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Bone Graft Surgery for Nonunion of Tibia (Page 1)

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Hi, all. I posted a question about this topic in another forum, but that thread is really, really long so I figured I start a new one.

On January 21, 2012 I broke my tibia & fibula while skiing (well, falling actually). The tibia was fractured mid-shaft, while the tibia broke about 5cms above the ankle. The tibia was extremely comminuted and the reduction was very difficult. After a four hour surgery, an IM nail and three screws were installed.

Two weeks after surgery, the staples were removed and a hard LLC applied. At twelve weeks, the cast was replaced by another hard LLC because I had so much atrophy that the first cast wasn't doing much good. I have never been allowed to put any weight on it and have been in the same hard LLC since the 12 week point.

Yesterday marked 21 weeks since the accident and I was declared to be nonunion at 18 weeks (May 28th). Needless to say, I was crushed to learn that I'm not healing. I have been unable to work or drive for five months and am financially devasted as I live alone with no one to share the burden of paying the bills. Anyway.....

The surgeon who performed the original surgery was here on locum at the time and have not seen him since; my case was referred to a local surgeon who has seen me for my follow-ups, but I always had the feeling that he wasn't particularly interested in my case. He has passed me back to OS #1, who will be coming back to town this coming week to do a bone graft surgery to get things going again.

At first it was thought that the IM nail would be removed, the canal reamed out and replaced by a larger one to stimulate blood flow. My surgeon is not comfortable with this because the reduction was very difficult and he does not want to lose it. He feels that doing only the bone graft will be the best course of action, but has not fully decided yet.

I am wondering if there is anybody out there who has undergone this bone graft surgery (with the bone taken from their iliac crest) who can tell me what their experience was like. How was the pain and recovery? How long were you hospitalized? Is it any worse than when you were originally injured (I have a hard time imagining how it could be worse!). Did your bone begin healing again?

Also, I'm wondering if not replacing the hardware means that the healing will again be very slow. I'm going a little bit crazy over here and really want my life back!

Any help or information would be greatly appreciated Smile Thanks in advance!

Pam.
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First Helper User Profile Gaelic
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replied June 19th, 2012
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Pam,

So sorry that your tibia did not unite. But, as you know, tibia fractures can be a pain in the ___. It is nice that they decided to go ahead and treat the delayed union, rather than making you wait till the six month mark was reached. But, I guess it will be about six months by the time you have surgery, won't it?

While, in some cases of tibial nonunions, you do have to reream the canal and put in another nail, this is not absolutely required. If there is concerned about losing the reduction, it is probably better to not chance that. And, actually, reaming of the canal causes disruption of the endosteal blood supply, and can cause less blood supply to the fracture site.

Remember, there is nothing magical about the hardware. It is just there to hold the fracture fragments in place, till the body can heal the fracture.

So, opening the fracture site, cleaning out the fibrous tissue within the fracture and packing it with autologous bone graft is probably the best way to get the little osteoblasts to do their job (bone healing).

Usually, patients complain more about the bone graft site, than the tibia site. You will be sore around where they take the graft from.

How long you stay in the hospital, depends upon several factors. Most patients only stay a day or two (a few actually do this as an outpatient surgery, but it is usually more than most can tolerate for that type of procedure). Again, it is usually the graft site that bothers patients the most.


Are you able to put any weight across the fracture site yet? We usually try to get patients weight bearing as soon as possible, as the stress across the fracture will help stimulate the body to heal the fracture (Wolff's Law - bone will respond to the stresses applied to it).

Also, you might look into a bone stimulator. They are indicated for any delayed or nonunion. They are noninvasive, placed on the outside of the leg/cast. If it works, great. If not, nothing is lost. So, you might ask your surgeon about the use of one.

Another thing, is dynamizing the nail. If the fracture is still very weak, then the nail will have to continue to be statically locked (screws at both ends). But, as the bone starts to heal, sometimes the screws at one end are removed (called dynamizing the nail), so that more stress is applied across the fracture site. The nail goes from being a load-shielding construct to a load-sharing construct. Then good old Wolff's Law can come into play. This is something else to speak with the surgeon about. It may not be something that can be done at this surgery, but may need to be done in the future (this is real easy to do).


Good luck with your upcoming surgery. Again, since you don't have the acute fracture pain to deal with, it is the graft site that will probably bother you the most. Talk to your surgeon about all of your options. Hopefully, the bone graft will do the trick and the bone will finally heal. (You can see why tibia fractures have such long healing times.)

Again, wishing you the best. Hang in there.
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replied June 19th, 2012
Thank you, Gaelic. As always, your information is truly unvaluable.

To answer your questions: No, I have not been permitted to put any weight on the leg (although I have had a few falls in the last five months that have resulted in me slamming the leg down as a desperate reflex. Not fun).

When I had the 18 week follow up with OS #2 (not the guy who did the original surgery), he did mention the idea of dynamizing the nail, but said that he would be afraid that my leg would just collapse on itself, it's so unstable.

