A third open letter to my 110+ TOTAL ANKLE REPLACEMENT PATIENTS:
Patient number one received the original letter and everyone else a copy...

In this note I will talk about your new ankles. To date there is one failure, defined as a patient whose implant had to be removed and their ankle fused. The patient/surgical photographs CD has been updated and all patients who would like to have one will receive a copy. Just let me know. I deemed the first CD less than desirable in terms of photo quality and decided upon the change using the latest Sony 95 digital camera with 10x/20 zoom. The results were worth the wait.

As normal curiosity may have overtaken many of you I report the following facts:

I implanted 72 patients from 11/98 to 9/30/2001, as FDA approval limited to 10 surgeons in the United States began 10/98. It is not known when the FDA will permit more surgeons to implant the Beuchel-Pappas ankle. (pronounced Beekel)

One patient had a STAR, (Scandinavian Total Ankle Replacement), performed twice. It failed both times and I removed the STAR and implanted BP ankle. So far, so good, 8 months later.

Three required reopening of the ankle: 1 for mal position of the prosthesis (which is now normal 16 months post op) and 2 for bone growing in front of the ankle extending over the implant to the foot limiting motion. This patient also required a return to Miami to lengthen his Achilles tendon to give him more motion. An intra-operative fracture led to later fracture fixation. He developed osteomyelitis and the implant was removed. His ankle will be fused.

12 patients had additional procedures performed at the same time as their ankle implant. The procedures included Achilles tendon lengthening, sub talar fusion, reconstruction of the ligaments on the outside or the inside of the ankle, and resetting of the heel bone to align the foot to the leg.

Two had delayed healing of the incision site, which required a skin graft to heal completely. One has a wound, which will be grafted a second time. He plays golf regularly despite the wound.

You range in age from 15-83, come from 14 States, Canada, Costa Rica, and Ecuador. Three will have their other ankle replaced sometime during the next 12 months. Four had previous ankle fusions and are now walking pain free with the prosthesis. The 15 year old patient has Rheumatoid Arthritis.

Two patients had/have adhesions of the nerve behind the leg as it enters the foot. They have periodic pain, which should resolve in time. Seven continue to have some degree of pain from rehab. No patient has pain anywhere near that experienced prior to surgery. No patient would choose not to have had the surgery, if they were to have to make the decision again. Two are over 350 lbs; one needs a sub talar fusion and outside ligament reconstruction. This was known prior to the implant procedure. The other walks satisfactory. Neither have lost any weight.

15 are golfers who would like to have a tournament sometime. There is no organizer. It will be in Las Vegas unless there is a vote for elsewhere. I have played 18 holes with 4 of you and have been beaten by all 4. I will not quit my day job.

One suggested a Web Chat Room on my site for implant recipients. I liked this idea and put it on my web site. It was deleted when inundated by spanners and crackpots with nothing else to do but destroy a good way for patients with a severe disease to talk to each other.

As a reminder, please know that the CD photographs are from several of you and no person, other than I, could ever tell whom. You will not, and could never know if it is your ankle in the photographs. As they are surgical photographs please be aware that blood and extensive remaking of the bones in the leg and ankle are everywhere in the pictures. If anyone does not wish their surgery in the album please let me know and you will be excluded.

I have had the privilege of treating many patients over the last 20+ years and have seen extraordinarily wonderful patient behavior but this is above and beyond. One of you, who shall remain nameless beyond even the identity of "Deep Throat", unless IT instructs me to do otherwise, funded a Foundation to make the Ankle Replacement Procedure available to patients who had no money or access to health care of any kind. IT asked for my permission to fund the Foundation from time to time. As the idea belonged to IT, I can tell you all that I was clearly speechless for perhaps the second time in my life.

With the financial backing given, the Ankle Joint Replacement Foundation was established 20 months ago and is a charity under Federal IRS law, so that 100% of contributions are fully tax deductible. I am the responsible party as President/CEO. 100% of every cent received, except for the initial lawyer setup and accounting, (figures doesn't it) fees will go to the purchase of the implant and hospital charges. My surgical fee is and will remain O. I do the procedure and all post operative care for free. The books are available to any person on the planet who wants a copy. There will be no expenses for anything other than those cited above as the hospitals do not give free care anymore, but will reduce the charges to what it costs them. The implant will be bought at cost from the manufacturer.

