Front view after fixation of fracture and reconstuction of extensor mechanism with cerclage wire.
Side view post fracture fixation and filling of a "gap" with bone cemented with antibiotics.
Injury happened 9 months ago.
After soft tissue reconstruction with a free flap and temporary external fixatour bone fragments were fixed with a locking plate and defect filled with a bone cement mixed with bone substitute loaded with antibiotics.
Extensor mechanism defect due to the loss of patellar ligament attachment was reconstructed using a wire.
Unstable lateral corner (this was not just "simple" PLC instability) was fixed with a 6.5mm screw through the fibula's head and knee "stability" was regained.
After couple of months bone cement was removed and second stage of Masquelet procedure was carried out. During the second stage of Masquelet foreign body membrane was identified, opened and bone graft was inserted into confined space. Antibiotics in antibiotic carrier were added and membrane was closed.
Front view post removal of cement and bone grafting.
Side view post removal of cement spacer and RIA bone grafting.
Unfortunately bone became infected with patient becoming properly septic after second stage of Masquelet procedure has been done. Additional surgical debridement with removal of bone graft and VAC irrigation was used to clear the infection. All the metalwork was removed and replaced with circular frame. Patient was put on prophylactic antibiotics after discussion with microbiology consultant. Bone defect was again filled with the bone cement mixed with a bone substitute loaded with antibiotics. Non-union of proximal tibia was still present.
Two-level TSF frame with "clickers" distally for callus distraction.
Front view X-ray of the same leg and on the picture on your left hand side.
Side view with fracture defect on proximal tibia visible and corticotomy on the distal tibia just above one ring before last.
After the infection settled subtotal removal of bone cement was done, one broken olive wire was removed and replaced with two olive wires. Distal tibial corticotomy was done using a drill-bit and an osteotom (low energy corticotomy) and distraction osteogenesis will start next Wednesday, 9 days post corticotomy. "Clickers" which were already included in the original frame will be used to lengthen the leg back to the length after the docking of the proximal non-union will cause leg to shorten in my estimate for around 5 cm. Corticotomy will also increase the blood supply in the area.
lengthen the leg distally to compensate for previous shortening but also shortening caused by compressing proximal non-union (my estimate 6-8 cm which will take 3 months of bone to grow).
Certain progress has been made. Distal tibia corticotomy has been done and lengthening started using Ilizarov apparatus. So far we reached around one cm of length with already visible regenerate. Also proximal fracture (non-union) has been disimpacted using TSF, lengthened and positioned (aligned) in preparation of docking of the proximal into medullary cavity of the distal fragment. On two X-rays below tip of the proximal fragment is marked with an yellow arrow and the medullary canal with white one. Hopefully docking will happen in next few weeks whilst lengthening will continue with the speed of 1mm/day.
Currently all pin sites are dry, no discharge, frame feels stable but weight bearing is a bit painful.
Ap view of the tibial with fine wire frame for limb reconstruction.
Lateral view of the tibial with fine wire frame for limb reconstruction.
One week after we started with the compression of the fracture site X-ray suggests that fragments are traveling in the planned direction. Speed of compression is 2mm per day, when distraction of distal corticotomy is 1mm per day. Leg is still shorter for around 1 inch but will get shorter in next few weeks for more than 2 inches altogether. This is my current estimate, but I don't know how far into the mid fragment we will be able to get the proximal fragment. More compression we can get, the better.
Corticotomy side is distracted for another 7mm (14mm altogether) and good bone regenerate is visible. All pin sites are dry including proximal half pin which is HA coated. Today we changed one strut, another one is due in next few days (as per TSF prescription).
Ap and lateral view X-rays are suggesting good apposition of the proximal fragments and good callus formation in the level of corticotomy.
AP view after compression of the proximal fracture started (Yellow arrow) and distraction of the distal corticotomy progressed tp around 15mm (Blue arrow).
Lateral view after compression of the proximal fracture started (Yellow arrow) and distraction of the distal corticotomy progressed tp around 14mm (Blue arrow).
Continue with compression of the fracture site until struts get really tight (we never use spanner to turn struts).
Continue with distraction of the corticotomy site with the speed of 1mm/day.
Weight bearing as tolerated, physiotherapy for lower leg; knee and ankle joint.
Follow up in one week with another X-ray on arrival to check proximal docking.