I also asked about the bone stimulator but he just shook his head and dismissed that notion without really giving a reason why. He has returned me to OS #1 again, so maybe #1 will have different ideas about that Smile

So we'll see! Thank you for your well-wishes Smile
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replied June 20th, 2012
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Pam,

As to the bone stimulator, some surgeons feel that the work, while other do not. Though insurance companies will usually cover them, for nonunion, the research on them is sort of neutral overall. In other words, you can find plenty of research that says they work, and just as much saying they do not. My idea is, if you have a nonunion, it can't hurt. As long as the insurance picks up the tab, there is no real down side to having the patient use one.

Hopefully, once your bone starts to heal well, you will be allowed to start placing some gentle weight on the foot. (You have been working on ankle and knee range of motion, hopefully.) When you do get to weight bearing, since you have been off the foot for so long, you may have some strange feelings in the foot. You will have to rebuild the toughness in the bottom of the foot.

Again, the graft should jump start the healing, as it brings in the progenitor cells, to heal the bone. Since it is the cancellous bone from the iliac crest, it also provides some scaffolding for the new bone to grow on. That is why autologous bone graft is the best all around (it provides both structure and cells.)

Good luck with your surgery. Again, hang in there, you have come this far.
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replied November 9th, 2012
Lots of news since I last posted. I got a phone call from my surgeon on October 29th, informing me that some OR tie had opened up the following day if I wanted to have the surgery done. I did!

So they did the bone graft from the hip, packing bone into two places, as well as a total hardware exchange in the tibia AND they also installed an IM nail (no screws) in the fibula.

I lost a lot of blood in surgery and ended up being in hospital for five days. My hemoglobin plummetted to 40 (doc said normal for me would be around 130-140?). They did not transfuse and my blood pressure was also very low (80's/50's) for a few days. I suffered from severe nausea and even what I call vertigo. I was extremely dizzy and couldn't even be pushed down the hall in a wheelchair without vomiting. It was surprising to me considering that I had had no such difficulties after the original injury and surgery at all!!

The pain was also much more severe than I had anticipating and I had a very bad couple of days there where I was hating life!

Now, after ten days, I feel like things are healing quite rapidly. I now have eight incisions, including the hip graft site and feeling better every day. It was difficult to get around for several days, but is getting better all the time! I am allowed to weight -bear as tolerated and am told that I should be ahead of where I was post-surgery by Christmas.

I have posted some new photos in addition to the ones you have already seen (below), but they usually take a couple of days to be approved before they will show. I don't have any from after this surgery yet, just the ones from October 18th, but you can get a better view of what was going on in there. Watch for them!

Pam
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replied June 24th, 2012
* UPDATE *:

I had a surgical consult on Thursday June 21, and was admitted to day surgery for a bone graft, with the option of doing a hardware replacement. Moments before I was taken into surgery, my OS came to me and told me that he had met with three other OS's and decided that it was too soon to declare me nonunion.

At the very last minute, my OS decided to try and dynamize the nail and removed the proximal screw and sent me home with instructions for 25% weight-bearing with an air cast. Talk about a totally confusing time!

The hope is that the dynamization will stimulate some new bone growth, although a bone graft is still on the horizon if no significant improvement is seen in eight weeks. Sigh.

I'm happy to have had a less painful and invasive surgery (and happy to be without a hard cast for the first time in five months), but also feeling scared that I will end up no further ahead in a couple of months. I will need to start working very soon so I'm hoping that I can begin to see some improvement, at least enough to be able to drive.

I have a follow up this coming Friday and I will update again after that meeting. Smile
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replied June 25th, 2012
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Pam,

Do try to do the weight bearing. A good way to determine the 25%, is to first figure out what 25% of your body weight is, then, using a bathroom scale, gradually put weight on the injured leg, till you reach the 25% weight. Do this several times, until you can achieve the 25% weight without looking. That way, when you walk with your crutches, you will know what the 25% feels like.

But dynamizing the nail won't work without the weight bearing. It is actually the stress across the fracture with weight bearing that will stimulate the body to heal the fracture. Good old Wolff's Law.

You may notice some aching and muscle soreness. That is to be expected. However, sharp, intense pain directly at the fracture site should be avoided. Also, the toughness on the bottom of your foot is have to be regained.

It will probably take several weeks till you know if this is going to work.

Good luck, keeping my fingers crossed that this will do the trick. It is a good step to try, before committing to the large bone grafting.

Again, good luck, hang in there.
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replied August 9th, 2012
UPDATE:

The dynamization seems to be working! Even though I couldn't see much of a difference in the x-ray, my OS said it's looking good. He told me to keep wearing the air cast but start using a cane and become nearly fully weight-bearing.

After six months of immobilization, I have been very nervous about weight-bearing and have been having lots of issues with my ankle. Apparently the fibula break was classified as a "Weber C fracture" (a term I had never heard before) and is associated with a total rupture of one or more ligaments, so this shouldn't be too surprising to me, I guess! I suppose the ligaments would have healed in a short and static position and are sure protesting now that they are being used Smile

A few days ago, I was sitting on the ground blowing up a kiddie pool. When I went to stand up, I felt a sharp pain around the area where the fibula was broken (as though something gave way) and I was unable to put weight on it for a few minutes. The acute pain subsided, but the area has been sore and there is a noticeable lump there now. I don't really know what to think. Guess I'll find out at my next follow-up on August 31st.

