Snowboarder vs. Tree

Snowboarder vs. How Fast Was I Going for Real?

2011-12-20T21:53:00.008-05:00

It's now four weeks without an update on the ankle. What's the deal? Update!

I needed a break. Dealing with ankle pain on a daily basis for two years can wear on you. The distraction arthroplasty surgery has, for once, given me that awesome break. The ankle has felt good enough over the last few weeks to finally forget, momentarily, the last two years. It still hurts -- just not nearly as bad as it used to!

I now walk without a cane. I stopped using the elevator last week and I've been hitting the gym regularly. The ankle arthritis has returned, but it's not debilitating. I'm still taking 200mg of Celebrex every morning. The pain is probably around 20% of what it used to be before the surgery. I still limit walking and time spent on my feet.

I apologize for not updating you all over the last four weeks. I've been taking it from all sides, including my good friend Phil.

Phil just recently moved to Denver for the sole reason to annoy me with the massive amount of regular weekend snowboarding he now does.

This past weekend, Phil took a short drive up to Breckenridge on a mission to bust a widely held belief that there was no way I could possibly have been snowboarding at 40MPH when I hit the tree. I thought that was awesome.

Without further delay, here is his write-up of his attempt to bust the myth!

MythBusters edition: Snowboarder vs. Collision Speed

If you have ever met Tony you know a few things about him:

He never plays practical jokes on anyone.
He never bets anyone to do pretty much anything
He never over-exaggerates

Point three is what caused this analysis to be completed. Tony's blog states that he ran into a tree at 40-45mph. I have been skeptical of this number for awhile as I have hit a top speed of 53mph on my bicycle and that was pretty scary. Since I have had no way to determine speed while snowboarding, 40mph seemed very fast. I know pro downhill skiers hit 80mph and average 30 – 40mph, but that is on some steep terrain. Furthermore, if you analyze the actual spot of the collision with the tree it is right off Lower American, a green (easy run).

The Test:

Take a similar route as Tony and wear a GPS unit to determine speed.

I spoke with Tony the night before completing the test to determine his actual route and possible variables in the setup.

Height\Weight\Snowboard

Tony and I are built nearly the same as far as height. Tony does weigh a bit more than I do, so that would also increase his speed [Editor's note: I weigh 200lbs now, jerk]. Tony's snowboard is 7cm longer than mine, which generally equates to a obtaining and holding higher speeds.

	Height	Weight	Board Length	Hair	Eyes	Riding Ability
Tony	6'4”	220lbs	165cm wide	Brown	Blue	Treetastic
Phil	6'3”	200lbs	158cm wide	Brown	Brown	Super Awesome

Route:

Tony started at the top near the Mercury lift then took American (blue\black diamond) to Lower American (A green) on route to clobber a tree. My route was a bit different due to American being closed due to a lack of snow. I followed nearly the same path as I took Sundown (blue) to Lower American (green). The section actually containing the tree was also closed, so I had to detour around a section of trees.

Note: Tony took American to Lower American before his accident. How much more patriotic can you get?

Here is a map so you can compare our routes:

Since our routes are nearly the same I do not consider this is be much of a factor in the test. Both runs are very similar, with American being a little bit steeper. Sundown and American are very steep for the first part of the run dropping 40 vertical feet in about a quarter mile. The runs both level out around 500 yards before connecting with the very flat Lower American. Tony would have entered Lower American earlier than I did, so his speed would have started to bleed off a bit sooner that mine. I believe this detail levels the playing field and negates any extra speed he would have had. The slight detour near I had to take around the tree is nearly the same grade as the route to the tree. Again, a slight difference, but it should not affect the results much.

Snow Conditions\Time of Day\Temperature:
The test was completed at 12 noon on ski runs consisting of groomed packed powder. The temperature was in the high 30's\low 40's.

Editor's note: my crash run took place a little after 9:30AM with groomed packed powder. The temperature was a bit colder -- low 30's.

Riding style: “You better go as fast as you can because that's how I do it.” -Tony, Dec 2011

I go fairly fast but I generally take it a little bit easy. After riding with my GPS my average speed when cruising around is between 20 and 25mph. I really had to step it up to meet the speed and agility of Tony.

Here is some interesting data from a few leisurely runs at Breck:
http://connect.garmin.com/activity/135261204

The Test:
On both runs I started collecting GPS data near the top of the run and stopped collected at the Mercury lift. The ski runs were not too busy so it was easy to cruise on both runs. I tried to straight shoot both runs as much as possible. To maintain stability I did have to edge somewhat, but did so in a manner as to not lose speed. I also took corners this way to ensure the most amount of speed was kept. I tucked a bit at high speeds so I was more aerodynamic and also 'pumped' the snowboard on rollers to maintain speed.

Analysis:
Two different test runs were completed, both with very similar results.

Garmin's site is terrible for analytics, so I imported the GPS data into map my ride.

First Test:
http://www.mapmyride.com/workout/82299108 (Click on splits and graphs)
http://connect.garmin.com/activity/135261228

Second Test:
http://www.mapmyride.com/workout/82296678 (Click on splits and graphs)
http://connect.garmin.com/activity/135261230

The actual collision would have occurred between two data points:

Based on the graphs it is easy to see how fast speed starts to bleed off as you continue on Lower American.

The other test I completed had my speed was about 1 mph faster, so between 34 and 35.75.

The Results:

My estimated speed at the point of collision: 32 – 36 mph.

Based on the data it is possible that Tony was going 40 mph when he hit the tree. This is due to the longer board length and because he is quite an all-American badass!

Speed	Likelihood
30	Too Slow!
35	For Sure
40	Probable
45	Unlikely

Editor's note to all of my friends that doubted me: I told you so.

Physical Therapy: Round Three

2011-11-24T12:21:00.001-05:00

In the last two years I've had to rehabilitate my ankle twice. Each round of physical therapy was four months. With eight months of rehab under my belt, I thought I could handle round three myself. I've seen all of the manipulations of the joints, the painful tendon stretches, and the strengthening exercises.

Turns out I don't know what I'm doing. I start round three next week at CORE Physical Therapy.

The joints in my foot need a lot of work. I'm not pushing myself hard enough on my own. My foot is still very stiff and painful from reversing the contracture caused by being locked up for twelve weeks in an external fixator. The contracture is clearly visible when compared to the much larger left foot.

The nerve damage in the ankle keeps the skin hotter than normal, quite red, and triggers the sweat glands to overreact. While unlikely at this point, it's still possible to develop complex regional pain syndrome. The neuropathy has died down significantly and feeling is slowly coming back. All good signs.

June 2010 Ankle

November 2011 Ankle

The ankle is still feeling good, but it's important to loosen up the joints in the foot to ease the pressure on the ankle joint.

The worst pain I have is when my blood pressure spikes -- something I've experienced regularly during the two rehab phases since the accident. The pain from the inflammation in the foot is at its worst in the morning. Ice and Celebrex are your friends.

The holes have almost completely healed. A few days ago I had this sweet crater in one of my pin sites. This thing was big enough to have its own gift shop at the bottom. Fortunately, it has healed up since this picture was taken.

Hope everyone has a great Thanksgiving! Since the accident I've had quite a lot to be thankful for -- not dying after snowboarding into a tree probably makes the all-time top ten list.

Snowboarder vs. Motivation

2011-11-20T15:02:00.005-05:00

After my third surgery last year, I worked out every day with one goal in mind: to snowboard one more time. But as the ankle pain grew each day, it became increasingly difficult to walk to the gym. Eventually I realized snowboarding was further away than I had hoped.

I stopped working out.

It was either the ankle pain or the knowledge that getting back to the slopes would be more difficult than I had imagined that killed my motivation.

Not this year.

One year later, I'm back in the same spot. I'm back in the gym regularly. I'm still motivated by the idea of being back on my board and dominating the slopes. But I've also learned my lesson from last year. Snowboarding is not my only goal (Dr. Jeng told me Friday to refrain from all high impact activities, including snowboarding, for one year).

Instead, my primary goal is to get down to and stay at about 190 to 180 lbs. I'm 6'3" and at 200 lbs now, so this isn't asking much. But the difference of 10 to 20 lbs will help manage my ankle pain.

With all of that said, I still dream about snowboarding.

I know. There were also a bunch of skiers in this film. If I can't maintain the dorsiflexion I need to snowboard, I've considered -- only briefly -- converting. But that's a decision I can put off for at least a year.

Yesterday was the most active I've been on the ankle without crutches. It's difficult to tell if I'm having ankle pain because the cuniforms, navicular, cuboid bones, along with the subtalar joint, are all experiencing wake-up pains -- and those are all near my ankle joint.

Here's what I've been doing every day to rehab the foot and ankle.

A half foam roll can be used to work on dorsiflexion and plantar flexion. You can also turn it over and use it to roll your ankle side to side. These things are cheap and worth it.

A wobble board is great for loosening up the ankle. It allows you to move the joint in all directions. I do three sets of 20 rolls in each direction every day.

A tennis ball is the cheapest and best thing you can get to rehab your foot. You can use it to stretch the toes and the tendons under the foot. If you have neuropathy, rolling your bare foot on the tennis ball helps. It does a great job of desensitizing the nerve endings in the skin.

One more video. This one's not motivational. It's just dumb.

New X-Rays

2011-11-18T19:57:00.001-05:00

The ankle feels great! I'm off the crutches and on a cane now. I don't have any pain in the joint (yet). I'm continuing to take 200mg of Celebrex a day, which probably helps.

Today we had our post-op x-rays taken of the ankle. Before we see the images, here's what the ankle looked like around this time last year.

X-Ray taken on 8 December 2010

Here are today's pictures.

X-Rays taken on 18 November 2011 (Side View)

There is more space in the joint. However, the ceiling of the tibia in the front of the ankle -- which is actually my pelvis from last year -- is collapsed into the joint. The X-Rays couldn't tell us if there was any joint space in this area. While I have no ankle pain now, this spot could end up becoming arthritic over time.

X-Rays taken on 18 November 2011 (Front Angled View)

X-Rays taken on 18 November 2011 (Front View)

Another noticeable difference is the bone is not as bright as the X-Ray from last year. This is because the bone is no longer sclerotic or as hard and dense. The distraction allowed the bones to develop osteopenia. While this is bad when it occurs on its own, it's actually very good for arthritic joints. Walking on soft bone is much easier on the joint than hard bone.

Also -- you should check out the comments from my last post. Two fellow arthritis sufferers, Carlos and Paul, discovered that they were seeing doctors from the same practice. Small world!

Paul recently had a similar distraction procedure performed on his knee (more awesomely gory pictures located here).

Carlos is considering ankle distraction and has found several other very promising research papers.

Thanks for sharing the papers! It reminds me that I need to finish my post on recent ankle arthritis research. I'll make sure to read these papers and incorporate the research in the write-up.

Finally, here are the flouroscopic images taken during the November 3rd surgery. You can see that there appears to be much more joint space than what we saw today. I suspect it's due to the fact that I hadn't started bearing weight.

Leg Holes

2011-11-14T23:33:00.000-05:00

The leg is looking good. Here you can see the 11 day old holes are healing up nicely.

This got me wondering: how many holes, incisions, and pins/screws have I had since my accident? Time to add it up.

Surgery 1 on February 13th, 2010

Three external pins.

One plate. Eight internal screws. Seventeen staples.

One incision.

Surgery 2 on March 1st, 2010

One plate. Eleven internal screws. Twenty staples.

One incision. Two holes for two internal screws in the medial malleolus.

Another hole due to infection in the top incision.

Surgery 3 on August 16th, 2010

Eight external pins.

Three new incisions. Fourteen staples.

Surgery 4 on August 15th, 2011

Eight external pins (nine if you count the temporary pin to find my ankle axis).

Two arthroscopic holes. Three tendo-lengthening holes.

Grand Totals

2 plates have come and gone
5 incisions
8 holes from screws, arthroscopy, or tendo-lengthening
19 internal screws (4 broken screws left)
19 external pins
34 holes from external pin sites
37 staples
39 holes drilled in my bone
44 holes in my skin and bone if you add the external pin site holes

Snowboarder vs. Neuropathy

2011-11-13T21:38:00.000-05:00

The leg has healed enough to finally take my first shower without my right leg hanging out of the tub since August 15th. While I was pumped to finally get this leg washed, there were some unfortunate consequences.

Neuropathy.

When I had my accident, my tibial nerve was severely damaged. I lost all of the feeling in my toes, the bottom of my foot, and the medial side of my ankle. After about eight months, the feeling returned. But in the first few weeks of my accident, the neuropathy was terrible. It felt like an electric shock in the toes and the bottom of my foot would feel like it was on fire.

Dr. Jeng warned me that distraction arthroplasty could re-injure the nerve. It did -- I lost feeling in my heel and some parts of the bottom of my foot.

Feeling has come back, but it's still partially numb. I suspect the shower removed a ton of dead skin and exposed some sensitive new skin on the bottom of my foot. As the nerves heal, sensations like a breeze or touch register as pain. It's awesome. And I imagine it's a million times worse than this when you get an amputation.

There are a number of ways to treat neuropathy, but from what I understand, most of the treatments don't stop the pain.

I think our best option is to desensitize the skin on the foot using things like capsaicin and a tennis ball. There's not much else you can do but grin and bear it.

Physical Therapy: Round Three

2011-11-10T21:13:00.000-05:00

One week later, how is the pain?

Before my surgery, I tried wearing my boot to see if it would help my arthritis. At the time, it was extremely painful to get in the boot, extremely painful to wear it, and even more painful when I got out of the boot.

Since last Thursday, I have not experienced pain like that, which is great. I don't feel or hear grinding noises (yet) from my ankle. These are all good signs.

Unfortunately, having undergone this type of recovery and physical therapy twice before in the last two years does not make the third time any easier. It definitely hurts. Tendons, ligaments, everything has atrophied, contracted, and stiffened up. However, reading what I was going through this time last year helps put things into perspective.

So far, I don't think I've felt any arthritic pain. I'm taking Celebrex daily, which makes it easier to cope with the process of waking up my foot and ankle.

I have, however, felt some spots in my ankle, particularly on the anterior lateral side, that might end up becoming arthritic sites. This is the area of my ankle I had the most pain before the surgery. Dr. Jeng specifically removed bone spurs in that area of my ankle to address it.

I'm still holding out judgement until after I finish physical therapy. We see Dr. Jeng next Friday to get x-rays.

Here's what my ankle looked like in December 2010, a few weeks into physical therapy. You can see that there isn't much joint space left. I'm hoping we see some improved joint space next week. The flouroscopic images from last week's surgery looked promising -- but I'm afraid I was too optimistic (and drugged) when I created the "enhanced" image to help show the new space.

I'll keep you guys updated. This is the part of the recovery that blows.

A friend of mine complained that there weren't enough gross pictures on my blog.

My leg has not been washed since August 15th, 2011. Take a big whiff. Be careful, though. Even over the Internet, the stench can make you faint.

Ankle Range of Motion in One Year

2011-11-06T21:24:00.000-05:00

Dr. Jeng, if you're reading this blog post, don't get mad at me. My dressing was making it difficult to wear my boot comfortably, so tonight I decided to change it tonight.

I took advantage of the opportunity to capture my current ankle flexibility and compare it against what it was a year ago -- a few days after getting out of my second external fixator.

November 6th, 2011

November 15th, 2010

It looks like in about one year, I've gained a little bit more range of motion.

Also, speaking of Groundhog Day, both of these videos, taken one year apart, have an NFL football game going on in the background.

Finding New Uses for an External Fixator

2011-11-05T13:45:00.004-04:00

Coaster

Leg stool to elevate the leg.

Someone suggested I turn my ex-fix into a lamp. I'm not sure my wife would like that.

Actually, I'm sure.

I had forgotten how much this thing weighs. It's about five pounds.

The ankle is feeling great. I'm experiencing the normal soreness and stiffness pains that twelve weeks of immobility will inevitably cause. I've been using a half-foam roll and a wobble board to help me work out the stiffness while I wait for the wounds to heal. Once they heal, I can start up physical therapy.

When I'm up and moving around at work, I'm back in a boot to provide stability.

While we're excited to see how much joint space we've acquired with distraction arthroplasty, I'm holding out judgement for about twelve more weeks. The articular surface of my tibia is like a meat tenderizer. Walking and moving the ankle will likely wear down the new tissue we've grown -- it's only a matter of time.

But that's the key question -- how much time have we bought ourselves before symptoms show up again? The research shows about five years, but the procedure is still relatively new. As a result, data on long-term outcomes is not readily available.

All things considered, it's amazing to see how far we've come.

From the initial injury above, to this, roughly two years later:

Surgery Number Five

2011-11-03T13:50:00.003-04:00

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!

I Should Be In Bed

2011-11-02T22:49:00.001-04:00

I made a promise to never wear breakaway pants ever again after last Friday.

But then I found these bad boys. Sweet silver breakaways that my parents bought me back in August. Even our dog, Spunky, is wondering why I choose to look like an idiot.

This stance may look stupid to you, but as most people with external fixators know, this is the stance you make in pictures the night before a surgery. Standard operating procedure, folks.

Let's Do This

2011-11-02T22:24:00.000-04:00

Dr. Jeng and I exchanged a few emails today. I wanted to double check he was still comfortable with me rolling in with my tripod and camera tomorrow morning to capture the surgery. He came back with, "Yeah that's cool. Met a patient the other day that is following your blog."

Whomever you are, there's no pressure to speak up. I'm just glad you found the blog! As you probably have discovered, Dr. Jeng rules. The dedication and attention he and his team bring each day motivate you to do the work necessary to prepare for visits. If you've got an iPad, bring it in to show him pictures, x-rays, CT scans, and videos if it's your first visit.

I bring it in each visit with a written list of questions, concerns, and ideas for addressing my ankle issues in the short-term and in the long-term. During our last visit, he was wondering what the joint looked like before we performed the distraction procedure to compare the differences in the subchondral bone of the tibia and talus.

With the iPad, that was a quick and easy image to dial up and show him.

Here's the last picture I'll ever take of getting legally stabbed. The condition of second-most proximal pin site on the lateral side of my tibia has deteriorated since I stopped taking antibiotics a few days ago. The hole around the site has enlarged and today I discovered it has started bleeding.

I also noticed that some of the sites on the lateral side of my forefoot are leaking milky and clear fluid. So, it is about time these metal pins and screws come out of my leg.

I'll let you guys know how it goes as soon as I come to from the twilight anesthesia.

The Final Countdown

2011-11-01T23:34:00.001-04:00

Tomorrow is my last full day with ankle distraction arthroplasty. We're at the twelve week point. The procedure on November 3rd is being treated like any other surgery, so we have to report to Baltimore bright and early, I can't eat or drink anything after midnight, and I'll be in the sterile environment of an operating room.

The big difference, from what I'm told, is I will not be under general anesthesia. Instead, I'll be put out with what's called twilight anesthesia. I've been given permission to film the entire thing, so I'll be marching in with a tripod and camera ready to go.

According to Wikipedia, during twilight anesthesia, "the patient is relaxed and sleepy, able to follow simple directions by the doctor, and is responsive. Generally, twilight anesthesia causes the patient to forget the surgery and the time right after."

