A White Rock man is the first person in Western Canada to have his ankle replaced with a 3D-printed “bone.”
John Jefferson, 71, was riding his motorcycle in the U.S., about 20 miles south of Osoyoos, in 2017 when he collided with a deer and then struck a guardrail.
He was going about 70km/h at the time, and his wife Shannon, who was following Jefferson on her own motorcycle, watched the dramatic collision and saw her husband’s talus bone being “popped out” of his leg.
Though small, the talus is a critical bone, sitting between the heel bone and the tibia. Essentially, it holds the ankle together.
After the paramedics loaded Jefferson into the ambulance, Shannon ran after them, and urged them to take the bone with them.
“My wife kept saying, ‘take the bone, take the bone,’ maybe they could use it as a template or something,” Jefferson said.
And it’s a good thing they did.
“They airlifted me to Seattle and they said if (I had) showed up without the bone, they would have amputated right there, because it holds your whole ankle together,” Jefferson said.
The bone was put back into Jefferson’s ankle but, unbeknownst to him, his two-year journey had just begun.
“Chances are that it’s going to get infected,” he said. “And boy, did it.”
Jefferson was transported back to Canada by ambulance and spent the next 14-15 months making intermittent visits to the Peace Arch Hospital. He was given IV antibiotics in an attempt to get rid of the “horrible infection.”
“Amazing staff at the Peace Arch Hospital, by the way,” Jefferson said. “Hearts and flowers to everybody.”
Jefferson was eventually told that his ankle wasn’t going to heal, and amputation would be required.
Unwilling to accept the loss of his foot, Jefferson began researching talus bone replacements and learned about 3D printed bones, particularly the success of doctors at the Duke University Medical Center in North Carolina.
He told his general practitioner about the 3D technology, and the information was passed on to St. Paul’s Hospital surgeon Dr. Alastair Younger in Vancouver.
“Dr. Younger took it from there,” Jefferson said.
Younger told Peace Arch News that he spoke with the surgeons at Duke University and thought Jefferson would make a viable candidate for the product.
The first thing he had to do, Younger said, was to get the hospital to agree to cover the cost of the US$12,000 device, which was paid for through the hospital’s surgical equipment budget.
A CT scan was performed on Jefferson’s healthy ankle, then reversed so it matched the side that was injured. The images were sent to a Texas company called 4Web Medical, which created the 17-ounce cobalt chrome alloy implant.
“The idea has been around for quite a while,” Younger said, adding that the Japanese have been doing this style of surgery with ceramic replacements for about 20-25 years. Ceramic replacements, however, are cost-prohibitive.
Younger also had to get the surgery approved by Health Canada – an effort that came with its own unique set of hurdles.
Jefferson recalled his reaction when he learned that approval for the surgery was initially refused.
“At one point, they came back after a couple of refusals and said they’re refusing it because it’s experimental,” Jefferson said.
“I said, ‘Experimental? If you put it in and it doesn’t work, then you cut my foot off. Well, you’re going to cut my foot off anyway, so let’s give it a try.’”
Jefferson described Younger’s persistence in pushing for approval, and added that the doctor seemed to have taken on the task as a personal project.
However, the challenge with Jefferson’s surgery, Younger explained, was that during the crash he’d also lost some of the bone on the end of his tibia, which also required a metal implant.
“We could no longer use just his tibia to articulate against the talus. We had to put in an artificial ankle and I think that was the biggest hurdle with Health Canada, because you’re mixing components from two different companies,” Younger said.
“Health Canada’s concern, which I think is very valid, is that there has to be some proof that those metals weren’t going to interact. That’s partly what took longer.”
Presented with evidence of successful ceramic artificial implant surgeries performed in Japan and the research papers produced by Duke University, Health Canada eventually approved Jefferson’s surgery.
The operation was successful, and Jefferson never saw a bill.
Younger said Jefferson was considering going to Duke University to get the surgery, which would have cost him approximately US$100,000.
“The cost on our side was about $12,000,” he added.
Younger said the cost of prosthetic limbs could run tens of thousands of dollars, or even more, if Jefferson’s foot had been removed.
Although not relevant in Jefferson’s case, another consideration for 3D-printed bone replacement compared to amputation is the loss to the general economy.
Younger said that St. Paul studies show that lost wages due to destroyed ankles, total approximately $22 million each year in British Columbia.
“There’s a huge lost opportunity in working-age groups if we can’t get people back to work. John is older, he’s in his 70s, but imagine someone who is 25 and we were able to get them back into employment. That’s a massive contribution to society that we don’t really factor into health-care costs as things are currently done,” Younger said.
Younger said he’s done “quite a few” amputations due to destroyed talus bones.
One example, Younger provided, was a young aspiring NHL player who came off his motorbike and damaged the bone.
The hockey player ended up travelling to Germany to see if his talus bone could be revascularized, but it could not.
“If we had this device, I think he wouldn’t have made the NHL, but he would have been a lot more mobile if it had been available at the time,” Younger said.
As advancements in 3D printed technology improve, so does affordability.
“I think in the longer-term, the ability to generate devices and implants is going to be a lot cheaper. Potentially, it might even move towards the operating rooms where you’d be able to manufacture the devices within the operating room,” Younger said.
“It would potentially save a lot of transport. It would still be a challenge to make it sterile. I think that technology is within the next 20-30 years when we’ll start seeing changes like that.”
Part of Jefferson’s motive for speaking with PAN was to educate other potential patients about the medical technology.
“I want to shout this from the rooftops and if one person catches it and can save an amputation on their foot, then it’s pretty exciting,” Jefferson said.
Six weeks after Jefferson received his implant, he was walking again. His goal for the year was to walk the short distance from his home to Laura’s Coffee Corner, which he accomplished on July 27.
“People say, ‘Is it sore?’” Jefferson said. “Yeah, of course it is – it’s healing. But every day it’s better and better. If this is the way it is for the rest of my life, I’d be more than happy compared to having my foot sitting in a dumpster somewhere.”