On a brighter note, there is very little pain at the tibial fracture site, although the displaced bone fragments are very clearly visible under the skin. The calf muscle is starting to come back, and I have been using a stationary bike and doing some lake swimming. I am terrified of slippery pool decks at the moment after a couple of bad crutch-crashes in the past. At the lake I can sit down in the sand and scootch my butt along until I am in the water. Highly recommended.

Well, that's the news for now. Thanks for the sympathetic ear! You are the best Smile
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replied August 9th, 2012
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powderpuff,

I can actually blow up my screen enough to see your fractures on your avatar.

You fibular fracture would be considered a Weber C. That is just one of the many classification systems of fibular fractures about the ankle. In a Weber C, the fibular fracture is above the level of the tibial plafond. The plafond is the horizontal end of the tibia, which makes up the top of the ankle joint. A Weber B is at the level of the plafond, and an A is below the plafond. The reason for the differentiation is it tells what structures are involved. In an A, the ankle ligaments are not involved, and these fractures can usually be treated like a bad sprain, with just some immobilization and rehab. In a B, the interosseous membrane is not involved. In a C, there is tearing of the interosseous membrane. So, in a C, you have to be sure that the mortise of the ankle joint is not widened. That the fibula and tibia are together, making up the top portion of the ankle joint.

Looking at your avatar, your ankle joint looks good. The distal fibular fragment is in good position, in the right place to form the mortise of the ankle.


As to the sharp pain you had, it is most likely some scar tissue tearing loose. This is not uncommon. Scar tissue is very vascular, so it will bleed some when torn. So, a lump is not uncommon. As long as the discomfort is getting less, it is not too much to worry about.


Sounds great that the dynamization seems to be working. Weight bearing in water is a great activity. You can adjust how much weight you put on the limb, by how deep the water is. Try to gradually put more and more weight on the limb. That is the purpose of the dynamization, to stress the fracture site. By stressing the fracture site, the body will respond and lay down more callus.


Good luck. Hope the bone continues to unite.
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replied August 26th, 2012
Thank you, Gaelic. Things are going along pretty well. I don't have a lot of pain at the site of the tibia fracture, although it is god-awful to look at Wink.

Most of my discomfort at this point comes from that lump of scar tissue around the fibula. Some days the pain from that area is so bad that I need to use my crutches for a while, but other days it's fine. There's also still lots of pain and swelling around the outside of the ankle, also depending on the day.

I have been doing a fair amount of lake swimming and water-walking in waist or chest deep water which feels amazing. It also really helps the knee, which has never been quite right since the surgery.

It's funny how we (myself and my surgeons) just kind of glossed over a whole pile of soft-tissue injuries that are quite serious on their own, because the tibia situation was the main concern at the time. Now, seven months later, it's like, "Oh, yeah, you pretty much destroyed everything in there". Huh. I know you haven't seen all the x-rays to know how bad the break was, but one doc went so far as to say that the only thing that kept my leg from just flying off altogether was the fact that I like to crank my ski boots down as tight as I can. Kept all the bits together, I guess. Gulp.

Anyway, next follow-up in less than one week, on August 31st, so we shall see what they say!
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replied August 27th, 2012
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powderpuff,

When I went back and looked at your x-ray that you use for your avatar, I noticed that you actually have some fracture lines on your fibula that go down into the ankle mortise. The main fracture is above the plafond, but you have a butterfly fragment on the lateral aspect of the distal fibula, at just about the level of the plafond. There is also another line proceedings inferiorly, going into the ankle joint.

Now, I will admit that blowing up the avatar is not the best picture, but I think these are true fractures and not just artifact. This would account for a lot of swelling over the lateral aspect of the ankle.

You might ask the surgeon about the fractures in the distal end of the fibula when you see him/her next week.

Good luck. Hope everything is progressing as it should be.
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replied August 27th, 2012
hmm, very interesting. I will tell him what you said. Here is a link to my original xrays (not great quality as they were taken of the monitor in the office), but might be better than what you were able to see on the avatar.

http://www.flickr.com/photos/pam_i_am/sets /72157631278327690/

Thanks again for your time. You are amazing!
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replied August 30th, 2012
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powderpuff,

Well, I can't really tell. If there are some extra fracture lines, they are nondisplaced. It would probably take some dedicated ankle films to tell (rather than long tibia films). Your surgeon can tell if there are some fractures down in the distal fibula.

Again, there appears to be some fracture lines there, but that could just be some artifact or overlapping shadows.

But, if you are having ankle pain, you may need to have some dedicated ankle films to check things out. Again, that is up to your surgeon, as he/she has access to all of your studies and can actually examine you.

Hope you are doing okay. That is a pretty nasty fracture. It's amazing what can happen when you stick a long lever arm on the end of your leg (a ski).

Hang in there. Let us know how the ankle pain is doing and what the surgeon determines it to be coming from.

Good luck.
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replied September 22nd, 2012
UPDATE:

Well, it turns out that I did indeed re-fracture the fibula and my surgeon briefly toyed with the idea of going in and plating it, but since the tibia is not totally healed yet, he decided against it. This tibia is healing nicely around the back side, but where the larger fragments are protruding along the shin, callous is very slow to form and fill in the spaces.