We are getting more problems (complications) recently but we are in the most crucial part of the job. This is certainly anticipated therefore follow ups in one week increments.
One of the slotted screws broke. doesn't happen very often but knowing that they are withholding 1000N force through the wire and compressing the wire (friction force between wire and the ring enables stability) to the ring to maintain the fixation is not a surprise. My estimate of torque required to fix a wire to the ring is in the range of 10-15Nm. It is certainly easier to mange than broken wire. Slotted bolt gets replaced with a new one and wire tension re-established the old fashion way - using spanners only.
Otherwise X-rays show progress as planned. Proximal fragment is moving into the mid fragment (yellow arrow) when distal corticotomy is getting bigger (another 7 mm since the last time, blue arrow). One of the expected complications (drawbacks) is tightening of the Achilles tendon due to the lengthening of the leg. Only physiotherapy can help at the moment but we will also slow down the distraction speed to 0.5mm per day as we have already reached 2cm of new bone and the risk of premature consolidation is smaller. But still can happen. Will keep an eye on it.
AP radiograph of the lower leg with proximal fragment going into the mid fragments (yellow arrow) and callus distraction gap (blue arrow) getting bigger.
Lateral radiograph of the lower leg with proximal fragment going into the mid fragments (yellow arrow) and callus distraction gap (blue arrow) getting bigger.
Continue with compression of proximal fracture (yellow arrow).
Continue with the lengthening of distal corticotomy site with 0.5mm per day.
In a week's time will correct apex posterior deformity between the proximal and the mid fragment.
Active physiotherapy to stretch triceps muscle (Achilles tendon) and regain the ankle range of movement.
Painkillers to help with the pain.
Everything is going well. Still pain at the level of the mid shaft tibia, not as much in the ankle joint. Pin sites dry and clean. On the X-rays below you can see that the proximal fragment is getting into the mid fragment as originally planned. Clinically it looks that we have achieved the "docking" point as majority of the struts are tight to the level where they cannot be turned anymore by bare hand. Another TSF prescription given to correct apex posterior deformity on the lateral view, but not compressed it anymore.
Due to the deformity, proximal ring is impinging on the skin. Skin is padded and protected, but further correction should remove ring from the skin. Hopefully. But it is difficult to predict due to the moving fragment around the place.
Distraction of the distal tibia is going well, good regenerate visible.
Ap view of the tibia with slightly bigger distraction gap (3.5mm since last time) (blue arrow) but proximal fragment's spike (yellow arrow) well into the intermediate fragment.
Lateral view of the tibia with slightly bigger distraction gap (3.5mm since last time) (blue arrow) but proximal fragment's spike (yellow arrow) well into the intermediate fragment.
Hopefully will hear from the patient and get some further images of the leg including pin sites.
I was on a holiday, therefore a bigger gap. But everything was under control.
Proximal fracture (yellow arrow) was translated and compressed further with some visual effect on the latest X-rays and corticotomy gained further length (blue arrow). Almost reached the length of the leg as per original plan. Another inch or so to go. Had to change clickers for longer ones (will be visible on the next X-ray next time) and longer threaded bars to allow further lengthening. No obvious infection around pin sites.
AP radiograph of the right lower leg post compression of the proximal fracture (yellow arrow) and distraction osteogenesis distal tibia (blue arrow).
Lateral radiograph of the right lower leg post compression of the proximal fracture (yellow arrow) and distraction osteogenesis distal tibia (blue arrow).
Continue with distraction until the same length is achieved. We might over lengthen it a bit and than compress to add to consolidation time.
Both legs have equal length. Distraction osteogenesis is completed. Patient is well in himself. Still pain in his leg and ankle, but less since stopped distraction. Pin sites are generally dry, clean, some discharge from few of them. Nothing to worry about at the moment. Ankle is still stiff but is improving slowly (close to neutral dorsiflexion). Knee movement is from 0-95 deg. I am very happy with it. Recent inflammation markers were normal. This is excellent news.
​X-rays were impressive today with excellent regenerate in the distraction site (blue arrow) but even more surprisingly was new callus formation at the level of the compression site (yellow arrows). I certainly did not expect to see callus at this point. Expected few months later, if I am honest. I am very optimistic.
Excellent regenerate at the level of lengthening (blue arrow) and new callus formation at the level of the fracture compression (yellow arrows).
As I have only presented X-rays recently I asked the patient if I can take few pictures to better present the soft tissues. Images are below.
