Operation Ouch - Splatt!

After my stroke, I was left with longstanding and permanent disabilities that affecting my ability to live independently and living a good quality of life. Luckily, I feel that I am still improving, I am relatively independent and my quality of life is much better than 9 years ago. I still have goals - physically and mentally - that I am working towards and I am still motivated. That’s the good news… 

The bad news is I am limited on my physical goals because I have a varus deformity (Eg. inversion) resulted from the stroke on my right ankle/foot. It is an issue that affects when walking with uneven surfaces where my affected right leg is not fully functional and not efficient. I am still prone to rolling my ankle now because of the inversion and this inefficiency caused me to tear my calf for the 3rd time in my affected leg during interval running training - the last time was in May 2022. If not treated, it could be detrimental for me if it causes stress fractures or other foot issues in the future. Ankle surgery will allow me to achieve those goals more safely and it is a very necessary preventative step before possible foot and ankle secondary injuries.

This video from the 10 km walk at the Melbourne marathon festival (in October 2015) illustrate how my right leg is compromised by my inversion:

Obviously I will never heal hundred percent - I am content with this - but I feel like my mind is keen to continue challenging myself however my body is not synced with my wishes yet. For example, I would love to hike with my sons, go skiing, and go to the beach without rolling my ankle, etc, etc however it is difficult now because of my foot issues. My biggest frustration is that I can’t deliver the best experiences for my sons because I have a disability. Granted, I am very lucky that I can walk and speak - relative to my prognosis over nine years ago - so am I asking too much? Maybe!! But seeking and reaching goals is the essence of stroke recovery in my opinion. While I accept that my life is very different from my pre-stroke life, longevity and quality of life is very, very important to me so I am not satisfied yet. 

After starting with running group over 6 years ago, I remember talking to Gavin Williams (eg. the guru of the running group and the head of the Physiotherapy Rehabilitation at Epworth) about some sort of operation to assist in walking with uneven surfaces and my inversion. Given I was new to running group - in fact I was not running at all yet at this stage - so I was not considering any surgery.  This was so far from my thinking that I never really thought it would be relevant to me but in the back of my mind, I thought ‘what if’? 

I really enjoyed running group - learning to run again was amazing - but I stopped going there because of Covid restrictions a few years ago, and I never went back. While the telehealth ‘revolution’ is great for communication (like Speech Therapy) but it is not ideal for physical therapy like physio, so because I was not allowed to go to the hospital, I started seeing a community physio (Kevin Lieberthal at Central Park) to help me with my running. Our sessions with Kevin were great and beneficial, but my inversion and tightness of my leg were impeding me to run faster and smoother. After seeing my Neuro-physician and a orthopaedic surgeon (Abhay Khot at VicOrtho) last year, they recommended that I consider doing an ankle operation - like Gavin alluded to many years ago and I am booked in for a Split Tibialis Anterior Tendon Transfer (SPLATT) operation next month. 

SPLATT Ankle Operation and Pre-and-post rehabilitation

I made the decision to join Epworth as that's the hospital that the surgeon and the neuro running group is connected with also recommended me to join Epworth’s outpatient rehab. They suggested seeing the spasticity clinic for possible Botox injections and wearing a new custom-made AFO [leading up the operation] from an orthotist. I started this process last year and finally the time has come.. 

I am not really qualified to tell the specifics of the SPLATT procedure (click the link for more details), but basically the operation involves splitting my lower leg/ankle tendons and aiming for a level and stable foot and provides me long-term much better mobility including uneven ground like walking, running and hiking. Sounds great, in theory, but most surgeries have risks, and it is a long recovery. That's why I stopped looking for jobs last year and I was focusing on my ‘prehab’ instead.

The predicted rehab timeline post-surgery is long (6-12 months). After the procedure, I’ll be staying in hospital for a few days and I will be discharged and I will be off my feet, non-weight bearing for three weeks at home. It will be a rest/recovery for my foot and watching live sports (eg World Cup - women's soccer and men's basketball), reading books and few Netflix shows. I will use a wheelchair for transfers and going out and after that, I will return to the hospital for 2 weeks and start the rehab journey, starting with neuro-physio 2x per week as an outpatient therapy patient. During the outpatient stay, I will relearn to walk (for the third time in my life!!) using aids like AFOs. 

Prehab 

My current physio at Epworth (Liz Moore) was happy for me to continue running with Kevin last year, but my calf issues affected my affected leg, so we decided to stop running completely until the surgery, because I can’t risk tearing my calf again because it will impact my prehab. After all is said and done, I hope I can resume running eventually as running is my ‘happy place’. 

While I am frustrated and (maybe grumpy!) without not running, the prehab exercises are hard work, sometimes painful, but enjoyable too. Instead of running, I’m doing lots of high-intensity drills/exercises to strengthen my calves and my ankles and a few cardio exercises like bike riding, the stepper and cross-trainer. Additionally, I am seeing a neuro Pilates instructor (Rachel Taylor at Neuro Solutions) every week to be ultra-ready for the procedure.

Recently, I asked Liz that the operation is still needed because I am improving a lot, but she reassured me. She said  “Although you’re making great gains, the surgery will achieve your goals much faster than I can”.   

She reckons that also I am the “perfect candidate for this surgery because I am strong in my tibialis anterior and my work ethic pre and post surgery will ensure the outcome we both desire - like walking without risk of rolling your ankle, walking on the beach barefoot, playing with your kids and walking without aids without concentration on what you’re doing.”

I can’t fault the Neurophysios (like Liz and Gavin) at Epworth and I am so thankful for them. Even though the operation is not done yet and we are at the ‘business end’ of this process, my leg is very ready for this because of their approach and the gold standard of care and support they provide. So thank you!!

(this video is a snapshot of our Prehab exercises)

Risks and benefits

Most people (including me) avoid surgeries, but speaking with other experts (E.g. trusted doctors and physios) everyone agrees that this operation will be beneficial for me and, more importantly, with my family too. I have given this decision a lot of thought, I am trying to be positive despite impact of this on my family. 

One thought is I am very pleased that there might be a ‘solution’ to my foot problem but like any surgeries, has risks. I am a little nervous about going under the knife, so it is a definite mental barrier for me and I am conscious about the after-effects with my ongoing fatigue as well. I am 9 years post-stroke and proudly I have put in a lot of work on my recovery and one risk is that my foot could be negatively affected. 

I remember when I was not independent - at Alfred and Caulfield Hospitals - I was very dependent on my wife and my family and I felt very vulnerable - it was a shitty feeling. I was fierce with my recovery and tried to be independent, and doing this operation now, I will be losing my (and my family’s) independence again. I feel I am risking a huge amount. Currently I am walking without any aids, I am driving and I am pretty independent - relatively speaking - with three big dependencies - my kids - and I’m a pretty-hands-on parent. Is it worth it to risk it?? 

Well my feeling is, yes it's worth it. So I am going ahead with this operation because it usually has good results despite the risks associated with it. I trust my surgeon and I trust my physios. I am relatively young and my kids are young too, so by doing this operation I'll be more functional with my legs and hopefully will be a better (functional) father with improved mobility and independence. I am pretty excited for the end result. Luckily my family is always supporting my endeavours and it is no different with this operation and I am so thankful and fortunate for that.

All the best 

Paul