Here is yours truly, holding a copy of a book I wrote when I was a whole lot younger. The book is a first edition of the Rigger’s Apprentice, first published in 1984. This copy is property of RN extraodinaire Terry Sanchez, who in addition to being a consummate medical professional is an avid sailor, and a world-class fly fisher. You never know who you are going to meet in a hospital.
I was at the hospital for a followup on the installation of my most recent ankle. Yes, they still make parts for these old models, but the first attempt got infected somehow, and had to be removed. The doctors took it out, and stuck a brick spacer in there to hold everything in place while we cleared up the infection, then after several months they took the brick out and put another articulating device in. This time so far, so good. Counting the model that originally came with my left foot, that makes it a fourth edition ankle. The book has also been greatly revised over the years, and I like to think that it and I are co-evolving.
For more on the original surgery, you can visit posts here, listed in order of appearance:
The first piece, “Falling,” became the germ of a book of the same title. You can find it Here. The majorly-updated Rigger’s Apprentice, and lots of other items, are available through our Store.
In other news, I am getting semi-mobile now, just in time for our upcoming 3-day Rig Your Boat workshop, happening May 3rd, 4th, and 5th. Only a few spots left, so sign up soon.
This is the last of a series of articles about my left ankle. To see other entries in the series, scroll down in the blog to see the “Ankle” entries. The first one is “Falling.” If you are just here for the Puzzle, you will find it at the end of this article.
From lifelong conditioning, when I think of surgeries, I think of masked and gloved figures, muttering the names of specialized utensils as they huddle around a sleeping patient. In the background there is an assortment of beeping, hissing machinery. A mercilessly bright overhead light throws everything into a literally sterile relief.
This is still a valid image, as far as it goes, but for many contemporary surgeries, including the ankle replacement that I recently underwent, my mental image has been missing a crucial component: a machine shop. We are talking drill press, plunge router, oscillating saw, the works, plus an assortment of jigs, clamps, and drivers that any shipwright might envy. All of these things have been loaded into operating theaters, thanks to the engineers and surgeons who have come up with tools, techniques, and parts to meet a powerful demand for aftermarket joint repairs and upgrades. We are talking actual joinery here, at a level of refinement that one would expect to find at a Port Townsend shipyard, but with scrubs instead of Carhart’s.
I was recently the beneficiary of this machinery, courtesy of the UW Ankle Clinic in Seattle. What follows is an interested layperson’s look at the technology.
I’ll start by saying that total knee and hip replacements are now so common that they almost seem mandatory for Baby Boomers; according to the Mayo Clinic, over a million hips and knees are installed every year. Prosthetic ankles, though, are still something of a rarity (fewer than 5,000 per year), as a relatively small surface area and relatively high, complex stresses have until recently made it a challenge to produce durable joints. Because of this, surgeons used to install ankles grudgingly, and only if they could be assured that you were a particularly lethargic couch potato, preferably of an advanced age, so there would be little chance that you might actually use your new ankle for anything more strenuous than toe-tapping.
But hardware design has evolved at a steady pace (meaning that engineers learned from catastrophic design failures), and surgeons have now had opportunity to hone their skills (meaning they have learned from catastrophic technique failures), so total ankle arthroplasty (meaning, well, you’ll see) is now an option for even relatively active old farts such as myself.
Contemporary prosthetic joints aren’t much to look at (figures 1 through 3) – just a pair of curved metal pieces, with polymer liners – but their precise configuration, including the transverse tenons across their backs, their exact curves, and the pitted surface texture, all serve to make the joint more functional and durable. This joint is the work of Zimmer-Biomet, and as you will see, the artfulness of the joint’s design is just one of the things they do well.
About that texture: In the process of healing, new bone will grow into the surface, creating a solid bond. The FDA requires that adhesive also be injected into some of the gaps between bone and hardware, and my surgeons complied with this requirement, but with a distinct air of amused tolerance for a pointless government mandate. Their belief is that porosity alone makes glue needlessly redundant. On the one hand I can understand their confidence that bone and steel will become inextricably interlinked. On the other hand, this is definitely a place where I appreciate the presence of a belt as well as suspenders, and I would not object to staples, throughbolts, and Velcro too, if it made the joint more durable.
As you can see, the pieces of this new joint are elegantly shaped, but they aren’t particularly complex pieces of work; the real challenge is how to install them into a living human being, and that is where the machine shop comes in.
