Thursday, 29 May 2008

One Legged Bowls and Sitting Down On The Job

During a visit last week from the physiotherapist I updated her on what I could now do, including getting back to wood turning at my lathe.

I mounted a small elm blank between the head and tail stock last week and turned the exterior shape and recess ready for turning around and holding with an expanding jaw chuck in preparation for finishing off by hollowing out the inside. I stopped after a while as I realised that I needed to shift body weight from time to time and this was not easy balancing on one leg.

I was told that I could do with a "Perching Stool" and sure enough one was ordered and arrived yesterday afternoon. This afternoon I adjusted the stool to its full height and continued where I had left off last week but this time by "sitting down on the job"!

I had expected that I would take the weight off my one good leg when adjusting posture during the hollowing out process but instead managed by and large by shifting around on the perching stool. I did have to get up from time to time to reach for sand paper, cellulose sanding sealer, friction polish and wax - all part of the finishing process - once the desired shape has been achieved through use of a variety of gouges and wood turning chisels.

I finished off the elm bowl and turned my attention to some cherry that I had sawn up when I could still stand before the latest operation. The cherry had come from my brother in law who we will be visiting this weekend so I wanted to see if I could repay the gift of the wood by presenting him with one of the products of his own garden.

The bowl is currently shaped, sanded on the outside and initially "finished" ( not really a contradiction in terms!). It is mounted in the jaws of the chuck ready for stage 2 and hopefully I will finish that off tonight or tomorrow morning.

A while ago I decided to "sign" the finished items and bought a wood burning tool set. At present I etch in the house name and year. I have not yet got around to numeric sequences nor do I think I will ever get that good or serious. However in years to come if ever the family collected together the various bowls etc that I would have made and given as gifts I am sure they would be able to see the progress I would have made.

Perhaps they might assign some of the designs to different periods of my "artistry" - you know that was his "early period", his "Laburnum period" etc. What I expect none of them will realise is that the produce of the next few weeks will in my mind at least be remembered as my "one legged period".

The wooden bowls that will result therefore will to my mind forever be examples of "one-legged bowls" i.e. not the genteel sport played by an amputee, but wooden containers for use around the house fashioned with the help of the very useful "perching stool".

Tuesday, 20 May 2008

Its "OK 4 GO" in T - 2 months ( and counting!)

Just got back from the follow up Orthopaedic Out Patient Clinic.
The questions were answered after a brief hands on exploration of the right thigh confirmed no apparent infection remained.

A 2nd stage Operation was still on, there would be no need for prophylactic anti biotics leading up to the operation as the joint would probably be cemented and or bone allograft with a cement collar at the junction with remaining bone above the knee. Progress after the operation would be normal ( all being well) and if cemented I would be weight bearing straight away although assisted with crutches/ walking stick(s) initially.

The operation will be scheduled within 2 months in preparation for which I had some blood taken to assess current inflammatory markers (CRP and ESR levels) and will be invited to another pre-op assessment.

The advice about weight bearing was interesting - I was still to work on the assumption of no more than 20% weight bearing. When I asked how can I tell the answer was blindingly self evident - in retrospect - "Stand on some scales with both feet then place the good foot on the ground and put pressure through the bad foot until 20% of the previous weight registers" - Of course - but why is this technique not known more widely e.g. by physiotherapists. Even armed with the knowledge of how to measure a percentage of weight bearing my muscle feedback mechanism is not that finely attuned yet to assess the difference between 10% and 20% so it still remains a very subjective (touchy feely) measurement.

We tried to export the X-Ray image to a memory stick and although the software allowed for this and the consultant was happy to give it a go we only succeeded in setting up an empty folder. Plan B was to take an image or two with a hand held digital camera. You can see the result. Both my wife and I realised that there was significantly more of my own femur in place than we had been told. It now appears that I have just under half of my own femur in place. The surgeon said that they also thought they had been more radical and that it is not easy to judge in the heat of battle (my phrase not his!). I expect one other reason for the inaccurate estimate is that I have relatively long legs for my height another is that they would not want to peel away more tissue than necessary just to get an accurate assessment.
Having said that the x-ray shows the metal rod fixed into the remaining bone and around which a cement version of the head of femur was constructed, so I assume it would have been possible to know how much of this rod had "disappeared" into my remaining length of bone. All academic really I suppose. The metal rod is the important thing here. The cement being formed into a temporary bone was more to store the slow release gentomycin to fight infection and to act as a spacer to stop leg length shortening. It did not matter that the junction between cement and bone was displaced as pressure would be through the rod not the cement.

