May 12 2014

goldman

Operative Report

Posted at 9:52 pm under Uncategorized

It’s now seven weeks, six days since my ATR operative procedure. I’ve been meaning to upload this for a while, finally got around to a) finding it, b) scanning it in, c) sanitizing the data. The scans following this post are the operative notes that my surgeon wrote shortly after the early morning procedure on March 18, 2014. I’ve removed IDs and names other than mine. I thought that this might be useful for other people to see the technical notes from an ATR repair that I think was mostly run-of-the-mill. Also, while I have read through it, I don’t know all the technical jargon yet, so I haven’t quite deciphered the entire procedure into layman’s terms. For example I have yet to determine if the #2 polyethylene FiberWire sutures are disolvable, or if they are going to be with me and my tendon forever.

The one deviation (I think) that my surgeon took from an even more run-of-the-mill ATR repair was to make use of the plantaris tendon (see page 2 of 3) to “improve” the healing of the Achilles tendon. I was told the day after surgery that it is a vestigial tendon, and that was why my doc used it to weave into the structure of the Achilles. On the web I found this blurb: “The plantaris is considered an unimportant muscle and mainly acts with the gastrocnemius”. I find this interesting because at the moment my right calf muscle, right around the gastrocnemius, seems to hang off my leg in a slightly odd way. I have no idea at this point if that is due to general atrophy of the region from lack of use and exercise and being in splint, cast, and NWB boot for a while, or if it has something to do with the plantaris. Perhaps others on achillesblog.com can enlighten me? One thing it might explain is why my heel is the most sore part of the area around my Achilles, and continues to bother me.

In the office the day before the procedure my surgeon described several possible things he might do to reinforce the repair once he got in and looked around. He mentioned animal tendon, such as pig; He talked about folding down some fascia, or something like that, but he didn’t mention the plantaris until two days later. I guess one should expect a pro to improvise as they see fit. Yet it feels a bit different when my Doctor does something unexpected inside my leg while I am asleep, compared to for example when my mechanic fixes an electrical short by cutting a cable under the hood and replacing it with something he likes.

Driving in my truck, and a man comes on the radio

Driving in my truck, and a man comes on the radio

Driving in my truck, and a man comes on the radio

13 responses so far

13 Responses to “Operative Report”

  1. sportion 12 May 2014 at 11:12 pm 1

    What I find most interesting is that your report is vast compared to my half pager. My obviously non-professional understanding is that the interior stitches are permanent. The tendon is essentially stitched together and it heals around the stitches, which essentially become buried inside the finished product. That’s about all I understand… For what its worth, here’s my operative report,

    “INDICATIONS: The patient is 42, visiting from Cleveland. He is skiing, ruptures his Achilles tendon today, presents for repair. He understands the risks and benefits, expectations, change of re-rupture, chronic weakness,
    wishes to proceed.
    OPERATIVE DESCRIPTION: The patient brought to the OR, placed in supine position. General endotracheal intubation achieved without complication. The patient turned prone. Left lower extremity prepped and draped in the normal sterile fashion. Incision is made over the obvious Achilles disruption. Plantaris tendon was encountered. It was still intact. The paratenon was opened up vertically of what was left. This was a very
    shredded, retracted Achilles tendon rupture, approximately an inch and a half from insertion on the calcaneus. The tendon and its fibers were brought into approximation with an Allen retractor and the correct tension held with
    the foot in neutral position as the repair was made with #5 Ethibond. Sutures were whip stitched in either end and the tendon re-approximated and the suture tied. I used an 0 Monocryl to re-approximate tendon fibers that could
    not contain the main securing suture. This tubularized the remaining tissue. The paratenon was then closed side to side with a running 3-0 Monocryl, as was the subcu. Running 3-0 Prolene closed the skin. Sterile dressing
    applied and back in the boot. The patient taken to recovery room in stable condition.”