1. The ankle joint, side view. The top piece is mortised into the tibia; a polymer layer separates it from the lower piece, which is mortised into the talus. Note the rough texture of the upper- and lowermost sections, which are made from a cobalt-chromium stainless alloy.
The tenons run athwartfoot on both sections, and are fitted into mortises carved into the bones.
3. The surfaces that contact the polymer are highly polished titanium. The lower section, pictured here, has a concave fore-and-aft trough, which allows some degree of lateral flexion.
The first machine shop component is a sort of jig, into which the patient’s leg and foot are clamped (figure 4). Well, not just clamped; the tibia is actually screwed to one of the longitudinal members of the jig. With the work fixed in place, the surgeons get to do a little old-school work, making a long incision, and pulling the two sides of the incision apart like a set of theater curtains. I will not show you what that looks like, given how squeamish some people have been about the relatively pleasant appearance of the X-rays and skeletal images shown here.
The surgeons approach the work from the outboard side. This gives the best option for machining, and gives blood vessels and nerve bundles a relatively wide berth. The fibula (the smaller of the two lower leg bones, located on the outboard side of your leg) is in the way, so the next step is to sever it a short distance above the ankle (figure 5), and then fold it down out of the way, to allow access to the ankle joint. I added those italics because, ignorant of the details of surgical procedures as I was/am, I’d never thought that the work could be so mechanical. Literally mechanical, like how you would pull a clevis pin to get at a winch’s gear cluster, or cut a hole in a ship’s hull or deck to replace an engine.
4.The foot and lower leg are very, very carefully aligned, then variously clamped and screwed securely to a rigid jig.
5. An oscillating saw (black line) severs the fibula on Bristol-fashion mitered angle. No butt joints here. The lower portion of the bone is then folded down out of the way, providing access to the ankle joint.
With the fibula out of the way, a drilling/milling jig on guide bars is slid into place next to the foot, and a series of holes is drilled on the talar (lower) and tibial (upper) sides of the ankle joint (figure 6). These holes are laid out on a centroid curve (relative to the ankle’s anatomic center of rotation). In other words, we are preparing a path that mimics the original joint’s path of travel. These holes are then enlarged, using a larger drill bit in the same jig, a process that will be familiar to any shipwright or machinist. The smaller drill bits allow precise arcs, and the larger bits remove most of the bone between the holes.
6. Using a rotating jig as a guide, a series of holes is drilled above and below the original-equipment joint.
The drill bit is then replaced with a milling bit, and the remaining material in drilled area is milled away (7), leaving an arced slot where the ankle joint used to be. The depth of the drilled and milled holes is carefully set. I have done this with a piece of tape wrapped around the shaft of the bit, as a visual do-not-exceed depth mark. The surgeons probably used something fussier…
7. A milling bit removes the remaining material, creating an arced slot.
Once the slot is made, more milling ensues, creating transverse mortises to accommodate the prosthetic’s tenons, plus channels into which adhesive can be pumped. When all is fair, the hardware is inserted (figure 8).
8. Prosthetic pieces installed. The two rake-like objects on either side are retractors, which are holding all the muscle, skin, etc. aside. This soft tissue material, along with the polymer in the new joint, is invisible to X-ray. The jig with the milling bit is at bottom center.
Once the hardware is in, it is time for reassembly, starting with flipping that fibula back into place, then screwing a sister frame alongside, to reinforce the joint (figure 9). Hardware taken care of, the rest of the operation is a matter of easing that flesh curtain back into place, and stitching the sides together. This is a reversion to traditional surgery, using actual needles and thread, but even here there is some degree of innovation. Specifically, the stitches that surgeons use to close wounds have changed, with some variation on a “Mattress Stitch” favored, as it provides a smoother, stronger closure than previous configurations (figure 10).
9. View from astern. the black rectangles are the pieces of the prosthetic. A metal plate is screwed to the restored fibula (note faint diagonal line at join, between the sets of screws). Two more screws, not readily visible here, fuse the talus to the calcaneus (heel bone).
A vertical Mattress or “Donati” stitch, in which each stitch penetrates each side of the wound twice, and is inserted deep into the tissue Source: Resident/Net).
