Wednesday, July 27, 2011

Week 11.5: Back to the Future @ VOSM

I have been emailing with the technicians at VOSM regarding the Exogen treatments, and they encouraged me to travel down to VOSM in Annapolis for our 12-week recheck appointment. We were about 1/2 week early for this recheck, but I was a bit concerned with how Taj has been using the leg the past couple weeks and wanted to have it looked at asap. We all piled in the SUV and headed down to VOSM - both Taj and Roo in tow. I took Rumi as a "therapy dog" and mental support for Taj. Rumi loves vets; for Taj, they are less than be to be desired.

Taj & Roo checking out the waiting room at VOSM
We arrived at VOSM early and waited for our recheck appointment with Dr. Christopher. VOSM has very nice bench cubicles that helps isolate dogs better while you wait for your appointment. Taj and Roo marveled at the large saltwater aquarium. Then, Taj then kept the neurotic look-out while Roo took a nap.

Roo mesmerized by the saltwater fish; Taj on look out!
Taj still on look-out...
Little salukis; big waiting room!

Our appointment time arrived and the technician took us back. We settled into the nice posh waiting room and the technician took Taj back to the "canine gym" so that his movement and leg usage could be assessed by Dr. Canapp. They also took some new radiographs. Finally, she bought a much-relieved Taj back to the waiting room.
Rumi explores while Taj is in the canine gym being assessed!

Dr. Christopher came in and gave us some good news! The healing is right on track for this time in the healing process. The 8-week radiographs showed moderate callus formation, but it looks like the callus is now MUCH bigger at ~12-weeks (Go Exogen Treatments Go!). Dr. Christopher was quite happy with the progress and said the fixator should be able to be removed in another 4-5 weeks! You can see the 12-week radiographs here! Our next appointment will be in 4-weeks (at 16-weeks) for the final fixator radiographs and an assessment to set the removal date. There are a few more places the doctors are hoping to see greater callus formation, but it looks like the Exogen is helping quite a bit. We will be continuing Exogen treatments for the next month +.

Taj disgruntled but happy the appointment is nearly over!

Dr. Christopher said that Taj may be using his leg slightly less for a number of reasons. There may be a very minor infection in a pin tract (although he could not see any visible signs of infection) so he gave us an antibiotic to use for 2-weeks (clindamycin - 300mg). The healing process itself may be causing slight discomfort - so if necessary - we can give Tramadol if needed. He also warned that if Taj jarred his leg against the Xpen etc that this might cause a bit of discomfort at the pin sites. We are to keep Taj as quiet as possible for another month!

Rumi being Taj's "therapy" dog.
Overall we got a big "thumbs-up"! We are STILL only allowed bathroom walks (10 minutes) a few times a day. We won't be able to build up any distance until the fixator comes off and the leg heals more. Taj is a trooper.

Taj has been feeling better - he has a bit more vigor in his walk and he wants to walk for further distances. He has also play bowed several times the past week to Rumi, and I am now letting him slowly walk up small half-flights of steps (not down yet though)! Despite being in an exercise pen now for THREE+ months (and one more to go!) he physique still looks decent considering.

We are finally seeing the end in sight! Slow and steady for the next month to the "finish line"!

Sunday, July 24, 2011

Week 10: Exogen 4000 - Ultrasound Therapy

The vets at VOSM got back to Dr. Rider regarding the 8-week radiographs and suggested that because the bone healing is so painstakingly slow, that we try ultrasound therapy. Dr. Canapp suggested that we buy an Exogen 4000 Ultrasound Bone Healing System made by Smith & Nephew. This system is actually intended for human use and has been proven with clinical FDA studies to accelerate bone healing. I had a lot of trouble finding information online so this will be a fairly thorough post as I would like to "nerd out" and share my hours of research to help other dog owners.

Taj modeling with his new Exogen system
First off - Exogen was intended for human use. This means that you will NOT be able to buy a new Exogen system - you can only purchase them used. This means that you will have to go scouting on Ebay, Craigslist, or other creative avenues to track one down. New Exogen systems cost around $4,500 for humans. Typically insurance companies will cover most of that cost so new human patients likely pay anywhere from $200 - $900 for an Exogen system. On the "used" market, you will see the systems run anywhere from $100 - $500.