I underwent twilight anesthesia when my boot was removed a few hours after my accident. When the nurse said I'd be awake but I wouldn't remember what happened, I called her a liar. I refused to believe that I was going to forget how bad it was going to feel to remove my snowboarding boot from my dangling foot.

Turns out they were right, I didn't remember a thing. Science 1, Tony 0.

Hopefully the video will be entertaining, but more importantly, I'm anxiously awaiting Thursday afternoon when I can finally walk around without a giant contraption that makes me feel like I've got fourteen steak knives stabbed in my leg.

I want to keep one of the rings from the ex-fix so I can drill it to the Breckenridge Memorial.

New Business Cards

2011-10-28T20:37:00.000-04:00

My new blog business cards came in today. I had this stupid idea the other day. Now I've got 250 cards to hand out to people at work and while I'm out.

Caught with my Pants Around my Ankles

2011-10-28T19:59:00.000-04:00

It's getting colder up here in DC. I usually wear gym shorts to work, but today called for breakaway pants.

Breakaway pants, particularly as they get older (I've had today's pair since last year), can become dangerous. The buttons, as they wear and tear from continued use, don't always stay buttoned.

Today, at work, I got up from my chair and my pants felt, well, let's say, a bit loose around the waist. As I took a step forward, my pants fell straight down around my ankles. Simultaneously, a friend of mine, Dan, approached my desk to see what time we were going home today (he was my afternoon ride).

Yep. He saw the whole thing happen, from start to finish. Dan couldn't stop laughing and all I could say was, "well, I never thought something like this would happen to me at work."

Fortunately, it was late in the day on a Friday -- around 6:00PM, so not many people were around.

But part of it is unfortunate. Had more people been around, I would have gotten a lot more laughs.

Pin Site Healing and Timeline

2011-10-23T23:16:00.001-04:00

Pin Site Healing

Above, from left to right, is a picture of my second-most proximal pin site on the lateral side. The first picture was taken on October 20th and the last one was taken today. You can see how the site is healing nicely, though on a weekend, I'm not walking nearly as much.

Snowboarder vs. Recovery Timeline

Today I spent some time creating a timeline I of my recovery since my accident in February 2010 twenty-one months ago. Laying it out like this helped me put things into perspective. This injury, and this blog, started almost two years ago. It's a daily struggle, but somehow, with great friends, family, and my awesome wife, we've managed to have fun with this stupid ankle and keep an optimistic attitude.

I'm still working on putting together a summary of the research reports I dug up earlier this month. It turned out to be a much bigger project than I had originally thought.

Lastly, here's a video taken today of the most proximal pin site on the lateral side. It's still weird to me how loose the skin is around the site.

The Soupy Pin Conclusion

2011-10-18T19:08:00.003-04:00

Earlier this morning, Brooke and I drove up to Mercy Hospital in Baltimore ready for today's game plan: soupy pin removal.

I loaded up on all of my available pain medication to make sure the pin site removal was as pain free as possible.

While Dr. Jeng went searching for the tools needed to remove the pin, I started taking off the dressings to get a look at the sites.

The "soupy pin," was as red as ever. This is the proximal wire on the lateral side.

Here's the same pin site but viewed from above. Ugly.

The medial view of the same pin was fine, though. Nice and crusty. This is how all of my pin sites ought to behave.

The second-most proximal wire in the second Ilizarov ring has started acting up in the last few days. Here's the medial view of that pin site.

It looks like it's having a great time being infected.

Yes, it hurts when I do this, but it's necessary to check for drainage. There was none.

The lateral side of that same pin did not look as bad as yesterday. Perhaps the Xeroform helped. It's still likely infected.

Dr. Jeng was walking in and out of the room quite a bit today. Each time he came by, he'd bring in something new. Eventually he got his hands on the tools he needed from the operating room to remove the wire. There they are sitting on the table across the room, wrapped in blue paper.

I believe he had asked for a giant sterile wire cutter, a sterile 10mm wrench, and some pliers.

When Dr. Jeng came in for the last time, he took another look at the pin sites and the x-rays. The wheels in his head turned for a second and wondered aloud if it was worth taking the pin out this late in the game.

With each pin site removal, we inherit more risks with weight bearing, e.g., fractures in the bone, ex-fix breakage, etc. Bearing weight and walking around on this thing is absolutely critical to having any chance of a successful outcome. Because the x-rays did not show any problems, such as a fracture or an infection in the bone, Dr. Jeng reasoned that the infection in the pin sites was something we could control with antibiotics.

So at the last minute, Dr. Jeng called an audible and decided to put me back on antibiotics (Augmentin) to try and buy us some time before the November 3rd removal. I was on board with his change-up for two reasons:

I want to continue bearing weight for the next three weeks to maximize the benefit of this procedure
I'd love to avoid the pain (and crazy anxiety) of having the pin removed today

While this is probably the best decision going forward, I unfortunately continue to have pain that we've yet to get under control with any of our pain medications. After discussing this with Dr. Jeng and Brooke, we reasoned that the pain I'm experiencing now is a result of over doing it with unassisted weight bearing on the ex-fix.

It's true. Sunday night I was walking around the apartment without crutches like I was a 27-year-old with no right ankle arthritis. Starting the next day the unbearable pain came into the picture. Cause and effect.

Lesson learned: never do things you'll regret the next day.

On a good note, while we were looking at the x-rays, Dr. Jeng noted that the ankle distraction has noticeably improved my ankle arthritis. In the picture above is a six week comparison of my ankle with the most recent image from today on the left.

The first thing you might notice is the difference in joint space. Today I was not bearing weight and six weeks ago I was. Nothing to discuss here.

Another thing you'll notice is the difference in brightness of the bone near the joint. When bone shows up bright white on x-rays, that typically indicates hard, dense, unhealthy bone. This is a result of the two bones grinding against one another and causing the subchondral bone at the surfaces to harden -- particularly with so much cartilage loss. This is one source of ankle arthritis pain.

The bottom line is that the ankle distraction has allowed the bone to heal. The cysts and lesions are going away and the bone is not as bright, suggesting that the subchondral bone at the surface is returning to a more normal and healthy density level.

All awesome news. I'll continue to rest the ankle until some of the pain is under control and try to monitor how much walking I do on the ex-fix when I'm feeling good. Only three more weeks until we get to test out the joint after a twelve week distraction.

One last thing we asked for before we left today was the post-op surgery report. It was very interesting and went over my head several times. I tried my best to look up some of the medical phrases and terms and link those in so the report is easier to understand.

Procedures Performed:

Right ankle arthroscopy and debridement, anterior cheilectomy
Distraction arthroplasty and application of multiplanar external fixator
Tendo Achilles lengthening

Anesthesia:

General, popliteal block and saphenous nerve block

Complications:

None

Tourniquet Time:

120 minutes at 350 mmHg

Implants:

Smith & Nephew Taylor spatial frame, four olive wires [I've been calling them Kirschner wires; I've yet to figure out the difference], two smooth pins, two hydroxyapatite coated half pins, and then a standard Ilizarov Smith & Nephew frame with two Taylor spatial frame hinges and two universal hinge struts.

Findings

Mr. Meehan is an amazing, handsome, extremely intelligent, and gifted athletic 29-year-old gentleman [I added the adjectives.] that had post-traumatic injury to his distal tibia and has undergone multiple prior surgeries first for open reduction and internal fixation and then subsequently sustained an infection to his ankle joint [This part is not exactly correct] which was washed out and then subsequently had his hardware removed. However, in this time he has developed degenerative joint disease in his right ankle with significant arthritis and osteophytes and subchondral cysts seen on his plain films and his CT scan. He has significant pain with ambulation and has seen various physicians for surgical options with regards to his right ankle. He was given options previously of fusion versus distraction arthroplasty and does not wish to proceed with any type of arthrodesis of his ankle. He has had no evidence of any infection in his ankle since his last wash-out [I've never had a wash-out surgery]. There has been no drainage. It was discussed with him various options including nonoperative management, arthrodesis versus distraction arthroplasty and given the patient's desires, he wished to proceed with the distraction arthroplasty. It was discussed with him that this may not be successful in the short-term but may be successful in the long-term or with a five-year period. The risks of the surgery included but were not limited to bleeding, infection, pin track infection, persistent pain, scar, stiffness, incomplete relief of preoperative ankle pain, hardware breakage, need for future revision or reconstructive surgeries, reaction to anesthesia, stroke, heart attack, loss of limb or death. The patient understood all the above risks and wished to proceed with the surgery [I probably didn't understand all of the above risks]. All his questions were answered in detail and informed consent was obtained from him. A copy of the consent form was signed by the patient and the attending physician and appropriate witness. A copy of this was placed in his permanent medical record [I didn't realize permanent records existed].

Description of Procedure

On the afternoon of 8/15/11 the patient was taken to the Mercy operating room and laid supine on the operating room table. He underwent general anesthesia via laryngeal mask airway and received 2 gram of Ancef intravenously. At this point a tourniquet was applied to the right upper thigh and then a timeout was called to correctly identify the patient, operation, operative site and all in attendance were in agreement and the procedure was begun, again by starting with a popliteal block, using a nerve stimulator with 40 ml of 1% Lidocane and 0.5% Ropivacaine. After this was performed the right lower extremity was prepped and draped in the usual sterile fashion. A tendo Achilles lengthening was made with three percutaneous stab incisions, two medial and one lateral given that the heel was in slight amount of valgus. After this was done the leg was elevated and the tourniquet was inflated to 350 mmHg. We first identified the anteromedial entry point with normal saline and then insufflated the joint and then placed the heel distractor on the patient and then distracted the ankle.

Heel Distractor

We made our anteromedial portal with a nick and spread technique and then inserted the arthroscope and then began our diagnostic arthoscopy. There were significant findings for complete cartilage loss on both the talus and the tibial plafond consistent with his preoperative radiographic imaging. There were very small islands of cartilage medially on the talar head [This explains why most of my ankle pain was on the lateral side], however, there was significant degeneration widespread throughout the joint. There was extensive synovitis which was visualized [This explains a lot of my pain]. We made our anterolateral portal under direct visualization with needle localization and then using a nick and spread technique inserted the shaver through the anterolateral portal [The camera was inserted on the medial side and the shaver on the lateral side] and debrided the extensive synovitis and as well as removed the anterior bone spur on the tibial plafond, performing and anterior cheilectomy. The patient again had very little cartilage on the talus or the tibial plafond remaining, but given the extensive nature of the arthritis, there is no area to specifically respond to with the microfracture so thus after doing our debridement cheilectomy, withdrew the instruments and then took traction off of his leg.

Following the ankle arthroscopy being completed, we then turned our attention toward placement of our Ilizarov frame. We used a standard Smith & Nephew two ring foot frame. We slid this over the foot and ankle onto the tibia and then identified the tibial crest and then placed a half pin through the most proximal frame, which was hydroxyapatite coated. Following this a second half pin was inserted along the medial face of the tibia for the second ring.

These were fixed to the frame and the smooth wires were then drilled in a perpendicular fashion to these half pins and then one was attached to the proximal ring and another to the distal ring and then these were both tensioned to 130 pounds per square inch and then at this point, held in place through the Russian smooth wire holders, the appropriate nuts were tightened to hold the wires in place. After this was done we then placed two olive wires in a cross fashion into the calcaneus [heel bone], again tensioning these to 90 pounds per square inch, and then sequentially tightening these through the Russian clips and tightening these with the nuts, and finally two more olive wires were placed in a cross fashion through the forefoot obtaining purchase in the fourth and first metatarsals, avoiding the fifth metaphalangeal joint [my pinky toe joint] and were tightened in a similar fashion, tightening to 50 pounds per square inch. At this point manual distraction was placed on the ankle and then using the four struts around the frame, the distraction was held in place and locked and then using fluoroscopy we checked the amount of distraction on both the anteroposterior and lateral views. We noted the cheilectomy that we had performed had smoothed out the anterior aspect of the joint and that we had obtained an increased amount of ankle distraction. These were then held in place and then the malleolar axis was identified under fluoroscopy, drilling from medial to lateral, from the tip of the medial malleolus to the lateral malleolus [they drilled in a pin through my ankle joint to line up the two universal hinges on the back of the ex-fix]. Using this as a guide we then placed universal hinges along the axis of the ankle, one medially and one laterally, and then locked these in place and then further distracted the ankle and locked these in place. Following this the four prior struts that were used were removed and loosened. We noted at this point that we could get 10 degrees of dorsiflexion and 20 degrees of plantar flexion of the ankle on the table. The two Taylor spatial frame struts were then applied to the anterior aspect of the ankle and then these struts were locked in place. Following this all of the half pins were cut and then the foot plate was attached to the bottom of the frame. Please note that all of the sharp ends of the half pins were capped and then the cut edges of the smooth pins and olive wires were bent and curled into the anterior aspect of the frame. The wounds were then cleaned and dried. The arthroscopy portals were closed with a 3.0 nylon and then covered with Xeroform and then 4 x 4's and over-wrapped with Webril. The pin sites had sterile gauze applied over them and then had foam spacers placed along them toward the outside of the frame and the frame was over-wrapped with an Ace bandage and then the patient received a proximal saphenous nerve block for residual postoperative pain relief.

At this point the patient was awoken from his general anesthesia and then transferred to the recovery room in stable condition. At the end of the case all needle, sponge, and lab counts were correct. Dr. Jeng was present and participated in all aspects of the surgical case.

How to Freak Out My Mom

2011-10-17T23:34:00.000-04:00

Everyone has a Mom. As you know, a Mom's primary job is to be concerned.

Tomorrow at 11:00 AM I'll be getting at least one Kirschner wire holding the most proximal Ilizarov external fixator ring to my tibia removed. As Dr. Jeng put it, he wants to get rid of my "soupy pin."

The plan is to get fresh x-rays of the pin sites to see if there are any issues with the tibia bone and the pins. If the images reveal any issues, there's a chance we'll remove more k-wires or just take the whole apparatus off since we're close to having this thing on for twelve weeks.

This is Step One to freaking out my Mom. She's far away and won't know what's happening until after it's already happened. In other words, she's worried about not being able to worry about what's specifically happening to me.

Step Two is showing my Mom new developments with my ankle without first running it by her on the phone.

Last night, Brooke and I discovered something interesting I can do with my new Achilles tendon. During my August surgery, my Achilles tendon was lengthened with three cuts. These cuts left three dark marks along the tendon.

When I flex my calf muscle, it appears that the skin, muscle, and fat all pull along the sites where the tendon was cut. In other words, I've now got awesome calf muscle definition that most people dream of. My definition just so happens to be severely deformed.

We'll talk to Dr. Jeng about what's going on here tomorrow, but I suspect it's scar tissue that's formed around the incisions made in August to lengthen the tendon. With physical therapy, this odd deformity will probably go away. This deformity might also be due to the fact that the joint is pulled apart by 5mm. This might also go away once the ankle is no longer distracted.

Step Three is to show more cross leaking pictures, including a new leaking pin site, and note that pain has become an increasing issue in the last few days.

This is the original soupy pin that will be removed tomorrow. Nothing new here -- it's still leaking.

Unfortunately, the lateral side of the second-most proximal k-wire is also leaking now. There's a chance that both of these k-wires get removed tomorrow.

But if those two wires are removed, then the argument for keeping the external fixator on the leg becomes harder to defend -- particularly with November 3rd just around the corner.

We'll let you all -- especially you, Mom -- know how it goes tomorrow!

Wire Soup and the Foot Race Society

2011-10-16T16:41:00.000-04:00

Let me quickly tell you how this post is going to go. It's going to start out gross, get grosser if you watch the video, then get sweet and sappy.

That's just how I do it, especially when the Redskins are down to the Eagles. At least the Redskins have realized it's time to pull Grossman and put in Beck.

Over the last week or so, I've experienced more pain and soreness in all fourteen pin sites -- particularly the proximal k-wire on the lateral side of my leg and the two pins on the lateral side of my fore foot. In order to sleep, we've had to resort to some of the heavy duty medication from several weeks ago to keep the pain managed.

As a quick aside, walking on an external fixator is a totally different experience than passively wearing one for three months. Last year, I was off pain medication within two weeks of the surgery. This year, it seems like as time goes on, pain medication is becoming more important to help me tolerate bearing weight. Bearing weight is an essential part of ankle distraction arthroplasty, as I'm learning from the research, so it's extremely important to me to continue walking on the ankle.

Part of my problem is edema. As the ankle and leg swells with fluid, extra pressure is exerted on all of my pin sites. If the pin site is not sealed, it will spring a leak (so to speak). The edema fluid will dry around the pin site and form a crust -- kind of like a scab. As the edema continues to build up, the skin inflates around the dried crust and causes irritation.

It's an endless cycle of awesome.

This is the proximal k-wire pin site on the lateral (outside) side of my leg. This picture was taken yesterday. Of all of my pin sites, this guy has caused us the most grief since mid-September. While edema is a problem here, Dr. Jeng and I are more concerned that either a latent infection is causing some issues or, worse, a partial fracture around the bone might be allowing the k-wire to move as I bear weight, irritating the muscle, bone, and skin when I walk.

The fluid leaking out of the site does not appear to be infected. It's clear and yellow, indicating that it's edema fluid. However, the pin site itself is continuing to get more red and the fluid is now draining from the site like its a bathroom faucet.

Warning: this video is gross.

You'll notice two things in this video, taken yesterday. First, the lemonade is indeed flowing from the pin site like a bathroom faucet. Second -- and this one takes a keen ear -- you can hear a clicking noise from my shin muscle rubbing up against something -- either the k-wire or the half screw.

After sending this video and other pictures, linked above, to Dr. Jeng last night, I got an email from him this morning:

We should get the soupy pin out this week. How many more weeks until 12 weeks?

Hence the Campbell's Wire Noodle Soup picture above. So it looks like on Tuesday we'll be taking this k-wire out. My immediate concern is whether or not I'll be allowed to bear weight without this k-wire. I assume he was asking me for the removal date to help him decide whether or not I could continue bearing weight.

We're currently sitting at three weeks until I've worn this ex-fix for twelve weeks. We'll see what happens Tuesday. I imagine we'll also take some X-Rays of the mid-section of my tibia to look for hairline fractures near any of the other pin sites. I will, of course, have video of the k-wire removal.

Now that the gross part is out of the way, now it's on to to the sappy and sweet part of the post. A few months ago, I was joking with my Grandmother that she and I should get matching canes. We were discussing with one another that we needed to setup an official race to see who was faster on their feet.

She was challenging me to a foot race. And, worse, I was very worried that she'd dominate.

Last week I had two custom canes made for both of us. It's a golden sienna derby walking cane with a black beechwood shaft and silver collar. In other words, it's extremely fancy.

More importantly, both of our canes have a custom oval engraving that includes our initials and our position in the Foot Race Society. My Grandma ended up beating me in the presidential race, so she's the President of the Foot Race Society and I'm the Vice President.

I'm hoping this stops her from continuing to challenge me to a foot race. Like I said, I'm fairly certain she'd beat me every time.