As of this writing, the stitches have been removed, and the incision is almost entirely healed, but it will be another month or so before I can put more than half my body weight on the new ankle; it takes time for bone to grow into that pumice-like surface, time for the fibula to mend, time for circulation and nerve function to return to normal. Basically I’ve spent most of the last six weeks supine, with foot elevated, trying not to go batty from inactivity. But while my conscious mind has been restless, the deeper parts of me have been stolidly, unceasingly, molecule-by-molecule repairing a relatively serious wound. The parts of me that are doing the work don’t know that this was careful surgery, done for my improvement. All they know is that I have suffered an injury, and they have marshaled all of my body’s resources to address that injury, working with a precision and skill that makes the surgeons – as I am sure they would readily admit – look like somewhat dim apprentices.
Note: The X-rays in this piece are of my ankle. Unless otherwise noted, the illustrations are from Zimmer, the manufacturers of the hardware, and of the machinery used to install it. For a much more detailed description of the procedure, see – http://www.zimmer.com/content/dam/zimmer-web/documents/en-US/pdf/surgical-techniques/foot-and-ankle/zimmer-trabecular-metal-total-ankle-surgical-technique.pdf. Many thanks to Dr. Sangeorzan and the entire team of careful, competent, friendly people who made it all happen.
And now for this week’s Fabulous Puzzle. In the picture below are what appear to be two knots, but since you can’t see the ends, a quirk of topology means that there might be any of four knots represented. All of the knots are bends (knots which join two ropes together), so there is an end and a standing part on each side of each knot.
If you can identify two of the possible knots, your entry will qualify you for a drawing to win one of our DVD’s.
If you can identify three of the possible knots, your entry will qualify you for a drawing to win one of our Point Hudson Fids, good for up to 5/8″ rope.
And if you can identify all four possible knots, you will qualify you for a drawing to win a personalized autographed copy of the new edition of the Rigger’s Apprentice.
If you win, and already own any or all of the above prizes, we will work out a prize of equivalent value for you.
To see these items and more, visit our online store, on this site.
As always, we welcome any and all additional rope geek information on the names, characteristics, history, etc. of the puzzle topics. We also welcome suggestions for future puzzles!
Send your entries to puzzle@briontoss.com before noon on the 10th of January. We will draw random winners from the pool of correct entries, and announce them on Friday, the 12th of January.
First there’s the waiting for admittance, then waiting to be called, then everything happens rather quickly. I am checked, briefed, and queried by at least one representative from every medical specialty. They are reassuringly thorough, and their questions have a reassuring amount of overlap; this is a team, and they all need to be in the same game.
Still, it is a lot to comprehend, let alone assimilate. I have been preparing for this for years. Every time I couldn’t dance with Christian, or walk more than a short distance, every time that the pain would wake me, I would think about how and when to get this work done, how to organize life, and put enough aside to have any hope of taking this leave of absence. In the end, of course, I was neither particularly organized nor solvent; the ankle just wouldn’t wait any longer.
The anesthesiologists arrive and start setting up, even as they conduct their part of the assessing/educating. One of them gives me an injection,and I start naming the epochs, counting back:
Cenozoic
Quaternary
Neogene
Paleogene
Mesozoic
Cretaceous
Jurassic
Triassic
Paleozoic
Permian…
I might have made it as far as Carboniferous. I definitely never got to Cambrian. And then a moment later my eyes pop open and a calm, attentive nurse is there, and beyond her a clock is claiming that five hours have passed. And then another nurse goes to get Christian and then she sweeps into the room, smiling that smile.
Discharge
In a hospital there are two major usages for the term “discharge.” One is a bodily effluent, often putrid or otherwise unpleasant. The other is a patient who is leaving the hospital. Both categories involve the patient’s getting cleaned up, checked over, and reassured. I am now a discharge.
My clothes have been returned, so I am rid of the silly gown. In a few minutes someone from physical therapy will come by to make sure that I know that I can’t go bowling tonight, or maybe even tomorrow. They will instead tell me, I hope, how to push myself physically, without endangering my recovery. I know that the coming weeks will be spent mostly in bed, but I do not want to waste away; I want to get back into the world, I want to dance with Christian.
A typical CT scanner weighs 4,400lbs and costs about $450/lb. It is a huge, glossy donut sculpture, with the hole being just big enough to allow the passage of a human being, lying flat on a special table that slides on rails. The whole thing looks like a prop for some ridiculously overproduced magic trick, but it is in fact a magical camera. It cannot see into your soul, but it can certainly pick up some adjacent, nearly-as-hard-to-detect details.
