Preparing for Your First Surgery

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

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:

1. Preparing your home for care and maintenance.
2. 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

1. Installed August 16th, 2011
2. Removal scheduled for November 3rd, 2011
3. 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.

• Bath bench - $24.00
• Hand-held shower head - $33.90
• Plumber's tape - $8.49

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.

• Latex gloves - $8.24
• Nurse scissors - $3.95
• Saline wound wash - $5.41
• Xeroform - $15.50
• Iodine - $14.94
• Chlorascrub swabs - $33.66
• Gauze pads (2" x 2") - $5.82
• Gauze pads (4" x 4") - $5.40
• Cotton-tipped applicators - $8.98
• 3M surgical tape - $13.96
• Foot brush - $3.25
• Skin lotion - $27.97
• 2" gauze roll dressings - $3.08
• Stretch bands - $13.41
• Tennis ball - $5.70

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.

• Pin Site Care from Orthofix
• University of Wisconsin Home Care for Pin Sites
• External Fixators Information from Royal Children's Hospital

The Nutcracker and Different Strokes

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:

1. When my ex-fix hit the desk, the metal circle around my leg moved, bending the k-wire by several millimeters.
2. 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

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

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

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!

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.