Monday, 19 May 2008

Preparing for a "Mid Stage Review"

Tomorrow I see the surgeon in his follow up Out Patient Clinic. I will be travelling as a passenger in my own car - driven by my wife - and not the ambulance that was booked when I left the ward over 6 weeks ago.

I will be dropped off outside the main out patient entrance and will use crutches to "walk" the 100 yds or so to the ground floor clinic. I expect I will have an X-Ray on arrival and then wait to speak to the surgeon or one of his staff.

If I can I will try to take a digital camera image of any relevant X-Ray - if only so the physiotherapist has a "clear picture" of the extent of the remodelling in cement of my right femur.

I will go wanting answers to the following questions:
  1. Is the 2nd stage still practicable?
  2. If so what can be done to minimise the risk of infection next time e.g. prophylactic antibiotics and/or wait a further 2 -3 months to be sure the infection is out of the system?
  3. Should the 2nd stage wait until my iron stores and haemoglobin levels have been boosted by the iron infusion course and EPO injections?
  4. How will the bone graft be formed into a femur?
  5. After the 2nd stage would the progress to full weight bearing be as for any other hip replacement?
  6. What should the physiotherapist be aiming to achieve with me in the next few weeks / months?

On a practical level I continue to gain in confidence and in the last week have not only managed to top up the bird feeders, have another steam shower, be driven to renal out patients for an iron infusion but have also managed to ascend the stairs to the converted loft on crutches which means no more "climbing" up the stairs by sitting down. I was even contemplating seeing if I could stand at the lathe long enough to finish off one of the two half completed bowls I started a couple of months ago.

I still notice that my right leg seems happier with my foot pointing out between 45 and 90 degrees. Great if I wanted to be a ballet dancer but otherwise not much use, although it would be the perfect angle for side footing a ball past a luckless goalkeeper diving full length to the left! Chance would be a fine thing!

Tuesday, 13 May 2008

X Rated X-Rays - not for those of a nervous disposition!

First the good news about continuing progress in terms of mobility. I have now progressed to regular use of crutches instead of the Zimmer Frame. I can now negotiate steps in the garden and have therefore been able to achieve one of the two targets I had not set myself for achievement until well after the 2nd stage operation - to be able to top up the feeders for the birds in our back garden. The other longer term target is to get back to wood turning. I will wait to hear what the surgeon says next week about weight bearing and might even be able to give this a try after the clinic appointment.

At that clinic I will try to take a digital camera image of the current state of my right thigh.
In preparation for that however I was playing about with transferring 94 X-ray images provided on CD by the local hospital in response to a request for personal information in connection with my thwarted PhD studies. (The new digital imaging archive service broke down in the middle of transferring my X-Ray library so I'm not sure how many more there are to incorporate into my lifelong electronic health record but I will find out when I request a further update after the 2nd stage operation.)

I have selected 2 images to illustrate the metamorphosis of my right hip. I begin with an image taken a couple of months before the initial hip revision operation.

It shows the extent of protrusion into the pelvic cavity of the cup placed there nearly 23 years previously. You might note that the left hip joint prosthesis looks altogether in a better state. X-Rays tend to show the view of the observer not the observed - hence the left side will appear on the right of the picture.

