Bone Graft Deliberations

I’ve been radio silent for much longer than usual. Earlier this month, my wife and I spent some time in Maui without the kids. Good times. For a short time, at least, my knee/leg issues didn’t hover like a guillotine above my head. It was just blue skies, cocktails and sand between my toes. Now it’s back to the gallows, er, reality. Anyway, while I was bummed to read about some of your setbacks, it was still nice to hear from my “ACI friends.”

Ok, I’ve spent several weeks researching the bone graft options, probably more time than I spent researching the ACI. Yes, there are synthetic alternatives to the iliac crest, and I’m furiously educating myself about them. When my OS first told me I needed a bone graft from my hip, I asked about other options. He acknowledged others existed, but was adamant they didn’t compare. In fact, he seemed pretty dismissive of them. And it’s true – everything I’ve read since my visit described the iliac crest as the “gold standard.” My second opinion OS also said the hip was the best graft site, and I don’t recall him mentioning other bone graft options. Critically, both surgeons downplayed the negative side effects to my hip.

My research, however, suggests a far greater % of patients suffer drawbacks. Anywhere from 10-25% experiences some type of chronic hip pain or serious limitations. I’m not gonna lie. That scared the cr*p out of me. Now, most bone graft recipients are older and generally undergo the bone graft to fix their spine, or repair a leg mangled in some horrific car wreck. It’s fair to say these patients were likely in worst shape. On the other hand, the failure of my leg to heal the first time suggests I’ve got weak bones, meaning my hip’s probably brittle. In any event, I’m steadfastly opposed to borrowing bone from my hip unless absolutely necessary. I’m scared I could create a brand new set of problems if my hip gets cut.

I’ve learned there are 2 less-invasive options than borrowing bone from the iliac crest. The first involves BMP-7, a type of osteogenic putty. Turgeon mentioned mixing this or similar material with the iliac crest bone graft, but nixed the idea of using it alone. BMP can also be mixed with cadaver bone.

The second option appears to be even less invasive. It involves a bone marrow injection from the iliac crest. I still don’t completely understand this procedure, but it appears the surgeon draws the bone marrow from your hip, and then injects it into the area of tibial nonunion. No cutting involved. Obviously, this would be the preferred route, though I have the sneaking suspicion this procedure remains somewhat experimental or won’t be covered by insurance.
I don’t know whether the TTO or ACI eliminates me as a candidate for either option. No clue. And I’m still trying to pin down the success rates for the different options. Some of the medical journals I’ve read suggest success rates for the BMP bone graft – whether alone or combined with cadaver bone – are 5-10 points lower than the iliac crest bone graft. I haven’t located comparable numbers for the bone marrow option.

Assuming these numbers are accurate, a 10-point decreased success rate seems like an acceptable trade-off to avoid getting my hip cut.

While I sort out the bone graft options, I’ve scheduled a PT visit with the guy the 2nd opinion OS uses. My quad remains weak, even after 16+ months. I’m not sure why. Even though the nonunion in my leg probably limits how hard I can push things, I think an updated PT session might be helpful. Plus, I’ll get a third set of eyes to check out my knee. Even as I stare down another surgery, I remain hopeful that my knee might approach something close to normal if I can eventually build up my quad after I fix the tibial nonunion. I’m probably clinging to hope at this point, but still . . .

Two days after my PT session, I meet again with Turgeon. I plan to question him about the non-iliac crest options. Assuming he disfavors the bone marrow injection and the synthetic bone graft and/or lacks experience with these procedures, I’ll seek out another OS. The problem is that I probably need to get my knee scoped, too, though the knee scope can wait. I prefer to schedule both operations at the same time to avoid multiple surgeries and recoveries. But I only feel comfortable getting my knee scoped by guys familiar with ACI, which pretty much is limited to Turgeon and Berman.

I also want to get a sense for what it would take for my bone and screws to shatter inside my leg. A kick? Getting sacked by LT? Just bumping into the corner of the kitchen table? If I learn my tibia is a ticking time bomb waiting to shatter inside my leg, I’ll need to make a decision asap.