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.

Good news or bad news and passing it on!

The good news is that I received an email from the Orthopaedic Consultant's secretary who after speaking to both the Consultant and Senr Registrar was able to write "both said that you should be touch weight bearing only (less than 20% of your body weight) until your next clinic appointment in May". I've passed this on to the community physiotherapist. I also feel a little more confident about trying to manoeuvre both into the steam shower and out of the front doors when the time comes to try again as I had previously interpreted the advice as 0% weight bearing.

The bad news came when the district nurse came to remove the one remaining dressing over the exit hole of the previous freely draining sinus. She was concerned that it is red and discharging fluid which smells offensive and has deteriorated since her last visit on Tuesday. I pointed out to her what I thought was another suture along the incision line which she was able to trim and in the process of trimming pulled it out. She also then noticed a suture remaining over the sinus exit hole which also pulled out easily.

As one of the GPs from the local practice is due to call around this lunch time for a medication review, BP and blood sample the District Nurse has left a note ( on some recycled paper I keep in the study - a stack of A5 sized sheets from A4 one sided printed matter) asking the GP to review the wound and asking "does he need oral antibiotics?". The District Nurse was hoping to discharge me today instead she will arrange for another visit on Monday.

So the questions are: is this a sign of internal sepsis returning or is it superficial - maybe associated with the non dissolving suture? and what if any antibiotic would be appropriate both now and after a swab ( if one is taken) has been analysed?

While the district nurse was writing her note to the GP in the opportunistic manner described I was receiving calls from my son who was setting up remote access on my mother and sister's computer (in Harlow) so I can provide support when required (from Sheffield). We had earlier "proved the concept" using his own set up and mine and tried to transfer this to their equipment.

How different this is to the way the NHS tries to keep in touch. It did occur to me again that the NHS makes a very poor relay team as messages get dropped all the time. In these circumstances if the patient does not keep picking up the pieces and passing them on perhaps the "race" would never finish.

POST SCRIPT

Its now over an hour after the latest time the Dr said she would visit so I rang the Surgery and explained the background. Despite the DR herself phoning and arranging the home visit it was not in the Surgery diary ( perhaps its because the Dr herself made the appointment over the phone and was then distracted). I was told that she had made a number of home visits and was now in her room with a patient. The Practice Administrator said she would speak to the Dr but it might mean another Dr may phone to see if he could advise what to do over the phone! Fortunately I still have 2 brands of oral antibiotics one of which proved less and less useful - both are what are called broad spectrum so hopefully the more recently ( and still in date) product could be used over the weekend if no Dr is able to visit from the practice. Yet another example of baton dropping - this time when being shuffled from one hand to the other of the same "runner"!

POST POST SCRIPT

A further call to the surgery towards the end of the afternoon elicited some of the facts behind the missed home visit. The doctor concerned had to spend more time on more home visits than planned as as mine was for a medication review it was understandably thought could be deferred. We learnt that a blood test was planned for Tuesday and after that the doctor would visit to review the medication etc.

In the meantime the need for a doctor to visit to check out the District Nurse's concern had been noted and the most approachable and sympathetic of the surgery's doctors had agreed to phone to discuss and if necessary to visit. This doctor also knew more about the complex history than others and had a more immediate recollection of the salient facts. After a short phone call he agreed to call in after his last planned home visit which was nearby. In the event it was about 7:30 when he arrived and about 7:50 when he left. He examined the wound and spotted yet another suture around were the sinus had exited and been cleaned away. There was a little blood and even less discharge on the dressing that was removed. There was insufficient for a swab. After a call to the on call orthopaedic team it was agreed to keep a careful watch. If it pus developed then my wife could take a swab using the kit provided and drop off at the local hospital. We would then await an analysis before starting on oral anti biotics. If over the weekend the area became red and hot then we could start using the antibiotics still in date and left over from before the operation. In this event I would need to call the doctor to speak to him at the surgery on Monday. We talked about me sending an email ( yet another!) to the Orthopaedic Surgeon along with a digital camera image of the troublesome wound area.

Having covered all bases in this way both my wife and I felt comforted and the "elephant in the room" of possible amputation receded from our thoughts. We had discussed it and I had spent some time this afternoon as a result imagining life with one leg instead of being a one hip wonder. I came to the conclusion of this happened it would be the final posting and definitely not the excuse for a sequel!