Continue with physiotherapy to improve ankle movement.
Further follow up in 4 weeks.
Frame will have to stay on the leg for at least another 6 months (6cm regenerate). Hopefully the proximal fracture will heal by then.
No major problems. Majority of pin sites dry with no signs of infection. Patient still not walking comfortable with one crutch due to the limited ankle dorsiflexion. Can only manage shorter distances with one crutch. Around 10-15 degrees flexion contracture in the right knee. Swelling of the leg significantly improved.
X-rays confirmed that the proximal fracture is healing with good callus formation and the distal regenerate is gaining in quality. So far as planned. There is clinically some valgus in his knee and X-ray confirms it (around 8-10 degrees). Question is whether to accept it or not?
I am personally more inclined to correct the alignment at the level of corticotomy using struts. This would represent third level of struts on one leg. It does sound complicated but certainly doable. To increase the stability will add a blind ring to the construct (to keep struts short).
Clickers replaced by struts. Prescription run. Leg alignment corrected. No problem with pin sites.
Gait pattern changed as expected. Can walk unaided on shorter distances, but knee certainly feels more stable. X-rays are below.
CT scan is booked in the next few days but images certainly look promising for the proximal fracture - in my opinion good callous formation.
Improved alignment of the leg. Significant t impact on gait. I believe I can see callus formation of the proximal fracture site when callus distraction site is maturing as expected.
CT scan was done and showed very promising signs of healing. Not healed yet, but did not expect it anyway. I am very pleased with the results.
Otherwise pin sites still OK, no signs of infection. Walking slightly better but not as I would like it to be. Created an additional prescription for TSF to translate the distal tibia medially, but keep slight external rotation of the foot.
Below you can see sagittal and coronal reconstruction CT images, where good calus formation can be seen. Also you can see how we really managed to "shove" the proximal fragment into the mid fragment's medullary canal. It really worked. You can also see some cement left in the lateral condyle which we were aware of from the beginning.
​It looks that we have completed the last prescription. The patient followed the prescription until noticed that the foot position is what he wanted and than stopped. This is exactly the level of involvement I expect from the patients.
​No problems with pin sites apart from occasionally appearing discharge in the mid fragment (described above) which in my opinion represents low grade infection, which we will keep an eye on. Does not look related to any pin site.
Patient can walk unaided for shorter distances but limited ankle dorsiflexion is still causing problems and forcing him to walk with more externally rotated right foot than he would like to.
Ap and lateral view of the tibia. Distal tibia joint line is now in perfect alignment against the tibial shaft. Much better than before and this has been confirmed clinically. Really impressive how theory works in practice.
Walking with one stick. Knee feels more stable and reliable. Pin sites are still OK.
​X-ray shows excellent consolidation of the regenerate (blue arrow) and further healing of the fracture (yellow arrow). Possible sinus mentioned previously has not reoccured.
Ap and lat radiographs of the tibia. Good alignment and further progress in the fracture union (yellow arrow) and further maturation of the regenerate (blue arrow).
No major problems. All pin sites clean, no irritation. Possible sinus at the level of the middle third of the anterior tibia is still quiet. Inflammation markers still inside acceptable limits (CRP 5, ESR 20). At the moment no major concern.
Patient is walking with the crutches but get pain from the knee. I am certainly not surprised about his knee pain. interesting part is that the extensor mechanism is still intact and working, despite broken wire and not augmentation ever performed for the patellar tendon. Lesson to learn?
Fracture is healing nicely with good regenerate. In my opinion the regenerate is still not strong enough to support the leg, when fracture is probably sufficiently healed. Regenerate will be strong enough when there will be no more visible line from the corticotmy (new knowledge?).
Patient walking with a stick. Main problem is still knee pain. Unfortunately this was expected from the beginning. No major pin site problems. Clinically everything looks well and progressing toward the union. Bone regenerate is also maturing satisfactorily.
From the regenerate perspective we can remove the frame, but not completely convinced that the proximal fracture has united.
AP and lateral radiographs of the tibia with progress of union on the fracture site with further maturation of regenerate.
One of the proximal wires broke and was removed today. The rest of the wires still solid and pin sites clean. Knee started to grind and made noises. Unfortunately something we expected.
CT scan confirmed good biological response on the fracture side but no clear union as yet. Regenerate is almost completely ossified. No other untoward signs.
