Close up of a BKA Stump

I've been doing a lot of YouTube research on amputation over the last couple of months.  I recently found an occupational therapist amputee that's made several videos of an amputation only a few weeks ago.  Her videos provide unique insight into what it's like immediately following a below the knee amputation (BKA).

Snowboarding is Awesome

My first hard fall snowboarding was also the first time anyone heard my lungs make that noise.  A gush of air departed my mouth − all of it − followed by loud, awkward moaning.  With each grunt, I tried to take back in some of that air I so desperately wanted, but my diaphragm had called it a day.  I'd obviously broken it.  This was going to be my end.  Death by catching my toe edge.

It turns out I'd only suffered temporary diaphragm paralysis, or what's known as getting the wind knocked out of you.  Like most snowboarders just starting out, I had forgotten to lift my toes as I turned down the slope.  Once the mountain grabbed the edge of my snowboard, my dumb face took one of the fastest trips back to earth its ever experienced.

Snowboarding is awesome.  It gets even better as you hold fewer yard sales on the mountain.  There's something about speeding down a top-to-bottom run surrounded by winter.  The people are great, too.  Lift attendants tell you to enjoy your run as they shovel snow under the chair.  On the way up the lift, you learn where strangers are from and how long they've been at the resort.

It's the only thing that gets me in and out of bed early.

It's going to be a long road.  The car's not even out of the driveway.  But I cannot wait to get out there again and worry about not catching my toe edge.

Why Am I Choosing Amputation?

In three operations over six months, orthopedic surgeons reconstructed my ankle with staples, stitches, screws, metal plates, a skin transplant, a bone transplant, and external fixators.  Each surgery was painful.  Each recovery was exhausting.  Each setback -- and man, were there some setbacks -- took a toll.  I've had more holes drilled in my leg than a Victorian home renovation project on This Old House.

But, hey, at least the orthopods saved my leg.

It's the protocol.  Save the leg and buy options.  Amputate and lose them.

Ankle distraction arthroplasty was the most recent option we've endured.  It came with two more surgeries, a third external fixator, and more pain.  The risk was low.  It didn't eliminate any other option in the ankle arthritis treatment protocol.  The reward was potentially high.  Pain relief.

Unfortunately, in the twelve months following the procedure, the pain increased and reached new heights.  More setbacks.

I lost my leg the moment I snowboarded into that tree three years ago.  When I tell people about my choice to amputate my right leg six inches below the knee, I'm greeted with concern, doubt, fear.  Remorse.  Why are you doing it?  Have you run out of options?

I'm making a choice between 1) keeping my leg at the expense of a lifetime of more surgeries or 2) regaining my quality of life at the expense of losing a leg.  I don't get to pick both.  This New York Times article from last year does a good job explaining my rationale.

It's an easy decision on paper, but it was still emotionally challenging to ask Dr. Jeng, "can we amputate this leg?"  It was a surreal moment when I heard those words leave my mouth in a hospital in front of a surgeon that can actually do what I'm asking.

I'm excited about what I'll gain with an amputation.  I want to go on walks with my wife, run around with junior, reign over the basketball court, and strap back into my snowboard.

I face some hurdles between now and Cutting Day.  I'm sure I'll have to justify my decision to friends, family, medical professionals, and even myself, for the rest of my life.  We'll all have doubts.  But I'm done with living in fear of pain and doubt.  We're getting my life back, and I can't wait!

When I asked Dr. Jeng for the amputation, he asked Brooke if she was on board with my decision.  She told him she was in favor of an amputation.  Dr. Jeng was shocked.  He told us he'd never seen a spouse so supportive of an elective amputation.

This is why Brooke dominates.  I love that woman.  I wouldn't be able to endure any of this without her -- especially the constipation.

Taking The Plunge

As a kid in Tulsa, we'd beg our parents to drag us to Big Splash Water Park to escape the blistering summer heat.  They had (and still have) the tallest water slide in Oklahoma -- the Silver Bullet.  The Silver Bullet actually had a twin, but Big Splash kept it out of operation.  The story was some poor kid flew off the other slide and met an unfortunate and premature end.

My anxiety and excitement would always grow with each step up the stairs.  When I got to the top of the Silver Bullet and looked down, I had never been more certain in my life: this was the dumbest thing I'd ever done.  On the way up I had the option of aborting the Silver Bullet for three mediocre slides.  But there was no turning back.  I had to take the plunge.  The other slides weren't nearly as fun.

