Tuesday, July 19, 2011

Time for Some Sweet Ankle Distraction Arthroplasty

Orthopedic surgeons are busy. Patients -- especially old ones and those in pain -- are mean and annoying. It's not surprising these guys seem rushed, preoccupied, or ready for you to shut up -- especially if I'm the patient.

As much as I liked Dr. Cooper last week, I was not prepared to wait two hours for each follow-up appointment. And after our struggle to diagnose an infection last year, I'm looking for the "attention to the details" trait in a surgeon.

My expectations were far exceeded during my appointment with Dr. Jeng today. It's remarkable -- I'm convinced that he and his team only came in to work today to discuss my ankle.

Here's what went down.

I went over my patient history with another doctor and his neighbor -- a junior at Towson University considering medical school. I brought my iPad with all of my photos and X-Rays -- it was extremely useful.

I told the guy (sorry, I forgot the dude's name) that Dr. Jeng would be my third consultation. He asked what other surgeons had recommended, and I mentioned Dr. Cooper recommended ankle replacement. To that, this guy said, "he's insane." I told him that's funny because Dr. Cooper said he was a cowboy.

When Dr. Jeng came in later, the first thing he said was, "Hey there, I'm Cliff. I hear I'm your tie breaker."

Awesome.

Dr. Jeng was pumped about the iPad photos. We spent about 10 minutes going through x-rays, videos, and photos while we discussed my ankle history.

After reviewing the data, Dr. Jeng examined my ankle. He took measurements of my dorsiflexion. He examined where I had pain. He had me walk barefoot without my cane. While my gait is surprisingly good, my ankle alignment is not perfect. I have a valgus deformity of about 5 degrees. This means I put more weight on the outside of my right foot and have a tendency to roll my ankle. Normally this should be corrected surgically by cutting the talus bone, but because I have severe pain in the lateral side of my ankle, repairing this deformity is not a good idea. It would put more pressure on that side of my ankle joint.

Basically, this valgus deformity is like someone telling you one eye is higher than the other and that there's nothing that can be done to fix it -- just that you should know you look stupid.

Once he finished looking at my ankle, he asked if I was familiar with my surgical options. I told him I was, so he assumed I had a good understanding of each option as he discussed them.

Ankle Replacement

This is not an option. I'm too young and too active to receive a replacement. The bone stock in my ankle is also not good enough to support a prosthetic ankle joint. There's a significant risk that the prosthetic could cause large fractures or collapse up into the bone due to the terrible quality of the bone.

I also don't necessarily have clean tissue in the joint because of last years infection. Dr. Jeng said there could be latent bacteria in the bone that, "like a terrorist cell," could spring into action at any moment once a joint replacement was installed.

He also mentioned that much of my bone is likely dead. If you look at the x-ray above, you'll notice how much of the bone near the joint is bright white. This is indicative of dead or necrotic bone. When this occurs, the bone becomes more brittle and non-unions become more of a risk. This makes ankle replacement a terrible idea and, realistically, not an option for me at any time in my life.

Ankle Fusion

It's the gold standard. If successful, my pain would be gone. While many patients develop arthritis in their adjacent joints, many patients do not experience symptoms for a long time -- up to 45 years.

However, I have the same risks of infection and non-union because of the poor bone quality. While Dr. Jeng could correct my valgus deformity, I would have less mobility. Walking up and down hills would be challenging. The bottom line with this options is that I'm at higher risk of it not being successful.

Ankle Distraction Arthroplasty

With this procedure, I'd wear a sweet external fixator for three months. Dr. Jeng even brought one out to show me. He put it around my foot and let me feel how heavy it is.

With this procedure, my ankle would be distracted to 5 mms immediately. He'd clean out bone spurs and dead tissue arthroscopically. I'd wear the ex-fix for about 3 months and start bearing weight two weeks after the surgery. Because the surfaces of the bone at the joint are not flat, there's a chance that this procedure won't allow new cartilage to stick around. The bone would grind it away just as quickly as before.

There's about a 30% success rate in patients -- not great. Part of this is because American's are impatient. Dr. Jeng said 50% of my results would be experienced within the first year, while the remaining 50% would take place over five years. American's tend not to be this patient. Only about 30% of patients have successful outcomes from this procedure.

Neuropathy is another risk with this procedure. Because I've had nerve damage in the past, I'm at risk for more nerve pain when the damaged nerves are stretched 5mms. While there's not much we can do for it, it's something that has to be monitored.

The bottom line, though, with this procedure is that it does not last more than 5 or so years. It's definitely a short term fix.

Amputation

After learning that my bone quality was poor, I asked if amputation was on the table. Dr. Jeng agrees said it's not a bad idea and that I would be a good candidate for an amputation. He asked that I start talking to amputees and prosthetists to get more information.

Decision

I decided to go with the ankle distraction arthroplasty. I want to see if I can regrow some cartilage and snowboard again. If after a few years this doesn't work, I'd like to get an amputation. I'll still be young and resilient to infection.

I eventually want to avoid having one surgery a year for the rest of my life. I feel like this is my last attempt to make the ankle work. If it doesn't, I'd rather have an amputation than a fused ankle.

The surgery is scheduled for Monday, 22 August 2011. I've got to take care of a few things before that date, so I'll be pretty busy over the next few weeks.

More to come later!

6 comments:

  1. I did a parody CD cover with Sonny Bono hitting a tree, on skies, and titled it....."I've Got Yew Tree."

    If ya ain't old enough, ask a geezer.

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  2. You're a trooper, Tony! (And you too, Brooke!)

    Love your analogy of eyes that aren't level. Only T-Bone Mehan (T-DEAD-Bone Mehan?) could make something like a valgus deformity sound funny.

    P.S. Saw a dude with an external fixator in Switzerland last month. He was super impressed that I knew what it was. :)

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  3. Hi Tony,

    I'm in the same boat (if you remove the tree and put in 3 broken ankle/tib/fib from basketball) and love that you posted all of this.

    I've opted for the same direction as you but will be about a month behind. I look forward to your follow ups and best of luck to you.

    Jim

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  4. So how did it all turn out? I'm in the same boat. Looking for a solution. Thanks!

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  5. Hi there,

    I'm currently considering a sweet ankle distraction arthroplasty from the Foot and Ankle Institute at Mercy as well, with Dr. Myerson (instead of Jeng). After a car wreck in 2004, this looks like a good option for me to get back to less pain and a more normal gait. But I've also thought about amputation as an option too. I'm in DC - any chance we could commiserate over drinks? Would love to pick your brain on these options from the non-medical side.

    Margaret

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  6. Good Info. Find the best Orthopedic Service by Best Doctors in pune.

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