The problem faced by ankle surgeons is that bone alignment shifts markedly when weight is applied. So while you can get wonderfully clear pictures, from all angles when the patient is lying on the table, you can’t use those pictures to determine how all the parts of a repaired joint will fit together after surgery. You can end up with a joint that won’t quite articulate, or one that is longer or shorter than it is supposed to be.
An obvious solution is to turn the donut on its side, with the patient lifted on a little pedestal in the middle, like Venus Rising from the Sea Tee. This is actually in the works for the Clinic, but meanwhile they have been making do with an ingenious,wonderfully low-tech assembly involving sailboat rigging.
They place a plexiglass “sled” on the bed. It is in two pieces, with rails connecting them so you can adjust the length. There is a vertical footboard at one end, and a low transverse stop or fiddle at the other. The patient sits on the sled, straight-legged, with feet planted square against the footboard, and takes hold of a small-boat trapeze handle, held to the footboard end with actual rope. The tech then takes up on two block-and-tackles, made up with ratchet/cam blocks, mounted low on either side, to draw the two sections together. This pushes the patient back, but their travel is arrested by the butt fiddle. The tech continues to haul away, balancing the two purchases, until a couple of Edwardian-looking brass cylindrical scales, in line with the blocks, show that the equivalent of the patient’s standing weight is pressing evenly against the footboard (assuming that weight can be borne).Then the tech fires up the stupendous computers, gets the table under way into the donut, and takes the pictures.
It is fair to say that the marlingspike work is not up to Bristol standards, and that the cordage is very much from the Home Depot end of the spectrum, but it is delightful that this gazillion-dollar pile of x-rays and algorithms could be informed by the efforts of a human being whose actions and hardware are nearly identical to those of someone taking up smartly on a main sheet. Can’t wait to hear the shanty.
Seattle is a hilly place. If you head east from downtown, the first hill you come to is First Hill. That is the official name, but although I grew up in Seattle I never heard it called anything other than Pill Hill, which is as accurate as it alliterative; the place is infested, drenched, chockablock, laden, dense, encrusted with all things medical. There are clinics, offices, labs, supply stores,research institutes, etc., and of course there are hospitals, great grand multi-story hives of allopathically-intensive activity.
Nurses work here. And surgeons and orderlies and lab technicians. Phlebotomists, anesthesiologists, optometrists, and all the other ists. Specialists, and generalists (but especially specialists), an army of people who work, right down to the molecular level, on human bodies.
Here you will also find people who manage all of those people, who do their accounting, keep their records, order and deliver the things they need, and who feed, clothe, transport, and clean up after them. The people and the structures comprise an ecosystem that is immense, complex, dynamic, and yes sometimes hideously expensive for the customers. I have no desire to go into the socio-economic mess that is US medicine, other than to say that because I have attained a certain age, and because we once had a rational, compassionate President, I will be able to get my ankle fixed, and thereby continue to lead a satisfying, productive life for longer than I otherwise would have. For the moment, though, I’d like to talk about scrubs.
People in Seattle typically wear colors that can be a found on the underside of a mushroom. But as you go up onto the Hill the palette shifts to the industrial pastels of surgical scrubs. At the center of things, at certain times of the day, regular street wear can seem out of place, because you are surrounded by people wearing the only uniform I can think of that doesn’t try to emphasize aspects of physique, or give an impression of competence and efficiency. It is a shambly, shapeless excuse for a uniform. If you had never seen one before, you would laugh and say, “Why are these people walking around in their pajamas?” But no one laughs, because these loose, thin garments proclaim that the wearers keep human metabolisms running. The sight of these garments elicits an instant, if queasy respect for the wearers, reminds us that we are fragile, mortal creatures, and that a test or an injection or an incision or a focused blast of energy from one of these people might restore our health, or even save our life.
One thing that scrubs have in common with other uniforms is that they are suited to a particular work environment. So they are loose-fitting because the work can make serious demands on physical exertion and range of motion, and thin because a hospital is a climate-controlled environment, and one in which exertion and mobility can cause one to work up a sweat, which is not always avoidable but which is discouraged, Patients, of course, are expected to sweat — and bleed and produce assorted other effluents and exhalations that compromise the overarching need for obsessive cleanliness — which is why scrubs are also easy to remove, cheap, and able to stand up to repeated, harsh washing.