In the last several months, my ankle pain has gotten worse.  I use a cane more often and acute arthritis now hits me on the medial side of the joint.  Ankle replacement and ankle arthrodesis (fusion) promise short term relief.  But the risks of failure are high, especially with my butter soft and piecemeal ankle.  And the rewards are small.  More surgery is a guarantee.  These are mediocre options.

I've known this for a while.  I need an amputation.  I need a Silver Bullet.  

Yesterday was my last visit with Dr. Jeng at Mercy Medical Center in Baltimore.

The x-rays show mixed results from the August 2011 ankle distraction arthroplasty.  The anterior (front looking) comparison above shows an improvement in joint space.  If you look at the medial joint space (on the left), you'll notice the gap is larger between the medial malleolus and the talus.

The lateral comparison isn't as good.  There's no noticeable improvement in the joint space.  It appears the anterior portion of the tibia is in direct contact with the talus.

There's no doubt, the distraction arthoplasty is adding joint space.  But it's not doing anything for my pain, and that's all that matters.  Dr. Jeng agreed.

I asked if we could move forward with an amputation.  Dr. Jeng agreed.  Of the three options it's the only one that can get me back to snowboarding, running, and my normal pre-accident routine.  But Dr. Jeng won't be performing the amputation.  He hasn't done one in several years and told us that he sucks at them.  Instead he's referring us to a vascular surgeon.  Dr. Jeng said he could connect us with some guys he knows, but he suggested we find someone closer to home.  He asked that we find a good vascular surgeon and a better prosthetist.  

So I've got my referral.  Because I've got a PPO, I technically don't need it -- but because this is an elective amputation, I probably need it to convince the vascular surgeon.  It's a little surreal to read this referral.  I'm at the top of the Silver Bullet.  It's scary.  It's frightening.  

But I can't wait to jump.  

I can't wait to run.  

I can't wait to snowboard.

Yesterday was my last visit with Dr. Jeng.  It was surprisingly emotional.  That guy rocks.  He asked that I stay in touch over email and let him know how things work out.  I'm going to miss working with him.

After the appointment Brooke and I decided to ease up on the gravity of the day and hang out at Eastern Market and buy some food.

Then we finished it with a couple of drinks to figure out our next steps.  

I haven't updated the blog regularly in a while.  Frankly I didn't have much to say.  Just that the pain was getting worse.  That's too depressing!  

I'll be updating more regularly now that things are picking back up.  My next couple of posts will provide some details about what I can expect with a below the knee amputation (sometimes called BKA or BTK).  My plan is to learn more about the procedure and start shopping around for awesome vascular surgeons in the local area.

I also wanted to thank everyone for the awesome support.  I'm really excited (and scared) about the next and hopefully last step to recovery.  But I know this is the right thing to do.  I can't wait to get back to normal life.  I can't wait to take the plunge!

Snowboarder vs Sailing

I know!  Dude, I know.  It's been a while.  Here's the deal.  I've been trying really hard to live my life like I don't have an ankle problem. 

How's that going?

Turns out it's unavoidable.  I've got an ankle problem.  More to come.  But 2013 will be a big year.  

In the meantime, here's a video I put together of a recent sailing trip to the British Virgin Islands.  If you have ankle problems, go sailing.  It's easier to move around on the boat than you think.  Much easier than a lot of walking.

Snowboarder vs. Ankle Distraction Arthroplasty

I forgot I had a blog.  My bad.

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

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

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

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

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

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

What about ankle flexibility?

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

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

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

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

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

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

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

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

Where are we after one year?  If I was happy with my current activity level, I'd say we've made huge progress on my ankle.  Unfortunately I have a few problems with where we're at today:

1. I want to be able to stand for longer than 60 minutes straight without needing significant rest the next day.
2. I want multiple days of activity without pain (no rest days).  Airport travel kills the first day of vacation.
3. I need more ways to get my heart rate high enough during cardiovascular exercise.  Swimming is great, but it's usually inconvenient.  

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

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

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

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

Snowboarder vs. How Fast Was I Going for Real?

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:

1. He never plays practical jokes on anyone.
2. He never bets anyone to do pretty much anything
3. 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.