When I left my last appointment on August 31st, the plan was to wait yet another month and see what happens.

I was expecting to see my surgeon in the next week or two (he is only here occasionally on locum, but was the doc who did the original surgeon). However, I received a phone call yesterday from the office of yet another surgeon (#3) who informed me that I have been referred to him now, with no explanation from #1. And now I'm at the bottom of this guy's pile and can't even get in to see him until Oct 24th. Needless to say, I'm very frustrated.

Yesterday was the eight month anniversary of my accident and I feel like I'm a hot potato.

I am getting around with a cane, but still have lots of pain and swelling aroing the fibula break and the ankle, as well as pain at the tibia fracture site if I put too much weight on it or walk too far. I just feel as though things have stalled and that nobody cares.

I live in a small town and would like to now be referred to a surgeon in a larger centre, but have no idea how to make that happen. Do you have any suggestions?

Thank you for hearing me vent, again.... Smile
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replied September 23rd, 2012
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powderpuff,

Sorry about your trials and tribulations. Go ahead and vent, it is good for the soul.


If you are having a lot of pain at the fracture sites with weight bearing, you may be pushing it a little too much. Be sure to listen to your body. Also, as I am always recommending on this site, you might look into doing some therapy in a pool. It might help your mental wellbeing, to be able to be more active in the pool. Just a thought. (No, I do not have stock in swimming pools, I have just found it to be a very good therapy venue, both personally and professionally.)


As to seeing another surgeon, at a tertiary care center, there are a couple of ways to go about it. If your insurance company requires a referral, then you will have to get one. But, it does not have to be from your current orthopedic surgeon, it can be from your primary care provider. But, at some tertiary care centers, you can just call and make arrangements to be seen yourself (they don’t require a referral). So, you would have to decide where you would like to be seen, then contact that facility and ask how their appointment process works. Each facility is different. But, most of them have websites, which you can access and find out a lot of information that you might need. Usually, the tertiary care center would like to have all of your medical records pertaining to your orthopedic condition. Some will take a narrative summary, with pertainent x-rays. Do you know where you would like to be seen?

Also, did you find out why your case has been sent to yet another surgeon? I understand that surgeons do not really like to follow other surgeon’s patients, but if you have been out and your practice is covered by a locums tenums, then you have to pick up the patients that the locums operated on. Not sure why surgeon #2 would send you to yet another surgeon. Maybe the locums surgeon is not going to be in town as expected and the third surgeon is covering all of his patients. Who know?


Again, make sure you follow your insurance company’s policies or you may end up paying for everything yourself. But, usually, in complex cases such as yours, they don’t have a problem as long as you have a referral. However, some insurance companies allow the patient to select where they want to be treated, as long as the facility takes your insurance.


Hang in there. You can see why I usually tell patients that it takes a year to 18 months to recover from a tibia fracture. They are notorious for having their “problems”, and when you get one hitch taken care of, another shows up. It can be really frustrating (mainly for the patient, but for the surgeon as well).

Wishing you the best.
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replied October 4th, 2012
Hi again. So I had a chat with my GP today and she helped me to feel a little better about my situation. We agreed that I will keep my appointment with surgeon #3 on October 16th, and if after that I still feel like I should be referred elsewhere, then we'll go ahead and do that.

I talked with her about my concerns that the circulation in the broken leg is not good (it is a completely different colour and is cold to the touch). She mentioned something called "reflex sympathetic dystrophy". Do you know anything about that?

She also reassured me that surgeon #3 is good at what he does, but is a bit "prickly", as she delicately stated it. She encouraged me to be pushy with him, so I will be taking her advice. It is also a regular office visit, so I should be allotted a decent amount of time instead of the revolving door of ambulatory care Smile

I also (finally!!!) have been sent to physio and start next Wednesday. My GP was a little ticked off that my surgeon didn't think that I needed it, but also said that it's not uncommon for OS's to poo-poo physio.

Anyway, I'm continuing on with swimming and using the stationary bike and it really does help with my mental state, in addition to shedding a few of the pounds I've gained since breaking my leg. I've also been drinking comfrey root tea. I figure it can't hurt Smile

Take care!

Pam.
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replied October 5th, 2012
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Pam,

Unfortunately, many physicians who are not used to diagnosing and managing RSD, often over diagnose it.

Reflex Sympathetic Dystrophy (RSD) is a term that is no longer used, mainly because of the stigma associated with the term. Similar problems are now called Chronic Regional Pain Syndromes (CRPS) Type I, II, or III.

Type I is a condition which can develop after trauma (and it does not have to be major trauma at all), where there is no actual nerve injury, but the sympathetic nervous system gets revved up and does not turn off once healing has occurred. This is the old RSD.

Type II is where there is an actual injury to a peripheral nerve. This used to be called Causalgia.

Type III is basically a bunch of "pain disorders" lumped together, that do not fit into the above two categories. This includes musculoskeletal back pain, psychosocial mediated pain syndromes, secondary gain syndrome, and the like.


But, there are very specific criteria for the diagnosis of CRPS I. The main point is called "pain out of proportion" with what would be expected. Many times patients will come into the clinic after a closed, simple forearm fracture; after the cast has been off a couple of weeks, cradling the arm on a pillow. Walking gingerly, so the arm is not jarred. They do not want to move any of the joints, at all. They interpret any and all feelings as extremely painful.

