AND NOW FOR SOMETHING COMPLETELY TECHNICAL

POST # 22

So when I woke up this morning thinking about all the various things that I could write about today, I decided that I should try and finish off this leg saga and what better way to do that than to describe the operation from the doctor's point of view.
So while I was off in "la la" land, she and her team with all their years of experience began the process of attempting to return my leg to something that resembles normal. The details that now follow are the doctor's words of what was done during the 4.5 hour operation on March 20, 2012. I've read the report a few times now, and the more one reads it, the more it makes sense. So here goes....


OPERATIVE NOTE

The patient was brought to the operating room and attempts were made to administer the spinal anesthetic and this was aborted to a general anesthetic. He received Ancef preoperatively. The carbon bar and the joints from the external fixator were removed, but the Schanz pins and the calcaneus cuneiforms and proximal tibia were left in situ. The leg and the Schanz pins were then prepped and draped free in sterile fashion. A thigh tourniquet was inflated to 300mmHg. An anteromedial incision was made starting just lateral to the subcutaneous border of the tibia extending down to the joint surface and then making a 60-degree turn towards the distal medial malleolus. This is extended to the medial side of the tibialis anterior and down to the pariosteum. This is extended down towards the level of the joint. The capsule was then opened at the level of the sagittal fracture. Next the joint was evaluated. There was a very large Volkmann fragment on the posterolateral aspect and a significantly smaller Chaput fracture fragment anteriorly. There was a large area approximately 1 cm x 1-1/2 cm of articular cartilage with some associated cancellous gone that was free in the joint. There was a medial malleolar fragment. Starting with the Volkmann posterolateral fragment, a K-wire was transiently placed into this fragment as was an osteotome and with distraction placed across the Schanz pins using a femoral distractor as well as pressure placed on the heel to invert the heel. This fracture fragment was reduced on the talar dome. It was secured by K-wires passed through the fibula subcutaneously into that Volkmann fragment. Once this was reduced onto the talar dome, the free fragment could be reduced onto the talar dome as well and held transiently with some K-wires through the medial malleolus into that fracture fragment. The Chaput fracture fragment was then reduced onto the Volkmann fragment. A one-third tubular plate was used as an antiglide plate initially just to hold it in position and then this was later exchanged for an anterolateral locking plate for the distal tibia. On the medial side, there was a large butterfly fragment and prior to doing the definitive internal fixation, this could be easily secured with two interfragmentary screws. This allowed the medial column to be reduced onto this secured shaft column. The medial malleolus was then secured and held transiently with some K-wires into the medial talus. The fracture fragments were then held transiently this way and the anterolateral plate was secured to the anterolateral tibia. A bicortal nonlocking screw was placed to lag the plate to the bone. Through the two lateral screw holes in the distal arm of the plate and under fluoroscopic guidance two lateral screws were placed and these were partially threaded cancellus nonlocking screws. These allowed the Volkmann fragment to be compressed under fluoroscopic guidance to the Chaput fragment and this completely reduced those fragments. It could be seen from the fluoroscopy that the free articular fragment was still elevated and by placing a reduction tool through the hole in the metaphysis this could be reduced back onto the bone and was secured with a partially threaded interfragmentary screw placed obliquely across the joint. Two more locking screws were placed into the distal end of the anterolateral locking plated and then three more proximal screws were placed, two of which were locking after all of the nonlocking screws were placed. The medial column still needed support to prevent it from going into a varus position. A one-third tubular locking plate from the small fragment set was then slightly contoured to the medial column. It was then secured and two locking screws were placed into the medial fragment and then three screws proximally into the arm of the plate. X-rays were taken and this was an anatomic reduction of a very complex pilon fracture. The loose cancellous bone that was removed from the joint initially was then packed into the metaphyseal region and this was further reinforced with some Allomatrix bone graft with some bone chips. The wounds were then irrigated. Attempts were made to close the fascia over the tibia and this was not possible. There was a bit too much swelling. Therefore a careful closure with some tension was performed using a 2-0 Vicryl for the subcutaneous layer and interrupted 2-0 Prolene sutures along the skin flap. Once the new incision was closed, the Schanz pins were removed and left open. A dry sterile dressing was applied and then a posterior splint.

Postoperative plans are to keep the foot strictly elevated for a week or two to allow the precarious skin with the incision to heal. If there are any concerns about dehiscence, then a VAC will be applied. The patient is to be strictly nonweightbearing for 12 weeks, but after the wound has healed at three weeks and the sutures are to stay in for 3 weeks, then he can start doing some gentle range of motion of is ankle.



So that's it then, the broken leg repaired in doctor speak. I have read the report now quite a few times, and each time I read it, it makes a bit more sense to me. But I doubt that it is of as much interest to the reader as it is to me. But now it's recorded in one more location, so if I ever need to relive the operation, I can always come back to blog #22 and refresh my memory.


I've had a great week and the highlight has been a visit from my friend Jay from Kamloops as well as my friend Bob from Calgary. Having a cat named Bob has caused a bit of confusion at times but we've all muddled through. It's been wonderful to have both of them here, and they have been a big help to me for which I am very grateful indeed. Jay left yesterday, and Bob drove me to Trail yesterday so that I could have my final visit with the doctor.
Soon Bob too will be heading home, and then next week I will be on the road again, as the owners return from their vacation next Tuesday. By this time next week I will be close to Vancouver where I will spend a few days, enroute to Victoria where I will begin my next pet/house sit.
My time spent here in the Grand Forks area has been memorable on many fronts, but I suppose the lasting memory will be the whole story surrounding the breaking of my leg.
I'll just chalk it up as yet another adventure on the road of life, and try to learn some lessons from this that I can use in the future. Some lessons are tougher than others, and this one has certainly made an impact on me.
But now it's time to move on, and with each day gain more strength, so that by June I will be able to finally put some weight on my right leg, and try to get my life back to being a bit more normal.
Next Saturday, I may be on the road which may or may not cause a delay in writing my blog, however I will do my best to get something written for all of you out there who have taken the time to keep up to date with the adventures of the Thoughtful Wanderer.

The journey continues.

Paul
The Thoughtful Wanderer