I will get into the science later in the post, but the system emits ultrasound waves (you cannot hear, feel, or see ultra-sound waves) within a range of about 2.5-3 cubic centimeters from where you place the transducer. This means, you MUST get the transducer right over the area that needs healing although with skinny dog legs - you have some leeway. One treatment on the system lasts for 20 minutes and you usually need to do one treatment a day. Exogen units are guaranteed for 150 treatments; however, I called the sales reps and they said typically the systems are usually good for 220 uses. After that their lithium battery can die and they will not adequately power up any more. The lithium battery is typically guaranteed up for 1-year; therefore, the newer the unit the better. The batteries can only be replaced by Smith & Nephew and they will only replace the battery if you are the prescribed owner of the unit. That means if the unit is for your dog - you are out of luck if the battery dies!
For example, this unit has 29 uses logged.
There are several things that you must be aware of when seeking to purchase an Exogen system.

1. Make sure the unit powers up before purchasing. Ask the seller to send you a photo that shows the full and partial uses left on the system. When you turn the system on it will flash how many full uses (i.e. full 20 minute uses) it has on it (a number flashes on the screen plus the ! symbol in a triangle - see above). Then it will flash a second screen that shows the number of partial uses (i.e. uses for less than 20 minutes). Finally it will flash a screen that starts the 20-minute treatment count down. If the unit does not perceive connectivity (i.e. placed on the skin with conductive gel), it will beep for 30 seconds then automatically shut off. If it does perceive connection for conductivity, it will commence the 20-minute treatment session. During treatment, the screen will count down (in seconds from 20:00) for the duration of the treatment while displaying a (((( symbol that means it is conducting properly. 

2. Ask the seller to send you a photo of the back of the unit which displays the serial number. This is very important! The first four digits of the serial number tell you the month/date the unit was manufactured. You want a unit that is less than a year old if possible to ensure that the battery will work for the duration of your dog's treatment. If the unit is older than 1-year, there is no guarantee that it will work (especially if it is 06, 07, 08, or even 09 model). 

3. The serial number is also important because the FDA recalled many Exogen 4000 units from 2008 and 2009. There were problems with the transduce that reduced ultrasound output. Make sure that the unit you are purchasing is not on this FDA Recall List.  

3. Realize the risk of your purchase. There is no guarantee that despite all these things the unit works. The Exogen does not buzz, vibrate, make noise, etc. If the screen displays what it should - it is very likely the unit is working. But if the previous owner mishandled it (like pulled the transducer wire system) it could possibly not work. I did a LOT of searching on Ebay and Craigslist (about a week) before buying my unit. I was comfortable with Ebay buyer I got it from and all the info he sent to me. Taj needs 60 treatments so I was comfortable with the unit having 20-something uses on it and it was manufactured in 2010. I ended up paying almost $300 for my unit (ouch!!! but that was the price to pay for a newer unit that I am confident will last all 60 treatments). Although the transducer does not vibrate I notice that I can almost feel an energetic microscopic "buzz" from it when holding it for 20 minutes to give Taj a treatment.

4. I would recommend buying from Ebay rather than Craigslist. I believe both Ebay and Paypal offer some guarantee when making purchases. A good seller will also offer at least a 1-week money-back guarantee that the unit powers up when you receive it and indeed has the number of uses displayed as advertised.

Also check out this guide - it's super helpful!
This is the Exogen ultrasound coupling gel needed to conduct the ultrasound waves from the device into the leg. If you run out of gel, mineral oil can be substituted.
The Exogen system contains the Exogen unit (white), the connective cord (gray),
the transducer (black circle), two bottles of conductive gel, wrist band attachment,
instructions, and a carrying case.
Conducting a treatment is easy! You just put some gel on the transducer and then hold it over the area of the break. I like to hold it on with my hand - as I find that easier than trying to rig up the strap (made for humans) around the leg. I keep a gentle firm pressure on it - but do not push hard. If at any time you lose connectivity the unit will beep and you have a 30s "grace period" to get the conductivity back of the unit will shut down. Taj usually sleeps through his treatments. Fine hair on the leg is ok - the vet said the machine should be able to conduct through it - more dense hair - you might have to trim or clip (but NOT shave)! The gel is actually very easy to clean off, and after the session you can just use a paper towel to wipe down the transducer and the leg.