The handle is my favorite part. I know you're jealous. You want one, I know.

Here's the President of the Foot Race Society proudly displaying her new can along with her beautiful October decorations outside her country home.

And here is the Vice President, proudly displaying the exact same cane in front of a deadbeat dog in the background that only knows how to sleep, eat, and fart.

I'm forcing a smile here because I just found out the Redskins lost.

American Healthcare II

2011-10-15T17:42:00.002-04:00

In March 2010, just a month after my accident, I was curious to see how much it costs to "fix," my ankle. I put fix in quotes because, obviously, we're still in the fixing stage. I titled that post, "American Healthcare."

It's been a hot topic in our country for a while.

After adding up the costs, my first reaction was shock. Over the three days I stayed at the hospital in Colorado, my medical bills exceeded $73,000! I found out later from a friend of ours that operating rooms bill you and your insurance company the same way Verizon and T-Mobile do it: by the minute.

That seemed nuts, so I Googled. According to this Consumer Reports article from 2009, "operating-room use is generally billed at rates that vary from $69 to $270 per minute."

That is nuts.

My second reaction at the time (and still to this day) was relief at how lucky my wife and I are to have jobs and to be covered by a good health insurance plan. Not once have we had to argue or dispute anything. Moreover, they've covered almost all of my costs.

Today I took a quick look at what providers have billed my insurance company since my accident on 13 February 2010 to 25 September 2011 (so we're still missing several visits to my family physician and surgeon).

The grand total: $288,947.54.

My insurance company negotiated those bills down to $161,986.16, a difference of $126,961.38 (a 44% discount).

Our out-of-pocket expenses so far have been $6,950.81. That's 2.4% of what we've been billed and 4.3% of what my insurance company negotiated with each provider. Another important thing to note is this out-of-pocket figure does not account for the hundreds, if not thousands of dollars we've spent on our own to help manage wounds, the ex-fix, and other rehab equipment. I'm betting our out-of-pocket figure is probably over $9,000.

The crazy part about all of this is we are not even close to being done with my ankle. My guess is we'll reach half a million before all is said and done.

New Crutch Tips vs. Piggyback Rides

2011-10-15T00:38:00.011-04:00

On October 2nd, I wrote a post about how to prepare for your first external fixator. One of the items I recommended was a new set of replacement crutch tips for the low, low price of $8.99.

I received my new extra large crutch tips on Wednesday, the 5th. Eight days later, the replacement tips were dangerously unusable.

Please keep in mind that I don't do much on my crutches. The most activity I see in a day is racing for the remote control on the other side of the couch when Grey's Anatomy comes on.

I have to make sure the volume is up high enough for me to follow TV's most compelling prime time drama.

I had two problems on each tip. The first problem was a minor tear in the grip. While this isn't terrible, these kinds of tears make it more important to keep your center of gravity over the points where your crutch tip meets the ground.

I'm not sure how I got this tear so quickly. I crutch on carpet, tile, hardwood floors, and rarely, sidewalks.

Here's problem number two. This is the most dangerous type of crutch tip break down. It highlights the importance of examining your crutches every morning and evening.

When the crutch tube is poking through the tip, you've lost all grip. At any moment, you could place too much faith in the gripping ability of your tips and end up having the crutch slip out from underneath you.

You could fall on your ex-fix or, hurt your other ankle, or even worse, injure your dignity.

Do not buy these replacement tips. They are terrible. I should have read the review, "Do Not Buy - They wore out in one week," before buying these tips. That guy was right. All it took was one week.

Instead of getting these replacement tips, ask your friends for piggyback rides.

This is my good friend Alison giving me, a 6'3" 215 lbs. (all lean muscle) man a piggy back ride on a bet that she couldn't carry me 30 feet. This is the same Alison that won the inaugural Injured Tony Award. To Alison's credit, she dominated it and carried me the entire distance.

The ironic and funny part of the story -- Alison injured her ankle.

Oh, no. Stop right there. She didn't injure it while giving me a piggyback ride. That would make sense.

No, she injured her ankle after trying to give me a high five to celebrate her performance. She had a poor landing on the way down from slapping skin. Perhaps I held my hand too high, or maybe she tweaked something during the piggybacking.

Whatever the reason, the lesson of this story is very clear: Alison is terrible at high fives, so don't buy these replacement crutch tips.

Ground Hog Day

2011-10-13T21:53:00.034-04:00

Have you seen the movie, Groundhog Day? If you haven't, leave right now, run to your nearest Blockbuster, grab a VHS or DVD (if you're lucky, Blockbuster should have one last rental sitting on the shelf in the Awesome Movies aisle), and park yourself on the couch for one of 1993's best comedies.

The premise is simple: a weatherman, played by Bill Murray, finds himself living the same day over and over again.

In many ways, the last two years of my life are taken right out of Groundhog Day. Instead of reliving the same day, I'm stuck in the same year -- over, and over, and over.

As the movie teaches us, reliving this experience is an opportunity -- a gift to learn how to be a better man. You'd think I'd learn. You'd think I'd be a able to handle the daily onslaught of questions from strangers about my ankle a little better.

I'm afraid I've learned nothing.

I usually stick with, "it's a snowboarding accident."

But some people are smart and quickly realize that it's not winter yet. So the questions continue. I average about ten new strangers a day. Each encounter is about a minute. That's over an hour a week of me talking about my stupid ankle.

Look -- I don't mind taking time to tell people how I was an idiot and snowboarded into a tree two years ago. I just occasionally wish these people would organize, form a board and write a charter, and then ask me all of their questions. Their secretary could write it all down and we'd be done. I'd just direct all of the new strangers to the board and have them review the minutes from previous meetings.

My friends have also suggested I get a business card with a link to this blog. That's probably a more practical idea. And not dumb.

An Idiot's Guid to Snowboarding into Trees
http://snowboardervstree.blogspot.com

I'm always polite and I try to keep it humorous to put the other person at ease. I really want people to feel comfortable and feel free to ask anything. Usually, the conversation starts because the other person is genuinely concerned about my well being. But once the friendly stranger comes to the realization that, yes, the pins and screws are going all the way through the skin, muscle, and bone, things turn and the friendly stranger ends up needing the counseling.

Last year, with the help of some friends, we came up with a list of alternative stories to make the daily grind of addressing the giant thing on my ankle a bit more entertaining.

Surprisingly, to this day, The Bear Trap post is the most visited on my blog. Is this because there are a lot of hunters (I'm assuming they're mostly Canadian) Googling for bear traps but are stumbling across a ridiculous post on the Internet?

No one knows. Probably.

Because I entitled this post, "Groundhog Day," I imagine I'll get a lot of hits from people either looking for the movie or what the holiday is about.

Sorry, dudes -- you're not going to get the answers you were Googling. Learn how to Google. Instead, you're going to get my 2011 list of alternative stories I need to start feeding to people.

10. I Didn't Make the Jump

First of all, from the very moment you hit play, it's obvious I'm not going to make it over the ramp. We didn't plan for enough road to allow my bike to get up to the 88mph needed to successfully clear the ramp.

Second of all, once I get to the edge of the ramp, I know the show's over. My brain should be coordinating a complex series of maneuvers to get me a quick, graceful, and pain-free exit out of the fall.

But instead, the brain uses that jerk tone of voice with me and says, "you got yourself into this, so I hope your face enjoys cement."

Then somehow I severely break my ankle.

9. I Watched an Intense Episode of House

I broke my left ankle just by looking at this creepy picture of House.

8. The University of Stanford Mascot

There are a couple of options here. The obvious one is I broke my ankle when I learned that one of the most prestigious universities in America has a tree as it's mascot.

Another idea is the Tree kicked my butt for making fun of how it routinely shows up in top ten lists for the worst college mascots in America.

Regrettably, I have little room to talk. This is my school's current mascot.

7. Troy and his Lu Lu Lemons

The other day, I was hanging out with my friend, Troy. He was wearing -- what I thought -- were regular eBay or hand-me-down sweat pants. It was a casual Sunday, and I wear either gym shorts or break-away pants all the time.

I'm not one to judge.

But then I found out they were Lu Lu Lemon pants. That changed the whole story. I did some judging and ended up breaking my ankle.

This one needs some work. I don't want to imply that Troy broke my ankle. That wouldn't happen.

6. Bath Crashers

Have you ever seen this show on HGTV? It's freaking awesome! This guy hangs out at Home Depot all day asking random people if he can use their bathroom. Then he surprises you by tearing your bathroom apart and building your dream office-at-home.

I'm not sure how this breaks my ankle. I just think this show rocks.

5. Marital Argument

I lose every time. If I attempt at defending myself over why I left an empty bowl of cereal out in the living room, especially after my wife gets home from a twelve hour shift that ran fourteen hours long, bones get broken.

I'm not even making this one up. She leaves the bruises in places where people won't see them.

She doesn't read this blog. Help me.

4. Complainers

We all work and know people that incessantly whine and complain about everything -- especially little, insignificant things. If you've been around someone like this long enough, you know there's a good chance you're ankle will snap when you slam your foot up his -- sorry, I forget sometimes I've got family reading my blog.

It's easy to break your ankle around a complainer.

Also, if you don't know of anyone that acts like this, then you're probably the whiner in your group of friends.

Stop whining.

When people try to complain to me about a bruise they have on their thigh or a sore wrist, I wonder if they're color blind. And by color blind, I mean I wonder if they're incapable of seeing eight steel pins stuck in my leg surrounded by a bird cage.

3. Las Vegas with my Friends

This is a friend of mine getting a wake-up call from two of my other friends in Las Vegas this summer. And with the way my friends operate, it's a never ending war of escalating pranks.

We've already passed buckets of water. Broken ankles are only a few more pranks away.

2. Rock, Paper, Scissors Accident

First of all, yes, this is real. I haven't quite figured out yet how to break my ankle doing this, but I'm sure if someone threw rock hard enough, it could cause some problems.

Did you know that there's an actual strategy to this game?

Here it is. Now you know how to resolve all arguments by proposing (and subsequently dominating) a rock, paper, scissors game.

1. Air Guitar Melted My Face (and Ankle)

This is also real. It also sounds just as stupid as a rock, paper, scissors league. Back in 2009, a few of us decided to go watch a live regional competition in Washington, D.C. We thought it would be terrible.

It turned out to be AWESOME.

This is C-Diddy. He's retired. But this is what started it all. Some of these guys are so good, they can easily break ankles.

Summary

That's my list. Let's see if we can outdo The Bear Trap post. I'll have some updates this weekend of a sweet new custom cane I had made for my Grandmother and myself. You'll be jealous (for about a second or so) that we get to use canes and you do not.

Working and Running on Columbus Day

2011-10-10T23:02:00.012-04:00

Across the world today, several of our close friends ran a marathon -- two for their first time.

Congratulations to Katy (left) for completing her very first marathon in Chicago with seasoned marathon runner Crystal. We're very proud of both of you! Nice work on a personal best time, Katy!

Halfway across the world in Oslo, Norway, our friend Ken also finished his first marathon. We're not as proud of him, though.

Why?

Hopefully this picture of Ken should explain why we do not care. Also, as a side note, if you're familiar with the Internet, you might recognize the following picture and see a close resemblance to Ken.

Days like today I usually make fun of my friends for having to work (or, apparently, run for 26.2 miles) while I sit on my couch and watch Sports Center all day long.

It sounds good on paper. I always enjoy making fun of my friends. But there are only so many times I can watch an ESPN segment about whether or not Tim Tebow should get the start against Miami or see what LeBron James had to say about it on Twitter.

Of course Tebow should start. Quit arguing about it every 45 minutes like there's a choice.

The ex-fix feels great. I'm able to walk around the apartment without crutches and it feels comfortable. Of course, after walking around like that for a few minutes, the pin sites get sore and Percocet is required to quiet down the pin site pain.

So I guess I shouldn't say it feels great. I should probably say it feels great until I use it. Then it feels terrible.

The proximal pin site on the lateral side, the one that's been giving us some grief for some time now, still won't quiet down and scab up like the rest of the pin sites. After walking around I usually start bleeding out of the site (as seen above).

This picture was unusual because the blood seeped through the Xeroform wrap we placed around the pin site. We would have expected it to hold in some of the drainage.

We decided to employ some Xeroform gauze recently because 1) we have a lot of it, and 2) it should help keep the site clean and protect it from contamination.

Here you can see that the site is still a bit red.

I decided that all of the hair was in the way of a good picture, so I spent a few minutes pulling it all out near the site.

Now, normally, if you pulled leg hair, it would make you cry. But, when your skin is in rough shape and hasn't been thoroughly washed since August, hair can be pulled right out without a problem.

I know. That's super gross. But, lesson learned. If you can't afford a razor and need to remove some leg hair, don't wash your leg for six weeks and it'll just start falling out.

I usually take videos of the squeeze test for questionable pins and hand them over to Dr. Jeng to review. This one is a bit gross, but not too bad. No infected fluid came out. Just some clear and bloody fluid.

I sent these pictures and videos off to Dr. Jeng earlier in the afternoon today -- primarily because I didn't want to get yelled at again for not keeping him updated.

We just got an email tonight from Dr. Jeng a few minutes ago:

How many more weeks before we remove it? Don't love how that pin looks.

We let him know that we're about three and a half weeks away from removing the ex-fix. I'm not sure what he's thinking, but I let him know I'm cool with removing this k-wire while I'm awake if I'm allowed to continue weight bearing.

I suspect he won't go for that idea since the only thing holding that Ilizarov ring would be one half screw in my tibia, but we'll see.

I'm telling you, when you pick a doctor, these are the kind of intangibles that you cannot unfortunately measure but are absolutely critical to ensure your recovery is as good as it can get.

Think about it.

It's Sunday night. There's a Bears at Lions game on. It's late. And here's this guy thinking, "Tony's pin site looks a little crappy. We need to do something about this."

A Review of the Ankle Arthritis Literature

2011-10-09T19:12:00.033-04:00

This blog post is going to get a bit technical and boring, so before we get into that, here is today's update on the pin sites.

The hindfoot pin sites on the medial side are looking good, but the forefoot pin sites on the lateral side are leaking a bit.

You can see the yellowish stains under the lower pin site from the overnight drainage. This isn't anything to worry about since the pin site is not red and the drainage is not a weird color.

This video shows the small amount of drainage I'll get with some squeezing. I covered this pin site with some Xeroform to help protect the site from bacteria.

One more thing before getting into the guts of this post. We bought our dog, Spunky, a new toy.

This was the scene a few minutes later.

She also grew a beard.

Now on to the point of this post.

Today I decided to download over twenty medical research papers on ankle arthritis. I focused on arthrodiastasis (ankle distraction arthroplasty), but I did find a few papers relevant to previous operations I've had, such as the iliac crest allograft. I haven't had a chance to read all of them yet, but I'll spend the next several days reading these publications and providing a summary here that's hopefully accessible and easy to understand.

In case you're interested in the articles I'll be reading, here's the list of papers and their abstracts, ordered by publication date:

2011

Is Total Ankle Arthroplasty a Cost-Effective Alternative to Ankle Fusion?

Total ankle arthroplasty (TAA) implantation is increasing, as the potential for pain relief and restoration of function and risks are compared with those for ankle fusion. A previous analysis with a simple decision tree suggested TAA was cost-effective compared with ankle fusion. However, reevaluation is warranted with the availability of newer, more costly implants and longer-term patient followup data. Considering all direct medical costs regardless of the payer, we determined if TAA remains a cost-effective alternative to ankle fusion when updated evidence is considered. Using a Markov model, we evaluated expected costs and quality-adjusted life years (QALY) for a 60-year-old hypothetical cohort with endstage ankle arthritis treated with either TAA or ankle fusion. Costs were estimated from 2007 diagnosis-related group (DRG) and current procedural terminology (CPT) codes for each procedure. Rates were extracted from the literature. The incremental cost-effectiveness ratio (ICER), a measure of added cost divided by QALY gained for TAA relative to ankle fusion, was estimated. To identify factors affecting the value of TAA, sensitivity analyses were performed on all variables. Results -- TAA costs $20,200 more than ankle fusion and resulted in 1.7 additional QALY, with an ICER of $11,800/QALY gained. Few variables in the sensitivity analyses resulted in TAA no longer being cost-effective. Conclusion -- Despite more costly implants and longer followup, TAA remains a cost-effective alternative to ankle fusion in a 60-year-old cohort with end-stage ankle arthritis. Level of Evidence Level II, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Outcome Evaluation of Ankle Osteoarthritis Treatments: Plantar Pressure Analysis During Relatively Long-Distance Walking

This study aimed to use plantar pressure analysis in relatively long-distance walking for objective outcome evaluation of ankle osteoarthritis treatments, i.e., ankle arthrodesis and total ankle replacement. Methods: Forty-seven subjects in four groups: three patient groups and controls, participated in the study. Each subject walked twice in 50-m trials. Plantar pressure under the pathological foot was measured using pressure insoles. Six parameters: initial contact time, terminal contact time, maximum force time, peak pressure time, maximum force and peak pressure were calculated and averaged over trials in ten regions of foot. The parameters in each region were compared between patient groups and controls and their effect size was estimated. Besides, the correlations between pressure parameters and clinical scales were calculated. Findings: We observed based on temporal parameters that patients postpone the heel-off event, when high force in forefoot and high ankle moment happens. Also based on maximum force and peak pressure, the patients apply smoothened maximum forces on the affected foot. In ten regions, some parameters showed improvements after total ankle replacement, some showed alteration of foot function after ankle arthrodesis and some others showed still abnormality after both surgical treatments. These parameters showed also significant correlation with clinical scales in at least two regions of foot. Interpretation: Plantar pressure parameters in relatively long-distance trials showed to be strong tools for outcome evaluation of ankle osteoarthritis treatments.

Reduction in Wire Tension Caused by Dynamic Loading: An experimental Ilizarov Frame Study

Small diameter transosseous wires are main parts of the Ilizarov frame concept. Wire tensioning is essential to gain the necessary transversal stiffness, and the wire fixators are therefore important, coupling the wire to the ring. The ability of three different wire fixator designs to maintain wire tension under dynamic loading is described. The three fixator designs were combinations of two types of bolts and one washer. In a simplified frame setup consisting of one ring and one wire, sixty wires were dynamically loaded in sequence with 200N for 450 times and wire tension was repeatedly measured. The tension loss employing the different fixator types at two wire pretension levels (883N, 1275N) was measured. Wire slippage in the fixators and the midpoint deflection angle of the wires were measured. Large differences in fixation ability were observed. Wire fixators holding a larger and rougher contact surface had significant smaller tension loss compared to fixators with a smaller and smoother contact surface. Both plastic wire deformation and slippage causes tension loss with slippage as the main contributor. Wire fixators’ design can be improved in order to maintain wire tension. Such improvement could be of clinical interest enhancing the mechanical stability of the fixator.Small diameter transosseous wires are main parts of the Ilizarov frame concept. Wire tensioning is essential to gain the necessary transversal stiffness, and the wire fixators are therefore important, coupling the wire to the ring. The ability of three different wire fixator designs to maintain wire tension under dynamic loading is described. The three fixator designs were combinations of two types of bolts and one washer. In a simplified frame setup consisting of one ring and one wire, sixty wires were dynamically loaded in sequence with 200N for 450 times and wire tension was repeatedly measured. The tension loss employing the different fixator types at two wire pretension levels (883N, 1275N) was measured. Wire slippage in the fixators and the midpoint deflection angle of the wires were measured. Large differences in fixation ability were observed. Wire fixators holding a larger and rougher contact surface had significant smaller tension loss compared to fixators with a smaller and smoother contact surface. Both plastic wire deformation and slippage causes tension loss with slippage as the main contributor. Wire fixators’ design can be improved in order to maintain wire tension. Such improvement could be of clinical interest enhancing the mechanical stability of the fixator.

