26 June 2018

One Step Foward, Two Steps Back (Literally...)

8 June 2018:  Four Month Follow Up



So...I started physical therapy about a month ago with some walk/run on a weight-adjusted treadmill.  Along with the therapy protocol, I also began stretching and range of motion exercises along with the running/walking.




Unfortunately, my pain in the foot increased with increase in intensity.  Not good.  My orthopedic follow up was a month after I started PT, and Dr. C had X-Rays taken to see what was going on in the joint.  The concern was the pin-point pain I am having around the joint, which was different than the general aching of the whole area.  The latter is acceptable, the former is not!






A Little Knowledge is Dangerous!



I do have a little knowledge of medicine.  A little anatomy here, a little physiology there.  Just enough to be dangerous.  So, when the radiology report says the following:






"Postoperative changes as described above with interval lucency surrounding the screw within the distal aspect of the proximal phalanx of the first toe. An element of osteolysis/hardware loosening is not excluded. Follow-up is suggested."

Words that attract my attention:  Lucency, postoperative changes, and hardware loosening. 

Not Good.  At least I know why I am feeling pain.  When my amateur eyes look at the comparative X-Rays, I can see what the Radiologist is talking about.  I can also do basic math and I do know that after 16 weeks, broken bones should show healing with no Lucency or hardware loosening.




One Week Post Surgery, 16 February 2018
 
Twelve Weeks Post Surgery, 4 April 2018.


Sixteen Weeks Post Surgery, 8 June 2018



Radiologist's Report:  "Postoperative changes as described above with interval lucency surrounding the screw within the distal aspect of the proximal phalanx of the first toe. An element of osteolysis/hardware loosening is not excluded. Follow-up is suggested."



Bottom Line

There should be no light gray or black around the screw, and the joint space should show more bone-growth.  This is Lucency, and it should not be there!  The joint space should not be visible by 12 weeks.  When compared to previous scans, there are 'postoperative changes'.  Dr. C stated that if these findings bear out with further scans, additional mobilization of the joint or revision surgery to further close the joint space with additional fixation hardware. 

Ugh.  Dr. C made it abundantly clear that I was to do NO running and try to limit walking as much as possible until our follow up July 13.  She did say that I probably increased my activity too soon and aggravated the joint hardware area. 

I know this because there are several risk factors for fusion failure:  Obesity (No), Smoking (No), Diabetes (No), Questionable Drug Use (No), Premature Weight Bearing Activities (Yes, possibly). 

So, I will find out in July what the next 'steps' are in the road to recovery.




03 April 2018

Before and After Pictures

The Old Joint.
 
 

Before X-Rays (See previous Blog about the various fragments, fractures and dislocations). 

Bottom Line, the yellow line (2) is where the Distal Phalanx is Fractures and dislocated.


 
 
The New Joint.  Well, not a joint anymore! 
 
The final product!  The joint between the distal and proximal phalanx is now fused.  One can see the old joint is slowly disappearing with new bone growth.  The screw is there permanently.  The fragments (#4 & 5) above were removed, as those two little buggers were causing the most pain. 
 
Therefore, I suppose I have one less bone in my body than before.  I have just a First Phalanx- rather than a First Distal Phalanx and a First Proximal Phalanx!






02 April 2018

Weight Bearing!!!


Weight Bearing!

It is Wednesday, March 28th 2018.  First come the X-Rays then the check up.  I am so looking forward to actually walking as normal as I possibly can and wearing normal shoes.  The X-Rays did make me a little nauseous, the 2-inch screw in my foot/toe is a weird feeling.

The scars are not too bad, but my foot is still a little swollen, especially where the tendon had to be cut and fixed.  The doctor said that is where the pain will focus on- the stretching and movement of the tendon as I begin to walk and improve the range of motion of the ankle/foot/toes.


Left:  A close-up X-Ray of my Right Toe with the screw and joint fused.  Right:  X-Ray of my entire foot. 

X-Ray from the side showing the screw in the bone fusing both the Distal and Proximal Phalanx of the Right Hallux.
 