Patient able to walk unaided on shorter distances. During the appointment all pins its were clean, but few days later one pin site became infected. Infection resolved on conservative measures.
X-rays in my opinion confirm further union but there is a possibility that the leg gained 1-2 degrees of extra valgus. Do not know how to explain.
Pt is still walking with crutches, shorter distances unaided. No further changes in lower leg alignment. At the moment there is 10-14 deg of valgus. Borderline deformity but we will accept it for now.
Pin sites still clean, no sign of instability.
X-rays show further progress towards union in the proximal fracture when regenerate is well matured.
X-rays also show that fibula has been left in place and did not travel together with the distal tibia. I don't know why I did not spot it earlier. Surprisingly there is no instability of the ankle joint neither any pain coming from the ankle joint.
CT scan confirmed additional callus formation but full union is yet to happen. It looks that the struts, even the short ones, do not offer enough stability for the fracture to unite. Therefore we changed the struts for threaded bars with hinges with a plan to correct the valgus deformity. I should have changed it earlier but was not expecting that.
Leg alignment almost normal. Corrected 7 degrees of valgus. Unfortunately the pain has increased in the knee itself.
Will continue with the correction until some varus is achieved whilst observing the knee function. Hopefully we will get mechanical axis to the medial side and minimise the pain.
Furthet improvement in alignement. No significant increase in pain. Pin sites OK, frame stable.
The knee feels much more stable. Pain improving as well.
Pin sites are OK, no major issue.
​X-tays suggest further progress towards union.
Activity level has improved significantly. No major pin sites or pin issues apart from one broken pin which was removed in the clinic.
​CT scan confirmed further progress towards union.
Level of activity is increasing. Still using crutches for mobilising. All pin sites are OK.
Dynamised frame to allow vertical movements (mainly) and review in 4 weeks. Hopefully there will be no changes in alignment.
X-rays will be taken next time - 4 weeks time.
As you can see from the comments patient has removed all the connectors (threaded bars) in-between second and third ring. He was able to walk without any additional pain. Clinically the fracture has united. It took 27 months. Very long time but I believe it was worth it.
Frame was removed 4 weeks ago. Walking is still slow and with a limp but the fractures are united. There is a possible "collapse" in the lateral tibial condyle. "Neofibula" is being formed.
Cement spacer war removed around 8 weeks ago and RIA bone graft from the right femur was used. As the micro samples showed bacterial growth patient was put on antibiotics for 6 weeks.
X-rays today show good progression although it is still a bit early.
Patient is mobilising unaided on shorter distanced with a stick for longer distances.
Leg looks clinically OK, no sign of infection.
Three years post injury. All wounds and fractures healed. No clinical sign of infection. The knee will cause pain on any longer walking or cycling as well as will the ankle, mainly because of the equinus deformity. No medial/lateral instability in the ankle.
Further Follow up in one year.
Before I start I must say how incredibly grateful I am to Mr Krkovic, his Orthopaedic team and Mr Wallace and his Plastics team for all the hours of work they have collectively put in saving my leg. I’m not there yet but I know Mr Krkovic is doing everything in his power to give me the very best possible outcome. I am always filled with confidence every time we meet. He says most of the recovery is state of mind but if it wasn’t for his expertise and motivational approach my situation would be very different.
It's been a while since my first comment. I continue turning the struts and I'm now on my third prescription and things are progressing well. I also continue with the clickers opening up the gap at the bottom of my tibia. My wife and I have changed two struts as they had run out of adjustment range. It quite daunting at first but it's no big deal as long as you've got a couple of spanners and you hold the frame so nothing moves. One big change for me is that all my pin sites have dried up and are clean. I was told about good pin site care, only using gauze and changing when wet. "If it doesn't look dry and clean change it". I've followed this and it's paid off. Sometimes the simple and common sense approach is the best - no need for anything except gauze and saline solution. Whilst my pin sites may look good it doesn't mean everything is fine, two are particularly painful even when resting. I know this is because the frame is pulling through my skin and soft tissue. It's very painful to bear any weight. I'm getting pain around the gap at the bottom of my leg and even more pain at the two pin sites. Nevertheless, I keep trying to exercise and bear some weight as I know it will help with my range of movement and promote good blood flow which helps with bone regeneration. The other area of concern is my Achilles tendon. As my leg lengthens my Achilles needs to stretch by the same amount. I now have very restricted range of movement at my ankle. None of this, I know, is unexpected but it's a bit disheartening as I'd worked hard to maintain a good range just to see it diminishing. Just this last week I've managed to break a pin securing bolt. Fortunately, the pin is sound and I'm able to secure it with two zip ties, but it will need fixing when visiting clinic in two days.