  2. normofthenorthon 12 May 2014 at 11:32 pm 2

    They both impress! For a minute I forgot just how good the recent non-op results have been! :-)

  3. goldmanon 13 May 2014 at 12:37 am 3

    Yeah Rob, I guess “polyethylene” has a permanent sounding nature in its terminology :-) but it did surprise me a little because prior to surgery I had read about dissolvable stitches and just assumed that would be the case. As far as the length of each report maybe some universal kama at play — you were injured and had the procedure done in hours, I hemmed and hawed for a couple weeks.

  4. davidkon 13 May 2014 at 10:49 am 4

    Goldman, thanks for sharing this report. Now I want to request mine. With respect to the suture question, from what I understand, the U.S. tends to use “permanent” sutures for the Achilles’ tendon repair, while in the U.K. they tend to use dissolvable ones. When I asked my OS about this, he said that the thinking in the U.S. is that the Achilles’ tendon healing process is typically longer than the life of the dissolvable sutures, which he estimated at ~6 weeks. -David

  5. Gavinon 13 May 2014 at 10:56 am 5

    This OS would obviously never consider the non-surgical and therefore non-suture route.

  6. goldmanon 13 May 2014 at 12:30 pm 6

    Gavin, this is a delicate issue. Obviously, or at least I think it is obvious but I am speculating a bit because when I saw the “final” surgical bill that my insurance company paid out to the hospital it was much less than I woulda thunk– anyway the OS doctors and their staff must make more money from a surgical procedure, right? And maybe that’s their comfort zone, not just because of the money, but maybe they and everybody they trained under did the same, who knows. I am a bit cynical too as your comment seems to intimate. I should call the hospital and my insurance company and ask about the somewhat low-looking bill. I was expecting to see something like $10K or $20K or a large figure, but it was much less than that. Maybe I wasn’t really seeing all the costs paid out to the hospital and doctor. Anyway I was completely set on getting surgery after first going the non-op route and then finding out I had a 5cm gap. At that time that’s what convinced me (perhaps erroneously — but in retrospect one needs experience with non-op and approximating the tendons correctly as Norm has pointed out a bunch of times now, so maybe I made the right decision in the context of my medical providers) to go the operative route. As I was meeting with my OS I mentioned the large gap distance from the MRI and he made some comment like, “distance doesn’t seem to matter,” so he did sorta present the other side. But I was not as informed then as I am now, so it kind of flew over my head at the time. At this point it’s about 1:30pm and suddenly I am torn again, no pun intended. What to do? I think I even spoke the phrase aloud. _THIS_ is when the whole staff, sensing I might change my mind yet again and go non-op, got into high gear, rushed around and quickly got me set up for 7:30am the next morning with a sure surgical time, all the requisite materials, tests, yada yada, and me in my slightly informed, but not well-enough informed state went with the surgery.

  7. goldmanon 14 May 2014 at 8:34 am 7

    perhaps this injury has given me too much free time these days. In any event here’s the latest definitive on Fiberwire#2:

    From: Lou Fraulo
    Date: Wed, 14 May 2014 08:20:21 -0400
    Subject: Re: #2 fiber wire
    To: Jon Goldman

    Fiberwire is not absorbable.

    Lou Fraulo
    Arthrex New England
    Kairos Surgical Inc.
    Cell 508-615-1773
    Fax 508-448-5555
    Lou@kairossurgical.com

    On May 13, 2014, at 10:55 PM, Jon Goldman wrote:

    Hi Lou,

    mainly I wanted to know if those sutures are absorbable, disolving ?

    thanks

    On 5/13/2014 5:40 PM, Lou Fraulo wrote:

    Jon,

    You recently requested information regarding fiberwire. Please give me
    a call at your earliest convenience to answer any questions you might
    have regarding fiberwire.