 
Pre and Post pictures are amazing to see.  The broken fragments are gone, the screw is in place, and the scars already somewhat fading.  I am now able to walk as tolerated with the help of the crutches. Dr. C said that for this type of surgery there is good pain and bad pain. 
 
Good Pain- the pain I feel at where the joint was and the screw is located.  Feeling chronic aching throughout the day is good.  It is the bone growing together and that is good.  The bad pain would be if this chronic ache turning into a stabbing, pinpoint pain.  this would mean the screw is moving or the broken bones are moving.  That is bad!
 
Bad Pain- where the tendon was cut, fixed, and reattached.  Dr. C said this will become the worst pain of the whole procedure.  As I work on walking and stretching the ankle and foot, this tendon is now shorter than before due to the trauma and repair of the tendon.  It will take time to slowly stretch and work out the scar tissue.  And it has to be done!  This is where the Pain is Gain, must stretch it to strengthen it. 
 
And Dr. C was absolutely right!  Walking heel-to-toe is VERY PAINFUL!  Even on a rubber track!  It is easy to avoid walking normally by walking on the side of the foot, but that will lead to potential stress fractures on the side of the foot.  So, take my time, take my pain meds and have patience.
 
My first walk pace was very slow.  Quarter Mile Time:  4:29, 4:16, 3:53, and a 4:01.  That would be a two-mile in about 33 minutes.  Not even close to passing the 2 mile run! 
 
And I since I put on the uniform in 1991, my personal APFT Commitment remains the same:  NEVER DO THE 2.5 MILE WALK! 

 
 

 
 

02 March 2018

Out Come the Stitches

D+16

Second Post-Op appointment came and with it looking forward to removal of the stitches and hopefully a boot rather than a cast.  With a cast, I would still need to take baths.  If I got a boot, then I could take it off and take a shower.

Dr. C was pleased with how much the swelling had come down, no sign of infection, and looks like no residual bleeding.  So, she began to take the stitched out.  One by one, only pressure, but no pain.  Until the last two.  She asked me if I had taken my Percocet or other pain med.  I said no, and asked why.  She said, these last two look like they may cause some pain- closer to the bone/joint.  She told me to lay back and relax.  She tugged, I breathed and watched my Fit Bit heart rate come down and down, and down (84...72...66...58...52...) and getting a little lightheaded as I felt a lot of pressure and pain.  I did not pass out, but saw my heart rate drop to 47 as she said, "I'm finished with that part."  Whew.  I was glad, then I thought, what did she mean 'that part'...?

Well, what she continued to say was "Are you OK?  The next part is usually the worst."  Really?  I thought that was pretty bad.  I would say 6-7 on the pain scale.  Not quite unbearable, but...


What she meant was the three stitches at the tip of my toe where the screw went in are the most painful for the patient.  The screw head is flush with tip of the phalanx, and close to the skin, where the stitches are located.  Not only is there pain from the incision, the area is very tender due to the screw placement and the healing of the bone around the screw.  Here we go again.  Fortunately, there are only three stitches, and she had them out quickly and was not nearly as bad as she anticipated.

No Cast!

She cleaned up my foot and ankle and checked out the incisions.  Swelling was markedly improved and the bandages and splint she took of was not dirty.  That meant I was not walking and obeying her orders! That meant she could trust me with wearing a boot.  If she saw evidence of walking, still swollen, and reddened- incision area, it would a cast for the next six weeks to force compliance!

 The Boot

This meant I could take a shower!  And see my ankle and foot!  So, I would see Dr. C in five weeks for another X-Ray and start partial weight-bearing.  This assumed I continued to obey and not walk on my foot until then.  Crutches and the boot for five weeks.  I will get my upper body workout!

Burgers

I thought this was funny.  We ate at IN-N-OUT on the way home and found the 'handicap' table was the most comfortable, so I had to take a picture.  I got to go 'Out' and enjoy the outside world!




 Atrophy

  
 Left versus Right.  Easy to tell...

Taking a shower was awesome.  After 16 days, it was refreshing.  Being in the military, I have gone for many days without a shower, but never this long.  I can also see that my right toe that is  a little shorter than before, but not much.  Dr. C said to expect this due to the fact that the cartilage was removed at the joint.  This was the first time I saw both my legs and could see a marked difference between the Left and Right legs.  I have a ways to go to get my running legs back in shape!