Subchondral Bone Remodeling is Related to Clinical Improvement After Joint Distraction in the Treatment of Ankle Osteoarthritis

In osteoarthritis (OA), subchondral bone changes alter the joint's mechanical environment and potentially influence progression of cartilage degeneration. Joint distraction as a treatment for OA has been shown to provide pain relief and functional improvement through mechanisms that are not well understood. This study evaluated whether subchondral bone remodeling was associated with clinical improvement in OA patients treated with joint distraction. Twenty-six patients with advanced post-traumatic ankle OA were treated with joint distraction for 3 months using an Ilizarov frame in a referral center. Primary outcome measure was bone density change analyzed on computed tomography (CT) scans. Longitudinal, manually segmented CT datasets for a given patient were brought into a common spatial alignment. Changes in bone density (Hounsfield Units (HU), relative to baseline) were calculated at the weight-bearing region, extending subchondrally to a depth of 8mm. Clinical outcome was assessed using the ankle OA scale.

2010

Anteromedial Impingement in the Ankle Joint: Outcomes Following Arthroscopy

Arthroscopic debridement is a well-accepted method of removing osseous and/or soft tissue impingement from the ankle joint. To the best of the authors’ knowledge, this is the first case series reporting the outcomes following arthroscopic resection of anteromedial impingement.

Reduced Tissue Hardness of Trabecular Bone is Associated with Severe Osteoarthritis

This study investigated whether changes in hardness of human trabecular bone are associated with osteoarthritis. Twenty femoral heads extracted from subjects without musculoskeletal diseases (subject age: 49–83 years) and twenty femoral heads extracted from osteoarthritic subjects (subject age:42–85 years) were tested. Sixty indentations were performed along the main trabecular direction of each sample at a fixed relative distance. Two microstructures were found on the indenting locations: packs of parallel-lamellae(PL) and secondary osteons (SO). A 25gf load was applied for 15 s and the Vickers Hardness (HV) was assessed. Trabecular tissue extracted from osteoarthritic subjects was found to be about 13% less hard compared to tissue extracted from non-pathologic subjects. However, tissue hardness was not significantly affected by gender or age. The SO was 10% less hard than the PL for both pathologic and non-pathologic tissues. A hardness of 34.1 HV for PL and 30.8 HV for SO was found for the non-pathologic tissue. For osteoarthritic tissue, the hardness was 30.2 HV for PL and 27.1 HV for SO. In the bone tissue extracted from osteoarthritic subjects the occurrence of indenting a SO (28%) was higher than that observed in the non-pathological tissue (15%). Osteoarthritis is associated with reduced tissue hardness and alterations in microstructure of the trabecular bone tissue. Gender does not significantly affect trabecular bone hardness either in non-pathological or osteoarthritic subjects. A similar conclusion can be drawn for age, although a larger donor sample size would be necessary to definitively exclude the existence of a slight effect.

2009

Ankle Arthrodiastasis

Degenerative joint disease of the ankle remains a challenging problem for the foot and ankle surgeon. A recent multicenter study has concluded by objective evaluation that the mental and physical disability associated with end-stage ankle arthrosis is at least as severe as that associated with end stage hip arthrosis. Unlike the hip and knee joints, the ankle joint is rarely affected by primary osteoarthritis. Saltzman and colleagues2 evaluated the cause of arthritis in a consecutive series of 639 arthritic ankles. The results demonstrated that 445 (70%) patients had posttraumatic arthritis, 76 (12%) had rheumatoid disease, and 46 (7%) had idiopathic arthritis (primary osteoarthritis). As opposed to primary osteoarthritis, posttraumatic arthritis of the ankle joint presents a unique set of challenges because it generally occurs in a younger and more active population. Conservative treatment of ankle arthritis is primarily symptomatic in nature. When conservative treatment fails, surgical options include ankle joint arthrodesis, joint debridement, osteotomies, or joint replacement. Arthrodesis is considered the ‘‘gold standard’’ and has been shown to be effective at eliminating pain, but at the expense of loss of joint motion and overload of adjacent or contralateral joints. Recent long-term studies have reported increased disability associated with advancing arthrosis of adjacent joints after ankle arthrodesis. The results of ankle joint replacements have been good; however, these implants have a limited lifespan and may not be indicated in the younger and more active patient. Ankle joint distraction, or arthrodiastasis, has been shown clinically to benefit patients significantly in the short-term and long-term treatment of ankle arthritis. In a retrospective study of 22 patients 7 years after Ilizarov ankle joint distraction, 16 (73%) showed significant improvement in all clinical parameters studied. Multiple scientific studies have also demonstrated beneficial intra-articular changes with joint distraction.7–10 For these reasons, arthrodiastasis, or ankle joint distraction, has emerged as a potential alternative treatment to decrease pain and improve joint function. Ankle arthrodiastasis as a treatment for ankle arthritis is based on the theory that osteoarthritic cartilage in the ankle has healing capacity. A recent cadaveric study comparing cartilage in the knee joint with that in the ankle joint has suggested that ankle joint chondrocytes have a greater capacity for repair. The reparative capacity of the chondrocyte is believed to be enhanced by mechanical offloading of the ankle joint by means of distraction with an external fixator, thus preventing further damage of the articular cartilage, unloading the periarticular bone, potentially decreasing the density of the subchondral bone, and allowing for decreased load on the overlying articular cartilage. The chondrocyte repair is nourished by the maintenance of intra-articular fluid pressure changes within the joint. This intermittent flow is facilitated by joint movement with the use of hinges in the external fixator or by allowing the patient to walk with the frame in place. The flexibility of the frame, or motion with the hinges, allows intermittent increases in hydrostatic pressure, creating a supportive environment for cartilage repair.

2008

Distraction Arthroplasty of the Ankle -- How Far Can You Stretch the Indications?

A growing number of patients are developing ankle arthritis from various causes. Many patients are seeking alternative treatment options to arthrodesis or total joint replacement. Most patients prefer to preserve their natural ankle joint and ankle motion. Although research into cartilage regeneration and repair is promising, it is too preliminary to offer a viable clinical option for the ankle at this time. Joint distraction with external fixation has evolved as an alternative to arthrodesis and/or joint replacement. The technique of joint distraction uses the principle of ligamentotaxis to restore the normal joint space, afford less joint loading, and provide an environment in which the joint cartilage can recover. The first reported joint distractions of the knee and elbow were performed in 1975 and of the ankle in 1978. Aldegheri and colleagues, from Verona, Italy, coined the term arthrodiatasis in 1979 to describe joint distraction (arthro [joint], dia [through], and tasis [to stretch out]). Indications for ankle joint distraction are congruent joint surface, pain, joint mobility, and moderate-to-severe arthritis. The indications may be stretched to include avascular necrosis of the talus. The success of the clinical outcomes varies with respect to the presenting diagnosis.

2007

Arthrodesis After Failed Total Ankle Replacement

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

Distraction Arthroplasty

Osteoarthritis is a progressive, degenerative disorder involving many different joints of the body, including the ankle. It is characterized by joint pain, tenderness, crepitus, inflammation, effusion, and limited range of motion. Radiographic findings include joint space narrowing, osteophyte formation, subchondral cysts, and subchondral sclerosis. The progressive nature of the disorder can lead to significant pain and long-term disability. The treatment of osteoarthritis is aimed at decreasing pain, limiting disability, and slowing progression. Initial conservative measures consist of a combination of activity modification, physical therapy, medications, orthotic devices, and footwear modifications. When these measures fail and function cannot be maintained, surgical intervention is indicated. Surgical options for arthritis of the ankle include joint-sparing procedures such as arthroscopy and tibial osteotomy and procedures that sacrifice theankle joint such as fusion and ankle joint replacement. Arthroscopic debridement is indicated for patients who have mild to moderate osteoarthritis. This procedure is proposed to decrease pain, improve ankle motion, and postpone arthrodesis but its utility in patients who have advanced osteoarthritis is unpredictable. Tibial osteotomies are designed to restore anatomic alignment and to improve biomechanical function of the ankle. Stamatis and colleagues reported on the treatment of 12 patients (13 feet) with supramalleolar osteotomy. The results showed an improvement in the average American Orthopaedic Foot and Ankle Society score from 53.8 to 87 points at a mean follow-up of 33.6 months. Because the indications for tibial osteotomies are narrow and primarily involve patients who have asymmetric deformity and partial joint space narrowing, these procedures may not be appropriate for many patients who have ankle osteoarthritis. For patients who have advanced degenerative changes, joint fusion and joint replacement are the mainstays of surgical therapy. Ankle arthrodesis has been shown to be effective in reducing pain but at the expense of joint motion and the subsequent overloading of adjacent joints. Coester and colleagues reported moderate to severe subtalar arthritis in 21 of 23 patients at a mean of 22 years after ankle fusion. Similar findings were also seen in the other joints of the foot. Arthroplasty has also been shown to relieve pain secondary to arthritis; however, the lifespan of these implants is limited, with a reported 76% of patients exhibiting signs of radiolucency and 11% of patients undergoing revision surgery at a mean of 9 years. Subsequent revision surgery requires significant bony resection, and the results are still unknown. Therefore, these interventions may not be appropriate for the young patient who has severe ankle osteoarthritis and has failed conservative therapy. In recent years, several researchers have studied the use of joint distraction arthroplasty, or arthrodiatasis, for the treatment of ankle arthritis. With this technique, a distraction force is placed across the ankle joint using a small-wire external fixator. Weight bearing is allowed, which, through a hinge or the flexibility of the wires, creates intermittent fluid pressures within the joint while inhibiting mechanical loading of the joint.

2006

Alternatives to Ankle Implant Arthroplasty for Post-traumatic Ankle Arthrosis

Ankle arthrosis can limit the patient’s daily activities and quality of life. A variety of surgical options are available beyond implant arthroplasty to treat posttraumatic ankle arthrosis. Conservative options are usually employed in combination and include the use of nonsteroidal anti-inflammatories, bracing, and orthoses, as well as injections of intra-articular corticosteroid and hyaluronic acid. If these conservative treatments fail over a proper period of trial, surgical intervention can be entertained. The operative treatment considerations depend on the overall general health of the patient, the severity of the ankle arthrosis, and degree of associated deformity. Alternatives to total ankle implant arthroplasty include (1) arthroscopic debridement, (2) arthrodiastasis, (3) peri-articular resurfacing using allograft or cartilage transplantation, and (4) peri-articular osteotomies to correct angular, rotational, or translational malalignment. However, ankle arthrodesis is considered the standard technique for end-stage ankle arthrosis. This article reviews the literature and presents an in-depth surgical technique for each procedure. The article also describes how to prevent and address the most common complications.

2005

Ankle Joint Distraction

The use of external fixation for joint distraction has evolved as an alternative to arthrodesis or joint replacement. The technique of joint distraction uses Vidal’s principle of ligamentotaxis to restore the normal joint space, afford less joint loading, and provide an environment in which the joint cartilage can recover. The first reported joint distractions of the knee and elbow were performed in 1975, and the first distraction of the ankle was performed in 1978. Aldegheri, from Verona, Italy, coined the term ‘‘arthrodiatasis’’ in 1979 to describe joint distraction (arthro [joint], dia [through], and tasis [to stretch out]).

2004

Joint Distraction for the Treatment for Ankle Osteoarthritis

There are few joint-sparing surgical alternatives for the treatment of ankle arthritis. Tibial osteotomies have been used with some success, but have narrow indications, primarily cases that are characterized by asymmetric deformity and partial joint space narrowing. Arthroscopic debridement remains limited to anterior osteophytes and offers little benefit for patients who have more extensive disease. Finally, although ankle arthroplasty continues to evolve, its indications remain poorly defined and only one prosthesis is approved by the U.S. Food and Drug Administration. Recently, the use of joint distraction was described for the treatment of ankle osteoarthritis (OA). With this technique, the ankle is distracted using a small-wire external fixator. Weight bearing is allowed, and as a result of a hinge or the flexibility of the wires, creates intermittent fluid pressures within the joint. At the same time, actual mechanical loading of the joint is avoided. Early clinical investigations into this novel approach to ankle arthritis reported substantial symptomatic relief and even a radiographic increase in the joint space. Laboratory investigations also have provided some insight into its underlying scientific basis. Nevertheless, further research is necessary to answer questions regarding its exact mechanism of action, long-term efficacy, and optimal surgical technique.

2003

Clinical Benefit of Joint Distraction in the Treatment of Ankle Osteoarthritis

Osteoarthritis is a slowly progressing degenerative joint disorder that in most cases is diagnosed at a late stage of the disease because of a lack of early markers. When clinically evident, osteoarthritis is characterized by joint pain, tenderness, and limitation of movement. Additional characteristics include crepitus, variable degrees of inflammation without systemic effects, and, occasionally, effusion. Pain, joint deformation, and stiffness of the joint capsule may lead to severe restriction of function and long-term disability. Primary structural changes of osteoarthritis comprise destruction of the articular cartilage combined with changes in the subchondral bone. Development of radiographic subchondral sclerosis, bony outgrowth at the joint margins (osteophytes), and subchondral cysts (representing focal loss of bone) are characteristics of osteoarthritis.

Complications of Iliac Crest Graft and Bone Grafting Alternatives in Foot and Ankle Surgery

Orthopaedic surgeons frequently perform operations that require bone grafting to augment bone healing and thus aid in the success of a particular procedure. The iliac crest has long been regarded as the primary source of autologous bone, but other sources of autologous bone, such as the metaphyseal ends of the tibia and the calcaneus, have been used. As the procedures to retrieve bone developed, the associated complications have become apparent. Bone grafting alternatives have become more popular as as a way to avoid the morbidity that is associated with harvesting autologous bone. This article discusses the complications that are associated with obtaining autologous bone and reviews bone grafting alternatives and their associated problems.

Use of Allografts in the Management of Ankle Arthritis

The repair or reconstruction of articular cartilage defects of the tibiotalar joint continues to be one of the most difficult challenges in adult reconstructive orthopedics. Although degenerative arthrosis of the hip and knee occurs predominately in the older sedentary population, arthrosis of the tibiotalar joint is usually posttraumatic and occurs in the young patient. Although arthrodesis currently is considered the gold standard for end-stage arthrosis of the tibiotalar joint, functional limitations remain. In addition, complications rates have been reported to be as high as 60%. One major concern of arthrodesis about the ankle is secondary, progressive arthritis at the naviculocuneiform, calcanealcuboid, and tarsometatarsal joints. In a search for an alternative to arthrodesis, prosthetic replacement was greeted initially with enthusiasm. The first generation of total ankle arthroplasty demonstrated suboptimal long-term success, particularly in younger, active individuals. Second generation prosthetic designs are currently in trial in the United States, but long-term outcomes from these implants are not available. Autologous chondrocyte implantation and mosaicplasty have been described for osteochondral lesions of the talus, but donor site morbidity has been a concern. Furthermore, these techniques seem to be indicated only for relatively small, focal lesions and not for diffuse articular disease. This led us to examine fresh osteochondral shell allografting as an alternative procedure to arthrodesis or arthroplasty. One advantage of allografting is the ability to resurface lesions with extensive articular disease with anatomically appropriate, mature hyaline cartilage. Previous studies in the knee and hip showed that such osteochondral allografts were a viable alternative to arthrodesis, reconstructive arthroplasty, and other joint preserving procedures. Goals in the treatment of end-stage tibiotalar arthrosis with osteochondral allografting are relief of pain, preservation of function, and protection of adjacent joints from degenerative arthrosis. A review of the literature demonstrated limited experience with fresh osteochondral allografts in the tibiotalar joint. Gross recently reported on nine patients who had focal osteochondral lesions of the talus that were treated with fresh osteochondral allografting. Six of the nine (67%) allografts remained in situ with a mean survival of 11 years. The remaining three cases required fusion for resorption and fragmentation of the graft. The use of fresh osteochondral allografts for the treatment of diffuse end-stage ankle arthritis is unreported. Over the past several years, our institution has performed fresh tibiotalar shell osteochondral allografts as an alternative management strategy for end-stage ankle arthropathy and focal osteochondral disease.

2002

Joint Distraction as an Alternative for the Treatment of Osteoarthritis

Osteoarthritis, including osteoarthritis of the ankle, is diagnosed in the late stage of the disease in most cases because of a lack of early markers. When clinically evident, osteoarthritis is characterized by joint pain, tenderness, and limitation of movement. In addition, crepitus, occasionally effusion, and variable degrees of inflammation without systemic effects occur. Pain, joint deformation, and stiffness of the joint capsule may lead to severe restriction of function and disability in the long term.

2000

Potential of the Genetic Algorithm Neural Network in the Assessment of Gait Patterns in Ankle Arthrodesis

The aim of this study was to develop an empirical model of parameter-based gait data, based on an artificial neural network and a genetic algorithm, for the assessment of patients after ankle arthrodesis. Ground reaction force vectors were measured by force platforms during level walking. Nine force parameters expressed in percentage of body weight and their chronologic incidence of occurrence expressed in percentage of stance phase period were used in modeling. Ten healthy persons and ten patients who had solid arthrodesis of the ankle were recruited in this study for developing the model. By applying the genetic algorithm neural network, the percentage of correct classification was 98.8% and the subset of discriminant parameters was be reduced to 9 out of 18. These key parameters were mainly related to the loading response and propulsive phase. This indicates that there was a reduction in the abilities in cushion impact and push off in the patients after ankle arthrodesis. Finally, the relative distance (Dr) was defined in this study and used in two new patients’ examinations to demonstrate its clinical utility.

1998

Function of Stiff Joints May be Restored by Ilizarov Joint Distraction

Three patients with joint stiffness caused by trauma or infection are reported. The involved joints are the interphalangeal joint of the thumb, patellofemoral joint, and ankle joint. As an alternative for the indicated arthrodesis in these patients, treatment with articulating joint distraction was performed. By use of adapted Ilizarov external ring fixators, gradual distraction was applied to loosen the joint, followed after loosening by a period of exercise during distraction. In all three patients this experimental approach led to a decrease in pain and improvement of joint function that persisted for at least 2 years after treatment. With the use of Ilizarov joint distraction, joint function in cases of joint stiffness may be restored, and the need for an arthrodesis can be postponed.

Thromboembolism After Foot and Ankle Surgery: A Multicenter Study

Thromboembolic disease presents a potential fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studided and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperatovie thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.