2.38 minutes left of treatment! Look closely to see the ((( sign that indicates the unit is working!
Taj typically naps during treatment. I think he just assumes now
his mom is slightly insane for all the things I do with him!
Applying the transducer directly over the worst part of the radial break. You can strap it
on with the wrist band, but I find holding it snug (but not hard) over the break site is easier. 
So does it work? This page explains how the exogen system works. My science background sometimes makes me a skeptic, but yes I honestly believe this works - quite well - both from the research studies I've looked at as well as anecdotal experience. After just 10 treatments, the leg seems "harder" under the break (e.g. I can now feel the callus). There is now even callus extending far out to that farthest radial bone that was significantly protruding. Taj is using the leg more, trying to bounce around more, and putting a bit more weight on the leg - he's even play bowing to Rumi!

So how does it work scientifically? Prepare for a total dork-out moment.

Well if you read the Nephew and Smith website - they are all about "up-regulation." Now what the heck does that mean? ;) Luckily, I can finally put my undergrad degree in genetics to some good use. "Up-regulation" is a really generic term that honestly doesn't tell you too much! It basically means that the cells in your body are increasing the quantity of different cellular components - like proteins - that help you build RNA (which is related to DNA) that eventually help build cartilage and bone cells. You are increasing gene expression and protein synthesis - e.g. you are making more of the building blocks that will eventually create bone.

The Exogen unit creates ultrasound waves (mechanical pressure waves). These waves are created by synthetic crystals that vibrate at a particular frequency because of their geometries. Now I don't mean vibrate in a "new age" way, I mean they vibrate because you are pulsing electric current through them. The vibration creates sound waves - ultrasound waves - that can penetrate skin and tissue - neat huh?

These ultrasound waves travel through the gel through the skin and into the soft tissue in the leg at the fracture site. These waves then alert the cell receptors called "integrins" that "Hey there is a problem here!" and that "you need to speed up the up-regulation!" So this process attracts more integrins to be "on alert" and they start to cluster in groups together. When integrins start to cluster together, this signals to the cell that "we need more resources/support" so the molecules that are responsible for gene expression head into the nucleus (this is like the "brain factory" of the cell) and they start making more proteins (i.e. building blocks for the cell). The increase in building blocks and resources accelerates bone healing. The ultrasound waves also encourage the cells to get rid of their waste products faster which also speeds up healing and they encourage increased blood flow to the fracture site (which helps reduce swelling).

As an ex-biologist,  I also do like that there have been FDA clinical studies (and several other studies in fact) that have shown benefits of ultrasound therapy (Azuma et al., 2001, J. Bone Miner Res; Cook et al., 1997, Clin. Orthop. Rel. Res; Dijkman et al., 2009, Indian J. Orthop; Heckman et al, 1994, J Bone Joint Surg Am; Martinez de Albornoz et al., 2011, British Medical Bulletin; Nolte et al, 2001, J Trauma). You can also see these Bone Abstracts from articles for proof! In addition, several ex-athletes as well as some nurses I have talked to stated that they did notice improvements when using ultrasound therapy. Nephew and Smith (the manufacturers) claim that in humans the Exogen 4000: heals 86% of non-union fractures, that it heals fresh fractures 38% faster, and that it heals fractures with risk factors 50% faster.

Hopefully Taj's next radiographs will confirm these findings!

So if you ever need an Exogen - feel free to email me for advice. I will be happy to share with you the name of my Ebay seller and I will likely have a working unit with at least 60+ good uses on it after our treatment!

We are heading down to VOSM for our 12-week check-up soon - so stay posted!

Monday, July 18, 2011

Week: 9 The Mega Slump

Well we were going strong and flying high through Week 8, but Week 9 seems to have become the mega slump - for both Taj and I. Taj is markably more bored, apathetic, and somewhat depressed... despite my efforts to keep him entertained. He has been living relatively confined now for over 2 months. It makes me sad to have to have to mandate such a drastic change in his lifestyle and I think we are now re-enforcing each other's "bummed out" states.

I tweaked my back again from lifting him up and down off furniture, stairs, wagons, etc. I also got a bug which had me in bed a couple days. Luckily Rich stepped in and has been helping me out a ton!