Because of not moving the hand, the fingers are very stiff, the motion creases on the fingers go away, they become shinny, red, warm, and the skin is beginning to get tight. As the disorder progresses, the red and warm hand moves on into the atrophic stage, where it is now cool, dusky, bluish/white. The skin is now very tight and the joints are essentially frozen.

Once the patient reaches the advanced stages, some x-rays changes will occur, mainly being periarticular osteopenia. A Technieum-99 bone scan will have a very specific look on a three phase study. But, all other tests and labs will be normal.


Though the literature continues to state that CRPS I is not a psychological or emotional disorder, many hand surgeon and pain management physicians do believe that a certain type of patient tends to develop the disorder. That there is some underlying psychopathy involved.

Diagnosis of CRPS I is confirmed by the patient’s response to a stellate ganglion block. The block (using local anesthesia) interrupts the sympathetic nervous system which is keeping the “disorder” going. If a patient fails to respond to at least one of three injections, then the diagnosis should be reevaluated. Because, it is probably not Type I, but probably more in the Type III category.

But, again, some physicians get so hung up on saying that their patient does have CRPS I (or the patient insisting that they have RSD), that they have actually performed upwards of 30 ganglion blocks, trying to get the patient to respond. The mainstream hand society states that this is uncalled for. The patient does not have CRPS I. This is one reason that the name was changed. Patients had read about RSD (or talked to another patient at therapy, at their church, etc) and how poorly patients did with it, that when they were told they may have it, they fell into being an RSD patient, where nothing done ever helped. It is true, that when RSD was first identified and treated, most patients were not picked up until they were very late in the course, when not much could be done. But, now days, with earlier diagnosis, the outcomes are so much better. Most of the time, now days, patients are very successfully treated with therapy for CRPS I. But, you have to really get on top of the problem and push the patient. You have to continually tell the patient that they are going to get better. For some reason these patients tend to generally fall into that group which are sort of defeatists, that always have a negative attitude, and have low pain thresholds (though they will invariably state that they must be having a lot of pain, because they have a very high pain tolerance). I have found through the years, that patients with very high pain tolerances, do not talk about it, they just do have needs to be done with very little comment, as if what is happening is normal to them.

There is also a huge amount of legal suits surrounding RSD. The medical-legal aspects of RSD are just astounding.

As you can see, this is a topic that is rife with controversy. But, it has gotten a lot better once the name was changed.



However, you are more likely having the usually problems with the venous circulation that occurs in limbs which have had significant injury and/or surgery. It is not uncommon for these patients to have cool/cold, dusky/purple toes/fingers. Due to the injury and surgery the veins and lymphatic channels have been disrupted and have to be reconstituted. New veins and channels have to grow across the regions of injury. Also, do to immobilization and not using the muscles as much, the swelling, edema, lymphatic fluid is not pumped back into the body core. The only way for venous blood and lymphatic fluid to be pushed up the leg is by the muscle contractions.

The muscles contract, this squeezes the tubes to push the fluid up the leg. The fluid cannot go back down, because there are actual valves in the veins, which preclude backflow. So, with each contraction, the fluids get pushed further and further up the leg. The only other way to get the fluids back to the body is with gravity; elevating the toes above the head.

So, again, it is quite common for patients to have altered circulation in an injured limb for a long time, months to years, in some cases (depending whether or not they had some preexisting vascular problems).


But, you can ask the surgeon you see if he/she thinks that you have CRPS I. Most likely you do not. You seem to be the type who really wants to get back to activity, to work in therapy, to get this thing healed so you can get back to skiing. Again, the hallmark of CRPS I is pain out of proportion of what would be expected (with the specific changes in skin according to stage).


Hope you get good news from you upcoming appointment. Good luck.
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replied October 5th, 2012
I did do some reading about it, and I would agree. I don't think I have any pain that's out of proportion to what's going on down there. It's just really really cold!
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replied October 5th, 2012
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Pam,

I'm sorry, but I do not remember if you are still in a cast or are in a removable boot. There are some things you can do to help with the cold feeling.

Warm packs are always a good way to start. Just be careful to not burn yourself, as your skin is probably pretty soft and sensitive around the fracture and/or surgery sites. These can be put on over a cast if necessary.

If you are out of the cast, you can try a hot bath or whirlpool (if you have access to one). (That was actually one of the best things we got for ourselves; we splurged and got a Jacuzzi. It is been wonderful for my knee and my spouse has poor circulation in the feet (diabetes). It warms them right up every night, just before bedtime!)

Also, if you are out of the cast, you can try some massage to help not only with the coolness, but also with maturation of scar tissue and softening of the soft tissues. Start distally around the toes and work your way proximally, all the way up to the thigh. Or, you can have your significant other do it for you. This also feels really good (as long as you do not push too deeply around the tender points). The massage also helps push the fluids towards the body core.

A note on the heating pads - You should really not leave them on for more than about half an hour at a time. After that the body habituates to the pack/pad being there and no longer keeps the circulation increased. It is better to keep the pack in place for about half an hour, take it off for half an hour, and then reapply it if desired. The "contrast bath" effect can actually help stimulate the circulation also.

