Tuesday, October 26, 2010

Week Three

Wednesday, October 20, was three weeks post-surgery. The cramps were still coming on strong and my foot felt as if it were burning; this was definitely my nerves "coming back to life" but it was so uncomfortable! I was also doing my best to ignore the abrasion on the back of my foot but it wasn't easy.

Meanwhile, the fall weather was cool and crisp and I wanted so much to enjoy it! Of course I wasn't ready to venture outside anywhere yet. My pain medication made me sleepy and getting around on my crutches or walker for too long tired me out. Not to mention my foot was still in considerable pain. Not only did that need to subside, but I also needed to build up my strength.

Thursday the pain was a little better and I couldn't decide whether it was the abrasion on the back of my foot or the actual ankle that was bothering me. I took my pain medication upon waking in the morning and was able to wait 6 hours before taking it again. There were still spasms but during the day they didn't seem to bother me as much. I decided I would continue taking the pain medication until the cast came off the following Tuesday. At that time I would be able to take care of the abrasion and possibly massage the cramps, and hopefully I could wean myself off the medication. It all depended on how the rest of the week went.

Of course, by Thursday evening I wasn't able to wait 6 hours before taking my pain medication again, and the next day my foot was still tingling and burning. My next appointment with my doctor was that coming Tuesday and I planned on asking him about the sensations I was feeling; I wondered how much longer they were going to last.

Saturday I was still feeling the spasms and tingling, and the incision site and ankle itself were also painful, although I noticed the abrasion on the back of my foot did not bother me as much that day. The spasms were making it harder to wait 5 hours before taking pain medication but I persisted. I wasn't sure exactly what type of pain I was supposed to be feeling other than the spasms; it seemed there were only a few times when the actual ankle hurt. I wondered if the pain medication was helping, since I didn't know what type of pain I was supposed to be feeling. Was I not feeling pain because the medication was doing its work, or was I lucky that the pain was not too bad for me? The pain was different from when I had initially broken my ankle; I would need to speak with my doctor at my next appointment.

Getting up and moving around helped the spasms but not always the tingling. I continued with my left leg exercises as well to keep the leg from atrophying too much. It had atrophied when I'd first been on crutches 7 years ago and I felt as though it never went back to being the same size as my right leg. I was worried it would be even smaller and more noticeable now. Hopefully I would be able to build it back up again.

Most of my days were spent reading and watching TV or movies, and occasionally napping due to the pain medication. I was able to log onto the Internet through my Netbook, so I could keep in touch with friends and stay posted as to what was happening at the shelter. Each day I would get up and move around the house in order to build up my stength but it was still very tiring. Not being able to sleep well at night didn't help; I would wake up 2-3 times a night due to pain or just being uncomfortable.

The next day the hard cast would be coming off and the walking cast would be going on. Although I knew the air cast would stay on most of the time, I began to worry about when my foot was out of the cast, when I was sleeping or in the shower. My foot would be able to move freely, and movement could hurt. All I could do was wait and see.

On Tuesday the hard cast was removed and the air cast was put on. My doctor said the wound was healing nicely, the swelling had gone down and everything looked good. He told me the tingling and the spasms were normal and would continue for a while. The pain medication was not helping those, and he advised me to start weaning myself off.

When he moved my foot back and forth it did not hurt too much; it actually felt nice to move my foot without the pain I was experiencing before the surgery! He told me I would be allowed to put weight on my foot as tolerable, but I still needed the crutches to get around. I was also supposed to exercise my foot by moving it back and forth, and start physical therapy. I tried standing up in the doctor's office and although it was somewhat painful, it worked!

I was so happy that I would be able to let my foot breathe again and that I wouldn't have to balance on one leg when standing. I wanted to do so much when I got home but I was exhausted from my busy day and needed to rest. I also knew I needed to take things one day at a time... baby steps.

I found a physical therapist in my neighborhood and made an appointment for Friday morning. I was nervous and excited at the same time.

By evening I could definitely feel pain in my foot and knew this is what I would have been feeling all along if I had not been taking my pain medication. But I was holding out for my bedtime dose so I could begin the weaning-off process.