1994

Can Ilizarov Joint Distraction Delay the Need for an Arthrodesis of the Ankle?

We applied joint distraction using an Ilizarov apparatus in 11 patients with post-traumatic osteoarthritis of the ankle to try to delay the need for an arthrodesis. Distraction for three months resulted in clinical improvement in pain and mobility for a mean of two years, with an increase in joint space. We considered that these effects may be produced by the absense of mechanical stress on the cartilage combined with the intra-articular hydrostatic pressures during distraction. We measured these pressures during walking with distraction, and found levels very similar to those reported to improve osteoarthritic cartilage when applied in vitro.

Preparing for Your First Surgery

2011-10-07T20:37:00.012-04:00

Quick Update on the Leg

Before my accident in February 2010, I had a couple of surgeries under my belt. However, none of them required the insane pain management we've had to experience with the last four surgeries.

Throughout these surgeries, Brooke and I have developed a process that helped us recover from three painful external fixator installations.

But before all of that, I wanted to give a quick update on the ankle. In fact, I'm not the one that was motivated today to take the pictures and video. I got an email this morning from Dr. Jeng.

How's it going over there? Need an update.

Working on a three day weekend? Dang!

The proximal k-wire on the lateral side is still acting up. Depending on the level of activity, we'll see a lot of clear and bloody drainage from the site. As you can see from the picture above, it's red and angry.

No scabs have formed on the site, so the skin moves around as I flex the shin muscles to move my foot up.

This video demonstrates how questionable this pin site is. The skin slips across the pin site fairly easily now, unlike the other pin sites.

When you get an external fixator, the medial side of your other ankle is going to occasionally take some abuse. I took a nice hit last night as I got off of the couch.

The pin sites are still sore after a long day of walking, and edema seems to be a growing problem the longer my ankle is relatively immobilized in this thing.

I'm definitely looking forward to the November 3rd removal.

Preparing for Your First Ex-Fix Surgery

1. Write down your questions. Come prepared.

Take time to brainstorm what you don't understand or know about your procedure and write down your questions. Print them out and bring them with you to your surgeon. If you're not going to see him until the day of the procedure, that's fine. Your surgeon will appreciate the work and effort you put in to show up prepared.

I had several questions during my surgeries. Because I had severe nerve damage, I usually asked about what to expect about neuropathy. With ankle distraction, your nerves will be stretched and nerve pain is a possible issue.

While I didn't end up with nerve pain, I did lose all sensation in my heel.

I also want to rehearse our game plan for pain management, so I usually make sure that things have been ordered and I'll wake up with a PCA. You might need to work with your nurse anesthetist or anesthesiologist and your surgeon about this.

2. It will hurt.

I'm sorry to say this, but it's going to hurt. It's a combination of swelling, stabbing, and a high amount of tension if it's a distraction arthroplasty. I've had surgeons and nurses tell me that ankle surgeries are one of the most painful.

The good news is if you're only getting an external fixator, it won't be that bad. If you're getting plates, screws, and bones internally fixated -- you're in for a wild ride.

Before you show up to the hospital, work with your surgeon, physician's assistant, or nurse practitioner to get a plan in place. It's always good to get things ordered going into surgery, like a dilaudid bolus when you're taken off of the PCA, and the appropriate oral pain medication as you are weened off of the bolus.

And because you're going to be on all of these pain medications, start taking Miralax a few days before you show up for the big day. Trust me. This is a good idea.

You'll also want to start asking for Benadryl early. The massive amounts of pain medications coursing through your veins will make your skin itch like crazy.

We always made sure I had a patient controlled analgesia (PCA) device hooked up to my IV. Usually, your surgeon will administer a nerve block under your leg to help with pain. As that wears off, you'll start to feel your ankle. Before the nerve block wears off, it's a good idea to get several PCA doses in your system.

3. Hospital physical therapy

If you've never had to use crutches, it might not be a bad idea to take a few lessons from the hospital physical therapist. Because I've been crutching for almost two years, I usually decline the hospital physical therapy offers.

4. Always stay ahead of pain

This is the most important thing to know about your surgery. That's why I ask for a PCA, a IV bolus on order, and oral medications of every kind. Don't mess around with pain.

Be honest and polite but stubborn with your nurse. Do not wait for the pain to get a little bit worse before asking for help. Do not get behind. If you're on oral medication, and you get behind on your pain, it might set you back to IV bolus dosages to catch back up.

That's a big set back.

Sometimes, when I ask a nurse for a bolus or something to help with pain, it feels like I'm getting into an argument. I tell my nurse I'm in pain (it's a 5 or 6 going on to a 7 out of 10), and she counters with, "there's nothing I can do."

This isn't always the case. There's always something we can do.

This is why it's so important to have every option available on order so your nurse doesn't need to bother your surgeon. My wife happens to be a nurse, and I've found that having her at my side to act as my squeaky wheel has really helped.

Just remember that the longer you're in pain, the longer you'll be staying in the hospital.

The same rule applies when you're at home. Once you get behind your pain, it takes a long time to catch up.

Preparing for Your First External Fixator

2011-10-02T13:56:00.037-04:00

Since the accident in February 2010, I've been through three external fixators. My wife and I have acquired unique knowledge and experience preparing for and living with one of these things for several months at a time.

There are primarily two areas where I think Brooke and I could provide some useful insight for someone about to get an external fixator:

Preparing your home for care and maintenance.
Preparing for your surgery.

Today we'll focus on what you're going to need to buy to prepare for life with an ex-fix. The prices I list here aren't necessarily what you'll run into -- I used Amazon.com for everything.

Before I go on, I should note that I'm not a doctor. My wife is a nurse -- studying to be a nurse practitioner -- but as always, you should consult with your surgeon on everything related to your ex-fix. We'll make another post in a few days to provide some ideas and questions to bring up with your surgeon to prepare for your surgery.

Here's the quick run down off my three external fixators. If you've been following this blog for a while, you can skip right past this section.

Ex-Fix Number One

Installed February 13th, 2010
Removed March 1st, 2010
Non-weight bearing

This is the first ex-fix I received following my accident. The surgeon in Colorado performed an ORIF on the fibula and used the ex-fix to stabilize the tibia fracture while the swelling improved. The large, softball-sized blood blister is a fracture blister.

After two surgeries, I ended up with two plates and nineteen screws.

Ex-Fix Number Two

Installed August 16th, 2010
Removed November 10th, 2010
Non-weight bearing

This ex-fix is my first Ilizarov frame. Due to the severity of my initial injury, and several complications, such as an infection, my fractures did not heal. Without knowing it -- you'd think the large amount of pain would have been an indication -- I was walking around and rehabbing on a fibila and tibia that had not healed. The two plates and screws in my ankle absorbed the majority of the stress from weight bearing. As a result, the fibula plate broke and several screws in the tibia plate snapped in half.

I still have a few broken halves of those screws hanging out in my tibia as a reminder.

Most of the broken pieces of plates and screws were removed from my ankle and a large piece of my pelvis was used as the missing puzzle piece to heal the non-union in my ankle. The ex-fix was used to hold everything in place.

Ex-Fix Number Three

Installed August 16th, 2011
Removal scheduled for November 3rd, 2011
Weight bearing and hinged for ankle movement when unlocked

Many of you are familiar with the situation surrounding the installation of this bad boy. Unfortunately, I ended up with an incomplete union from last year's ex-fix surgery.

My ankle is definitely a mess.

I'm trying out ankle distraction arthroplasty to see if we can address some of the severe osteoarthritis I developed after my second ex-fix was removed. It was also important to me to see the images of my ankle from the arthroscopic procedure. During our initial consultation, Dr. Jeng suggested the tibia bone was unhealthy and likely to incur numerous revision surgeries if any of the salvage options available to us, like a fusion or replacement, were attempted. I wanted him to go in and verify for himself that the bone was unhealthy.

After the surgery ended, he told us, "your ankle is terrible." That's what we expected, but we needed to know for sure.

Preparing For an External Fixator

Here's a gigantic list of things you're going to want and need to help adjust to life with an external fixator.

The Bathroom

The biggest adjustment you'll probably make will be in the bathroom. Below is an essential items list.

Total: $66.99

The plumber's tape is needed to make sure the seal is water tight when you install the shower head. Having a nice long hose is absolutely crucial. I started out putting trash bags over my ex-fix, but that adds a good half hour of time to showers. I learned eventually you can just place your ex-fix out of the tub and use the shower curtains to hold the water in around your leg.

I also used a small stool to prop up my leg when I used the toilet. I needed that, however, because my initial injury was too severe to not somehow elevate my leg at all times. I don't think most people will need that setup.

Sitting, Sleeping, and Getting Around

Get ready to learn how to sleep on your back if you're not already comfortable doing that.

Wedged pillow - $24.99
Aluminum reacher with magnetic tip - $16.13
Ice packs - $6.95
Replacement crutch tips - $8.99

Total: $57.06

As your pin sites heal, you should start experimenting with sleeping on your side and stomach. Don't be afraid to rest your ex-fix on top of your half screws. I do it regularly without any issues.

We used wedge pillows for a while to help elevate my ankle, but two pillows ought to be enough for your ankle.

The picture above is from March 2010. I ended up not using the long grabbers that much. This is more of a novelty item. I'd encourage you to just get up and do it yourself. Always find excuses to motivate yourself to get up and exercise.

Also notice I have a giant water container nearby. This is huge. While I said getting up is always good, having a giant water bottle nearby is essential.

Keep in mind that you'll be moving from your bedroom to your living room. It can be a pain in the butt to carry pillows back and forth, so doubling up on pillows is not a bad idea. The bottom line is it's time to stock up on pillows.

But stock up on even more ice packs.

I have tried several types of ice packs -- including bags of frozen vegetables. I think the best option is gel packs. Just make sure you don't have direct skin contact with the ice packs.

Renting a wheel chair is awesome. I usually rent one through my insurance before surgery and keep it the entire time I have the ex-fix. This allows me to go on walks with my wife at night when we let the dog out. Check out your insurance first, but for several months I'll only end up paying about $40.

However, it's extremely important to avoid relying on a wheel chair to get around. You want to focus on building up your crutching strength and endurance. The more you use the chair, the harder it will be to crutch around and get your strength back. Only use the chair for those times when you're going out and aren't sure whether a seat is guaranteed -- like a bar or a ball game.

Lastly, I've gone through uncountable sets of crutches. The tread usually wears out after six weeks if you're using your crutches for eight to ten hours a day. Replacement tips are essential. Always check your crutches for wear and tear. It can be extremely dangerous to crutch on worn out tread.

Pin Site Care

Depending on how long you have an ex-fix, pin site care can be one of the more expensive aspects to life with an erector set around your ankle. If you've got a flexible spending account through work or some other means, it's time to put it to work.

Also, as I've said before, always ask your surgeon about what he or she prefers you do for pin site care and management. Let me first give you a list and then we'll talk about a few of these items. Some of them are obvious (latex gloves), while others are not.

Total: $169.27

The stretch bands are awesome for keeping your toes loose. Once you're in an ex-fix, the tendons under your foot will tighten up as they atrophy. Run this by your surgeon, but if you get an ex-fix that you can walk on, these bands are also useful to help ensure you don't stub your toes as you walk.

Another thing to ask your surgeon is whether you can take a shower with your ex-fix. I was unable to do this with my first and third ex-fix, so skin care and maintenance became something for us to focus on. Scrubbing the dead skin off your leg and keeping it clean and healthy is crucial. Just make sure you don't start peeling skin away from new skin. If it isn't flaking off on its own, it isn't ready to come off.

We've never used xeroform around our pin sites. That stuff is fairly expensive, but it's a good way to keep bacteria out of the pin site while a scab and crust builds up around the pin.

When you get your ex-fix removed, a tennis ball is awesome at loosening up the tendons under your foot and stretching out your toes. I keep one at work to roll my foot on while I'm sitting at the computer.

One thing I didn't list above was a Dynasplint.

The idea behind this splint is to give you a slow and steady stretch while you sleep. Here you see the Dynasplint configured to improve my dorsiflexion while I sleep. You'll have to work with your surgeon or physical therapist to get one of these. I never got to a point where I could go a whole night with this thing on. However, this was during the period of time when I was walking on a broken ankle.

Lastly, managing the infinite number of medications, shots, laxatives, and more medications you'll have to take on regular schedules can be difficult. I recommend you put them on a Google Calendar and set your phone to remind you when something is due.

So that's just a little bit of insight from our experience. Our next post will provide some details on how to prepare for your surgery and what questions to ask your surgeon. It's always important to keep in mind that even though your surgeon works for you, you have to come to each appointment prepared.

I usually showed up with an iPad with pictures and a list of questions. If your surgeon sees that you're putting work into the relationship, he or she is more likely to appreciate your attitude and reciprocate the attention and focus.

I found a few links related to pin site care. While these aren't specifically for ankle external fixators, the principles are still the same.

The Nutcracker and Different Strokes

2011-10-01T23:44:00.013-04:00

Friday was the first day to bear weight on the ex-fix while I walked around work from meeting to meeting to meeting to meeting to meeting. As the day progressed, I noticed a common theme throughout the many comments my co-workers were making.

"Tony, I think you're leg is bleeding."

Sure enough, they were right. Both sides of the proximal k-wire were draining much more fluid than normal.

I threw my leg up on my desk and rested it on the two black metal circles surrounding my leg to try and get a better look when I made two important observations:

When my ex-fix hit the desk, the metal circle around my leg moved, bending the k-wire by several millimeters.
The nut attached to a screw holding the metal circle to the large half screw in my leg was loose. In fact, when I touched it, it only took two spins for it to fall off of the screw.

This was a eureka moment. It explains the sounds and pin site agitation I've been having for the last few weeks. I imagine I knocked this nut loose after a small fall a few weeks ago. Because the metal circle was no longer held in place tightly around my leg, it was free to move and bend the k-wire as I walked around.

I neglected to blog about the fall because a) it's embarrassing, and b) my parents would freak out.

I called up Dr. Jeng, again on a Friday afternoon, again late in the day, and he called me back at work to talk me through the problem. I explained the situation and he instructed that, when I got home, I needed to grab a size 10 wrench and get to work stabilizing my ex-fix.

This guy rules.

He also wanted to see pictures of the bleeding and the loose nut to evaluate the situation.

While I've got a good collection of tools, I only have one wrench. And, I think I stole it or neglected to return it to my Dad when I moved out of the house for college (sorry, Dad). Turns out, it was the right size for the problem at hand -- a size 10!

We examined the pin sites on both the medial and lateral sides to see if there were any problems. The movement of the k-wire all day had broken up the scabs and caused the bleeding, so it's a minor setback.

After sending the pictures over to Dr. Jeng, he responded:

Looks good. watch pins closely over next couple of days. hopefully should cool off after the frame has been better stabilized.

Now that the ex-fix is stabilized, it feels much better to walk around in it.

Before I continue on with an extremely funny anecdotal story from last night, I wanted to let some of you know that I will be making a few detailed posts in the coming days on what you need to do to prepare for an external fixator and for surgery. My wife is an ICU nurse, so I've been lucky to have her experience and knowledge. If she hadn't been around, I would have been clueless. So stay tuned.

Now on to last night's story.

These are three of our good friends, from left to right, Crystal, Alison, and Katy.

The guy in the Adidas shirt is Paul. He's dating our friend Michelle, the blond to the right behind Katy. These pictures were taking during Alison's surprise going away party last weekend.

Last night, our friend Binoy, shown here celebrating a touchdown pass for the Buffalo Bills, threw another going away party for Alison. At some point in the night, I'm not sure when, Katy, the Union Boss of the circle of girl friends up here, decided to pull a fast one on Crystal.

She told Crystal that Paul used to be a child actor on a TV show, Different Strokes.

Crystal bit immediately.

No one in our group of friends, except for maybe Troy, is old enough to remember this show. I had no idea what the show was about or who was on it.

Throughout the night, Katy colluded with several of our friends, including Crystal's wife, Troy, to help build the case. Even Paul got in on it, telling Crystal that his parents forced him to be a child actor on this show.

Troy , who is originally from Australia, solidified the belief when he explained to Crystal that while growing up in Australia, he received two TV channels. One of them only showed American shows, including Different Strokes.

"I think that's Dudley, the neighbor."

I helped out by drafting up an email to a friend to brag about how I was at a party with an actor from Different Strokes. Before I sent this fake email, I showed it to Crystal and asked her, "I heard there was someone here from an old TV show, Different Strokes?"

Instead of saying she didn't believe it, she instantly started bragging about how smart Troy is.

"Oh yeah! And Troy even picked him out as the neighbor, Dudley, because he watched it growing up."

Needless to say, we were all having a blast with this.

Not having seen the show, I was curious to see how closely Paul resembled this character, Dudley. It was time for Google.

As you can clearly see, the answer is a resounding, "nope." Dudley was played by an actor named Shavar Ross. Shavar, as you can plainly see, is black. Paul, as you can plainly see, is white. There is absolutely no resemblance between Paul and Shavar.

Katy, Troy, and I laughed for approximately twenty minutes before we could get ourselves composed. We were all in tears.

This evening, I brought it up again with Crystal. I asked her, "you should look up Paul on the internet to see when he was on that show, Different Strokes."

About two minutes later.

"Dudley's black!"

We all started laughing for about another twenty minutes -- except for poor Crystal.

As Crystal discovered the extent of the prank, Troy was sent to the dog house for playing an integral role in pulling the wool over Crystal's eyes. He's facing a $50 marital fine. I told him I could help arbitrate and get his fine reduced.

Man, I love my friends.

Response to Your Comments

2011-09-29T20:27:00.005-04:00

First, you'll notice I've switched back to the original blog design I made last year. The new stuff just isn't ready.

I wanted to take some time to respond to some comments people have made.

Dear expert snowboarder, I'm also thinking about the distraction surgery. I fractured my talus 5 years ago and I recently had my achilles tendon lengthened in hopes that it would allow for more ROM,but instead I just have horrible arthritis pain and I limp constantly. Thank you for your blog! I also have been blogging about my experience...it really helps knowing that you aren't alone. Keep up the good work!

Thanks for the awesome feedback! I think ankle distraction arthroplasty could definitely buy you some time, but from what I understand, we're on the clock once the ex-fix is removed. I'd ask your surgeon what to expect 5, 10, and 20 years from now. I'd also discuss other salvage options, like replacement and fusion, if your bone quality is good and you're at the right age. I believe I've got an earlier post of a few long videos on the current medial treatment protocols for ankle arthritis.

My surgeon, Dr. Jeng, suggested that almost all patients develop arthritis again at some point after this procedure. However, some patients may not have nearly as much pain for the rest of their lives. From what I understand, this is a relatively new procedure, especially in the United States, so there isn't much data out there on patient outcomes. My surgeon said he sees about a 30% to 40% success rate in terms of pain reduction after an ankle distraction arthroplasty.

I think age comes into play here as well. I'm only 29 and my wife and I have not started a family. We want to minimize surgeries and minimize pain so we can get on our with lives. We decided several months ago to get an amputation at some point and, fortunately, our surgeon agrees that I'm a good candidate for one.