Again, hopefully, you will get some good news on the 16th, heaven knows you deserve some. But, you have been a tiger so far and tiger moms can be pretty tough. Hang in there.
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replied October 5th, 2012
Thanks again, Gaelic! The tips and advice are great.

Yes, I've been out of the cast for over three months now. I used the walking boot for about a month, but phased it out as soon as I could. I really felt the urge to get that ankle in motion after having been in the hard cast for five months. I was careful not to put a lot of weight on it at first, just used both crutches and practiced "walking" until I was able to start using a cane.

I'd say the ankle is the thing that might give me trouble the longest, and troubles me the most after being on my feet for a while. I'm hoping that physio will be able to help. I've been doing the alphabet, but that's about all I have in my repertoire.

My hip is very tight and I'm having a very tough time trying to stretch it, since all of the exercises I know involve pushing or pulling on the lower leg and I can't do that right now Smile I'm sure physio can help with that as well.

I do wish I had access to a hot tub. I also wish I had a man-servant to rub my feet (no significant other, either) but so it is... great advice on the heating pads. I wouldn't have known to only leave it on for 1/2 hour.

Anyway, thanks again and I'll be back after the 16th.

Take care,

Pam.
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replied October 5th, 2012
Especially eHealthy
Pam,

If you have access to a warm swimming pool, that is a great place to stretch the hip without worrying about putting too much stress on the lower leg. You can also work on all the other parts of the lower extremity, as the buoyancy of the water makes you essentially nonweight bearing (in chest deep water).

Look forward to news of your appointment.
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replied October 25th, 2012
And the saga continues...

My October 16th with "surgeon #3" appointment was pushed back to the 18th, no big deal. He looked at my x-rays and we had a chat and agreed that it is time to move forward with surgery. Unfortunately, surgeon #3 is not operating in November/December so I can't have it done locally until January. He decided to refer me to another surgeon for a second opinion. By the time I left the office, I had an urgent CT scan scheduled and an appointment booked with a trauma specialist/lower leg reconstruction specialist in Calgary (a 4 1/2 hour drive away).

I met with the specialist yesterday and he agrees that I can now be officially declared non-union. He is recommending a total hardware exchange with bone material displaced from the procedure used for grafting the larger fragments, as well as plating the fibula and maybe even the front of the tibia where the fragments are poking out.

While I was hoping to get this happening sooner than January, I have decided that I don't want to be operated on in Calgary, as I don't know anybody there and would need to return several times for follow-ups in the middle of winter, which would require driving over the Rockies.

So it looks like January, but now I'm even wondering if I should wait until the spring so I'm not snow-bound while I'm recovering. Anyway, lots to think about. At least right now I can work a bit and I can drive. That's not nothing...
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replied October 25th, 2012
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Pam,

I'm so sorry that you have gone on to a full nonunion.

As to waiting until spring, that would be an option. You would have to be careful to not put too much repetitive stress on the nail, as it could conceivably fail from the stress. But, as long as you listen to your body and pay attention to any increase in pain around the fracture site, you will probably be okay.

Some surgeons would put you in a “Sarmiento” fracture brace, if you wanted to wait till the spring. A Sarmiento is a very light weight, custom made, and form fitting brace which supports the tibia. It is made out of a thermoplastic material, such as OrthoPlast. Dr. Sarmiento was a big advocate of treating almost all tibia fractures with fracture braces, rather than surgery or casting. However, he was “old school”, where a little deformity at the fracture was acceptable, as long as the leg was functional. But, as you can imagine, nowadays, that does not sit very well with most patients.

But, the Sarmiento brace may provide enough external support that you would not have to worry so much about the nail failing, if you waited till the spring. It is not mandatory, it was just a thought. Being very conservative myself, it just came to mind as on option.

Again, sorry that you have gone onto a nonunion. But, hopefully, this surgery will finally take care of the problem and you can get this darn thing to heal. Hang in there. Good luck.
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replied November 5th, 2012
bone graft
Wow i just had a bone graft on my tibia
About a week ago and this conversation really help me a lot.
It good to Se other peoples opinions. Smile i wish u powderpuff that the surgery goes well and that u have a fast recovery...
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replied November 9th, 2012
Hi, Quico! I would love to hear more about your surgery and recovery. I don't know anybody else who has gone through this.... I will post my update below. Good luck to you!
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replied November 9th, 2012
Here are the x-rays from both the crash day/initial surgery, plus from October 18th. I just had a graft and hardware exchange done on the 30th of October, but don't have any x-rays to post yet from that. There is a photo of my leg with all of the bandages, lol.

http://www.flickr.com/photos/pam_i_am/sets /72157631278327690/
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replied November 10th, 2012
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Pam,

Hope you are doing well at home.

Sounds like the surgery went well, though you had some road bumps after.

Most patients state that the iliac crest is more tender than the tibia. Hope your hip is doing okay.

Hopefully, the new bone cells will get the tibia to finally heal and you can get back to the activities which you like to do.

Good luck. Keep working hard in therapy.
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replied November 24th, 2012
Recovery from the hardware exchange/bone graft is going well, for the most part.