Post-Op Checkup

The Checkup

Here we are at D+10 and time for my first post-op checkup.  My first trip since going under the knife and was nice to get out and feel human again!  Unfortunately this visit also included X-Rays.  This was probably the most painful moment since the surgery.  The technician had to help me pull back my toes so my big toe (aka First Hallux) was by itself for her to get a good picture for the surgeon.  Suffice it to say, my entire foot and ankle were very stiff and painful to move.  After several minutes of trying to manipulate my foot, ankle and toes, we finally got a good picture.  Unfortunately, I did not take any pain meds before the visit, nor did I bring any to take after today's poking and prodding!

Anyway, this is what my foot looks like at D+10.  Funny, one can still see the surgeon's initials on the top of my foot.  Dr. C warned me about the surgical site looking worse than it really is.  The dark black lines are actually the ink she used to mark the incision site, it is not dried blood!

The incision starts at the medial side of my big toe, comes across the top of the IPJ, and continues down towards the lateral side of the toe.  This allowed the surgeon to open up the joint, remove the cartilage, ream/drill the intermedullary canal where the screw will go.  The second incision is at the tip of the toe where she will continue to ream the canal where the screw would be inserted and drilled through the Distal Phalanx, through the IPJ, and into the Proximal Phalanx.  The screw would be counter-sunk into the Distal Phalanx so as to not 'stick out' and cause problems with wearing shoes or running. 

 It looks worse than it feels!

The screw would naturally compress the two bones together at the IPJ and over 6-12 weeks would heal like any broken bone would do.  So, over the next six months, the joint will continue to heal and become one fused bone, rather than a distal and proximal phalanx, it will be distimal phalanx!

Dr. C was pleased with the healing, but the stitches were not ready to come out.  She replaced the Steri-Strips and re-bandaged the foot and ankle.  Her only concern was there was no signs of bone healing yet, but no worries.  Everyone heals at a different rate.  She reminded me to not poke or scratch at the foot and ankle.  And continue to obey her (and my Wife's) instruction and NO WEIGHT BEARING!!!

It is probably all in my mind, and when talking to Dr. C and reading up on ORIF (Open Reduction, Internal Fixation), I realize the sensations I feel are part of the healing process.  When I think about the 2" Screw in my foot, I can almost talk my self into feeling the screw.  I know that I can't really feel the hardware, but I swear I can feel it!  It is a weird sensation in the foot, but those sensations will gradually go away.


 The Screw, and it is not loose!




This is why they want the patient out during these procedures!  Being in a dentist chair and hearing the drill is uncomfortable enough!  I could not imaging the sensation, albeit only pressure with no pain, of seeing the surgeon pull out a big ol' Black and Decker drill and drill out and ream a bone in your body.  Ugh. 
Not the Actual Drill...


We Have Come a Long Way

Go back only 150 years to the U.S. Civil War and think about how we conducted surgery.  It was rather simple:

1.  Get Shot by a musket ball.
2.  Hope not to bleed to death as you are carried back to a barn, house or church.
3.  Lay in line hoping the surgeon sees you in time, again hoping not to bleed to death.
4.  Buddy lays you on the blood-stained kitchen table or pew.
5.  Surgeon says, 'the leg has to come off before infection sets in!'
6.  One person gives you a big stick to bite down on and gives you a big swig of whisky to help with incoming pain.  Another soldiers lays on top of you to keep you from moving.
7.  Hopefully you pass out at this point.
8.  The surgeon wipes off the saw from the last amputation and begins to saw...
9. If you survived this far, and haven't bled to death you would possibly still die of infection.



One of My Convalescent Leave Tasks



One of my tasks to complete during this time of recuperation was to design an album of paintings my mother-in-law has done over the years.  This is part of my in-law's 50th Wedding Anniversary.  It is called 'Blue Heron Studio' and has painted may different works of art over the years.  It came out pretty good, and hopefully she will enjoy the finished product. 



01 March 2018

The Routine without Drugs...