Because of the severity of the initial injury and the complications I ran into (infections, non-unions, etc.), salvage options like an ankle fusion or replacement are more likely to fail and require more revision surgeries on my ankle. A fusion also reduces your range of motion, causing stress on the adjacent joints. Not only am I too young for these options, my tibia bone is in rough shape, indicating that these salvage options put me at a higher risk of failures and revision surgeries.

Good luck to you. Stay in touch and feel free to ask any other questions.

Hey there... Thanks so much for your blog. Here's my story -- Tib/Fib break jumping off a pier in 2001 when I was 17. Four surgeries later and my doc says I have the ankle of an 80 year old. She said she would recommend I have a fusion if I wasn't so young. My pain is pretty under control (I can function most days) but I have really limited ROM. Like between 3 and 5 degrees passive dorsiflexion and 10 or 15 degrees active plantar flexion. The new doc I just saw today said that he would recommend distraction arthroplasty (that's how I found your blog -- journal articles are a bit dry and don't convey some of the important recovery bits). I have read that DA is for folks with decent ROM. What was your ROM before the surgery? I am wondering if I have enough ROM to be a good candidate. I am also struggling with the idea of a long recovery since I'm in the midst of a doctoral program. Any advice/info? PLEASE keep posting! Kate

I also read that ROM needed to be very good. At my high point in March, I hit 11 degrees dorsiflexion. However, when I saw Dr. Jeng at Mercy, there's no way I was more than 5 degrees. I think Dr. Jeng moved the universal joints around so that I could get more plantarflexion out of my movement.

Since I'm quickly moving into year two of this recovery, I know exactly what you're afraid of. I quickly got into "crutching shape," so I could fly around and keep up my endurance. I also kept my wheelchair rental for the entire duration of this recovery for going out to events and parties where I know it'll be hard to find a place to sit down and prop up my leg.

The second thing that is important is having friends in the workplace or on campus to give you rides. I rely on several friends to get to work since my right ankle is in the external fixator. You might be able to drive around if it's your left ankle. I tried to show my wife that I could drive with my left foot, but she shot me down!

The third thing that's helped me, above all else, is my wife. She's picked up the slack on everything I've been unable to do, and without her, there's no way I could have survived the recovery at this point.

It sounds like you might be a good candidate for ankle distraction if you're not having much pain right now. Also remember that you can walk on it. I was out of work for about three weeks, but that was because we did a very poor job coordinating pain management ahead of time with our surgical team.

If you get the surgery, work with your surgical team to get all of your pain management ordered ahead of time. Definitely get a PCA. Get Dilaudid bolus on order for when you're taken off the PCA and get the oral pain meds ordered as well. Overdo it like crazy so you don't have to fight with nurses to call doctors late at night to get an order or approval. We did this for my second exfix last year, and because my pain was so well managed, I was able to return to work within about two weeks. Once your pain is under control, you're allowed to leave the hospital. This seems like the best way to guarantee your hospital stay is short.

With that said, this exfix was definitely more painful than my second one last year. The tension placed on the joint is hardcore, so that might have contributed to my slower return to work. Also, I struggle with pain every night after walking on it all day at work. The combination of walking around to meetings eight hours a day and not propping it up to prevent edema probably contributes to all of my pain. I take Percocet at night to help with that pain.

If you've never had an external fixator, I also recommend Valium. When your muscles atrophy, they'll spasm. You'll sometimes get a, "slamming the brake," spasm in your foot, and if your ex-fix isn't open, that'll hurt. Valium helps with this quite a bit.

I also recommend you meet or talk to a physical therapist to get a few exercises down that you can do with the ex-fix to do your best at addressing atrophy. Try emailing the physical therapist I used at C.O.R.E. Physical Therapy, Kim Stepien, here in DC. Just say Tony referred you and ask for a few examples of things you can do while you're in the ex-fix.

Do you have digital copies of your X-Rays? Are they in dicom format? If so, you can use free PAX tools to measure the distance in your joint. The more space you've got, the more I'd recommend you get the procedure. Keep in mind, though, that I'm not a doctor. Just a computer scientist. If you get stuck, I don't mind taking them and measuring the distance for you. Your surgeon, though, might be able to do this for you.

I hope everything goes well! Please keep us updated on how things go and, as always, if you have any other questions, just comment away and I'll get back to you.

Tony, I'm a 39 year old male and I currently have an ex-fix on my ankle as well since 8/11/11. The day after surgery I was able to stand on it and walk with it. I take Vicodin for the pain, no real probs for the first 2 weeks but once I started making the adjustments it got more difficult to walk around because of the pain. It is difficult to sleep at night but I find that hanging my leg off the bed helps me sleep for a few hours before I have to readjust again. Although it has been a challange I am optimistic that I will get good results and pray for the best. I hope that you are able to recover and get back on a board, because my passion is in cycling and it has me sidelined since the surgery. Keeping you in my prayers.

Thank you so much for keeping us in your prayers. I'd talk to your family physician about getting a drug called Flexeril. I ended up doing this when we thought the Valium I was taking was causing my four-day hiccup binge (turns out it was probably just the combination of all of the drugs plus the way I was sitting). This is a hard core muscle relaxer that is guaranteed to help you sleep for at least eight hours. Buy a pill cutter in case it's too much. I highly recommend this if you're having problems sleep.

I also learned to sleep on my back when I had my initial accident. Propping it up on one or two pillows helps, as well. I like to sleep on my left side occasionally, so I'll also occasionally put a pillow below my right knee.

I'm also hoping to return to cycling as soon as this ex-fix is removed. Snowboarding is the end goal, but cycling was something I got into a few weeks before my arthritis got to the point of forcing me to get this surgery.

Good luck to all of you and please stay in touch to let us know how everything goes. We're a tiny community, I imagine, but we can learn from each other. I started this blog to just keep my friends and family up to date, but I'm beyond ecstatic to see that we can use this blog to communicate with one another and help each other out.

The bottom line for all of you is find the right surgeon. I've had three so far. For this fourth surgery, I talked to three surgeons. In fact, Dr. Jeng's first words to me were, "so I'm the tie breaker?"

Credentials matter, but patient interaction is more important. Does your surgeon feel rushed when he sees you? That's a bad sign. Does he stick around until you're done asking questions? That's a great sign. This idea was the reason I switched to Dr. Jeng at Mercy in Baltimore. When I first met him, I felt like he came into work that day only to see me and my ankle.

His awesome attitude is what led him to working with me on my infection last week through email, Picasa, and YouTube only -- no visits! Every day, including weekends, I was sending him high resolution video and picture updates, and Dr. Jeng was emailing me ideas, thoughts, and instructions every day.

Again, good luck to all of you. Let's stay in touch. If you want, let me know who your surgeons are and I can speak to Dr. Jeng about them. He and his clinic at Mercy seem to be fairly popular on the East Coast, so I'll be more than happy to ask him about his thoughts on your doctors. He told me that one of the surgeons I had seen was insane for recommending an ankle replacement, so he's definitely going to be honest.

The bottom line is to stay positive and keep a good attitude. Some days it comes naturally, and some days you have to force it. Lean on your friends, force yourself to go out, and talk to people about how you're feeling.

I'm all ears.

Walk This Way

2011-09-29T20:05:00.002-04:00

The pin sites are looking great. They've scabbed up nicely and there is no more drainage. Today, Dr. Clifford Jeng gave me approval to begin walking on and moving the external fixator again. This is great news.

Here are a few pictures of the pin sites taken today.

I've streamlined pin site management and care down to the bare essentials.

Scissors, tape, latex gloves, rolled gauze, saline wound wash, large gauze pads, hand sanitizer, and a TV remote control.

Here's a video I took today trying to produce some drainage around one of my pin sites. As you can see, it's bone dry!

I've also successfully captured an awesome noise that my external fixator makes depending on how I bear weight on one of the rings around the proximal part of my tibia. I sent this off to Dr. Jeng this evening to prove I'm not crazy.

Don't worry, it does not hurt. I'll have to keep an eye out on it as I start walking again.

Now I just get to sit back and start annoying my wife again with constant ankle movement while I sit on the couch.

Design Change

2011-09-28T23:49:00.001-04:00

You might notice we've got a new design for the blog. It's been a while since I've changed it, so I'm going to be doing some experimenting over the next several days. Please feel free to provide any feedback you may have on the changes!

I've also received several comments from other people following the blog and checking out my YouTube Channel thinking about getting an ankle distraction arthroplasty procedure. I will make sure to respond to each and every one of you shortly. Thank you for your support and kind words!

Quick update on the ankle. I've been sending daily updates to Dr. Jeng so we could monitor the infection situation. The good news is that the pin sites are improving dramatically. Click on the Picasa web album above to see more gross, but better, images.

The bad news is we might have a loose k-wire. I've been in discussions with Dr. Jeng about some movement in the frame, so he and I have been talking about meeting up again before my November 3rd removal to see what's going on. We'll keep you posted!

Football Disappointments, Infection Progress, and Surprises!

2011-09-27T00:17:00.017-04:00

The Redskins are my team. I'm from Oklahoma. I despise Texas with a passion.

It was a natural fit to become a Redskins fan when I moved here.

Tonight was the big rivalry game at Dallas, so we hosted a watch party with our friends. If you don't know me, I tend to -- prematurely boast our wins. Tonight, I created a "Cowboys Excuses Box," for the two Cowboys fans to write excuses on paper for why they didn't win.

At the end of the game, we'd draw one of the excuses and that would decide why the Cowboy's lost.

I even created Troy and myself custom coffee mugs.

Here you see the Redskins arrow through the Cowboys star, and Jerry Jones, the gregarious owner of the Cowboys, picking his nose.

Here you see the other two pictures on the mug.

On top, Tony Romo is crying about something. I'm not sure what, because there are a million pictures of Romo crying about something on the Internet. I'm assuming it's because he just heard R.E.M broke up.

The other picture at the bottom is of our good friend Binoy. While he's a Dallas Cowboys fan, we decided to make him a custom Buffalo Bills jersey earlier this year.

Here's the quick story behind that. The number on the jersey is Scott Norwood's, the kicker for the Bills infamous for missing a 47 yarder wide right that cost he Bills the Super Bowl. There are daily situations, such as a failure to successfully parallel park, when we tell Binoy, "ooooh, wide right."

The name, "Hands," is a nick name that Binoy claims was given to him in collegiate flag football for having great hands as a wide receiver. No one has been able to corroborate this story, and Binoy has declined offers to display his talents in a mock combine.

Because of the overwhelming lack of evidence to support the validity of the nickname, we decided to start routinely calling Binoy, "Hands," to remind him that he should never make such claims without the ability to back them up.

The other half of the mug is the Redskins' fight song.

Unfortunately, we didn't get to sing the fight song much tonight after the Cowboys beat us with only field goals. It's embarrassing. I haven't stopped receiving text messages from Binoy and Crystal.

So, the ankle. How's it doing?

Much better -- all due to Dr. Jeng. I am convinced you cannot find a better doctor than Dr. Cliff Jeng. Since Friday evening, when we first discovered a potential issue, he has been in daily contact with us over email.

Each day, I take high resolution images of my leg before and after cleaning it. I upload them to a Picasa web album and send Cliff an email with a brief description of the changes, improvements, and any new developments of the pin site situation.

Here's how it's gone so far.

Friday, September 23rd

I spoke with Dr. Jeng on the phone Friday evening. He asked that I start sending him daily updates through Picasa. Here was what we found that concerned us.

Saturday, September 24th

On Saturday, things were looking a bit worse. Dr. Jeng emailed us back after seeing both sets of images.

All right. Sounds like not getting any better. Give me a pharmacy number and I will call in some augmentin tomorrow. Stop duricef and start augmentin. Eat yogurt so you dont get the runs. Updates daily. Are you allergic to anything?

It's difficult to name a doctor that's worked on a weekend with a patient like this -- every day!

He works up in Baltimore. I live in D.C. We're working on a possible infection together using the Internet on the weekend. He's calling in drugs on a Sunday when most surgeons are watching football and relaxing.

Who knows, twenty years ago I might have waited the weekend, maybe longer, before seeing someone -- and by then it would have been much worse.

Oh, and, yes, I have stocked up on yogurt. He was absolutely correct on that one.

Sunday, September 25th

By Sunday I had the new antibiotic. The new pin site management we employed seems to have helped. The doctor's orders to discontinue weight bearing and ankle mobility exercises also helped reduce the stress on the pin sites.

After seeing this series of pictures and notes, Dr. Jeng commented:

From what I can see not too bad. The augmentin should kick in by tomorrow. Not too worried...

Monday, September 26th

Today looked even better. Here was Dr. Jeng's comment this evening:

looks good. cute dog. once pins are quiet lets begin weight bearing and Range of motion again.

I'm super pumped about getting back on my ankle and moving it around again. I forgot how frustrating it is to wear an external fixator without bearing weight or getting a chance to move your foot.

Did I say how awesome Dr. Jeng is?

While we were doing all of this work on Sunday, we threw a surprise going away party for our good friend Alison. We secretly coordinated a massive gathering at our party room and awaited her arrival.

Alison ended up being late, so our first attempt at a surprise was a false alarm. She went downstairs to get some orange juice for what she thought was a girl's brunch.

Here was the real surprised Alison. We totally got her! She had no idea.

We had a great show of support and we're really going to miss having Alison around. She's awesome, and I'm not just saying that because she won the inaugural Injured Tony Award last year.

And finally, thanks for sending the cookies, Mom and Dad! Brooke has hidden them from me, probably in a place I cannot reach. But from what I hear, they are still delicious.

Drainage: Day Two

2011-09-24T19:32:00.010-04:00

It's been twenty-four hours since we first discovered drainage from two pin sites. Dr. Jeng asked us to send him daily updates, so let's take a look and see where we're at.

The area shown above is the primary area of concern. All of the wires and screws you see here are in close proximity to one another. All of them are in the tibia. And all of them are near the site of a possible future amputation.

After a quick examination, the first thing we noticed was a new, third drainage site. The dressing from last night was stained around this pin on the lateral side of my leg, suggesting the drainage had not stopped since last night. We didn't need to do any squeezing of the skin nearby to produce this drainage. As you can see, this is a slightly different type of fluid draining from the pin site than the other two from yesterday. This pin is on the lateral (outside) of my leg and the most proximal (closest to the core of my body).

Brooke was not too concerned about this new drainage, primarily because of its color and its consistency.

I trust her judgement for a three reasons:

She's my wife and I'm obligated to trust her judgement.
She's been in school for a few years to become a nurse practitioner.
She recently and successfully diagnosed someone with genital warts instead of herpes when the rest of her class group incorrectly believed it to be herpes. I'm not sure how that applies to this situation, but, in my book, her ability to correctly diagnose disease is a good reason to trust her.

The picture above is the most proximal k-wire on the medial side (the small wire at the top of my leg on the inside). After squeezing the skin around the site, the same type of fluid we saw yesterday emerged.

I have been discouraged from referring to this liquid as yogurt.

This site concerns me the most of the other two. There is very little "meat," between the pin site and my tibia -- which means very little tissue for an infection to traverse before reaching the bone.

Same k-wire picture from above but a different angle. This time I made to sure to wear my latex gloves and had Brooke take all of the pictures.

The second-most proximal k-wire on the medial side is also continuing to drain the white, sticky fluid. It's the same amount as yesterday.

The odd thing about trying to squeeze out fluid from this particular pin site is that it feels like a giant reservoir of this fluid is sitting just underneath and around this pin.

Now, I imagine that many of you refused to watch yesterday's drainage video -- because, well, it's gross. I've modified this video a little bit to make it easier to watch.

Make sure your volume is not on mute.

This is probably the first video on the internet of someone draining infected bodily fluids out of a pin site to the tune of Benny Hill.

You might be wondering at this point, "why is his skin brown and disgusting looking?"

You have made a valid point. We've not washed the skin around the pin sites since the surgery on August 15th. Dr. Jeng preferred we keep the site clean with weekly iodine soaked gauze pads.

How does it smell?

Ask Spunky, she's the expert on bad smells.

After seeing the pin site drainage, Dr. Jeng has asked that we revert to the pin site care and management we used last year -- but without using running water. After draining as much fluid as we could, we spent a lot of time cleaning the pins and the skin around each site.

To clean the skin around the pins, we used something called a chlorascrub. It's extremely important to clean the skin around the pin sites. Bacteria love places that never get washed.

Here are a few pictures after we spent some time cleaning the skin. This gives you a more clear indication of how the skin is doing around the sites.

This is the second-most proximal pin site from the medial side after it's been cleaned. The skin around the site still looks good. The skin is also not warm to the touch compared to the rest of my leg, which is always a good indication of no infection.

Here's the same pin site from the top. After cleaning the skin around the site, it looks better. The skin just around the pin is a bit red, but, as Dr. Jeng said yesterday, it isn't angry.

Here's a view from the bottom of the most proximal k-wire on the medial side after it was cleaned with a chlorascrub.

Here's a view from the top of the most proximal k-wire on the medial side after it's been cleaned.

And finally, here's a view of the same proximal k-wire from the lateral side. The skin looks good, which is always a good sign.

Here's a view from a different angle of the lateral side of the proximal k-wire.

After examining the pin sites and cleaning the skin, we wrapped up the area with several two-inch flexible dressings. We've stopped using iodine soaked gauze pads since they could be caustic enough to cause some of the irritation of the sites we're seeing.

The game plan is to continue monitoring the situation until we've finished the Duricef antibiotic run Tuesday morning and to keep in touch with Dr. Jeng.

Brooke and I are going to go back to watching Tulsa get destroyed by Boise St.

Looking for Some Breaks to Catch -- Got Any?

2011-09-23T16:54:00.015-04:00

Ladies and gentlemen, uhhh, this is your Tree-Hitting Snowboarder speaking. Please, uhhh, return to your seats and fasten your seat belts. Remain calm. There is absolutely nothing to, uhhh, worry about. This is just standard operating procedure. Our systems indicate that, what we refer to as a rough patch, is heading right for us, and, uhhh, there's a slight chance our ankle recovery could crash and burn spectacularly. Thank you.

This was one of those blog posts where I had to call Mom and Dad first to help manage some expectations. Otherwise, the phone line would be busy until the cows come home.

Before we go any further, there's no need for you to freak out.

Well, not yet.

Here, just let me quickly summarize what you're about to read: the first act will be scary, the second act will be scary but optimistic, and the third act will leave you hanging until the sequel comes out.

Like some sequels, it could be totally awesome -- perfect example: The Dark Knight.

But, like other sequels, it could be absolutely awful -- see Speed 2: Cruise Control.

Yes. This movie actually exists. This is probably the first time you've heard about it. It was that bad. Or, at least, so I've heard.

Act One

Today I stayed home from work to wait for a repair guy to fix a minor leak in our air conditioner. Since my accident, I've always payed careful attention to how much annual and sick leave I use. Each hour I use is a serious decision.

After the technician did an excellent job fixing the small leak (thank you, Fry Plumbing), I decided to change my dressing several days early. Due to some new pain, I wanted to get a good look at a few troublesome pin sites. The pain is not unbearable, but after a long day of walking on pins (no needles), I have to resort to my pain management medication. Moreover, I can no longer walk without crutches due to the pain.