    Lou Fraulo
    Arthrex New England
    Kairos Surgical Inc.
    Cell 508-615-1773
    Fax 508-448-5555Lou@kairossurgical.com

  8. goldmanon 17 May 2014 at 1:43 am 8

    $$ update — I talked to my insurance company yesterday about compression socks and while I had the rep on the phone I asked about the cost of the operation. Turns out insurance paid out to my hospital approximately $13,000 for the March 18 procedure, which included one overnight stay.

    There are of course plenty of other expenses incurred from this injury - a handful of OS consultations, primary care visits, AirCast boot, crutches,wheelchair rental, comfort items like extra pillows & boot socks & sweatpants & shower stool, Ultrasound for DVT + ER visit + medication + followup, exercise bike, evenup shoe ballancer, PT (which I finally got my overly cautious Doc office to write a prescription for), and probably items I am forgetting — add another three or four thousand dollars at least, some paid by insurance, some paid by me. These costs however counterbalanced by the fact that I have gained a wonderful community of like minded, some also like me — misguided weekend warrior types who strive to maintain their health, youth, and beauty in the face of the eternal adversary: the marching tick of time. Sniff Sniff, I’m getting a little verklempt here and need a moment… ahh ok, thanks it passed :-)

  9. Gavinon 17 May 2014 at 3:32 am 9

    With those earnings I would have expected all OS to recommend surgery for all atr’s. I don’t know what mine cost, maybe I’ll ask!

  10. goldmanon 17 May 2014 at 9:07 am 10

    Gavin, def U should ask (and report here). My general mantra in life is transparency is good - for both parties. Obviously not everybody acts/thinks this way, but doesn’t mean I can’t “improve” the situation and encourage you to do same.

  11. Gavinon 17 May 2014 at 9:26 am 11

    Too late now but makes me remember how much my premiums cost and that many go for surgery so they get best value for their money and easily persuaded. Wasn’t until I experienced the painful downside of surgery that I decided to go non surgical if it happens again, even if it does cost my insurance less $.

    We live and learn…

  12. Tom Winteron 05 Aug 2014 at 12:22 am 12

    Here is my surgery report: Aug 28, 2013. — I need to ask some more details about your status because I would like to compare with him. I am frustrated at lack of my progress: I still have pain walking particularly when going down stairs. When doing this, I have sting pain in interior of heel and I also have pain lateral at lower point of heel at one spot in particular. It feels like there is so l surgical area there. I take tramadol and gabapintin twice daily to deal with pain. —- Here are the notes from my surgery to compare: An incision was made posterolaterally. Of course I preferred to go medial but he has a previous Haglund’s type of procedure and I was obligated to use his old incision. Dissection was carried down through the skin and subcataneous tissues where the insertion of the tendo Achilles was identified. I took this down sharply. He had pain that located mainly laterally. I basically took the lateral side down completely. The medial side was only partially elevated, preserving the length/tension relationship. then exposed the posterior aspect of the os calcis. His area of maximum paindid indeed correspond with an area of a tendon that was significantly abnormal. An oscillating saw was used to remove the large posterior exostosis from the calcaneus. The was smoothed down with a rongeur. FOllownig this. I used an Arthex SpeedBridge to perform the secondary repair of the tendon. Fibertape was place in the tendon, and it was advanced distally. The distal anchors were then place and the tendon was then tided up with a small Vicryl suture. This secured things very nicely. THere were no problematic knots from the suture or large prominences. Once this was completed, I reapproximated the subcutaneuos tissue and subsequently, the skin in the interrupted manner. There are the notes. — Just seems like I am not advancing like almost everyone else and as studies I have read would indicate. As I said I am frustrated and depressed.

  13. goldmanon 05 Aug 2014 at 7:52 am 13

    Tom Winter, do you have your own blog? If not, might be good to put one together describing your situation, which from the notes and looking through this blog it appears to me that it started around… Feb 2012 (?) and that you have had more than one procedure. Might not be comparing apples-to-apples since I have only had the “standard” ATR repair surgery, but I can give you more information on my status if you would like?

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