D+3 through D+7
The Routine

For the next five days, I developed a routine.  Get up as normal and take a 'bath' after everyone else had theirs and were about their day.  I never really slept well on my back and on top of the bedsheets.  I would wake up every 2-3 times a night as the pain medication wore off.  Or, more commonly, I had rolled over and found a sharp pain shooting up my foot because I had bumped it in the night.

By the following Sunday, D+5, I stopped taking the Percocet and started taking Motrin/Ibuprofen.  I did not like the side effects.  I did feel a little uptick in pain, but was not worth the constipation, dry-mouth, nausea, and loopiness it gave me.  I was also edgy to my family when I took the pills.  The pharmacy gave me enough Percocet to last me two years, it seems.  Way too many!


The worst, I will say, was the constipation.  They gave me a laxative to take along with the Percocet.  But when you finally have to 'go' at three in the morning, sitting on the toilet with all the blood rushing to your foot makes for an extremely painful experience.  Not worth it!

Maybe it is just me, but the 'feel good' was there for a little bit after I took the Percocet, but I didn't feel the need to continue to take the meds.  I certainly wasn't Dr. House and had to have my fix every four hours.  However, I did some research on the couch.  Now, I don't have a chronic pain condition that the fictional Dr. House had, nor real people with real chronic pain.


However, I do have an appreciation for how it could be easily to become addicted.  It is my understanding that addiction is nearly non-existent up to around the initial five days of use. However, when someone crosses the 10th day, addiction skyrockets.



I just hope my unit Drug-Demand-Officer doesn't announce a drug-test in the near future.  Looks like my spit and pee are good-to-go.  But lay off my hair...





D+7
 
Sadly, I was in no shape to go to church on Sunday.  I was able to watch all of it on Livestream, which is a great ministry our church does for those who are not able to physically attend.  I would find myself doing this the next Sunday, too. 



28 February 2018

Feeling Good!

Feeling Good!

Of course I was feeling good.  I couldn't feel anything below my knee, couldn't see my foot, and was able to relax on the couch.  The only problem was the impending pain that would come in 12-18 hours when the nerve-block would wear off.  That would occur sometime around 3am Tuesday morning.

The Percocet would be helpful to get me past the initial few days of pain as the block wears off. 

My view for the next few days, a lot of Ice on the foot!
 
 
I would be bed-ridden for the next few days.  Once the blocks wear off, then I would be able to feel where my leg was.  I was very afraid during this time that I would hit my foot and toe using the restroom or moving about a little.  There was blood/drainage from the incisions, and all I could think about was that I had hit my toe and either tore open the incision, broke the screw, re-broke the toe, or something worse. 
 
Not Remembering
 
After the surgery when I was still 'out', R talked with the surgeon.  Dr. C told her a few things:
 
1.  During the surgery, she found the culprit of my ongoing pain that was hiding in the CT and X-Ray. Two bone fragments were dislodged and had moved into the joint.  This was causing my chronic pain.  She decided to remove these fragments and not plate or screw them back into place.
 
2.  Dr. C had to cut the Extensor Hallucis Longus Tendon.  This tendon attaches along the metatarsal and phalanges of the top of the foot and big toe.  It is what allows us to dorsal-flex our foot upwards.  This was one of those "potential problems" we talked about during the pre-op appointment.  The tendon was strained and out of alignment because of the fracture, and she was not able to move it out of the way in order to get to the joint.  So, she had to cut the tendon above the joint.  
 
 
 
The Tendon that had to be cut at the IPJ of the Big Toe
 
 
So, if the only serious problem is having the tendon cut, not so bad.  It only means a little longer to fully regain the flexibility of the foot and toe.  I'll have a bump on the top of my toe where the tendon was reattached to the metatarsal, and a little shorter in length.  Hopefully, I can slowly stretch out the tendon to the original length over time.
 
I suppose I won't miss those two fragments.  Dr. C said since the joint if fused, you don't need them anyway!
 


Here Comes the Pain
D+0 and D+1
 
I took my first pain med before heading off to bed.  Well, I really didn't 'head off' anywhere.  I stayed where I was, on the bed.  I only got up to use the rest room and wash up a little.
 