Taj doing his best to look totally bummed out
while taking a supervised bed break
Taj has been favoring the leg a lot more lately, which really has me worried. If I don't see any marked improvements in the next week, I am going to call the vet. He did really well - incrementally - up through Week 8, but with Week 9, I feel we are back-tracking. He will still put weight on the leg when walking, but when standing he will not put as much weight on it and it seems more "wobbly" to me. The leg is not sensitive to the touch, but he's been favoring his paw quite a bit. I don't know if maybe this is part of the natural healing process and a bi-product of hard callus formation? Also the protrusion from the fragment of radial bone that is the furthest out has been looking more pronounced to me, I am wondering if this is causing him any discomfort.

Slight discoloration of fixator leg paw pads -
I've been putting Musher's Secret on the pads to help protect them
Radial bone fragment protrusion slightly more noticeable (see bump)
Taj got to take a mini-trip out to the pet store and to a new wagon trail. This seemed to only mildly cheer him up a bit. He also got to see Rich, which again he enjoyed, but he's just not himself. I am hoping that this is just another phase in the normative healing process, but my "mommy" instincts have me worried.

Trying to cheer up Mr. Taj
More annoyed than cheery?
Baby Roo ice-cream steal!
New wooded wagon trail with Rich!
Rich puts on the Ferrari-style speed trying to get
any emotive response from Mr. Taj

Wednesday, July 6, 2011

Week-8: Let there be Callus (and Rainbows)!

We have made it to the big landmark of 8-WEEKS post-surgery! Woohoo! We are now (hopefully) half-way through the fixator process - I think I've earned an honorary veterinary technician degree! ;)  

Taj is definitely feeling more active. I have to be much more careful with him now out on a lead. He will attempt to get up on furniture if I am not watching him like a hawk. Furniture is not allowed (unless I pick him up and put him on it, sit with him, and then lift him off). He cannot do anything that would incur the leg to impact the ground (aka like jumping off a couch or bed). He has also started to dig in place now (usually digging into his blankets). The vet said that this digging is not allowed outside in the dirt - although a little blanket digging won't hurt.

Waiting for the Vet, Taj is doing recon for escape routes!
Other than that a few of the pins were slightly more pink/red this week. This was due to a comfy-cone fail! Taj has figured out how to beat the comfy cone completely (with licking), so now I have to put on 3 collars in addition to the comfy cone at night (otherwise he'll slide it down his neck and work around it). It looks ridiculous - like he's some ornate giraffe, but we do what we have to do. This new collar methodology has worked and the pins are back to normal.

Dr. Rider said that the leg is looking absolutely great and that everything is going very smoothly! (I believe that's the equivalent to an A+ gold star for his home care). He said to just do the same exact thing we're doing - one more month. The olive wires and rings are all still very secure and the pins have very little drainage. It looks like it is healing well! 

Dr. Rider took new radiographs (you can see them here: radiographs). The gist is that the ulna is repairing nicely and that the radius, while slower to heal, is showing significantly more callus formation than at 4-weeks. This confirms my behavioral observations of Taj using the leg more (walking on it longer outside, attempting to jump up on things, new digging behavior, etc). You can see the new leg comparison photo here.

Looking at the new callus formation on the radiographs!
The radius is looking better, but still has a lot of healing to do!

We are still only allowed bathroom walks (10-15 minutes of ambling around down to one end of the block and back). Therefore, the daily wagon rides will continue through the next month until the 12-week appointment. I figure that I've now pulled Taj over 80 miles in his wagon (and am starting to gain the biceps to show it)!

This afternoon after our re-check visit, we had a brief thunderstorm and I ran outside with my camera to capture htis photo of a rainbow over our house. Hopefully this is a good omen for Mr. Taj! 

Friday, July 1, 2011

Week 8 Radiographs and Update

Good news!

In case you missed it, go to the Monthly Radiograph Progress page to check out the X-rays and see what the vet has to say.

Decepticon Salukis!

Shooter & Hottie on set with Dawn Carlson and Patrick Dempsey
The third installment of the Transformers movie franchise Transformers 3: Dark Side of the Moon is out.  Surprisingly, there are two beautiful salukis from Aeolus Hounds of Southeastern Wisconsin featured in the movie as Patrick Dempsey's dogs!  My brother Jo and I chuckled in disbelief when they twice appeared on screen, rather beautifully I might add.  Salukis are the last breed I'd expect to see in a movie, let alone Transformers.
Very cool!
(posted by Richie)