The incisions have healed nicely, staples (47!) are out, and the grafts are all taking well, the x-rays look great. I did find out less than a week ago that the pin (looks like a crochet hook) in the fibula was backing out and that it could be taken out if it was bothering me. Three days later, I could see it under the skin, about to pop out... I went to my surgeon and had it taken out yesterday. They just froze me up, cut me open and took it out!

It's a bit sore today, but nothing too drastic. I added three new photos to the album. The x-ray is from the day of the surgery, so you can see pin in the fibula (terrible quality). The other two are from last night, after the pin was removed.

Have a good weekend, Gaelic!
http://www.flickr.com/photos/pam_i_am/
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replied November 25th, 2012
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Pam,

The pin taken out of the fibula is called a Rush pin. That is after Dr. Rush, not that they are quick and easy to put in.

They are a solid metal rod, which has one of three different types of ends (hook, loop, or flat with hole). They come in a variety of diameters and lengths. Rush pins have been used for intrameduallary fixation for decades. They have mainly been replaced with the hollow IM nails for the femur and tibia, as those can be interlocked with screws, while the Rush pins have to be used in pairs, relying on their curvature and “spring” to maintain the fracture reduction. Rush pins are now mainly used in the smaller diameter long bones, such as the fibula, ulna, and radius. The hook end is left outside of the bone, so that its removal is easier.

You probably didn’t need to know all that, but just in case you wanted to know.


Looks like the larger diameter tibial IM nail is filling up the canal nicely. It is now just a matter of waiting for the bone graft to consolidate in the fracture callus.

Hope you are doing well. Good luck.
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replied December 5th, 2012
Hi Gaelic,

Yesterday was five weeks since the graft/hardware exchange and I will be going for x-rays tomorrow. The leg feels pretty good, I'm still on crutches but putting more weight on it. I was a little bit hesitant to weightbear after the rush pin in the fibula was removed, but it seems OK.

My question is related to what happened in the surgery itself. I was supposed to be in hospital for two days at the most, but ended up being there for five days. I was very ill post-op, nauseous with any motion whatsoever, couldn't eat, fainted several times, very low blood pressure, etc.

It was almost casually mentioned to me that my hemoglobin was "quite low", due to blood lost during the surgery itself, but nobody was willing to say that that was why I was so sick.

Now that I'm getting around a little better, I'm really noticing how utterly exhausted I am after the slightest amount of activity, and very short of breath. I started doing a bit of reading about anemia and it sure sounds like that's what's going on.

When I was in hospital, my surgeon told me that my hemoglobin level should be around 130-140 (which I believe is grams per litre?) for a woman my age, and that post-op it was 40. He went on to say that I was "on the bubble" in terms of being a candidate for a blood transfusion, and he didn't want to go that way.

I was never offered any advice or anything about how long it would take for my levels to get back to normal, but everything I've read has told me that a level of 40 is extremely low and worth worrying about.

Do you know anything about this or can you refer me to some good information? Should I be going to my GP and asking for a blood test?

Thanks again, Gaelic Smile

Pam.
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replied December 5th, 2012
Especially eHealthy
Pam,

An hemoglobin of 40 is pretty low. In most cases that would be transfused, but not in all.

The usual “normal” range for hemoglobin and hematocrit (the H and H of blood tests) are given as below:

> Hemoglobin (HGB) - Women: 12.1 to 15.1 g/dL (121 to 151 g/L, or 7.51 to 9.37 mmol/L) (this is the amount of the oxygen carrying protein within the blood).
> Hematocrit (HTC) - Women: 40% (this is a percentage of the red blood cells within the liquid blood)


When I first started training (many years ago), we would transfuse any patient who dropped below an hematocrit of 30 (sorry, in my training we used the ‘crit more than the hemoglobin, so that is what I am used to looking at, but that would translate at a hemoglobin of around 100).

Then, the HIV/AIDS epidemic hit and it was not known, at that time, if the blood supplies were safe. Testing for HIV had not been instituted yet (the virus was still to be indentified). So, a lot of research was started to see if it was really necessary for every patient who’s H ‘n H dropped below 30/100 to be transfused. It was found that, if patients were healthy, had no cardiac problems, that they could go a lot less than that, and not have any significant ramifications. So, the “trigger point” for transfusing dropped. It is not uncommon for the hematocrit to get down to around 16-18 (hemoglobin of around 60), before surgeons even start to consider transfusing in healthy patients.

The following may be of interest:

The American Society of Anesthesiologists Task Force on Blood Component Therapy recommendations based on hemoglobin concentration are:

* Hemoglobin > 10 g/dL -- transfusion is rarely indicated.

* Hemoglobin 6-10 g/dL -- indications for transfusion should be based on the patient's risk of inadequate oxygenation from ongoing bleeding and/or high-risk factors.

* Hemoglobin < 6 g/dL -- transfusion is almost always indicated.


(You did not know the units your hemoglobin was recorded in, but this is probably equivalent to yours, if you add a zero to these numbers, ie yours was in g/L rather than g/dL.)


Yes, the patient will be tachycardic (fast pulse) and may have a little lightheadedness for a short period of time (especially upon standing), but in most cases, this is temporary and the patient will rebuild the red blood cell volume in a short period of time. The patient is given fluids to replace the volume deficit, but the body will have to rebuild the red blood cells content from the bone marrow supply.