As a side-sleeper, I knew sleeping on my back was going to be the most difficult part of this.  However, when I took my first Percocet at 10pm, that was no longer a problem!  Until about 4am, just like clockwork.  I could feel the meds wearing off, along with the nerve block.  When I attempted to get out of bed and take another dose, gravity took over.  I didn't fall, but when I swung my legs off the bed to crutch to the bathroom- I quickly discovered the pain and blood rushing to my foot. 
 
So, I put my foot back up above my head and tried it again slowly...
 
It still hurt, but was bearable.  I was able to use the restroom and take another dose.  I set my alarm for every four hours to take the meds.  I kept the meds at my bedside for future use!
 
 


D+2
 

Getting Ready for Bed
 
 
I got into a routine of slowly ambulating around on crutches and sitting on the couch rather than in bed.  I managed to take a bath on the second day post-op (D+2).  Actually, not a bath, but sitting on the side of the tub and wash up and feel normal. 
 
 
D+3
I began working on my 'assignments' on Thursday.  The Winter Olympics were starting today, so good timing for me!  I had some items I wanted to get done since I would be home for 3-4 weeks. 
 
1.  Do our 2017 Taxes
2.  Go through all our photos and put them together in albums. Nothing fancy, just go through and organize.
3.  Blog- this one.  About my experience.  Not like most of what I read with other people's experience. I'm not blogging about 'Embrace your Pain', 'Accept your Circumstance', 'Acknowledge your Discomfort', and 'Mindfulness and Mending'.  Ugh.  Spare me that stuff.  I broke a bone, it hurts, doctor fixed the bone, hurts more.  Move on.
4.  Read.  "Medical Response at the Pentagon on 9/11", "Echoes of Glory:  Battle Sites in Texas", "Reformation Guide to Scripture", and several professional journals.
5.  Pod Casts:  Catch Up!  Civil War Podcast, Wretch Radio, Al Mohler, Truth for Life, and Freakanomics.
6.  Watch the Winter Olympics.  Live.  Why not?  I'm up at 4AM taking my meds anyway!
7.  Create a large 'Coffee Table Book' that contains various pieces of artwork of my Mother-In-Law.  This is part of a larger gift to her and my Father-In-Law for their 50th Wedding Anniversary.
 
MEDs

OK, time for a break and take my pain meds!
 
 


And Then I Woke Up

And Then I Woke Up


"I can't feel anything below my knee."  That was my first comment when I woke up, according to R. 
Something else I think I said was "When are we going to get the surgery started?"  And the my nurse said something like, "It's over, you are in recovery.  Your wife will be able to come back in a few minutes."

Actually, the only thing I clearly remember is waking up at home a few hours later.  Anesthesia is a wonderful addition to the world of medicine.  I woke up to my foot and ankle bandaged and not feeling anything.  It wasn't long before I was able to put on my clothes, very slowly.  I had no control over my right leg, so I had to carefully not bump or stand on it. 

When an infection outbreak happens, blame the staff and Central Sterile!
 
Fall Risk
 
 

One picture I did take before we left was of my 'good foot' where there was a 'Fall Risk' warning tag.  I certainly was.  This made me feel like one of my cardiac rehab patients back when I was working in the hospital.  I am used to placing this on geriatric patients, not being the recipient of one! 
 
Watch Out, Fall Risk!
 
 
Lunch
 
On the way home, R stopped at a Texas Favorite for lunch.  I hadn't eaten since before 6pm the night before, so it had been going on 24 hours since and I needed to get something in my stomach in order to take the potent pain medications.  Again, I don't really remember.  

 
 
 






Never 'NO' Again

Never 'NO' Again
 
After today, Monday February 5th 2018, I will have to check 'YES' when asked if I have ever had surgery or other medical procedures. 
 
Here I am, with my awesome wife, who will take care of me for the next few days while I am couch-ridden until I am able to move around on crutches.  We check in and am taken back to the pre-op area.  I meet Dr. C, my pre-op nurse, the CRNA and the process begins. 
 
I am anxious, and hungry!  Dr. C writes her initials on my left foot, and am asked for the 756th time my full name, date of birth and what I am having done.  And...
 