I continued turning the struts and clickers as per plan. I have endured considerable pain on two pin sites and down the front on my leg and in my ankle. I thought I knew what pain was after what I’ve had over the last fourteen months but…… this, for me, was on a different level. “Pain relief” that I’ve been using up to now very successfully just didn’t have the same effect. Oramorph helped immediately after strut turning but soon wore off. As far as I can see it’s a case of “grin and bear it” with not a great deal of grinning though. The last couple of days two struts got very stiff to turn. I was warned that this may happen and not to use a spanner. It’s a sign that it can’t move any further - job done! Well, that one any way. One thing that is very noticeable to the naked eye is that the overall length of my leg is getting much closer to the length of my other one. That’ll mean, in the not too distant future, no more turning the clickers so all is looking good so far.
I’ve had my first session of Physio mainly concentrating on my Achilles. There was some success, I think, and I continue to pull hard on a strap around my foot to increase the degree of bend. I know with hard work this will improve and, hopefully, once I get to weight bear I’ll get more range. It’s a case of keep at it and the results will come. I have a list of exercises and make sure that these (and more) are religiously done at least three times every day.
Back to the clinic on Tuesday and as usual x-ray first. As always, I get to sneak a look and even to my very untrained eye its clear to see that all the turning has worked and the two sections have docked. A short wait and Mr Krkovic confirms that yes the two sections have docked and compressed. So the pain is worth it. Onto the next stage.
I need to have a new prescription to correct the slight bend that has developed. Mr Krkovic calls up the software program, inputs the numbers that he wants to correct and it does the calculations producing a view of a leg showing the expected results. Once Mr Krkovic is happy it’s saved and a prescription is printed out. It's only over six days, I’m very happy about that. New prescription means that two struts need changing for shorter ones. I get to hold the two rings apart while Mr Krkovic removes the struts. I’m surprised at the sheer force required to keep them from moving. Naturally I have a vested interest to ensure they don’t. It still doesn’t get away from the fact that my fingers have turned a nice purple and white from the amount of pressure required. All that force is compressing my bone, that really is quite something.
I’m now starting to see the results of the pain and daily strut grind. All of this is only temporary and if that’s what it takes, it’s a small price to pay. I remain positive, encouraged and engaged. I encourage anyone who is unlucky enough to be in the same position to be exactly the same and focus on the big prize at the end.
This is the longest period between being seen by Mr Krkovic. I've previously had the comfort and reassurance of a weekly check in. Whilst this may not seem a big deal to most but not having that regular reassurance can and has my case has had a significant effect psychologically From a physical point my leg does seem more stable and pain level is significantly lower.
After two changes of the clicker threaded rod to and it's fair to say a considerable degree of continuous discomfort I finally stopped turning them September 18. I'd already stopped the compression at the top of my leg after completing the last prescription and all the pin sites had cleared up very nicely. After approximately 10 days things seemed to stabilise with most pin sites dry. The pain was very much getting me down. I'm having Physiotherapy weekly at my local hospital I'd of course prefer more as there is such an improvement but I do understand that demand outweighs the resource. I'd happily pay for extra but also understand the issues this can cause with having two different people working on the same patient My actual Knee bend is 95 deg and 16 deg off straight, I'm continuing to work on both. For the foreseeable future it's lots of massage on my foot and ankle, it's surprising how much this helps as afterwards there is a small increase in ankle movement. I can push against a force but free movement is very limited but does improve significantly after massage, things are improving albeit very slowly it is going to be a much longer recovery than I had naively hoped for. From a physiological point of view I have finally accepted that I will not make a full recovery I this is not a case of giving in more accepting what I've already been told. This said I am continuing to push just as hard for the best possible outcome.
This is the longest period between being seen by Mr Krkovic. I've previously had the comfort and reassurance of a weekly check in. Whilst this may not seem a big deal to most but not having that regular reassurance can and has my case has had a significant effect psychologically. As the saying goes " all good things must come to an end". In my case it's the frequency that's had to change this of course I fully understand the reasons.. From a physical point of view my leg does seem to be more stable and pain level is significantly lower.
