S.T.A.R.

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

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

I like Dr. Cooper.

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

• Snowboarding
• Golfing
• Bicycling

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

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

Option 1: Ankle Distraction

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

Option 2: Ankle Arthrodesis (Fusion)

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

Option 3: Ankle Arthroplasy (Replacement)

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

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

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

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

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

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

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

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

Next up: Dr. "Cliffy" Jeng.

New Animations

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

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

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

Ankle Arthritis Treatments

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

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

Part 1

Part 2

Moving Forward

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

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

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

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

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

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

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

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

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

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

Snowboarder vs. Healing

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

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

Impression:

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

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

Distal Tibial Metaphysis

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

Incomplete Bony Union

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

Subchondral Sclerosis and Cystic Degenerative Changes

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

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

Next Steps

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

We'll keep you all updated!

Swiss Cheese Ankle

Dudes, what's happening? You're still on the Internet? Nice! My bad on not updating this blog. Turns out I wanted to act like I didn't have an ankle problem, so I stopped updating. If I'm not spending time on the computer, I'm out using the crap out of my ankle and enjoying having two working legs.

I finished physical therapy in March. While it was painful, I finished with more than 10 degrees of dorsiflexion and I could walk without a cane. While my activity level increased a little bit, the pain in my ankle has gotten worse, a little bit at a time, day by day. I rock the house cane on a daily basis. I have no dorsiflexion in my ankle. There are 78 year-olds out there that could dominate me at an Ankle-Off.

Last Wednesday, I finally decided to see Dr. Buchanan. I went into the visit with two ideas: 1) ankle arthrodesis (fusion), or 2) amputation (below the knee). The pain has been that bad, even with 800mg of Ibuprofen every 8 hours.

The X-Rays didn't reveal too much. They suggested I had bad arthritis in the ankle joint. Dr. Buchanan suggested ankle fusion with an arthroscopic procedure. He'd like to put in three screws to fuse the joint and fill the gaps with some bone and marrow from my pelvis or shin. I'd lose a few millimeters in the length of my leg, but it wouldn't be too noticeable. I'd have about a year recovery.

Dr. Buchanan was absolutely against amputation. He said 100 out of 100 orthopedic surgeons would not recommend it for me.

I plan on seeing a few other surgeons to get some other opinions.

This morning I had a CT scan. I wasn't sure what the ankle would look like. I'm no radiologist, but from my sweet Googling skills, I think I've got a case of osteochondral lesions -- possibly cystic. The CT scan videos are below. Notice the massive amount of Swiss cheese forming at the join. Those are possibly lesions or cysts.

I'm not sure how these lesions are treated. I don't know what it means for whether or not I'm a candidate for fusion.

Seriously, cut this thing off.

The Memorial

A friend of mine was visiting Breckenridge last week to go skiing with some buddies. We thought it would be awesome if he stopped by the tree I hit to deliver a special payload: some of my broken ankle hardware from my fibula.

He hand crafted a laminated memorial and found the tree using the Google map I made in one of my first posts to this blog. I was worried that the tree I had marked on the map wasn't the right one, but as soon as I saw these pictures, I recognized the beast that destroyed my right leg.

Friends, family, meet the Tree of Death.

This is one of the snowboarders on my friend's trip, reacting my accident. This is exactly how it happened.

Here's the memorial. My friend's story follows. With exception to his zings and snowboarder-hating, the story is pretty awesome.

Here's how the day went down. It was our first day of skiing in Colorado, after having arrived on Wed. night. Our plan was to hit Breck on Thurs, Vail on Friday, and Copper on Sat. (Vail, btw, was absolutely epic. We received 8 inches of fresh snow Thurs night and the Eisenhower tunnel was closed Fri morning (thus preventing visitors from Denver) and on top of that, we were joined by a Vail guide that one of us happened to be friends with ... Ok, I digress. I'll cease the bragging since you had to sit this season out).

So Thursday at Breck it was myself, two other skiers, and a boarder (I know, I thought the same thing: snowboarding... weak, right?). I had briefed them on your situation and each of them had spent an hour or so catching up on your blog. I let them know that I had some authentic ankle hardware from the accident and they were pumped to memorialize the murder tree along with me. Starting from the Peak 7 gondola, we headed over to Peak 8 where we proceeded to dominate the summit from the Imperial Express Chair -- thousands of feet above the tree line. The visibility was pretty terrible so we headed over to Peak 9, which you may better recognize as "Pain Peak".

At this time you and I were corresponding via email while I was on the lift. Your recollection was that the incident occurred somewhere near the Mercury Superchair near Lower American... a GREEN CIRCLE, as you may recall ... SA-WEET! (Ok in your defense, you can really carry a head of steam bombing down from the upper runs: American, Columbia, or Bonanza).

The first run down we scoped out potential incident locations. While many of the tree clusters looked quite menacing on this nearly flat run (zing!), most of them had trail markings or other signage near them, which you had not mentioned. Our next run down we focused in on just a few likely candidates. My friend turned on his GPS and fired up the Google Map from your blog. This allowed us to see our location in real time as we honed in on your suspect.

We found a sinister looking tree nearly directly where you had identified on your map. To both its left and its right stood dense tree clusters, but this angry bastard stood alone. It coincided almost perfectly with your marker on the map. It was time for vengeance (or, at the very least, some public shaming of the tree).

Before I left for Colorado, I printed out a pic of one of your xrays, to which I attached the ankle hardware. I did my best to protect it with some "lamination", although as you can see in the pics, attaching tiny hardware to a luggage-crumpled piece of paper in the back of a minivan winding through slippery mountain roads is not nearly as easy as it sounds. I managed to drive a couple nails through it into the tree and bent them over to secure the notice, like a staple. An off duty ski patrol dude happened to come by, curious as to what we were doing. We gave him the abbreviated version of the story and explanation of the sign. He nodded his approval and skied off with the standard ski-bum farewell: "Gnarly!" (Seriously, I can't make this stuff up -- people really still say that out there).

Below are a few pics of the memorial. I tweaked the name of the tree to be "Tree of Pain" instead of "Death" since, well, people actually do die running into trees and I didn't want to come back to the tree and find it adorned with wreaths and candles. We also took the time to shoot a brief re-enactment of the event (too soon?). There on the Tree of Pain shall the memorial stand for all eternity -- or until the next tree-hugging hippie or stiff breeze comes along and rips it off.