Tuesday, October 19, 2010

Week Two

Wednesday, October 13, was one week post-surgery and the pain was somewhat worse that day; the medication helped but not as much as before. The day before I was fitted for my walking boot and the additional pain could have been from walking around on crutches that afternoon. Could have been part of the healing process. Could have been from doing my leg exercises. I'm not one for calling the doctor for every little ache and pain; I planned on calling my surgeon if it didn't get any better or got worse within the next few days.

On Thursday the pain was better. When walking around or doing my leg exercises, I focused on how I bent my leg, using my thigh muscles rather than my knee. I thought that may have been the problem the day before and planned to keep an eye on things.

Friday was better. I was watching how I bent my knee and I noticed that the more I moved around, the better my foot felt. Laying down and elevating it too long seemed to make the tingling worse. Of course, walking around too much didn't make it much better! A good mix of getting up and moving around along with resting helped, but there were still small spasms of pain in my foot. My surgeon had mentioned the nerves were "coming back to life" and I figured this was the cause of these sensations. I also noticed I was able to go a little longer between pain medication, from every 4 hours to every 5 hours.

By Saturday I realized most of the discomfort I was feeling was due to the tingling in my foot and not actual pain at all. At least, not until the pain medication started to wear off, and once that did the spasms themselves were painful. Now and then my foot would twitch inside the cast, on it's own, and that hurt the ankle joint itself. Understanding where my pain was coming from was helping me cope with it.

As the week went on the swelling subsided and the cast became looser, which caused what felt like an abrasion on the back of my foot, along the heel. It was frustrating but I had no other choice but to ignore it, since there was nothing I could do as long as the cast was on.

I still did not have feeling along the bottom of my toes or foot and hoped that would change soon, especially since the tingling and cramps were still coming on strong. The cramps were very uncomfortable and had a "charley horse" type of feeling.

The mornings were probably the most difficult part of my day because my foot felt very stiff and tingly upon waking. It was also hard to get comfortable because I could only lay either on my back or my right side, with my foot elevated either way. I also tried sitting with my foot elevated differently because the abrasion on the back of my foot was bothering me. If I was able to have my foot sideways it didn't hurt as much. It also felt better when I got up to move around or to do my leg exercises. I couldn't wait for the cast to come off next week so my foot could breathe and I could tend to the aches and pains.

Sometimes I would become upset thinking about how my surgeon had told me I would no longer be able to participate in mountain biking. This was my favorite hobby and it would be very hard to give up but I knew the surgeon was right. I couldn't risk loosening the implant and shortening its lifespan. My friends were supportive and reminded me there are plenty of other activities out there to enjoy. Some even said the surgeon could be wrong, if I modified my style of riding or rode a full suspension bike then I should be fine. I knew I couldn't take any chances and instead of focusing on what I couldn't do, I focused on all the things I would be able to do. For over a year I hadn't used my elliptical machine or Wii Fit, and I hadn't gone hiking with my family or gone for morning walks around my neighborhood. The simple tasks of cleaning the house or grocery shopping had been very difficult. I reminded myself that giving up one of my hobbies was a small price to pay in exchange for doing so many of the other things that I enjoyed doing. Plus... who knew what other new hobbies I could take up!

Thursday, October 14, 2010

Week One

On the morning of the surgery I was still coming up with excuses not to go through with it, but of course I did. My husband accompanied me to the North Shore Glen Cove Hospital but he was not allowed into the holding room with me. Any time hospital staff approached the gurney I was sitting on, I would burst into tears. Dr Segal, my surgeon, came to see me and assured me everything would be fine. I asked him what kind of hardware he had decided on and he told me he would be using the Salto Talaris. The design is small and implanting it would require removal of less bone than other prosthetics out there, making it ideal for the future when revision surgery may be necessary.

The anesthesiologist came over and assured me I would not wake up during the surgery nor would I be able to fight the anesthesia and not fall asleep. Everyone told me I would be fine. A nerve block was injected into the back of my left knee. I was brought into the operating room and placed on the table. A mask was placed over my nose and mouth and off to sleep I went.