A procedure is in place to assure me that the patient is indeed medically destitute. After the 60 MINUTES program about the man who lied about having no money to get an Arm Transplant I want to be certain the patient is needy no matter what State he/she comes from. If the patient is from out of Florida I will arrange free post operative and rehab care for them. Among you is a true hero.

Twenty months ago the first Foundation patient was implanted. She walks pain free having sustained a broken ankle many years prior to her implant.

A reminder about the AIR CAST STIRRUP brace. You should all wear this ankle brace for a year or more after surgery. Every single one of you who are walking has had so little pain, other than that of rehab, that you do not wear the brace. I know it is a pain to put it on....and shoes are not normal....and lots of other excuses....BUT....Remember....

I explained that the ligaments on the outside and inside of your ankles; the two bones you feel around your ankle, have been mal-aligned, stretched or torn from the initial injury or the way you were walking for so many years. Prior to surgery, the ankle and foot anatomy are profoundly abnormal. One of the objectives in replacing the ankle with the prosthesis is to realign the foot to the leg and the foot to the ankle. In doing so the anatomy that is realigned places different stresses on these ligaments that support the ankle. For you anatomists; the deltoid and the 4 lateral collateral ligaments are the structures involved.

As you begin to learn to walk normally again, these ligaments, which have been stretched or torn, need support to heal and become stronger as they support both sides of the ankle. The Air Cast Stirrup does precisely that; providing support for the ankle as you walk while allowing the ligaments to become strong enough so that you will not have to wear it forever. Of course this process will be time different for each of you as no two fractures and ligament injuries are exactly alike. Hopefully, you were told when you had your original broken ankle that the healing time for ligaments is 3-4 times longer than the broken bone (s). This is because these thin rubber band like structures have a much smaller blood supply to them than a bone does and thus takes much longer to heal. I know it is a pain, but other than nightly trips to the potty, you need to wear it all the time until total ligament healing takes place.

REHAB: Several of you have encountered over zealous therapists who simply over stretch the muscles and tendons and the limits of your new ankle's motion. Severe pain has been the result. Several have overdone your own rehab in an effort to get your new ankle to function like the opposite side. Statistically, 70% of patients have 80-90% of the motion in the unoperated limb, 18 months after surgery. Some patients will take longer to reach full motion.

The result of "too much, too soon", has been a very painful swollen ankle. You may take Celebrex, Vioxx, Naprosyn and the like for this pain and swelling. You may also get a Jobst like stocking from the store you bought the Air Stirrup from. The stocking should have no more than 35mm of pressure in them. The minimal is preferable. It is important that you know that there is no special rehab. protocol given to your therapists when I talk to them, and I have talked to all of them. This is because every therapist already knows how to rehab a patient who has had a broken ankle. The rehab for your new ankle is the same. They must reeducate the muscles and tendons that control the ankle and restore function and strength.

The gastrocnemius/soleus muscle group, peroneals and posterior tibial muscles and tendons must be made to strengthen and function again correctly, in addition to the ankle ligaments. Every therapist knows how to do this or the Title they do not have. The exercises and therapeutic regimen for this rehab is well known to them as they do it every day of their professional lives. They should not rush the process, as it takes twice as long to rehab a total ankle replacement as that from an ankle fracture. The process will take 3 months in some patients and 12 or more for others. The best, warmest, and most wonderful results, LIKE MAKING LOVE, are obtained when it is done slowly and over a long, long time.

Change your therapist if they will not listen or cause you too much pain. You should never ever hesitate to call me. You all have my office, home and beeper numbers. Pick up Alexander Graham Bell if you have a question or e-mail....

When you have been walking about 3 months or so, you should have your Podiatric Surgeon make you orthotic braces to wear in all of your shoes. Your shoe size should not change. The objective of this in shoe brace, worn with your Air Cast, is to hold your heel bone perpendicular to the ground and thereby stabilize your foot. As I wear glasses, so too will you wear the orthotics while you are on our planet as they provide the foot support you will benefit from. Aligning the foot to the ankle and the ankle to the leg, not only makes you walk without pain, but in doing so less stress is placed on the implant and thus its life is prolonged.

That about does it for the first information letter to all of you. Thank you for your courage in undergoing this new procedure and for granting me the privilege of being a part of your lives for at least the next 50 years.

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