These are significant changes in a matter of a few days. That's usually not a good sign.

Unfortunately, removing the dressing revealed drainage in two k-wires in the top of my tibia on the medial side (the inner side of my leg).

Drainage from a pin site can mean many things. It could be from agitation from pin movement or skin movement around the pin, it could be fluid build-up from the initial trauma of the surgery six weeks ago, or -- in a worst case scenario -- the fluid could indicate an infection.

The drainage was very minimal, but as I poked around the skin, it felt like a water bed underneath my skin. It was time to use some skills I picked up as a teenager and play, "Pop That Zit." As you can see in the picture above, a small amount of warm, sticky yogurt oozed out of the pin site.

This is your Tree-Hitting Snowboarder again, reminding you that, uhhh, we've conveniently placed barf bags in the seat pocket in front of you.

I'll give you a few moments. When I squeezed that bad boy, I had to take a few minutes myself to recover. Two years ago, I would have fainted after getting my blood drawn. Now, I'm pushing bodily fluids out of metal wires sticking through my tibia, muscle, and skin on both sides of my leg.

Back to the yogurt. As an experienced external fixator wearer, pin site yogurt is a red flag. Immediate action is necessary: continued squeezing and popping to see what other items emerge from the pin site.

I'm was hoping for something awesome and better than pin site yogurt. As you are probably well aware, pin site yogurt serves no purpose in life. I can't sell it on eBay and I can't trade it to replace Arian Foster on my fantasy football roster.

After more squeezing, not much more fluid came out. Without Brooke at home, I quickly assembled an action plan. I decided to examine all of my pin sites, take high quality pictures of questionable areas, and contact my surgeon, Dr. Jeng.

Here are several pictures of the same pin site on the medial side of my leg.

After thoroughly documenting this pin site, I noticed that the most proximal k-wire on the medial side was also oozing the same type of fluid -- without any application of my super zit popping techniques.

The skin around both pin sites looks good -- the oozing, along with the pain while bearing weight, appear to be the only two symptoms at the moment.

Both k-wires on the lateral side of my leg seemed fine. There was a bit of redness around the most proximal k-wire, but no yogurt.

Act Two

After taking pictures and uploading them to a Picasa Web Album, I called up Dr. Jeng's surgical coordinator, Denise, to let her know about the new pin site drainage. Because it was so late on Friday, I was expecting I'd have to leave a message and wait until Monday to hear back -- if I was lucky.

But that's not what happened at all. Denise quickly tracked down Dr. Jeng in the office and we spoke on the phone for a while. This was late in the day -- around 4:30PM -- and here's Dr. Jeng taking time out of his busy schedule to discuss my concern.

This is the type of doctor all others should emulate.

Dr. Jeng asked me to email him my web album to his personal email address so he could take a look. He insisted the pictures be taken with a high resolution camera with adequate lighting. He also instructed me to stop bearing weight and to stop moving the ankle.

While I waited for Dr. Jeng to review the images, I tried my best to ward off the Eeyore mood. Sometimes a good mood just comes to you naturally, and sometimes you've got to force it. Either way, bad attitudes can be detrimental to a recovery.

But the Eeyore thoughts were racing through my head. I could live with a pin site infection anywhere on my foot -- but a pin site infection in the same part of my tibia where a future amputation will take place is bone chillingly frightening.

That part of my leg needs to be pristine.

I eventually kicked Eeyore's tail out of my head when I realized how lucky I was to have taken the day off. If I hadn't, I would never have caught Dr. Jeng on the phone. And, how awesome was it that Dr. Jeng was willing to take time away from the end of his work week to work with me over the Internet?

Pay attention, doctors -- this is the right way to do things.

Act Three

Dr. Jeng called me a few hours later after reviewing the pictures. He said he was encouraged that the skin around the pin sites did not, "look angry." He asked if I had taken a shower with it yet. I had not.

Dr. Jeng really did not want us to put the pin sites under running water due to a study his old roommate did on shower head bacteria.

He asked if the pin sites and pain had improved since we started the Duricef on Tuesday, and I replied that it had either stayed the same or had gotten worse.

Dr. Jeng told me that, fortunately, k-wires are extremely easy to replace in case this ends up being an infection. He reminded me that I should have enough antibiotics left to last me until the beginning of next week.

Being the awesome surgeon that he is, Dr. Jeng wants to see daily updates. I'll have to take photos and videos of the pin sites so he can track the progress over the weekend.

That's the kind of care, concern, and professionalism that inspires awe.

Dr. Jeng is awesome.

So, stay tuned for the sequel. We'll keep tracking the pin sites and work with Dr. Jeng this weekend to see if we notice any improvements. In the meantime, I'm no longer bearing weight and I'm no longer moving my ankle. While this will slow down any cartilage growth opportunities, it's worth the sacrifice to prevent an infection in this part of my tibia.

One of my good friends told me today that I just can't seem to catch a break. If anyone's got one, please email it over or fax it. I need a couple. And while this might be bad news, it's helped show us that we've picked the right surgeon.

It takes a special person to work with someone as annoying as me over the weekend during college and professional football season.

Maybe Dr. Jeng is willing to give up Adrian Peterson for some yogurt.

Snowboarder vs. The Million Dollar Idea

2011-09-20T18:37:00.014-04:00

Last night was my first night to go out with friends after work. It was my friend Scott's 26th birthday, so I decided to dust off my old sweet dance moves and bring them back out to liven the party.

These moves can be performed with and without an ankle injury.

This morning I had my second follow-up visit with Dr. Jeng. This time around, we remembered a thumb drive to bring back the X-Ray and arthroscopic images taken during my surgery.

My ex-fix will be removed on Thursday, November 3rd -- just around the corner. I was not able to convince Dr. Jeng to let me stay awake and take video during the procedure this time -- he thinks it'd be too painful.

But I was persistent -- or, more likely, I was annoying -- and got him to meet me half way. He conceded that I could setup a video camera on a tripod during the removal procedure. Hopefully we can get him to provide some good narration to provide some educational value and insights in addition to the awesome gore we'll see when the wires and screws are removed from my leg and my ankle snaps back 5mm into its socket.

Now on to the pictures from the August 15th surgery.

You can see how much space the distraction therapy adds to the joint. We haven't seen that much space in my ankle in almost two years. While it feels awkward and painful to walk on 6 k-wires and 2 half screws, it's simply amazing to be able to walk with absolutely zero ankle joint pain.

The lateral view shows the same massive amount of healthy space. This is exactly what's needed to promote cartilage growth. Compare this space to what I was dealing with in June when I posted about my Swiss Cheese Ankle. It's a significant improvement.

Now on to the arthroscopic images. I thought it might be useful to provide a quick diagram of how ankle arthroscopic surgery works.

One hole is used to insert a camera -- the arthroscope -- and another hole on the opposite end of the ankle is used to insert instruments to clip, chew, and claw away pieces of bone and scar tissue to clean up the joint.

Before we go on, keep in mind that normal articular cartilage is usually shiny, smooth, and milky white. You will not be seeing normal cartilage, if any, in the following images.

Here you can see one of the instruments used to clean up the joint. Most of the arthroscopic work was done on the lateral side of my tibia to remove bone spurs (osteophytes) that had built up from bone rubbing on bone. It's basically a callous on your bone.

Whatever it was -- it caused the most amount of pain. Unfortunately, while removing bone spurs helps reduce pain in the short term, it's by no means a long term fix to ankle arthritis.

I believe the bottom bone in the picture above is the talus. You can see some cartilage, but it's not smooth, congruent, or shiny.

In fact, it's barely hanging on.

To perform ankle arthroscopic surgery, the joint needs to be distracted. By the time Dr. Jeng was performing this part of the surgery, my external exfixator was likely already installed and pulling the joint apart 5mm. Saline is usually pumped into the joint to keep debris out of the view of the camera.

In the picture above, you can see a patch of cartilage that seems to be somewhat more healthy than the first image. I suspect this is the medial side of my ankle (the inside part) where I have no arthritis symptoms at the moment.

This is a picture of a barren wasteland.

I suspect this is the lateral (outside) side of my ankle. The metal instrument you see was used to remove the bone spur from the part of my tibia and talus causing me issues.

Dr. Jeng reported taking out the bone spurs was like taking a hot knife through butter -- not a good sign. In healthy bone, it's very difficult to remove osteophytes. This, along with the non-union last year and the incomplete union this year, all suggests operations like fusions and ankle replacements lead down roads of more revision surgeries, pain, and frustration.

Quick tangent -- did you know that for half of my marriage with my wife, Brooke, we've been dealing with this ankle? We're ready to be done.

I'm not sure how this picture of a geological cave ended up in my arthroscopic image set. This can't be an ankle.

This view, however, is a promising image. I see several patches of cartilage still holding on for dear life. Maybe we'll get some growth out of this patch. I believe you can see one of the malleoluses in the background -- I'm just not sure if it's the tibia or fibula malleolus (the boney part that sticks out on either side of your ankle).

Another cave picture. Not a piece of cartilage in sight. I like how some of the bone has brown spots. And by like, I really mean it's terrible and I hate it.

So that was the view inside the ankle. It's a lot to take in. So while you're digesting that, here's what the pin sites looked like today.

This was one of the pin sites we were a bit concerned about. It's red and irritated -- probably because it runs through the muscle used to pull the foot up. I've been prescribed an antibiotic as a precaution just in case there's an infection brewing.

Now what about this million dollar idea?

My boss is awesome. In one weekend, she crocheted the first external fixator cover ever created -- in my aluma mater colors, no less.

How awesome is this?

Snowboarder vs. YouTube

2011-09-17T16:03:00.007-04:00

Last November I asked to have my second external fixator removed while I was awake so I could capture it on video. I thought it would at least make for a unique video and perhaps help educate people on external fixators.

The video recently exceeded 10,000 views on YouTube -- earning a whopping $7.38 -- so I wanted to take a closer look at the video's statistics. Why were people taking an interest in this video?

The demographic breakdown was just as you would expect. It's mostly dudes around my age looking for something gross. It's the Internet version of rubber necking.

Further supporting that theory is this "hot spot" graph. The graph on the left is "viewer attention" over time. I'm not sure how YouTube measures viewer attention, but you can see it's at its highest when the drill is removing the half screws from the tibia.

That's my favorite part, too.

Since the video's been up on YouTube, I'm discovering it's serving another purpose. While there aren't many of us, other people go through similar injuries as mine. And if they're anything like me, they want to know as much as possible about what they're about to go through.

It's one of the best ways to eliminate fear.

A few days ago, I got this message on YouTube from another viewer about this video.

Hey man. I saw your video of getting your external fixator removed, and i saw a link to your blog and read a bit about your story. I broke my leg playing highschool football last septemver. Tib-fib compound fracture. The doc put in a nail, which led to infection, and eventually an external fixator on for about 4-5 months (got it off this July) Before i had the removal surgery I watched the video, and it really calmed me down, and helped me understand that it wasnt as serious of a surgery as I had thought, so thanks!

This injury has put my wife and me through what seems like an endless cycle of surgeries, rehab, pain, and healing. I've made it a goal to work hard at maintaining a great attitude through the whole ordeal, but, of course, it can be difficult to find the silver lining. Certainly, hitting a tree has brought me closer to my wife and made me realize how amazing my friends are.

But the message I got a few days ago from this YouTube viewer surprised me. It was an unexpected silver lining.

It's amazing how much easier it is to cope with your own severe injury when you know that, by sharing your story, you've helped at least one other person's ability to cope with his or her injury just a little bit easier too.

Let's be honest, though. Seeing that drill take out that massive screw from my shin like a carpenter uninstalling a table top is totally awesome!

VIP Parking Pass

2011-09-14T22:02:00.003-04:00

It's a new era in my life -- the handicapped era. I decided a few weeks ago to get my VIP parking passing. Parking is starting to become a problem at work, so what better way to guarantee a spot than to exploit my ankle.

For the longest time I didn't want to get one of these. It was like I was admitting defeat. Then I realized -- it's awesome to not worry about parking, especially in this city. For the next year, I can get the best spot anywhere I go.

I was an idiot not to get one.

My left ankle is taking some abuse from the ex-fix. I've hit it about four times now.

You're Killing Me, Nissan

2011-09-08T00:05:00.002-04:00

Dear Nissan,

You're killing me. This new Versa ad campaign you've got running on every single channel in America every eight minutes?

It's a healthy ankle parade is what it is. And, it's to the tune of a catchy song called "Don't Stop."

It certainly hasn't.

Something needs to be done about this commercial.

Snowboarder vs. The Island

2011-09-05T17:23:00.005-04:00

Pain killers are great and pain killers are a burden.

Pain killers are great at taking terrible ten out of ten pain and turning it into a tolerable pain or no pain -- and, if anything, pain killers let you forget it ever happened.

But when you stop taking them, at least for me, I take a ride through a series of steps in withdraw. For the first time, with a clear mind, I'm able to face the reality of my situation. It hits you all at once: eighteen months have rushed you by with four surgeries and, guess what?

You're ankle?

It ain't fixed and your prognosis ain't good.

When I saw a picture of what's left of my cartilage -- a tiny island in the middle of barren, unhealthy, incongruent bone -- it was my first opportunity to see my enemy face to face. And I saw it winning; dominating.

This is the first step in withdraw for me -- I'm finally able to assess my situation with emotion. And, holy crap, there are a ton of emotions that I run through.

While all that's happening, you get to hang out with some other pretty awesome withdraw symptoms.

Night sweats with chills (quite the paradoxical experience). No energy. That constipation problem you had? Imagine that problem as one end of the spectrum, and, after you stop taking the drugs, you're tossed on the opposite end of that glorious spectrum -- arguably the worse end.

No, it cannot be argued. It is manifestly worse.

There are a few methods to cope with withdraw. The best one?

Delicious slumber. Sleep. More sleep. When you wake up, go back to sleep. Each time you wake up, you feel better.

So, I'm feeling much better. Unfortunately, withdraw impacts more than you think in your life. I missed two fantasy football drafts, opportunities to be with good friends, and I'm sure my awesome wife, Brooke, loved hanging out with a sleepy, quiet, pooping husband.

But I finally feel myself. Thankfully this is the fourth time I've had to go through it, so I know how to handle it. It's never easy, but at least we know what to expect.

So, how is the sweet ankle? We put on a new dressing last night. It looks like it's improving -- slightly.

You can see how one of the k-wires has pulled my skin out. How does it feel? Pretty amazing.

Above is a picture of the top part of the exfix. This is an area that we're concerned about because it looks slightly inflamed. We tried to push down on it to see if we could get any fluid to come out of the pin site holes, but no toothpaste came out.

Something to keep our eyes on.

So, with withdraw defeated, I'm feeling much better about my situation. My ambition and focus on returning to snowboarding has returned. I'll do whatever it takes. I'm hoping for the best with ankle distraction arthroplasty and preparing for the worst.

And as for surgery number five? Brooke, Dr. Jeng, and I all agree -- it's my last one.

Snowboarder vs. Ankle Distraction Therapy

2011-08-31T15:41:00.002-04:00

After yesterday's doctor's appointment and quick visit to work, I was exhausted -- that was the most active I'd been in several weeks. When I got home, I crashed and did not wake up until this morning. I'll need to be more careful about pacing myself.

This morning I decided to try walking around without crutches -- and, of course, I captured it on video.

It's an odd feeling to bear all of your weight on 6 k-wires and 2 large screws in your foot and tibia. I can feel a lot of my weight on the top screw on the top ring, so I'll start using crutches to ease the burden on the ex-fix for the next few weeks. Walking on the ex-fix doesn't hurt, but it also doesn't feel amazing.

I'm using large rubber bands to help pull my toes up while I walk so that I do not stub any of my toes while walking. This also helps stretch the toe tendons -- especially the big toe. Without substantial flexibility in your big toe, it's very difficult to walk. This will be another thing I'll need to focus on for the next three months.

The next video shows you how to unlock the ex-fix to release it for moving the ankle.

You can see our dog, Spunky, was extremely interested in this instructional video. Oh, by the way, please don't tell Brooke I let her on the couch. I'll get into a lot of trouble.

Unlocking the ex-fix feels weird. You can feel the large amount of tension used to pull apart the ankle joint move from the two rods in the front to the rest of the ex-fix. I fear that because it's so difficult to unlock one of the rods that I won't move my ankle as much as I should.

What I need to do is come up with a schedule to exercise my ankle since I intend on walking on my foot everywhere.

Gross Pictures and Videos, Aww Yeah!

2011-08-30T17:25:00.009-04:00

First, let's start with a video of the unlocked ex-fix. I got to move my ankle for the first time in a few weeks. Yes, this hurts.

Now come the gross pictures. Click on them for some high-resolution gore!

Unfortunately, we couldn't get a copy of the x-rays or the arthroscopic images. Next time we show up, we'll bring a thumb drive and get those copied onto the blog. I did get a chance to capture some of the x-rays they took today as they were displayed on the monitor.

You can see how much joint space has been added. Now I just need to start walking and moving the ankle to encourage cartilage growth. It hurts, but it's the only way to do it.

Snowboarder vs. Driving

2011-08-29T23:43:00.001-04:00

Earlier tonight, Brooke and I decided to visit our new vehicle to see if my wheelchair would fit in the caboose.

After our doctor's appointment, I intend to visit work for a bit while Brooke searches for nurse practitioner preceptors for her final year of college. I'd like to roll into work on my chair while visiting friends since it'll be easier to keep my foot elevated.

Brooke ended up doing most of the labor while I ran some experiements. I wanted to know if it would be possible for me to drive a car.

I think the evidence speaks for itself. The right leg fit nicely over the console and the left foot reached the pedals without any issue.

What do you think?

First Follow-Up and Las Vegas

2011-08-29T12:55:00.017-04:00

The Two Week Follow-Up

My first follow-up appointment with Dr. Jeng is tomorrow morning at 11:20AM. This will give us an opportunity to get a good look at the ankle since the surgery two weeks ago.

There are three goals for this visit. First, the stitches from the arthroscopic incision sites will be removed. Second, the 14 pin sites and two incision sites will be assessed for any signs of infection. Finally, Dr. Jeng will provide instructions for operating the ex-fix hinges. The hinges must be locked while walking and unlocked to move my foot while I'm at rest.

I'm curious about what it's going to feel like to move my ankle after the joint's been cleaned and the Achilles tendon has been lengthened. Amazing? Wonderful? Kill me now? Only time will tell.

Tomorrow we will also get an opportunity to see two different and interesting views of my ankle.

The first view will be from the images taken from the camera during the arthroscopic procedure to clean my ankle joint. We'll (hopefully) see the color, texture, and any fractures of the tibial mortise. I image we won't see much cartilage.

The second view is one we're all used to by now. After we remove the bandaging that was applied immediately following the surgery on the 15th, we'll finally see my new ex-fix and the 14 pin sites in all their glory.