Approximately four hours later, I was in the recovery room with the hospital staff telling me I had made it and the surgery had gone well. I was very drowsy and feeling no pain and I was back! Things had gone well as everyone had promised me.

During the next few hours I did not experience any pain. The nerve block worked well until the next morning when the pain started to set in. Still, I did not think it was as bad as I had expected. I was feeling rather good and was already anxious to go home.

Thursday morning the physical therapist came in and had me get up out of bed and use a walker. The blood rushing down to my foot caused such a stinging, burning, tingling sensation that I was close to tears. It was almost impossibile for me to move around because of the pain. I got back into bed and was told we would try again the next day.

Over the next couple of days the painful bloodrush I felt when getting up to do my physical therapy became easier to tolerate. The therapist had me practice going up and down stairs on crutches and walking down the hallway with my walker. When I got back to my room I was pretty tired! Muscles were sore from not being used in that way before. Thinking back, it would have been good to do exercises at home before the surgery to strengthen my legs, arms and shoulders to prepare me for getting around on crutches and a walker. I was never much for lifting weights, I would much rather do aerobics or walk or ride my bike. But I would say now that lifting weights would have definitely benefited me.

By Saturday, October 9, I was more than ready to go home and got the doctor's clearance to be discharged. My first night home I slept like a rock! It was good to be back in my own bed. The next few days it was a little hard to get around, I would become easily tired. The pain was still under control with medication.

On Tuesday I was put into a hard cast and it would stay on for two weeks, after which my surgeon would remove it and the stitches and put my ankle into a walking boot. However, I was told I would still not be able to put full weight on my foot for another three weeks.

There had been tingling in my foot and the doctor told me it's because the nerves had been "asleep" during the surgery and while the block was in effect. Nothing to worry about, it was perfectly normal. I was also instructed to keep my foot elevated as much as possible to help the bruising subside.

My first week was over and I was feeling pretty good.

Preparing for the Big Day

For the first few weeks after I made my appointment I was excited with thoughts of pain-free mobility and doing all the things I'd missed out on for so long. I couldn't wait!

Then, as the surgery date drew closer, I began to get nervous. Maybe my ankle was fine and I didn't need the surgery. I could still get around fine, the weight loss had helped with the pain. I had Celebrex and my brace and I knew my limits, I would just rest when I needed to. And how could I be off my feet for weeks, not able to help around the house or with errands? My husband and son would need to do more than their fair share for as long as I was off my feet. My husband reminded me of my limitations and of the things I hadn't been doing that I missed doing. He reminded me that the doctor told me I'm a good candidate for this surgery and no complications were foreseen. He also told me he did not mind helping more around the house; the next few weeks would be hard for us but in the long run it would pay off.

Still... I was scared and I realized that I wasn't afraid of the actual surgery itself, it was the anesthesia. I didn't know why that bothered me, especially since I had been under anesthesia two times before in my life due to my ankle, and I had had a C-section when my son was born and although I was not under anesthesia, there was another surgery done! For some reason I was afraid of either going to sleep and never waking up again or waking up in the middle of the surgery. My husband continued to reassure me everything would be fine. I had to continue to remind myself that I was young and healthy and strong, and if there were any issues my doctor would not be going ahead with this surgery.

I felt the need to prepare for the few days I would be at the hospital and away from home. I made sure bills were paid, ran last minute errands, cleaned and reorganized the house and tied up loose ends at work and at the shelter. I felt as though I had the nesting syndrome many women feel when they get close to the end of their pregnancy.

Two weeks before the surgery I was told to stop taking my Celebrex and all other supplements I was taking except for the multivitamin. I also began taking Vitamin C and iron, although it then turned out that I did not donate my own blood. This was a personal decision and I would recommend anyone considering this surgery speak with their own doctor regarding blood donation.

Soon the night before the surgery came... the next day would be a big one!

The Decision

When I began the search for the surgeon who would do my ankle replacement, I started with my health insurance company. I needed to make sure the procedure would be covered. Luckily it was, under ICD 9 code 81.56. Once I understood how the coverage worked and what exactly was covered, I needed to find a surgeon who participated with my health plan.

