Thursday, November 3, 2011

Surgery Number Five

Mom.  Before you watch this video, maybe you should get Dad in the room to keep you calm.  The beeping noises you hear are all normal.  I'm safe and everything went as planned.

Here's the 22 minute video of this morning's operation.  I apologize for the quality, but my camera only allows me to capture approximately 10 minutes of HD video.  While this video is not as exciting as last year's cowboy ex-fix removal video, I think this video is more interesting and realistic for other patients undergoing a similar procedure.

Most people should be asleep for this procedure, particularly if the half screws are removed by hand instead of a drill from your surgeon's garage.

I had a local nerve block for this procedure, but it was not as intense as the August block.  When I woke up, I could feel my foot and leg.  As the block continues to wear off since this morning, I'm starting to feel more pain in the ankle joint -- particularly the posterior medial side of the joint.

I'd encourage you to continue taking Oxycontin and Oxycodone for a few days after this procedure, but plan on switching over to something like Celebrex soon.  I intend on easing off of both Oxycontin and Oxycodone this weekend, using Valium to help deal with the withdraw symptoms associated with discontinued use of these drugs.

Back to the video -- you probably noticed my awesome operating room nurse struck a pose after cleaning my pin sites in the beginning.  Another interesting moment was seeing how securely the two half screws were embedded in my tibia.  Particularly the distal screw -- Dr. Jeng had to bring in some elbow grease to get that one going.

Now on to some pictures taken before the procedure.

As you can see, I stuck with the plan to wear my sweet silver breakaways.

This is, hopefully, the last time you'll see an external fixator on my right leg.

The proximal pin site on the lateral side was continuing to leak normal edema fluid.  This is not a sign of infection.

The second-most proximal pin site had scabbed up since yesterday, looking much better.

The lateral pin sites in my fore foot were leaking fluid yesterday, but today they seemed fine.

So, after twelve weeks of ankle distraction, what were the results?  Here's where we started -- pay attention to the lack of space in my ankle joint.

There's no joint space here in this X-Ray taken in June 2011.  Now look at the flouroscopy images taken during today's surgery.

What's this I see?  I have joint space!!!!!!  Hard to tell?  Take a look at this enhanced image.

I was blown away when I saw how much joint space I now have.  Keep in mind that I have not been weight bearing on the new joint -- this is still only a few hours old -- but compare this joint space to the absolute lack of joint space I had in the June X-Ray above.  In June, my ankle was in a bone-on-bone contact situation, making the subchondral bone at the surfaces of the tibia and talus too dense.  When the bone becomes dense, it does not readily absorb the impact shock of walking as less dense bone.  Moreover, as joint space narrows, the synovial lining around the joint becomes inflamed and painful -- this is called synovitis.  It hurts.

During the first weeks of this procedure, especially after seeing the arthroscopic images, my hopes were not high.  Neither were Dr. Jeng's.  He managed our expectations and let us know that my ankle was in terrible shape.  There wasn't much cartilage to work with.

But now my hopes are a bit higher.  In one of the research papers I read last month (I'm still working on that post!), it's not just new cartilage growth and repair that helps increase the joint space after ankle distraction arthroplasty.  In fact, it is very challenging to regrow cartilage.  What we're finding out is other tissues grow in the joint space and act like cartilage.  Here's a very interesting quote from the 2002 paper, "Joint distraction as an alternative for the treatment of osteoarthritis:"
We have to keep in mind, however, that the observed clinical benefit might not be dependent on cartilage repair, bony changes, and cartilage–bone interactions alone, but may have many different origins.  For example, stretching the nerve endings during treatment, or a diminished synovial inflammation after treatmentmay relieve pain.  Also, the formation of fibrous tissue could explain the increase in joint space width.  Because the fibrous tissue is a soft tissue, it may change load transfer in the joint.  This could absorb stress during joint loading and by this mechanism diminish pain directly, or indirectly by way of secondary changes in subchondral sclerosis.
I think it's safe to say this research might be confirmed with my results so far.  I had essentially no cartilage left in my ankle, but after distraction for twelve weeks, I've got significant joint space widening.

We'll continue to monitor the pain and joint space as I start easing into walking again.  Stay tuned!


  1. Great news man! Great news! I thank you again for sharing all this experience; it allows people like me to educate ourselves about our options. I was heading straight to fusion based on medical assessments, but I am know having a serious conversation with my surgeon here in Texas about distraction. Hopefully there would be a local version of Dr. Jeng here to help me. Again, I am very happy everything went smooth and looks so promising. Carlos

  2. Great video!! Looks like things went well...hope the pain management stays on course and you have a restful weekend. Boys have been practicing the Wii snowboarding and they are gonna kick your butt!! No mercy! lol We love you. Rach

  3. Look at all that WHITE SPACE in the X-ray! That's so cool. The video was a little (a lot) freaky, but the end result (no bear trap, an increase in joint space) is worth it. :)

    P.S. Nick commented that one of your calves is now the same size as both of his. He assures you that the smallness of his calves bears no relation to the size of his...heart.

  4. That looks very promising! I want one, ankle distraction that is :D

    Fredda / Sweden!

  5. Been loving your blog. Thanks for letting the world join you on this journey! Getting my external fix off in the morning!! Best of luck to you and your ankle. (skiing is not too bad...convert!)