After two changes of the clickers threaded rod to allow further extension and it's fair to say a considerable degree of continuous discomfort I finally stopped turning them September 20 having achieved equal leg length. I'd already stopped the compression at the top of my leg after completing the last prescription and all the pin sites at the top had cleared up very nicely. After approximately 10 days the lower pin sites seemed to stabilise with most sites dry. The pain after exercising and Physiotherapy sessions however was getting me down. Thankfully this is now not the case. I'm having Physiotherapy weekly at my local hospital I'd of course prefer more as there is such an improvement but I do understand that demand outweighs the resource. I'd happily pay for extra but also understand the issues this can cause with having two different people working on the same patient My actual Knee bend is 95 deg and 16 deg off straight, I'm continuing to work on both. For the foreseeable future it's lots of massage and stretching and pulling on my foot and ankle, it's surprising how much this helps as afterwards there is a small increase in ankle movement. I can push against a force but free movement is very limited but does improve after massage. Things are improving albeit very slowly it is going to be a much longer recovery than I had naively hoped for.
From a psychological point of view I have finally accepted that I will not make a full recovery, this is not a case of giving in more accepting what I've already been told. This said I am continuing to push just as hard for the best possible outcome.
I haven't commented for nine months, the only reason being is from my point of view there has been no significant change, physically. Medically, I know this is not correct and is unfair. I also know and appreciate the work Mr Krkovic has put in and continues to put in but this is from a patients (my) perspective. Yes we finished turning the posts and the clickers but in reality it does very much feel that we are treading water now, just waiting. I was really hoping that around June we may have been starting to work towards removing the frame. To be fair I had built June up to be this big date. To be told that whilst there are signs of things starting to happen but no union yet and to have the frame on for another six months was a pretty hard message to take. There has been some good news in that the actual bone regeneration is complete but still not the news I was so desperately wanting to hear.
I know that there is no exact science regarding time but this has hit me psychologically. "will I ever get this thing off?" "What if?" that constant gnawing feeling. Feeling very much a passenger. I have taken a very positive approach throughout. From day one of this journey right back to when I was woken up in June 2014 following my accident with the news that my leg was at risk and then in January 2015 when I had the infection and subsequently having the frame. The mind is a very complex thing and mine has certainly been working overtime lately. It has taken a lot to remain positive for such a long time. I've never known anything like it. We all have periods of uncertainty in our lives but usually fairly short lived. This is anything but short lived and at times is very hard. It is a very long journey but the prize at the end is still the same. I personally do not think that the psychological aspect of having a frame on or any visible disability for a long period should never be underestimated. I have a very supportive wife and close family so in that regard I'm lucky but for those not so fortunate I'd like to think that there are support networks to help them through.
I am all for helping others and if there is anyone starting a similar journey or even part way through I'd be more than happy to share in more detail my experiences and how I get over the low days to remain positive and focused. Next consult is August 23.
May 21 2017 - I attempted to loosen off the four securing nuts on the brackets holding the compression rods to further dynamise the frame. Unfortunately because of the angle the previous compression introduced I was unable to release the tension. After a quick email exchange with Mr Krkovic I very carefully loosened off all securing nuts and bolts therefore allowing full release of any tension. Very gingerly I tried a few successful weight baring steps. I felt no pain at the fracture site although I did experience increased local pain in my knee. I continued weight baring throughout the day resting in between. The following day I removed the rods and brackets as it was clear that they were offering no support whatsoever. I have continued mobilising short distances around the house with the aid of a walking stick. Longer distances with the aid of crutches. I return to clinic in eight days where hopefully everything will be in order and we can arrange for the remainder of the frame to be removed.
February 10 2018 - I'm mostly walking unaided and it's relatively okay. Not enjoyable but bearable. Distances up to 100m are absolutly fine and I’m back to work full time and able to do anything that is required. I’m getting no pain in my knee or at the original fracture site. Slowly reducing the Tramadol with no ill effectss..I’m finding that I do not need to elevate my leg as much now and moving more naturally. My ankle continues to be quite stiff but I’m persevering and my walking pattern is getting much better although I do have a fairly pronounced limp. I guess this is expected especially when considering what the original injury was like.. I’ve had no issues with infection and will continue to keep pushing forward. Looking forward to the nicer weather when we can get back out on the roads. Thanks again to Mr Krkovic and his team.