1.  No, I have no allergies.
2.  No, I have had nothing to eat since 6pm yesterday.
3.  No, I don't have diabetes.
4.  No, I don't have a fever (didn't the thermometer tell you that four minutes ago?)
5.  No, I don't have any open cuts on my foot (didn't you just examine my foot two minutes ago?)
6.  No, I don't consume any tobacco products.
7.  No, I have not consumed alcohol, If it would help, this is what you could get me downstairs...
8.  My full name? Again?
9.  My full date of birth?  Again?
10.  What am I having done today? Again?
 
Most of this is in jest.  I have worked in hospitals for years, and wrong-site surgery and near-misses are a real thing.  It can be frustrating for those who have never been part of an investigation of these issues.  I have, and they are not fun, especially for the patient. 
 
 
Anxious
 
So, my nurse shaved my foot, and got out the multiple drips and IVs.  She was very good at her job and helped allay much of my nervousness.  I wasn't nervous, but just couldn't relax.  They let my wife, R, come back for a few minutes.  I did have to take off my clothes, except I could keep my underwear on, but everything else had to go.  I asked if I could keep my Fitbit watch on as I was curious to see the various metrics, but was told no.  Oh well.
 
So I put on the compression stocking on my good leg, the CRNA came in did an ultrasound so she could mark where she would inject the nerve blocks.  She said there would be three: at the ankle, behind the knee and somewhere on my thigh.  As the nurse got the IV started, I was feeling a little more comfortable. 
 
So far so good.  I watched my nurse hang a couple of bags of IV solutions, and I continued to watch the monitor hoping to help my blood pressure come down. It started at 134/92, which is very high for me.  As I relaxed and breathed more regularly, I was able to get it down to 122/82.  Much better.
 
The nurse covered me up with a blanket and checked the IV bags again.  She took one bag and hooked it up to my IV.  The CRNA and the assistant got out the various nerve block needles and continued to verify the locations with the ultrasound. 
 
Then I asked the CRNA, forgetting that she had just told me, "How many nerve blocks do you do for this..."
 
I never finished the question...
 



Decision Day

Decision Day

Thursday, January 4th was my follow up with the surgeon to check on the results of the steroid injection and to make the final decision.

The injection did help reduce swelling, along with the icing and rest of the foot.  However, there was minimal pain reduction.  The continued pain perplexed the surgeon, as she thought the pain should have subsided, but that is an issue I will address in a later blog.

Needles don't usually bother me, but the steroid injection I talked about earlier was not too bad, it was the pressure and knowing what was going on.  The orthopedic tech told me, jokingly, that if you think this was bad, wait until your day of surgery and the post-op poking and prodding!  I always joke about needles and that I USUALLY don't have problems with them. 

The only exception is when someone starts to 'fish' for veins if they don't hit it at first.  When I was a new Evacuation Platoon Leader as a 2LT, we would routinely train our medics on starting IVs.  My Platoon SGT would routinely ask the rookie-medics to start IVs on the senior medics, and me.  I was the perfect pin-cushion as they had about 20 seconds to find the vein, and if they didn't find it and began fishing, I would pass out!  No pressure....


You Might Die, and Other Things...
 
It is one thing to sit on the clinical side of an Informed Consent and know that odds are nothing will happen and all will go as planned.  However, one must go over what MAY go wrong.  Infection, non-union, hardware may break, tendons cut, nerves severed, and other items.  When going over all the possible complications, one stuck out.  You may die.  Of course this has to be said and discussed.

However, on the more humorous side, I thought about a situation that must be addressed.  I didn't update my living will to include what should happen if the Zombie Apocalypse happens while I am unconscious?  If Rick Grimes had updated his, then he would not have had to deal with leading people around Georgia for eight years.  That was my real concern!

I did not want to wake up and see this.  If the zombies break through, just put me out!
 
 
It is a Go!

Monday, February 5th is surgery day.  All the paperwork is signed, Convalescent Leave is approved, work is covered and I have my non-weight-bearing assignments ready for me to accomplish.

My surgeon showed me the X-Rays and reviewed, again, what I should expect before, and right after surgery.  She showed me what my toe will look like afterward the surgery.  Bottom line, there is no going back.  Open up the joint, remove the cartilage, smooth the distal and promixal phalanges, drill a hole from the tip of my toe, through the both phalanges, take a ~2 inch titanium screw and insert it down the drill-hole.  the screw will compress the two bones together and over 8-12 weeks will become fused. 