One other way that scrubs are like other uniforms is that they mark the wearer as a member of a group. This can, it is true, diminish the significance of individuals, and encourage conformity, detachment, a cold uncaring. But it is at least as likely to engender a feeling of purpose, of belonging to something larger than oneself. People can achieve competencies and autonomies in the right group, things not available to loners; when you act in isolation, you lack context. When you have a rich context, you can become more fully human, and therefore humane. This matters in the world of medicine, an art so profoundly intimate that it becomes literally — but not, we hope, emotionally — sterile. You don’t want some heartless cypher in charge of your well-being.
This morning my legs will be the subject of a hyper-computerized portrait, a template for the surgeons who will be rebuilding my ankle. The machinery for this will take center stage, but the people who guide me to it, and tell me where to stand, and operate it, and analyze the results, will provide every bit of meaning to the exercise. They’ll be members of a modern tribe of healers, and they will be wearing scrubs.
48 years ago I was at the top of a 45-foot-tall scaffolding tower. It fell over. As I was about to die — it was obvious that I was about to die — my last words were, “Oh no, oh no.” Some time later, from a great distance, I heard someone saying, “Oh no, oh no,” and realized it was me, not dead yet. My right knee hurt, my back hurt, my head and a few other things hurt, but mostly my left ankle hurt.
A deputy from the nearby town of Tenino came rushing up to where I lay amidst a tangle of torn and fractured steel. He had been there to monitor us as we cleaned up after a rock festival. Until that moment it had been boring duty, but now he had an actual emergency to deal with. I told him that I thought I’d broken my ankle. Whipping out a huge, very sharp knife, he prepared to cut off my ridiculously expensive, much-beloved hiking boot. I pointed out that it laced down to the toe, and that he could just untie it. He was crestfallen, but he put away the knife and eased the boot off. Then he went to pull my sock off, but my ankle was now grapefruit-sized, visibly expanding, and pulling on it made for passing-a-kidney-stone levels of pain. Granted, I have never passed a kidney stone, but it seems likely that one’s pain meter is pretty well pegged when you get to the gasping-as-you-almost-faint level. I pointed out that he could cut the sock off. This really made his day. Out came that knife, and off came the sock.
What followed, in the short term, was a cast on the ankle, bandages on assorted other body parts, and slow recuperation in my parent’s basement. I taught myself to juggle, studied knots, read many books, and thought a lot about mortality.
What happened in the long term was a life: a series of ludicrous mistakes tempered by love and education. Along the way the ankle decayed, little by some, until it felt like that sock was being pulled off every time I walked on it . Eventually I had it fused, which, interestingly enough, involved someone approaching it holding a very sharp knife. The good news is that the pain went completely away. The bad news is that the adjacent joint (the subtalar, for you anatomy nerds) now took up the slack in stress, which it was not even remotely designed to handle, until it, too, became seriously decayed.
I recently had my foot X-rayed. The technician took one look at the picture, then turned to some nearby colleagues and said, “Hey guys, take a look at this!” They all crowded around, marveling. I stood on my little pedestal, in one of those charming hospital gowns. One of the techs said to me, “How can you walk on this thing?” In that moment, it occurred to me that I might have been being just a bit too stoic.
No ankle has an easy life. We expect it to bear up under our entire body weight (okay, minus the foot), and to articulate in all directions, dealing with major levels of impact and static loads, in torque, shear, tension, and compression, sometimes simultaneously, and to do so utilizing a laughably small surface area, with amusingly short lever arms. Accordingly, it is a very easy joint to damage, and a very difficult joint to repair, which is why surgeons are much more likely to recommend fusing a badly-damaged ankle than installing a prosthesis, unless the owner of the ankle is a particularly lethargic couch potato. To an active person, they are likely to say, “We could give you a new ankle, but compared to a hip or knee replacement, the hardware is flimsy. You would probably break it.” That is what they told me, hence the fusion. After the passage of years, with the doctors working on the I-hope-mistaken assumption that I am less active and/or more careful than I used to be, plus advances made in hardware, they are now graciously willing to install a new ankle joint.
Which brings us up to date. Christian and I have just finished one type of journey, and now I’m about to embark on a different type; in about a week I’ll be in an operating theater in Seattle, having some hardware installed. It is apparently a tricky operation, and this version of it has been done only a few hundred times, anywhere. I am not looking forward to the operation, but I am looking forward to writing about it.