The operation to replace this initial prosthesis required the removal of the metal ball and spike and the cement that was used nearly a quarter of a century earlier to secure it in place.(Nowadays most hip replacements are cementless and use sterilised and pulverised bone removed from previous operations to pack the metal spike into the cavity otherwise filled with marrow.) This would be quite normal, however in my case - because of the extent of protrusion - the bone that surrounded the cup (or acetabulum) had to be remodelled with pulverised bone. Like mending a rusty car wing with plastic padding the bone needed to be kept in place until it could graft onto my own bone and a metal grid was used and kept in place with a number of screws. In theory once the bone had grafted successfully the metal cage and screws could be removed - this would not normally happen in practice and would be left in place along with the prosthesis.
So this is the same hip after the extensive remodelling 4 years ago. All of the metal has since been removed along with a lot of the femur and soft tissue that became infected. In time I hope a new metal prosthesis will be in place without the need for any additional metal work. ( We'll see!)
I should explain what the loop is that appears wrapped around the top of the metal head of femur. It is in fact some wire that was helping to keep the surrounding bone at the top of the femur in place! Apparently during the insertion of the metal spike some of the surrounding bone at the top of what was then left of my femur chipped and was cemented back in place and secured with the metal wire looped around. So in addition to the metal spike my right hip had 7 screws a metal mesh and some metal wire to keep various bits in place. All of this metal was removed in the operation to fillet my right thigh nearly 2 months ago.
Although not conclusive the 2 X-rays do point to a difference in the relative lengths of both legs. Slight leg leg differences are one of the risks associated with this type of surgery. My previous 3 operations had not caused me any problems but in the years leading up to the revision I had lost half an inch of length in my right leg (due to the protrusion into the pelvic cavity)and walked with a waddle until provided with a polystyrene wedge to place inside my right shoe. This low tech solution straightened my posture and allowed me to walk with the family without too much pain. It was a pity that it required a referral from rheumatologist to physiotherapist and then from physiotherapist to podiatrist a chain of referral that took 6 months.
After the revision I felt that my right leg was longer than the left. It took about 12 months before this was accepted and I had a prescription for up to 3 shoes a year to be fitted with a half inch wedge to be inserted into the soles to compensate. I will wait until the 2nd stage operation before getting these removed.
The latest X-Ray shows a few inches of femur above the right knee and a "rudely" fashioned femur made entirely of cement with a knob at the end to act as a spacer. (I hope to provide a picture of this in a week's time) As the swelling in my right leg recedes I am becoming aware of the limitations of the knob that was fashioned. When I stand and let my right leg swing free it twists out to between 45 and 90 degrees. When I sit down I have difficulty drawing my right knee toward ny left and when I do my thigh sticks out to the right while my lower leg is bent inwards. I am not complaining as this is both temporary ( I hope) and I was not expecting any kind of fashioning to have been possible.
All in all though now that I am able to get around the house and garden - and further afield as a passenger in a car - I am beginning to contemplate a return to what I have considered normality for the previous 3 years. I did not think that this would have been possible while I was a one hip wonder so I remain grateful for the "emergency" remodelling that the surgeon managed during the extended operation.

Wednesday, 7 May 2008

Ferrari Like Pitstops near Bluebell Woods

Yesterday was a sunny day spent with friends from Germany visiting nearby Italianate gardens during their bluebell fortnight. This marked my first car journey as a one hip wonder so was noteworthy on a number of fronts.

During my friends' stay I made a number trips out of the house and around our own garden. We had a carefully rehearsed process of someone fetching the mobility scooter from the garage below and driving it to the front door while under supervision I used the zimmer frame to negotiate my way outside. We of course had the reverse process also well rehearsed for when it was necessary to return inside.

We gave Bank Holiday Monday a miss because, tempting though it may be to explore the nearby Peak District, the Bank Holiday traffic takes away any enjoyment.

Yesterday was different and with my wife driving we drove to Renishaw Hall (home of the Sitwell family where for 2 weeks each year around this time the gardens are open to the public to explore and enjoy the wooded park resplendent with its English bluebell carpeting).

Getting me into the car went easily - along the lines previously described. However getting the mobility scooter dismantled with 3 willing helpers took a little longer. There is a sequence that needs to be followed to unhook, fasten down, manipulate, lift and pull apart different components. In skilled ( i.e. my)hands this takes about 90 seconds. With 3 willing but novice assistants it took a little longer. Eventually the various bits were loaded into the boot of the car along with the trusty zimmer frame and for the first time in about 5 weeks I drove out of the front gates and back into the "wider world".

On arrival at Renishaw Hall I was very impressed with the speed with which my "pit crew" (having learnt very quickly) managed to have the red scooter assembled and ready to roll.
It was almost like watching the Ferrari pit crew in action during a Formula 1 Grand Prix.