 Not my X-Ray, but what my Right Hallux IPJ will look like after the fusion
 
Of course, as I researched this procedure, if I obey the weight-bearing instruction by the surgeon, I could be back running in June or July.  That means no weight-bearing for six weeks, partial weight-bearing for another six weeks, and then finally back to street shoes after 12 weeks.  A long time, but now there is an end in sight!





























Military Medicine Firsthand Experience

The First Surgical Consult
 
 
On Thursday, November 17, I had my first appointment with the Orthopedic Surgeon at Brook Army Medical Center.  Working at the Army Medical Command for the past two years, I am aware of the significant changes coming in Military Medicine.  Purple Medicine is coming.  My initial surgical consult with an Air Force LTC.  He explained the procedure in gruesome detail!  It was what I expected.  He wanted to wait and try a steroid injection first to continue to reduce the swelling and get an updated CT. 
 
He also recommended I have a second opinion because of the "permanent solution" to my pain.  Fusing the joint is a serious decision, especially with the big toe and the secondary effects of weight-bearing activities and compensation of the other joints. 
 
Brooke Army Medical Center, Fort Sam Houston, Texas
 
Second Surgical Consult-CT-Steroid Injection

 
My second opinion was scheduled for Tuesday, December 19th at Wilford Hall Ambulatory Surgical Center (WHASC).  At Lackland AFB, this is the primary health care facility for Lackland AFB and beneficiaries on the west and south sides of San Antonio.  In the 1990s, Congress mandated that acute care services at WHASC be moved to BAMC.  With this, routine and outpatient services moved to WHASC. 
 
I had my CT and XRAYs completed at BAMC prior to my appointment at WHASC.  My appointment was with an Army Podiatric Surgeon.  So, I saw an Air Force Surgeon at the Army Hospital, and an Army Surgeon at the Air Force Hospital.  Interesting.  What takes the cake is the providers at either facility cannot access radiology reports from the other facility.  Talking to a colleague at the Defense Health Agency (DHA), Purple Medicine, said this is due to old contracts that are still in force that have proprietary aspects. 
 
So, at WHASC, my surgeon, (I will call her SJ), fortunately was able to get a CT that morning and could see the exact issues.  The only problem is I had to hang out for a couple hours.  She also said she did want to try a steroid injection.  I said I have one schedule for January 5th at BAMC.  She said, "Let's do it now!".  OK...
 
I will say when she and the assistant manipulated my toe (and the broken joint), it was not a pleasant experience.  

Wilford Hall Ambulatory Surgical Center
 
So, my toe and foot hurt for several hours afterward, with the hope that the effects of the injection would take hold and reduce the swelling and pain.  I would find out on January 9th if any progress was made.


19 February 2018

Boot, Insert, Plate, Repeat...

Boot, Insert, Plate, Repeat...
 
 
On September 19th, 2017 I had my first orthopedic appointment at Brooke Army Medical Center (BAMC).  Between the orthopedist and the podiatrist, they agreed that I had two choices.  First was surgery now and minimal pain later.  Or chronic and worsening pain for the next few years resulting in surgery later. 
 
Hmm...didn't seem like there is much to dwell on in this scenario!  The reasoning was that the fracture was in the joint and since there are bone fragments not healing, any wrong step could dislodge these fragments and cause even more damage to the surrounding tissue.  Not Good!
 
Also, and just as important, these types of fractures (in the joint), will speed up the arthritic breakdown of the joint based on activity level.  And based on my activity level, running, trailing-running more specifically, would further speed up this process. 
 
However, the joint was still swollen and sore when the doctor worked the joint through a series of range of motion exercises.  This did hurt!  So we began down the road of reducing the swelling and giving the joint some rest. 
 
 
The Boot
So, we began with the Boot.  For four weeks.  Wear it all the time except for bathing and sleeping.  No running.  So I began my gym workouts.  I do not like the gym.  I would prefer to be outside running, even if it is 110 or 10 degrees!  I would need to ice/heat my foot four times a day.  This was a pain as when you wear one, you have to put an insert into your other shoe so your feet/knees/hips/back remain even.
 

