Wednesday, 23 November 2016

Leg lengthening, 0-5mm

I've been to physiotherapy today in Liverpool. I got picked up in a car by East Midlands Ambulance Service by a nice driver who took me to Liverpool. It was very good, I was comfortable in the back. We arrived about 0940. I had my appointment at 10. I showed the physiotherapist the strut that's not behaving properly, seems like the nut is threaded maybe and I've been using pliers to make sure it works. He took one look at it and decided to replace it - I'm still not sure if adjusting this with it threaded matters or not. He put on a temporary strut to keep the tension while the other one was taken off and a new one put on. Then he went and got me clip removers so Rebecca can take the clips out later (the clips from where they cut in to chisel my tibia) and I also asked for and got a big bag of dressings so Rebecca and I can be change them again in about a week from now. It's really great how they trust me so I can just ask for stuff and get on with it myself and with Rebecca's help. That has been a constant throughout my treatment at Preston and here - I really can't speak highly enough of all those NHS professionals that have looked after me.

For actual physiotherapy we did stretches of my knee, my forefoot and my toes. It really makes a difference to the range of movement in my forefoot which has to be maintained so that I can walk properly without an ankle that moves. I must also do the knee stretches to try to stay in the 'honeymoon period' for longest. What is the 'honeymoon period' I hear you ask? Well I asked him about not being sure anything was really happening and them having built this lengthening procedure up as a really tough thing etc. So he explained.

There's always a 'honeymoon period' while the natural stretch in your tissues is used up - it varies for different people, you can check it just by stretching your skin with a finger, but it could easily be 5mm so I'm obviously still in that period now. What happens when the limit is reached is that the soft tissues can no longer keep up with the extension you're making, so then it's like over-stretching a muscle. If you overstretch it for a few seconds and then relax, no problem. If you were to hold the stretch for more than a few minutes, you'll probably feel pain and want to relax. If you hold it for more than an hour, the pain gets worse because you're having to constantly deal with it. Until you relax the stretch. So what's going to happen is that once I get as far as the natural limit of my tissue, it will be like stretching a muscle and never relaxing it. That will be painful. Oh and there's the other stuff I talked about previously about wounds around pin sites. So that's where we're headed - the knee stretches may help increase the length of this period so I'll be keeping on doing them ha ha ;)

Anyway after this enlightening conversation about pain I went for an X-ray and since I can't wait until next Tuesday to see, I asked the radiographer if I could see them. You really can see the gap, it's not my imagination, it might even be 5.25mm ;) Fab! See below, where I have also made some blow ups of the interesting bits!

Here's my photo of the screen in radiography, this is the top view x-ray. Once you orient yourself to
what you're seeing, you can see my fibula, still (and forever) in several pieces, and you can see the gap opening up,
see the blow-up below.

And here on the right is the side view, close up of my knee, you can see the gap opening up.

This is a close up of the side view knee x-ray, you can see the gap and the staples over the wound to the right.

Here you can see the three nails or screws that they put in to hold my ankle together.  One of them is at an angle that I can't really understand, like it went in from the top going downwards, I'll ask about that next week because it doesn't seem to fit with the description before the operation. 

Here's a blow up of the top view x-ray, you can see the staples and underneath the gap opening up in my tibia. It's definitely there, it could even be 5.25mm!

Thursday, 17 November 2016

Operation 16 and What Happens Now

The cut through my tibia was made on November 8th in an operation which lasted around 90 minutes. Everyone was happy and I was feeling pretty strong the day after so I was discharged with, as usual, a big bag of meds and dressings. There was the usual wait for pharmacy to deliver the drugs, but they did in the end and we got home about 7pm. The only visible change is a new dressing where they cut in to get at my bone.

After Op 16. Dressing covering incision to break tibia.

Incision with clips. Pretty? :)

What happens now is 10 days waiting for the bone to begin to knit together, then lengthening starts. So this is tomorrow now, Friday November 18th. I have my instructions and spanner. The break is where the incision is, meaning that the ring near my knee will not move, but everything else on the frame will. One quarter turn on the square nuts four times per day, that's one turn per day, which is 1mm extension. We're going for about 20mm give or take, so 20 days of adjustments to come.