Initially I wanted the surgery done at the Hospital for Special Surgery in Manhattan. After all, they specialize in this sort of thing! So I searched on the insurance company's web site under the criteria "orthopedic surgeons" and "Hospital for Special Surgery." When the list came up I narrowed the doctors down by location, keeping in mind that I would be going for follow-up visits and knowing my family would be visiting me at the hospital.

Then I began calling the doctor's offices and crossing off the surgeons that did not specialize in ankle replacement surgery (many specialized in knee or hip). The list was finally narrowed down to three doctors and one of them didn't have an appointment available until March 2011. Of course that was too far away so I made appointments with the other two.

On August 20, 2010, my husband and I sat down with Dr Ayal Segal for a consultation on total ankle replacement surgery. He went over the various options that were available to me, from having a cadaver part put in, to having the ankle joint "stretched" with a surgical splint, to ankle fusion.

Having a cadaver part put in is a very experimental procedure and Dr Segal would have had to refer me elsewhere to have it done. This procedure didn't really appeal to me; I wanted something more concrete. The splint would stretch my joint and buy me 2-3 more years before I would have to undergo the replacement surgery. I didn't want to have to have surgery now and then again 2-3 years from now, so that procedure was out. Ankle fusion would basically render my foot motionless for the rest of my life and I would have to wear special shoes. Arthritis would most likely set into to the knee and hip joints of the same leg earlier on because I would be walking differently. The good thing about this procedure is that it would only be done once; I would never have to have surgery on my ankle again. But I didn't like the thought of never moving my foot again and having other joint problems due to the fusion. So then it came down to replacement.

Total ankle replacement is a relatively new procedure but within the last 10 years the technology has come a long way and the success rate for patients has improved. With the replacement I would be able to do everything I've done before, with the exception of high-impact sports such as running and tennis. But I would be able to walk around my neighborhood again, hike with my family, use my elliptical and Wii Fit again, and do so many other things that I haven't been able to do in over a year. Dr Segal told me I am an excellent candidate for total ankle replacement. I'm young, thin, healthy and active. If I were 20-30 years older I would have to have fusion; replacement would not be an option for me.

My husband and I felt the consultation went well. Dr Segal answered all of our questions, layed out all of the facts regarding the options available to me, and didn't pressure us in any way toward a particular option. He had done many ankle replacement surgeries previously and specialized in complex reconstruction of the ankle. He would do my surgery at North Shore Glen Cove Hospital. This was not initially the hospital I had wanted to have the surgery done at but I decided that the surgeon was more important than the hospital. Not to mention the hospital was only a half hour from my home, whereas the Hospital for Special Surgery in Manhattan would probably be over an hour away.

I knew this was what I wanted to do and I felt comfortable with Dr Segal. I made the surgical appointment for October 6, 2010, and canceled the appointment I had made with the other orthopedic surgeon.

Tuesday, October 12, 2010

An Introduction

I decided to start this blog so I could help people with their decision to have total ankle replacement. Since I hadn't planned on recording any of this I do not have photos to post or exact timeframes for certain things before this year. The main purpose of this blog is to explain the factors leading up to my decision to have total ankle replacement surgery and to document my recovery afterward. I am hoping my experiences will help those of you out there considering having this surgery.

I will be 40 years old this month. I have always been an active person. Years ago I was enjoying hiking, mountain biking, snow-shoeing, rock wall climbing, softball, aerobics, Tae Bo... anything that would keep me healthy and fit.

On June 17, 2003, my life changed. I was playing softball and a baserunner slid into me, breaking my left ankle. I was told it was a trimalleolar fracture, which basically involves three bones in my ankle joint. Pretty bad break. I had open reduction internal fixation (ORIF) surgery, which resulted in a plate and screws being placed into my left fibula and initially three screws into the left ankle itself. After the stitches were removed, a hard cast was put on for about 6 weeks.