The Boot
 
 
 The Insert

October 24th, I returned to BAMC for a checkup and to see how the joint was doing.  It was stiffer, but less swelling.  That was a good thing, but also I had more pain in the joint, which kind of made sense.  However, it meant that probably the fragments were not healing and continued to move causing the pain.  The next 'step' was to keep the ankle from stiffening and the Doc moved me to a stiff shoe insert.  At least I could wear normal shoes and boots again.  Its purpose was to keep my foot and toes from flexing and aggravating the joint.  We would try this for another three weeks then come back for a follow up appointment.


The Carbon-Fiber Plate Insert
The final attempt to reduce swelling and stabilize the joint was this little beauty.  An insert that would not allow any motion at the great toe joint.  I certainly did its job, but the side-effects were worse than the pain at the joint.  I could not tolerate this it caused a significant amount of pain across the metatarsal heads of all toes and inflamed the arch of the foot.  I could not wear this as prescribed. 

 
 
Final Follow Up
 
The week after Thanksgiving on the 28th of November, the Podiatrist saw me for our final follow up and basically said, it is time to take it to the next level of treatment- Surgery.  The follow up X-Rays showed the same as before, no changes in the location and healing rate of the fragments.  So, we scheduled a visit with the Orthopedic Surgeon for pre-op evaluation. 
 
 
My podiatrist gave me an overview that didn't sound too appealing!  He told me he has done hundreds of them over his career, but his surgical days are behind him and that the 'younger whipper-snapper surgeons' have a much steadier hand than he does.  The process would be to fuse the joint.  Permanently.  He recommended surgery because it would be inevitable based on my activity level, age and the fracture at the joint. 

 
Go for the surgery now while I am young and can adjust biomechanically now rather than wait and have a more difficult time at a later age. As an added bonus, I will have this surgery done at a world-class facility by a health care team that is second-to-none in helping Soldiers-Sailors-Airmen-Marines recover from injury and illness.  
 

The diagnosis...

The Diagnosis
 
"Displaced, Comminuted, Intra-articular Fracture of the Distal Phalange of the Right Hallux with >2mm Displacement"
 
 
In plain English, Please!
 
1.  Displaced- the Interphalangeal Joint (IPJ) of the big toe is dislocated laterally (to the right).
2.  Comminuted- more than two pieces of bone are fractures and not attached to where they should be attached to.
3.  Intra-Articular- the fracture occurs in a joint.  This is BAD.  This means that I have a jump-start on arthritis (more about this in a later post!)
4.  >2mm Displacement.  That means the dislocation is not only laterally 'out of joint', but it is horizontally depressed across the joint.
 
 
The X-Ray.
 
I am fortunate to work with some great people at the Army Medical Command's Center and School at Fort Sam Houston.  I work with Nurses, PAs, PTs, Combat Medics, Physicians, and many other highly skilled providers.    This is how a few of those friends explained my X-Ray to me. 
 
1.  This is the Distal Phalanx,  It should be pointing straight ahead, but it is not.  It is displace laterally towards the second toe.
 
2.  This is the fracture line where the distal phalanx is in two pieces.  The Proximal piece is still attached, as it should be, to the joint.  Unfortunately, the distal piece of the Phalanx decided to do its own thing and broke off and became displaced.
 
3.  This is piece one of the Distal Phalanx that has a hairline fracture.  This is the fracture point that involves the joint, as it is separated from both pieces of the Phalanx.
 
4.  Another piece of the Phalanx that is fractured and not attached to any part of the phalanx.  Never good to have a piece of bone just floating around.
 
5.  A smaller piece of the Phalanges that is fractured.
 
As one could imagine, this hurts.  Because of this X-Ray, my Doc asked me again, "How long have you been walking on your foot like this?"  He answered for me,  "Too Long, right?"
 
My next stop was with the Orthopedic Specialists at Brooke Army Medical Center. 
 
Should I say this again, I have never been a 'patient' before.  I have always been on the other side of the Healthcare System!
 
Now I go into uncharted waters...
 
 
 
5.