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!

In Depth: Ankle Distraction Arthroplasty

Surgery four is a big one. The only thing I know about it: I want to have it in August. Depending on which treatment option I elect, future treatment options may no longer be available.

Time to research the crap out of these options.

First up: ankle distraction arthroplasty.

Also referred to as arthrodiatasis, Greek for "to stretch out through a joint," distraction is a relatively new and experimental procedure to treat post-traumatic ankle arthritis. I hadn't heard of it until doing some research on Dr. Jeng last week.

This technique was first used on knee and hip joints in 1975. By pulling it apart, a low-pressure environment is created in the joint, allowing cartilage to repair itself. Studies have noted a "significant reduction in pain along with improvement in function and radiographic appearance of the ankle...in most adults with post-traumatic arthritis undergoing ankle joint distraction."

Because the procedure is new, there isn't much data available on its success rate. The first article I read, "Five-Year Followup of Ankle Joint Distraction for Post-traumatic Chondrolysis in an Adolescent: A Case Report," discussed an outcome for a 15-year-old treated with this procedure around 2002.

The external fixator for this procedure is similar to the one I wore last year -- with one key exception: it's hinged, allowing you to bend your foot. The treatment also requires you to bear weight while wearing the external fixator for approximately 3 to 4 months. In fact, most surgeons will recommend weight bearing a day after surgery. This one-two punch has been shown to encourage cartilage growth while the joint is pulled apart.

The article indicates that the patient's joint was distracted to about 5mm by turning screws on the external-fixator 0.5mm a day. I found a video on YouTube showing how this is done.

As you pull the joint apart, it puts a great deal of pressure on the pins through your foot. I've read that as you distract, it's quite painful to walk. But after a transition period of pulling the joint apart, it becomes easier to walk.

This is a before and after x-ray of the patient's ankle. As you can see, before the treatment, the patient had no joint space. Six months later, you can see a significant amount of joint space has returned to the joint.

Another article, "Treatment of Ankle Arthritis with Distraction Arthroplasty," published in June 2010, recommends arthroscopic surgery to repair any bone spurs or other deformities before attaching the external fixator. To achieve dorsiflexion, the Achilles tendon can be lengthened and soft-tissue impinging motion can be removed.

This paper also surveyed existing literature on the subject, noting that there are more reviews on the topic than clinical studies. Here's a link to another preliminary review from 2009 discussing some early outcomes of the procedure. In general, results continue to improve for most patients after 1 to 2 years, but some had to have a fusion within the first year. Another paper indicated 16 out of 22 patients experienced clinical benefit for up to 7 years after the procedure.

Unfortunately, "patients with limited range of motion were not thought to be good candidates for distraction and were offered arthrodesis." My range of motion was good a few months ago -- around 10 to 11 degrees of dorsiflexion. I'm not sure where I'm at now. If I had no pain, I could probably get back to 10 degrees.

So let's get down to pros and cons:

Pros

• It does not "burn bridges," meaning I can still opt for arthroplasty or arthrodesis
• Snowboarding is an option
• Reduced pain

Cons

• Patience
• Pin site infections
• There's a 25% chance it may not work
• The results may not last long

S.T.A.R.

I've been looking forward to this morning's appointment with Dr. Cooper for several days. The clicking and grinding from the joint is getting louder. Occasionally, it's nearly impossible to walk. I'm ready for some relief!

Dr. Cooper was straightforward and, Georgetown University Hospital being of the Jesuit tradition, dropped F-bombs within the first 30 seconds. I had brought in my iPad to show him old X-Rays and photos of the accident. As soon as he saw the original fracture, he told me my ankle "was f**ked from the moment it happened."

I like Dr. Cooper.

I showed him more photos on my iPad. He went through my CT images. I told him my most important goals were:

• Snowboarding
• Golfing
• Bicycling

I don't golf (anymore). I'm terrible at it. But I told him it's a goal because golfing requires walking six miles up and down hills and other types of terrain. I want to be able to do that kind of activity.

He gave me three options -- all of them considered salvage operations.

Option 1: Ankle Distraction

I mentioned this as a possible treatment in a previous post. I'd be fitted with yet another external fixator to pull apart my ankle joint. He would do a bit of debridgement of the bones at the joint. By separating the joint by 6 mm, it allows the surfaces to heal and repair themselves. I'd wear the external fixator for about four months and probably would not start seeing any results until two years from the day of the procedure. He said this requires a ridiculous amount of patience but shows promising results.

Option 2: Ankle Arthrodesis (Fusion)

This is the option Dr. Buchanan suggested last month. Dr. Cooper told me what we already know: I'm guaranteed more arthritis and more fusions of the adjacent joints in about 10 to 20 years with a fused ankle. I would not be able to do a whole lot on it.

Option 3: Ankle Arthroplasy (Replacement)

In older patients with post-traumatic arthritis, Dr. Cooper often chooses to install a prosthetic called the Scandinavian Total Ankle Replacement (STAR). He said most surgeons would be nuts to put one in my ankle because I'm so young and active, but that he's just insane enough to do it. With a replacement, Dr. Cooper thinks I'd be walking in two weeks and snowboarding this winter.

I can always fuse the ankle joint once the prosthesis fails -- when, as he eloquently put it, I "don't give a s**t anymore about snowboarding."

I asked him about amputation, and he laughed. He said that's always in the back of an orthopedic surgeon's mind with an injury like mine, but that there are too many other options for us to try first that might work better. He said knee arthritis is a concern in below-the-knee amputees, in addition to skin breakdowns and bone callous formations in the stump.

