Tuesday, August 28, 2012

Snowboarder vs. Ankle Distraction Arthroplasty

I forgot I had a blog.  My bad.

After one year, ankle distraction arthroplasty has helped reduce my pain.  I no longer hear and feel bone-on-bone grinding.  My average daily pain was reduced from a 5 or 6 out of 10 to about a 2 or 3.  But more on my pain later.

I visited Dr. Jeng at Mercy last Tuesday to discuss the progress we've made over the past year.

Here is a comparison of last week and a visit in April 2012.  It's a little difficult to see an improvement in joint space.

The anterior comparison is clearer.  Dr. Jeng indicated he saw a slight improvement in joint space medially.  I'm wondering if that dark spot under the arrow is an osteochondral cyst or a space left in the bone from the pelvic bone allograph transplant.  

Here is a comparison of last week's x-ray with one from before the distraction arthroplasty in June 2011.

Same deal -- anterior view.  This comparison is pretty good.  You can see the talus is no longer touching the tibia on the medial side.

What about ankle flexibility?

This was taken right after the external fixator was removed last November. 

This was taken tonight.  The plantar motion is epic, but the dorsiflexion is probably only a degree or two above 90.  Spunky digs it.

Now what about pain?  It all depends on my activity level.  To help keep track of it, I've been trying different pedometers.

The Tanita FitScan pedometer saves steps from the previous 14 days.  I've recorded every day's step count since May 2012 (with exception to a week earlier this month) to help measure my progress since the surgery.

You can see a local pattern in the chart above -- each day's spike is usually followed by a low count.  The more steps I take and time I spend upright, the more I pay for it the next day with increased arthritic pain.  Fortunately, the pain subsides with rest.  Overall, though, the step count each day rarely reaches more than 5,000.  Some low step counts are a direct result of too much pain while other low counts are due only to the anticipation of pain.

Here are my average step counts over the last four months.  May's count was 4,537, which is very close to two miles given my height and stride length.  

My pain management plan has changed since I last updated the blog.  Earlier this year, I used Celebrex to manage pain.  But I've recently switched to Tramadol (Ultram).

Ultram is great for days when rest is not an option.  I tend to go through periods of Ultram use lasting several days with longer periods without it.  I suspect it's because I'm able to push my activity level higher while taking it which results in increased pain the next day.

Where are we after one year?  If I was happy with my current activity level, I'd say we've made huge progress on my ankle.  Unfortunately I have a few problems with where we're at today:
  1. I want to be able to stand for longer than 60 minutes straight without needing significant rest the next day.
  2. I want multiple days of activity without pain (no rest days).  Airport travel kills the first day of vacation.
  3. I need more ways to get my heart rate high enough during cardiovascular exercise.  Swimming is great, but it's usually inconvenient.  

It's still unclear whether I can snowboard in my current condition.  I imagine I could only do one run down the mountain before riding my toe edge resulted in too much weight on the anterior part of the joint.  

What's our game plan going forward?  Dr. Jeng and I will continue to monitor the ankle for any signs of clinical improvement over the next 12 months.  Recall that patients that undergo ankle distraction arthroplasty can show clinical improvements for several years after the procedure.  

If after 12 months we see no clinical improvement or we see an increase in average pain, we've both agreed a below-the-knee (BTK) amputation is our best option for me to return to a more active lifestyle.  This CT scan indicates ankle replacement is not an option -- the bone stock is terrible.  An ankle fusion will most likely have the same three issues identified above with the increased risks of adjacent joint arthritis and more surgeries.

I'd think I'd be very excited to have an amputation, though I need to continue speaking with amputees.  It probably sounds crazy, but imagine doing nothing all day not because you're in pain, but because you feel great and you don't want to ruin it.