After the hard cast was removed one of the screws in my ankle was taken out. This was outpatient surgery and I left the hospital the same day. Physical therapy was not difficult for me. I tolerated it well and was back on my feet, without crutches, by September 2003. My orthopedist, Dr Steven Erlanger, attributed my good recovery to my healthy lifestyle, which had kept my body strong. I continued with my active lifestyle for a few years without any complications. I even started volunteering at a local cat shelter in December 2006 so I could give back to my community.

Then in 2007 I began having discomfort and stiffness; my orthopedist told me osteoarthritis was setting in. I received a cortisone injection that year and it helped tremendously. I was back to doing all the things I loved doing, including going for morning walks around my neighborhood before work each day.

In 2008 I received a couple more cortisone injections and had a brace ordered for my ankle so I could walk longer distances. The brace did not help with the pain but it helped give my ankle the extra support it needed. Things were starting to get a little tougher for me. The cartilage in my left ankle was wearing away quickly. I could no longer go for my morning walks, which was something I really enjoyed doing. I decided to purchase an elliptical machine; the low-impact workout was good for me. I also purchased a Wii Fit and used those games and exercises to help. I was unable to do the "running" portion as it was too much for my ankle. I was still able to mountain bike but anything hard-impact like hiking or walking were no longer options for me to exercise. After doing any sort of exercise I had to rest my foot, elevating it with an ice pack.

Having my foot flat on the ground was too painful; I could no longer walk barefoot. I had to wear shoes with a small heel so I could walk easily. High heels were out of the question, even though I never really wore them to begin with. My shoes had to either be sneakers with a heel lift inside or comfortable wedges, which have a flat sole and a slight heel, no more than 2" for me. I was now wearing my brace whenever I volunteered at the shelter.

My orthopedist prescribed Celebrex, 200mg once per day, and I was able to stay relatively active, including the use the elliptical and Wii Fit, until the middle of 2009. By then any sort of activity was hurting my ankle badly, including things like cleaning the house. I was also unable to carry anything heavy and walk at the same time. The extra weight on my ankle was just too much. The 2.5 hours on my feet every other day at the shelter basically put me out of commission for the rest of the day. The cortisone shots were not lasting as long as they had in the past. I began parking as close as possible to entrances whenever I went to work or ran errands. A cane was sometimes used for extra support. My orthopedist recommended ankle replacement surgery and although I thought about it, I did not take any steps towards it right away. I wasn't sure about having surgery just yet.

I researched foods that were both good and bad for osteoarthritis and started taking supplements such as glucosamine chondroitin and fish oil to help with my painful joint. I tried keeping a journal to keep track of what factors were affecting my ankle, such as weather or food or activities. In September 2009 I decided to sign up for swimming three to four nights a week at my local YMCA. Swimming is a great total body, low-impact exercise! By December I was getting into a groove and becoming stronger.

My ankle was also becoming weaker. I was unable to be on my feet, walking or standing, for more than 20 minutes. Cleaning the house was almost impossible; I would have to do little by little on the weekend and rest in between each chore. There were certain errands I couldn't run simply because there was too much walking involved. Luckily I work in an office and sit for most of the day, but I was unable to complete tasks that required walking to the other side of the office or upstairs to the next floor. My daily activities were becoming severely limited.

It was time to take action. My first step was losing weight. In April 2010 I joined Weight Watchers with the intent of losing 20 lbs. I knew this would significantly reduce the stress on my ankle. I joined an arthritis forum group and read about other people's experience with osteoarthritis, what they were doing for relief and also if anyone else had undergone surgery. I searched for blogs and forums and read up on people's comments about their experiences. I searched online for sites explaining total ankle replacement surgery, what was involved and what the recovery period would be like.

In June 2010 the x-rays showed there was absolutely no cartilage left; I was completely bone on bone. My worst fear was ending up in a wheelchair and my orthopedist told me if I didn't do something about my ankle, that was exactly what was going to happen.

By the time August arrived I was close to reaching my weight loss goal and although my ankle was doing better because of this, I was still very limited in my daily activities and I knew my ankle would not last much longer. My journal showed that food, weather and activities may have had some impact on the pain and discomfort, but the fact of the matter was that my ankle had deteriorated and would not be getting better any time soon. The time had come to seriously consider undergoing total ankle replacement surgery.