Ahnadlass’s AchillesBlog

I started physical therapy yesterday with a therapist located a short walk from where I live.  I will be going 3 times a week for the next several weeks.  It’s too early to do any exercises or stretches on the ankle/tendon (just 18 days after surgery).  Thus, a session will consist of massage and thigh muscle exercises.

Very happy to be PWB after 2 weeks of NWB.  Still in my Vacocast which is super comfortable.  I can put up to 15-20kg on the leg.  I am a bit worried about the feelings that I am getting in my right foot - it’s tingling along the sides and heel - and it can be painful at the bottom of the scar which is just above my heel where I think a scab is forming.

I had an appointment with my surgeon yesterday.  She changed my dressing and pronounced that the incision is looking okay.  We spoke about her rehab protocol, which is normally PWB of no more than 15-20 kgs (33-44 lbs) for the first 2 weeks after surgery.  However, because of the extent of my surgery, she recommends NWB for the first two weeks.

She also showed me photos of my surgery that she took at various moments.  As opposed to the standard Bosworth procedure in the diagram below, there was no full gap as she only cut out a portion of the tendon at the rupture site due to its necrotic state.  Thus a small portion of good tendon had grown back and could remain.   Then she took 3 strips from the upper tendon instead of the 1 strip shown below to strengthen the rupture site.  Everything was then sown together - there must be 50 sutures in my tendon!

I had general anesthesia and local anesthesia for the surgery.  I woke up 3 hours after the surgery with the Vacoped on and with a small tube coming out  which was draining some blood out.  The first night was a tough one, and they gave me some morphine which helped a lot.  Right before being discharged I met with the surgeon who changed the dressing and pulled out the drain.  It is a very very long incision running from just above my heel to the middle of my leg.  The surgeon told me that once she (she is one of very few female orthopedic surgeons here) was inside she found that the tendon at the rupture site had degenerated.  She also found that the calf muscle was not the right size for VY plasty and so instead she used a "modified Bosworth" procedure to bridge the gap.  Here’s a diagram on the original Bosworth technique:

The clinic is admitting me tomorrow night (Tuesday) before the surgery, which is on Wednesday morning.  I guess the thinking is that they can take some blood, do an EKG, make sure I have a light dinner meal, get a good long betadine cleaning in, etc.  This is different than the other clinic I went to where the night before I was at home and took a betadine shower and used the chemical hair remover on my legs which is awfully smelly.  Looking forward to Friday when I should get out.

http://uk.news.yahoo.com/spains-king-recovers-achilles-operation-061949168.html

Met with the Anesthesiologist today at the clinic where I will be having surgery.  It was a short discussion - basically to see what type of drugs I wanted.  He recommended general during surgery followed by a morphine pump which I will control.  That sounds like I won’t feel a thing so I was pretty happy about that.  It is almost the same that I had for my ACL surgery except that the nurses administered the morphine in my IV.  For the Tenolig surgery, they did a local anesthetic so I was awake but groggy during the surgery.  I will be entering the clinic the night before the surgery, and that is when they will do the final checks - a blood test and an EKG.

I am very happy with my new surgeon’s decision to use the Vacoped boot (Vacocast in the US). Whereas last time I had a cast for the first 3 weeks and then a standard heavy metal orthopedic boot for about 4 weeks, the Vacoped will be used for both periods. It really reminds me of a ski or snowboard boot because of all the various adjustments, adjustable inner cuff, and look. It came with 2 removable soles, a flat and a "equinus". I also had a choice of buying or renting it. It was about €500 to buy it and €250 to rent it for 10 weeks, so I will rent it and it is not covered by the French socialised medicine. I noticed on the US website that it is cheaper in the US. After the rental, they send it back to the company, throw away the inner cuff which probably gets pretty messy, and either clean the plastic parts or melt the plastic parts and reuse the plastic. I also noticed on the website that they are promoting 25% faster healing. I hope that works for me too.

I had an ultrasound (US), and the US doctor told me there that the tendon was thin and that there was a cavity in the tendon at the rupture zone. Then I went back to the surgeon that had done the first surgery. He had a quick look at the tendon and the US results. His opinion was that the tendon would slowly get better with physical therapy and time, and he encouraged me to continue my re-hab. Also, since it was already 3-months after the first surgery, he felt that the chances of re-rupture was fairly small.

I then went to the surgeon that was recommended by my sports doctor and PT. She is also not satisfied with the Tenolig results and has done several re-ops on patients whose tenoligs had failed. She had a look at my tendon and the US results and pronounced that a re-op was likely but an MRI would be necessary in order to determine the extent of the problem.

I did the MRI at about the 3.5 month mark, and it showed the same state - a hole/cavity in the tendon - although the tendon had thickened up a bit at the rupture site.  Here’s the shot from the MRI - notice the white spot in the middle of the black tendon:

I went back to the 2nd surgeon, and she confirmed that she was ready to cut. She gave me the likely sequence of the re-op:

1. Make an incision to open up the tendon and lower gastrocnemius.
2. Cut out the portion of the tendon at the rupture zone that has not properly re-attached, which includes the cavity.
3. Depending on the amount of tendon removed, lengthen the tendon by doing a V-Y plasty or turn-down flap. This involves cutting the gastroc or tendon and reattaching in a way to lower the upper part of the tendon.
4. Reattaching the tendon with sutures.
5. Closing the incision.
6. Start the standard open surgery re-hab PT etc.

We agreed on a re-op date of 14 September 2011, and I am not looking forward to it.

The Tenolig is an outpatient surgery, and I went home with a cast on my lower leg with strict immobilization instructions. There was wasn’t any pain until the evening when it started feeling like the cast was too tight. I was in agony that night, and called the doctor that day to get a stronger pain medication as apparently the cast was not too tight. Luckily after a few days the pain was much reduced. Tragically my mother died suddenly two weeks after my surgery, and I decided to make the train trip from France to the UK. This was a very painful experience as being seated or upright was uncomfortable after more than 15-30 minutes.

The cast came off after 3 weeks, and I started with an orthopedic boot in a toe-pointing position. I was allowed to put a bit of weight on the toe, and start sessions with the PT. My first sessions with the PT did not go well because the wires in the ankle were so painful I could barely move my ankle or move my toes. I also started back at work, and sitting at my desk for about 8 hours a day was also very painful. At 7 weeks, I went back to the clinic to have the wires pulled out, and the surgeon told me that everything was looking fine even if I hadn’t been able to do many exercises at PT.

I started doing more exercises with the PT at this stage - mostly balancing and stretching - after 7 weeks. I was wearing a shoe with a 3-part heel lift inside and using 2 crutches for stability, speed and safety especially on public transport. My PT had already expressed to me reservations about the Tenolig, but at this time he started noting that the tendon felt very thin at the rupture point. At 3 months after the surgery, this thin portion was still present, and my sports doctor who is in the same office as my PT suggested an ultrasound, and a second opinion. I also made an appointment with my first surgeon.