Amputation, though, will increasingly become an option as I have more surgeries later in life.

Those were the three options he gave me and after hearing my goals, decided to go with the ankle replacement. The concern would be whether my insurance would approve an ankle replacement for someone as young as I am.

I told him I had one more opinion to get from Dr. Jeng in Baltimore before I decided what to do. As I was leaving, he noticed I had brought a cane with me and said, "we need to get you off of that cane."

I also walked out with a prescription for Celebrex, which I can take up to two days before surgery. One reason for the switch is that my blood pressure was a stratospheric 145/85! It's never been that high in my life. This does explain other random symptoms over the last week or so. I suspect the increase is due to the 15mg Meloxicam I've been taking.

So that's it. Even though I waited for about an hour and 45 minutes, I was glad to hear a new option. He sold me on a replacement. He said I might not have much pain after the surgery, recovery would be very fast, and that I could do all the activities I wanted to do (except running or other high-impact sports).

Next up: Dr. "Cliffy" Jeng.

New Animations

It's amazing to me that, to this day, I am still suffering the effects of taking a metric ton of opiates last year.

Example -- while I was preparing for tomorrow's visit to Dr. Cooper, I came across some 3D reconstruction images from my CT scans on the day of the accident that I have never seen.

What's irritating is that these images are awesome. It shows how the surface of the tibia folded up in like a ping pong table near the fibula malleolus.

Ankle Arthritis Treatments

I've been trying to do as much research as I can on treatments for ankle arthritis. I've yet to come across anyone recommending an amputation. It seems surgeons look to salvage a limb at the cost of painful surgeries and lengthy recoveries.

I came across this video today on ankle arthritis research. It's a bit long (3 parts), but it's a good discussion on the problems with treating post-traumatic ankle arthritis.

Part 1

Part 2

Moving Forward

With the radiology report in hand, today we had an opportunity to schedule more appointments with other orthopedic surgeons in the Baltimore/Washington area.

First up on the list was Dr. Paul Cooper, Director of Georgetown University Hospital's Foot and Ankle Center.

Because Dr. Cooper works at a University hospital, you can find several publications on the Internet touting his work.

• Cadaver ankle used to treat arthritis
• First use of the Scandinavian Total Ankle Replacement (STAR) in the US

I'm very interested to see what Dr. Cooper recommends.

Next up we have Dr. Clifford Jeng at The Institute for Foot and Ankle Reconstruction at Mercy Medical Center in Baltimore.

Word on the street is that the Institute for Foot and Ankle Reconstruction at Mercy is a good place for ankles. They even have a video and a regular newsletter.

In fact, Dr. Jeng has an article published in the latest volume describing alternative treatments of ankle arthritis for younger patients -- right up my alley! According to Dr. Jeng, "By 22 years after ankle fusion, nearly 100 percent of patients will have developed neighboring joint arthritis in the hindfoot, midfoot, or forefoot."

He goes on to describe another technique to treat arthritis called distraction arthroplasty. This treatment is yet another external fixator that pulls apart the joint to allow cartilage to grow. I suspect I'm not a good candidate for this procedure, though, since my range of motion is terrible at the moment.

I'm excited to hear what my options are going forward. My appointment with Dr. Cooper is on July 12th and Dr. Jeng on July 19th. I'm hoping to have a decision at the end of the month so I can get in surgery in August.

Snowboarder vs. Healing

We just received the radiology report in the mail last night. It was short and to the point.

A comminuted fracture of the distal tibial metaphysis was noted. The fracture extended into the ankle mortise. The fractured segments were in anatomical alignment. Moderate sclerosis was seen around the fractured segments. Some bridging callus formation was noted as well. Multiple old screw tunnels were detected in this area. Moderate narrowing of the anterior and lateral margins of the ankle mortise was seen. Subchondral sclerosis and cystic degenerative changes were seen in this narrowed region of the ankle mortise.

Impression:

1. Status post comminuted fracture of the distal tibial metaphysis with evidence for post internal fixation. Anatomical alignment noted.
2. Incomplete bony union noted.
3. Moderate apparent traumatic arthritis involving the anterior and lateral margins of the ankle mortise.

What does this all mean? Time to Google it up!

Distal Tibial Metaphysis

Distal is the bottom part of the bone. Tibial is my tibia bone (the big one). And metaphysis is the wider portion of a long bone between the hollow part and the end (the epiphyse). The fracture described in the report starts around the bone graft from my pelvis and extends into the surface of the joint (the mortise).

Incomplete Bony Union

This means my ankle bones are really good at healing. And by really good, I mean terrible.

Subchondral Sclerosis and Cystic Degenerative Changes

Subchondral bone is the layer of bone just below the cartilage. With osteoarthritis, there is increased blood flow and other changes that develop in the subchondral layer -- including subchondral sclerosis, subchondral cyst formation, and increased pressure within the bone -- all of which contribute to osteoarthritis pain.

Subchondral sclerosis is defined as increased bone density or thickening in the subchondral layer. This often occurs with progressive osteoarthritis and shows up on x-rays as abnormally white (dense) bone along the joint line.

Next Steps

Now that I've got my CT scan and report, I will schedule appointments with other orthopedic surgeons in the area. I'm worried that I'm at a higher risk of a failed ankle arthodesis (fusion) because of the multiple non-unions I've already suffered. I suspect all of the non-unions were caused, in part, from the infection I had last year.

We'll keep you all updated!