While we haven't seen what the installed ex-fix looks like without bandages yet, we have a pretty good idea of what to expect from the ex-fix Dr. Jeng put on display in our first appointment. The Ilizarov ex-fix is comprised of three rings.

1. Bottom Ring
The bottom ring anchors four k-wires through my foot -- two through the forefoot and two through the hindfoot. As I bear weight while walking, most of the force will be carried through these four k-wires. From the people I've talked to online that have had this procedure, the forefoot wires will hurt the most.

2. Middle Ring
The second ring in the middle is held to the leg with one k-wire all the way through the tibia and a large half screw into the tibia. This is the first ex-fix I've had with a k-wire that goes through my entire leg this high up.

3. Top Ring
The third ring at the top has the same setup as the middle ring: one k-wire through the tibia and one large half screw into the tibia. Can't wait to see that k-wire going through the middle of my leg.

From the picture above, you can see how all three rings are connected with several rods. The two pairs of rods between the first and second ring are special and quite different than the ex-fix I wore last August. One pair of rods is hinged near my ankle joint and the other pair contains screws that control the distraction distance.

Above is a picture of one of the distraction rods. With equal twists of each screw in this rod, the distance in my ankle joint between my talus and tibia can be reduced or increased.

During the surgery, my ankle was immediately distracted to the maximum desired distance of 5mm. As a result of this continuous stretch, I've lost sensation in the bottom of my heel. I suspect it is also related to the tibial nerve I damaged I suffered during the initial injury. There's no telling when the feeling will return. It could be a matter of weeks, when the ex-fix is removed, or never. We'll be sure to bring up the question with Dr. Jeng tomorrow.

Before I left the hospital, Dr. Jeng encouraged me to try bearing just a little bit of weight on the ex-fix. In the last few days, I've given it a few shots. Surprisingly, it has not been too uncomfortable -- though I've only put about 15% of my body weight on the right leg.

Now, I know what you might be thinking: "How did he come up with that 15% measurement number?" It's a great question. And if you know me at all, you know it came from the same place I stick those glycerin suppositories. I really have no idea how my weight was distributed.

Here's a front and rear side view of me bearing some weight on my ex-fix. I experienced no pain or discomfort. However, I only stood like this for a few seconds.

Here's a few side view pictures. The bottom of the ex-fix has a horseshoe shaped rubber pad to make walking easier. It's also curved, much like my Shape-Up shoes, so I'm able to roll the ex-fix as I walk. My foot does not touch the floor at all. All of my weight is on the k-wires and half screws through each of the three rings.

Las Vegas

Now on to something important. This story about Las Vegas is related to my ankle. Several of my good friends and I have held an annual Las Vegas trip in the summer for several years. They always turn out to be great reunions with old friends and inevitably we come back with some great memories.

Unfortunately, because of my new August surgery tradition, I've missed out on the last two Vegas trips. My friends have asked me to come out anyway with a mobility scooter, but I had a feeling it was only so I could carry the thirty packs and use my disability to cut in lines.

Pranks tend to occur with high frequency in this group of friends. This morning I was sent a video of perhaps one of the funniest pranks pulled so far (this video is safe for work, home, small children, etc.).

The victim in this prank, Chris, has a reaction that is totally unexpected. From what I've been told, he had only been asleep for a few hours. There's an excellent chance that Chris might still be inebriated from his last night in Vegas. Certainly, he looked the part.

I fear this sets a dangerous precedent for future Vegas trips. I might need to schedule another surgery for August 2012.

How To Have a Terrible Day

2011-08-29T00:03:00.034-04:00

I occasionally -- no, I obsessively worry about "crossing the line," with these blog posts. My friends, family, and co-workers all read this blog. These people all mean something to me in my life and I want to try my best to keep my posts tasteful, informative, and honest.

I've had to, however, pull the, "well, at least it's an honest post," card quite often.

To everyone that reads my blog, you need to understand where the posts' tone, style, and substance comes from. Most of you probably already know, but for you new followers, look no further than the narcotic pain medications prescribed to patients with impressive injuries such as my wrecked ankle.

These drugs, when used appropriately, usually take care of the pain. Unfortunately, they have many side effects -- including constipation and making me look like Martin Prince from The Simpsons.

When you've got a giant external fixator attached to your leg, and the muscles in your foot, ankle and calf haven't had a chance to do some work in weeks, you start to suffer from amazing atrophy twitching. Not surprisingly -- because it's the worst time of the day -- these atrophy twitches tend to occur in the morning while I'm asleep in bed.

So what's it like? It's difficult to describe. Staying with the Martin Prince theme, this picture is a very accurate depiction of what I usually look like when I wake up with an atrophy twitch in my externally fixated ankle.

So let me give a shot at explaining what one of these twitches does to you. Imagine your foot, ankle and calf muscles decided it would be totally radical to chug thirty Red Bulls in five minutes. According to Red Bull's website, when my foot, ankle and calf muscles chugged those thirty sweet energy drinks, they:

Increased performance
Increased concentration and reaction speed
Improved vigilance
Stimulated metabolism
Makes you feel more energetic and thus improves your overall well-being

However, according to my patient testimony, here's what I believe is actually happening:

Increased pain -- going from 0 to 120mph in 1 second
Increased concentration on pain and no way to react -- except screaming
Improved vigilance: my ankle is out to murder me
Stimulated Spunky from her slumber
My well-being was neither improved nor enhanced

When something traumatic like this happens to me, it's difficult to get up until I take my medication and sit and wait for the magic set in. While I'm waiting, there are occasions when the classic race between "the call of nature" and "narcotic relief" take place in my bed, and nature tends to get out in front and hold onto a substantial lead.

Enter the bedside urinal we brought home with us from the hospital.

Now let me tell you one thing. When I first saw this by my bedside at my second surgery, I was petrified. I've never:

Urinated in front of people
Urinated while laying down
Urinated under severe pressure ("Pee in this cup or we'll insert a large tube in your penis.")
I've never measured how much urine I typically produce in one session.

When we came out of the PACU into my final room during the second surgery, my Mom was hanging out with us. She asked about the bedside urinal and I, of course, opened my mouth. Trying to make a joke (which is never a good idea when you are heavily medicated), I told my Mom it is a bedside urinal and she can hold it for me -- referring to the bedside urinal. Unfortunately, and probably inevitably, that is not what everyone else in the room thought I meant.

So a few days ago, I get a Red Bull twitch. After being vigilant and increasing my reaction to the pain, I determine it's business time. Now, remember, I'm groggy. I have just woken up from a deep slumber because my ankle downed a million red bulls and decided it was time to dance the night away in my ex-fix. I reach for my bedside urinal and pull it toward the fire hydrant area to proceed with the operation. Unfortunately, the last jerk to use the bed side urinal did not clamp down the lid.

While Brooke, bless her heart, empties out the bed side urinal when it becomes full, she cannot get every ounce or drop of fluid out of that disgusting jar. Occasionally, there are stragglers. Free riders.

The Start of The Terrible Day

So, as I reached over for the jar and made the move for the fire hydrant, I noticed a light, spotty, cold splash across the crouch of my shorts.

"Is that water?" I asked myself -- mainly hoping it to be true so that I could buy myself some time before the inevitable sank in. It was about two seconds later when it sank in.

Expletives were declared, expressions were emoted. Cries of, "Why me?" and "Holy Moses Smell the Roses," echoed through our new apartment.

I just started my new day by technically peeing on my lap from a pee bottle. Now am I going to cower down into a ball and whimper all day and night?

Hell. No.

Yes, I just came this close to peeing in the bed with a previous day's leftovers. But I'm going to take this like a man. I am going to go out in that world with a level of confidence through the roof, ready to take on anything -- just as soon as I get a change of shorts and a shower.

Operation Pink Gorilla

2011-08-25T13:14:00.020-04:00

While I was in the hospital last week, my wife provided me with the emotional strength and unwavering support I needed to get through several painful days. She is amazing and one of a kind. Her selfless commitment to me and my health since my accident a year and a half ago just goes to show you how much I dominated at choosing my partner for life.

When I got home from the hospital last week, I leveraged what little functioning neurons I had left to brainstorm ways to say thanks to my wife. Shoot -- let's not even call it a brainstorm. It was more like a braindrizzle.

I came up with one dumb idea.

The best way for me to relay my appreciation and love to Brooke was via the ancient and sacred art of the singing telegram.

Surprisingly, American Balloon Company still offers singing telegram services here in Washington, DC. One of their employees, who cannot possibly be getting paid enough, shows up to a location of your choosing to sing an impromptu song and deliver several large balloons, a coffee mug full of Jelly Bellys, and a personalized letter.

After employing their services, the next step was to develop and execute a plan of attack -- code named Operation Pink Gorilla.

What is the best way to deploy a singing Pink Gorilla to Brooke with the right amount of embarrassment and maximum entertainment value? To solve this problem, I enlisted the help of the three lovely ladies responsible for the recent covert operation to unpack our apartment while we were in the hospital: Alison, Crystal, and Katy.

Over a series of secret emails, Operation Pink Gorilla was developed and set to go for today at approximately 12:45PM. At a prearranged meeting location setup by the girls, a Pink Gorilla wearing a top hat found Brooke in line about to make her food order.

As you can clearly see from the video evidence, absolutely nothing will divert Brooke's attention away from food -- especially when that girl is hungry. I know for a fact that if held at gunpoint, Hungry Brooke wouldn't back off of a Stromboli or discontinue mowing down a bowl of chicken and dumplings.

This was clearly poor planning on my part -- the unfortunate side effect of my earlier braindrizzling. Brooke, on an empty stomach, will beat up small children and puppies to get nourishment.

That said, this was still extremely funny and totally worth it to see the surprised looked on her face.

Here's a picture of the personalized card I had delivered by the Pink Gorilla. If you can't read it, here's what it says (well, what it should have said -- it appears they misinterpreted some of the things I asked them to write down):

Viss,

Thank you for being a loving wife, an understanding partner, and that Mom from the hospital scene in Steel Magnolias.

You are the love of my life,

Your Crippled Husband

"Viss" is what we used to call Brooke in college since her last name used to be Visser. I still enjoy calling her that, and some of our friends up here in DC have jumped on board with it. Although I've not seen it, Brooke was telling me that Shirley McClaine plays the role of a mother with a sick child in Steel Magnolias (I'm now being told it's Terms of Endearment) who goes nuts on a nurse that fails to take care of her child's pain.

Here is a photo of my wife sitting down for some gelato with my co-conspirators. From left to right we have Alison, Crystal, Brooke, and Katy. I had asked Brooke to pay for their gelato under the guise that it was payment for unpacking our apartment -- but in reality, it was my payment to them for their participation in this operation.

Turns out that crap is expensive. Yet another casualty of my braindrizzle.

I found out later that I narrowly avoided disaster by asking too many probing questions. Last night Brooke was stressing out about how busy her day was going to be today. Not wanting her to miss out on the singing telegram, I probably asked too many questions about her schedule.

So I'd say it was a successful operation. Thank you so much to Alison, Crystal, and Katy for yet again taking part in Operation Pink Gorilla. Your efforts and hard work are commendable.

And, thank you, Brooke, for being an awesome wife. I love you!

Lovenox Instructional Video

2011-08-24T16:40:00.003-04:00

When I got up this morning, I realized that my Buddha Belly has yet to make an appearance on the Internet. I wracked my brain a bit to figure out the best way to display this piece of art to the world and came up with an instructional video on how to administer Lovenox injections.

At first I thought there couldn't be that many instructional videos on administering Lovenox injections. But as it turns out, everyone on the Internet has uploaded an instructional Lovenox injection video.

Important Blog Update

2011-08-24T04:21:00.003-04:00

The website snowboardervstree.blogspot.com, can confirm at this hour that our friend Laurel, introduced in the previous post, does indeed not enjoy close range Spunky farts (where "close range" is defined as 12 inches or less). While this is contrary to the current popular opinion and goes against what is trending on Twitter at this time, evidence has recently come to light to support this important and very relevant announcement.

The evidence: Spunky farted and woke Laurel up. Laurel got upset and called our dog stinky.

Further experiments will be necessary to calculate the degree of dog fart appreciation as the distance from dog butt to Laurel's face varies. Graphs and Excel workbooks will be in order and a peer reviewed paper discussing the outcomes must be completed before we can make our analysis official.

I am unfortunately up late due to a late night pain battle. The good news is we've finally gotten it back in control, but for a while there I would have taken anything over being in pain -- including close proximity Spunky farts.

Earthquake!

2011-08-23T11:41:00.010-04:00

Earlier today a magnitude 5.8 earthquake struck Washington, DC. That was the first one we've ever experienced. We're all okay -- nothing broke or fell. However, our dog, Spunky, was quite upset that the Earth woke her up from her nap.

We visited our family physician yesterday to see what could be done about the hiccups. I was a bit embarrassed to be seeing a doctor about hiccups, but I couldn't take four days straight of hiccuping.

My family doctor suggested we change my muscle relaxer medication from Valium to Flexeril. He also noted I have poor posture when I slouch in a chair to elevate my ankle on my left leg. He suggested I try and avoid that position and move around the apartment more often. By avoiding the slouched position, I'll reduce the amount of pressure on my diaphragm. I still had a few bouts of hiccups last night, but not nearly as many as the last few days, so it looks like it might finally be under control.

One of our friends, Laurel, is staying with us tonight before she moves to Philadelphia for school. Laurel is a recent addition to our circle of friends. She used to be a nurse with Brooke. It's unfortunate that she's leaving us so soon!

As you can tell from this picture, Laurel either 1) does not know about the power of Spunky farts, or 2) enjoys Spunky farts. The butt to face distance is quite frankly too short for this to be a mere coincidence. I'm fairly certain option 1 is what's going on here, but we cannot yet rule out option 2. When Laurel wakes up from her nap (perhaps after Spunky rips one), we will ask Laurel which option is correct and update the blog.

Finally, I've been using large rubber bands (not the kind you use to wrap newspapers) to help stretch my toes up. Without doing this, my toe tendons that run along the bottom of my foot would tighten up, making it more difficult and painful to walk months from now. I'm not sure how often I'll do this, but, as our potential dog-fart-loving friend Laurel pointed out, it adds some flare to the external fixator.

Snowboarder vs. Hiccups

2011-08-22T12:43:00.002-04:00

My Mom did some Interneting last night and discovered that some people have reported developing hiccups after taking massive amounts of Valium -- which is exactly what I'm doing. Last night I stopped taking my 30mg a day.

Unfortunately, last night was more of the same as the previous four nights. I went for bottles of Sprite (carbonation), spoonfuls of peanut butter and jelly, and held my breath for as long as possible. All with little to no success.

This morning I called my family physician. We go in to see him at 2:15PM today. Here I am, a guy ambulating on crutches with a giant, bloody bear trap on his ankle, hobbling into a doctor's office complaining about -- hiccups.

This is ridiculous.

They Won't Stop

2011-08-21T21:45:00.001-04:00

I cannot stop hiccuping. No sleep. Nothing. I've gone through two jars of peanut butter. I've held my breath. I'm at a loss.

I hate hiccups.

The Hiccup Chronicles

2011-08-19T17:13:00.003-04:00

The hiccups continue on. Don't laugh, but hiccups are worse than pain. I can't explain it, but try hiccuping every 30 seconds for about 20 hours straight.

I'm not sure how hiccups work, but the above diagram is supposed to shed some light on it. I called the surgeon's office today only to find out I'm the third young male in as many weeks to call in a few days after surgery complaining of hiccups.

Brooke asked that I request Thorazine, a prescription drug for hiccups, but the surgeon's office recommended -- believe it or not -- peanut butter.

Surprisingly, peanut butter gives me some relief for about an hour or so. I've gone through several spoon fulls so far. Hopefully this will end soon!

The Hiccup Problem

2011-08-19T10:10:00.006-04:00

Late last night we came across a new problem -- uncontrollable hiccups. I'm not talking about a few hiccups every now and then.

No.

We're talking about a massively uncontrollable hiccup from the bottom of my gut every 30 seconds. You could set your clock to it. They started around 09:00PM last night and kept going through the entire night.

At around 05:00AM, Brooke woke up with me and came up with an idea. She had leveraged her recent graduate school skills to conduct some important, life-saving research.

Apparently honey and peanut butter eliminates hiccups. Sounds ridiculous, right? I agree. But it also sounds delicious.

This odd concoction worked for a few attempts. I'd take a spoonful of peanut butter and honey, and I'd stop hiccuping. But inevitably, a few hours later, I'd start back up again -- only this time, I had a belly full of delicious, sugary condiments.

This morning, I decided to crutch around outside to get some fresh air and exercise. That seems to have done the trick for the time being. It's surprising how badly out of shape I'm in after spending three days in a hospital.

So the first few nights we lost sleep due to pain. Last night it was hiccups. What's it going to be tonight?

We Meet Again, My Arch Nemesis

2011-08-18T22:04:00.017-04:00

Last February, a few days after my accident, I wrote up a post about the pharmacy I had established at home. On this our fourth time around, we've reduced our inventory to the bare essentials:

Lovenox Injections
Diazepam 10 MG (Valium)
Hydromorphone 4 MG (Dilaudid)
Oxycontin 20 MG
Glycerin Suppositories

The Lovenox injections help thin my blood to avoid blood clots while I sit on my butt all day. The Valium reduces the number of muscle spasms I experience in my leg. This is especially common in a limb that is both recovering from a nerve block and experiencing atrophy from a lack of muscle movement. The dilaudid is an emergency narcotic that's used to recover from significant and sudden spikes in pain while the oxycontin is a slow release narcotic that lasts around 12 hours.

The last resort -- but ol' reliable -- medication is the bottle of slightly used Suppositories, dedicated to a solitary and lonely life of fighting my evil arch nemesis -- constipation. The Lex Luther of poop.

At first, it was quite surprising to me that Lex Luther didn't even show up on the Bristol Stool Chart. But then it occurred to me -- usually Lex Luther's evil schemes play out without a single soul knowing what went down (except the poor sap that ends up constipated). He does his damage and escapes in the cover of night without notice.

How does one summon the hero necessary to defeat an enemy brought on by excessive use of narcotics? Batman and Robin had the Bat Signal. Captain Planet had the Earth, Wind, Fire, Water, and Heart rings. The Superman of Constipation -- he's got one gigantic suppository.

And I do mean gigantic. That's a pinky finger. Typically, pinky fingers are considered small. Let's be honest -- those people are blind.

Two of the warnings on the suppository bottle frightened me a bit. The first one, "Insert 1 suppository well up into the rectum and retain for 15 minutes," suggests to me that I can't just joke around and leave the suppository sitting at the front door. Apparently, I gotta run this thing all the way into the house and leave it in the kitchen. The second warning, "you may have rectal discomfort or a burning sensation," kind of makes me upset. If there's a chance that this is going to burn, why not tell me about the chances of it being awesome? "You may have rectal discomfort or, you may win the lottery after sticking this suppository up your rectum."

Well, Lex Luther is a formidable foe. I had been battling him since Monday -- and I had lost every single battle. Today I had enough. I called in Superman and, together, we defeated my arch nemesis yet again.

I don't understand how drug addicts get addicted to drugs. You never get to poop!