Shortly after that we were all wandering through the formal gardens and enjoying the sight of the bluebells on the ground under mature trees with the sun dappling through. It was just calling out to be photographed..... so here is one that captures both the moood and the achievement.

Thursday, 1 May 2008

Onwards and Upwards - Talking the talk if not yet Walking the walk

Today is Thursday and I've just returned to the study after 3 trips outside of the house and a further trip up to the converted loft. I also managed to transfer into and out of the passenger seat of my car.

The reason for such rapid progress all in the one day was the presence of the community physiotherapist (accompanied by colleague). I reported that I had managed the initial crossing of the front door threshold and also made it up the stairs to the converted loft - under supervision and with the assistance of my wife. I stressed that I had not yet repeated either of these accomplishments.

I was able to talk and eventually hop through the process (note I carefully avoided using the word "walk" - I may talk the talk but I'm a long way yet literally from walking the walk!).

In the process of demonstrating how I managed to negotiate the change in levels on the way through the inner and outer doors and then again out into the front patio I referred to the concern I had about the wheels on the front of the zimmer frame moving away from me when I was shifting my centre of gravity forward of centre. The answer proved simple - to swap the front wheel components for static feet. Fortunately the colleague of the regular community physiotherapist had 2 in his car. So with those in place and using the more straightforward route we had worked out before, getting out was really no problem. I made my way over to the small round table we have outside and sat on one of the 2 chairs in the afternoon sun and thought I can now return to sitting out on the "front decking" like the retired cotton pickers of old with a cup of fortified coffee and a good book to read.

Having got this far we then made our way back. I would like to have said "headed" back but this would be misleading. I find it easier to negotiate the steps to get back inside if I approach them in reverse. Because I had only made this journey once before in my current state I forgot that one of the manoeuvres required a single long stride backwards and subsequent second or two supported in mid air with both feet off the ground. I initially tried this particular manoeuvre in 2 stages and it felt wrong. Both physios recognised that this would be better as a single step backwards and so it worked out. It was good to have a second (and third) opinion and gave me more confidence.

Once back inside safely we then discussed the progress I had made with "climbing" the stairs to the converted loft. I demonstrated this and asked one of them to be behind me at the top of the stairs ready to steady the shower stool. Having got up to the converted loft I was asked why I wanted to get there - was it to sleep? So I pointed out the ceiling mounted projector, sky box, sound system and Nintendo wii and explained that with friends from Germany coming in a few days it would be good to be able to set up a game or two on the wii. (I realised this went down as an example of "boys toys" so stopped there) This seemed an acceptable reason all round but especially to the colleague who wished to do something similar in his house - provided of course he could persuade the wife!

After returning to the ground floor without any mishap the three of us discussed the risks involved in trying to get into the car. If I had a full hip replacement there would be special considerations regarding the angle that my leg could be bent so as to avoid the hip joint dislocating. As this did not really apply in my circumstances and because I had demonstrated that I could manage to lever my way up and down stairs it was agreed that I could attempt to get into the car under supervision.

So another trip outside was required. In preparation for this "journey" to the car - which was either by steps ( definitely ruled out) or slope - we agreed that I should use the mobility scooter to travel from front door to the car below. As it happens my son was visiting and in the process of loading up a hire van with some furniture. A shout to him resulted in the mobility scooter appearing at the front door before I got there. 2 minutes later I was sitting in the passenger seat of my car - having ratcheted the car seat up to its highest extent, pushed the seat back as far as it would go and reclined the back to 30 degrees. Past experience of managing with newly replaced hips came back to me as I laid back as far as I could and positioned myself over the handbrake before swivelling round and lifting my filleted leg over the car door sill. Getting out was easier and I got back on the mobility scooter made my way back (again under supervision) to the front door and once again reversed my way back with the zimmer frame into the house.

Later that afternoon my son wished me to advise him on stuff to keep or dispose of in the garage and as my wife had by then returned the three of us repeated the careful egress from the house one more time.

About 40 minutes later after acting both as gaffer (barking out instructions) and labourer (moving a few items around the garden on the mobility scooter ) I returned to the house a final time.

All in all an afternoon of moving both onwards and upwards and if not quite yet walking the walk I was at least talking the talk :-)