Now, here is the thing: I have been told often that this is tough, the lengthening process. In fact, I was told at physio this week that they once had a patient who was in the SAS and had been on tours in Afghanistan and Iraq, and this process broke him. Here is why: it's not the bone. You can 'grow' your bone 1mm per day no problem, in fact I've done this before in 2012 with the straightening process. It's not the bone, the pins move with the bone, the issue is with the soft tissue, the skin and flesh. Moving the frame down means I will cut open wounds wherever a pin enters my skin below the cut. There are 12 of these sites. Opening up a 20mm wound in each of these locations. And soft tissue doesn't want to stretch at 1mm per day either, wounds notwithstanding. So I think I understand now why this might get tough. Hopefully though I've so little feeling in my lower leg that I won't feel so much as the pins cutting through. It does sound a bit like self-inflicted torture I guess..

On the plus side, the physiotherapist did say I had already been through a lot (true) and that I looked like an excellent coper (also true, I think). Well we will see won't we, whether I'm tougher than the SAS. I'm ready. Lengthening and cutting starts tomorrow then.

Expect regular updates and measurement photos like last time :)

Bonus free spanner to adjust the frame with!

Monday, 7 November 2016

Operation 15/15b/16

Operation 15, to sort out my heel and ankle, and put the frame on and break my tibia, was a complete success. My ankle and heel are now held together by pins and a big nail going up from the sole of my foot (lovely), or something. And the frame is on ahead of the leg-lengthening. BUT, they didn't actually do the break of my tibia, so that is going to happen this week, on Tuesday 8 November. Apparently when I came around after op 15 I was a bit disappointed about this, this being 'plan B' not 'plan A', but they explained to me that it was best for me and for them, they were tired after 6 hours of operating on me, and they want to get this last bit exactly right. So fair enough. Look, I'm never going to complain am I?! They've all been brilliant.

In fact the level of care at Broadgreen Hospital is pretty amazing. Everybody seems to know exactly what they're doing and just gets on with it. It seems like a good place to work. My 5 day visit was really good in that respect. Even the food is nice! It's a new unit, maybe 18 months old, and it shows at least in the sense of organisation - everything is quite close, like the physiotherapy gym is just at the end of the ward, opposite where you go before your operation. 

There's no A&E at the hospital, and I think that helps to give it a calm feel. Anyway, I'll be spending another night there this week which I don't mind at all.

After (left) and before (right) operation 15.

The way of dressing the pin sites is something I've never seen before - you can barely see the pins afterwards. They use syringe drivers to hold the dressing against the pin site (clever!) and then wrap each group of 2 or 3 pins in a bandage which has them ending up looking like garlics you get in the supermarket, or meringues possibly. It's really clever because none of the pin is exposed. It makes me realise how exposed I've had them in the past - I mean, I was showering and then putting a gauze over and cutting a dressing to slot around the pin, meaning only the bit near my skin was covered. This is much better. They also last 10 days dressed like this so when I come to do it myself, much less work and hassle to maintain them! Excellent.

I can't weight-bear on my left leg for 3 months. I should have realised this, but it did come as a slight eyebrow-raise, not a complete surprise. The other times I've been able to touch weight-bear, so this is different, and will be more of a challenge. I'll end up with an even stronger right leg and upper body! But it adds an extra element of nerves, because I really can't afford a mishap now. It's because the ankle and heel fusion has to heal before I can put weight through it. Fair enough. I like a challenge.

I've spent most of this last week since I was discharged readjusting to life on crutches; how to transport a cup of coffee from the kitchen to the living room; how to have a shower (bin bag over leg, bath board); how to find a comfortable position to sit for extended periods with my leg elevated, etc. A lot of moving involves balancing on my right leg, but I'm pretty good at that. Outside I've only been as far as the supermarket, coming back up the hill was OK but a bit tiring. If I go to work on the train it'll be tough at the moment, so I'll probably have to rely on a lift for a while.

Anyway, back to this week, operation 15b or 16 (let's just call it 16) will be a short one to cut my tibia near my knee (on a healthy bit) and then after a week or so for it to settle down, the lengthening process will begin. I should be in for 24 hours this week. The consultant who spoke to me said they weren't going to "just burn through it with a saw" but rather they'll "use chisels to get a nice controlled cut". Lovely. Glad I'll be asleep.

