.

Most young patients have a lot of difficulty restricting their activity level. If the procedure does what it is supposed to do, reduce pain, they want to go out and catch up on everything they've been missing out on. So, they want to play sports, do impact dancing, and generally beat the heck out of the joint. With a joint replacement, patients are advised to limit their weight bearing, impact activities. Instead, it is recommended that they do things like swimming, bicycling, walking, yoga, tai chi, etc.

Even though the total joint implants have been improved over the years, they still only last about 15 years, give or take. And that's only if they are taken care of properly. I don't know if you know who Bo Jackson is. He was a professional American football AND baseball star, who injured his hip joint. He underwent a THR and went back to playing professional level baseball. That lasted about two years or so, before he retired, because he was no longer "fast enough in running the bases". However, his joint couldn't stand up to the stresses he put on it, and it failed. He is now on, at least, his third replacement, before the age of 45.

And, the problem with the repeat replacements is that every time the procedure is done, more scar tissue is produced and more bone is stock is lost. And there ultimately comes a time, when a replacement just can't be done anymore. Also, the risks and complications go way up for each successive replacement.

Some patients say, no problem, if they can't do another replacement, I'll just have the joint arthrodesis (fusion) done at that time. Well, life's not that easy. By that time, there has been so much bone stock lost, that an amputation may be the only thing that can be done.


Arthrodesis of the ankle is a procedure that has been done for decades with very good results. It takes away the vast majority of the pain. It provides a very sturdy platform and the patient can do manual labor if required. And it is durable.

However, it is not without problems. To ambulate, patients usually externally rotate the hip, so the toes are pointed outward (the opposite of pigeon toed). Then, they sort of roll over the longitudinal arch of the foot. As you can imagine, this puts a lot of stress on the joints of the midfoot. It puts more stress on the medial side of the knee joint and can cause problems with the tendons around the hip joint. Of course, not everyone has problems, and a lot of patients can return to full employment, even in heavy manual labor jobs.



Hopefully, your daughter will not have to worry about either of these options for several more years. She should go to college and major in a field where she doesn't have to do a lot of physical activity. But, by no means should she give up on doing any activity. She should stay as active as possible right now. Deconditioning can lead to cardiovascular problems, weight gain, muscle atrophy/weakness, and osteoporosis. Isolation, not going out with friends and family, can also lead to depression, which is a serious medical problem. Depression also makes pain worse.

So, both of you should speak with her orthopedic surgeon about all of the options, along with the risks and benefits associated with each one.


Wishing you the best. Hang in there, good luck.
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