Saturday, 22 October 2016

Operation 15

It's been a long time since I blogged about my leg. Unfortunately that doesn't mean it's been all back to normal, it just means there's been nothing significant to write about, but now, well, there is. On Wednesday October 26th I'll have an operation to break it again, this time in Liverpool (at Broadgreen Hospital). About 18 months ago my consultant in Preston referred me to the Specialist Limb Reconstruction Unit there, and I saw them for the first time in July 2015. They were so positive about what a difference another surgery would make that it felt inevitable that I would go through with it, and so, after a bit of a delay, I am doing.

This is elective surgery which means that I've chosen to have it. That makes it quite a lot different in principle from my previous operations, which have really been compulsory to regain any sort of function in my leg. You may, or may not, remember that my last operation in 2012 was necessary because my leg healed up with a 17 degree bend in my tibia (shin). That absolutely had to be corrected for me to be able to weight bear again. You'll remember I was in external fixation for 6 months to straighten it out and wait for it to heal up. While that operation allowed me to walk unaided again (as well as bike, etc.) it didn't correct either the length of my left leg, which is 2.5cm shorter than it used to be and than my right leg, and it also didn't correct the angle of my ankle or the relative positions of my knee, ankle and heel. You can kind of see the problem from the photo Rebecca took of me recently from behind after I'd been biking. I'm lop-sided and my foot doesn't hit the ground properly.

Photo of my legs from behind. You can clearly see I hope what the problem is!

Anyway, the length of my leg and the positions of my ankle and heel will be corrected all-at-once by this next operation. Ultimately this will mean walking will be easier, less painful, and I won't be damaging my ankle and back further by trying to behave normally. So it's worth doing, even if it does feel like a massive step backwards. I've been talking myself into it for ages now basically along the lines of the following conversation:

"I don't really need this operation, I can manage just fine now, I've adapted."

"Yes but what about in 10 years' time, will you be able to manage then?"

"I don't know, possibly not if it gets worse."

"Well if you can't, or if it gets much worse, will you regret not having this operation then?"

"Yes I will."

And that is not good, and that is why I'm going through with it, even though I know what it means in terms of mobility, pain, and hassle. I will have a frame bolted to my tibia not unlike the previous one, except this time I will adjust the struts to lengthen my leg out, not straighten it. You can grow your bone 1mm per day, so that will be about 25 days of adjustment, after an initial settling-in period of about 2 weeks if it is like last time. Then you are just waiting for the bone to fill in the gap you've made. That will probably take 4-5 months. At the same time, they're going to break my pretty much completely fused already ankle, and re-fuse it in a better position, more perpendicular to my leg, so I can put it flat on the ground. And, they will break my heel bone and pin it so that it is in better alignment with my ankle and knee. So all these adjustments are to improve my biomechanics, make them more like a normal person would have.

In hassle terms, it means wearing the frame for about 6 months, which is awkward and irritating because it's bulky, you can't wear normal clothes, it looks awful, and mainly because you have to keep the pin sites, the bits where metal enters your body, very clean. In practice it means cleaning and dressing them all probably every other day. This means lots of dressings and stuff, but I remember all that stuff from the two previous times so as long as I can get everything from the pharmacy it should be OK, it just takes time and you have to do it properly because infection would not be good. Really not.

This is what it looked like last time.  This time will be similar, except my leg is now straighter,
and it may be longer this time, going down closer to my ankle.

Obviously it means no driving, no biking, difficult to get around. I now have quite a lot more going on than I did last time, so I'm probably going to get more frustrated than I did last time, and then on top of that there's the knowledge that I chose to have this done and I'm doing it from a position of relative activity, not like last time.

I haven't written this to make you feel sorry for me, not at all, just to explain what's going to happen so that if you see me afterwards you know some of the story. This is operation number 15 in total. It will hopefully be the last. If you want to know the full story, look at my previous post called 'Recover' ( Or click on 'The Accident and My Leg' above.

Another thing that's very different from last time is that I have a lovely wife at home who is prepared to suffer me, and a great extended family through our church. This will make a massive difference I'm sure. We started going to Revive Church just before my last frame was removed, in November 2012. I'm really thankful for how my life is now. I thank God every day for it, but the truth is that the good is inseparable from the 'bad'. What happened to me and the resulting changes in my life and faith are completely inseparable, so I thank God for my accident and my dodgy leg. And for the NHS and blood donors. For my wife, my family, our church, my job and my altered perspective.

No doubt I'll feel the need to blog again about this, and post photos, after the op :)