For example, when a person donates a unit of blood to the Red Cross, the plasma (the liquid part of the blood) is replaced by the body within a couple of days, with just taking in oral fluids. (A unit of blood is not enough to cause any symptoms. In the US, a usual donation is 450ml or cc). The red blood cells are usually replaced in a range of 20 to 60 days. This is why a person has to wait several weeks before he/she can donate again.




The decision as to whether or not to transfuse is based primarily on the patient’s symptoms and if the patient has underlying cardiac problems (with which a low H/H could cause problems, ie heart attack). The surgeon knows how much blood was lost during surgery (and in any drains that may have been placed). The H/H is looked at as a guide, but it is the patient’s symptoms that are really the determining factor.

The day of surgery and the day after, your nausea may have been from the medicines given during anesthesia, same with the lightheadedness. After that, it was from your low blood volume.


In orthopedic surgery, blood loss is reduced with the use of a tourniquet. It would be almost impossible to do a lot of the bone work without a tourniquet. But, when there is reaming of the intramedullary canal, there is a bit of blood (and marrow) lost. And, of course, a tourniquet cannot be used for the iliac crest graft harvest.


So, during your surgery, the iliac crest was opened, usually through a “trap door” on the top of the crest. The cancellous bone and marrow is scooped out with a curette (looks like a very small ice cream scoop). Once enough has been obtained, the trap door is replaced over the “hole” and the muscles reattached and the skin closed. If a structural graft is needed, often the trap door is harvested also, and the defect will fill in with time.

Then, the incision at the knee is opened, the tip of the nail is found. If any interlocking screws are in place, they are removed. A guide wire is placed down through the nail. The slap hammer is placed over the guide wire and screwed onto the end of the nail. Then, the nail is hammered out of the tibia. The guide wire is still in place. The intramedullary canal is then sequentially reamed with bigger and bigger reaming tips, until there is “clatter”, meaning that the canal has been cleaned out. The new nail is then inserted over the guide wire and hammered into place. The guide wire is removed. And the incision closed. If interlocking screws are needed, they are not placed.

The fracture site is opened. Any fibrous tissue from the nonunion which is present is removed, back to raw bleeding bone. The resulting defect is packed with the cancellous bone graft which had been harvested from the iliac crest. This wound is then closed.

The Rush pin is then usually placed through a stab wound at the tip of the lateral malleolus, under c-arm guidance (real time x-rays).

So, that is what is usually done in this type of procedure.



Thus, again, the surgeon has to decide if your symptoms are significant enough (along with any health/cardiac problems you might have) to warrant a transfusion. You were a “couple quarts low”, did have some symptoms, so it could go either way. Some surgeons have a low threshold to just go ahead and transfuse patients, will others are very conservative and transfusion is a last resort.

Transfusions are not benign. Contraction of an infectious disease is actually a very rare occurrence and not really of that much concern anymore for most of the world’s blood supply. But, it still does happen on extremely rare cases. It is the transfusion reactions that are of concern. Because of all of the antibodies and antigen that we carry around in our blood, unless you get your own blood (which is done in elective orthopedic cases, patients can donate their own blood to be held for their surgery, but it has to be done months ahead of time, it is usually done for total joint patients), there is never an “exact” match. The blood bank matches the blood as closely as possible, but transfusions reactions still occur.

A transfusion reaction can range from a very slight elevation in temperature with some skin itching, to having trouble breathing, and in some cases, all the way to death. So, in most hospitals, any time a patient has to be transfused, the protocol usually requires a nurse to be with the patient during the transfusion and the vitals taken every 15 minutes for several hours after, and continued very close monitoring for 24 hours. It takes a lot of staff, time, effort, etc. If it is necessary, of course, it is no problem. But, again, a transfusion is not a simple little “fill ‘er up”.


So, again, it is a judgment call on the surgeon’s part.


As long as you do not have any health problems affecting your bone marrow, you will replace the red blood cells gradually over time. Some surgeons will send patients home on iron tablets. If you were not given these, you might ask your primary care provider (or surgeon) for some, or you can buy them over the counter at the pharmacy. We used to send any patient who had a low H/H home on pre-natal vitamins and iron supplements. Of course, we also told patients to eat a proper diet, with extra “organ meat”, such as liver, and vegetables such as spinach.

Your primary care provider can do a CBC. If you are anemic, besides looking at the RBC H/H, there are other markers such as the MCV, MPV, RDW, etc which will tell him/her what type of anemia it is. Usually, post-op it will be iron deficiency anemia, which is treated with iron supplements.


Hope that answered your questions, without getting you too confused.

Hope you are doing well and your appointment goes well. Good luck.
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replied February 27th, 2013
bone grafting
OMG I was soo amazed to read your story, last April 22 I jumped from a 2 story building to escape a fire, I broke my right fib/tib, my left thigh bone and crushed my left ankle, I spent 7 and half weeks in the hospital, my doctor REALLY let me fall through the cracks. I had been complaining of bad pain in my fib/tib, finally in Oct he referred me to another dr saying I had a non union, I had a really tough time finding a dr that I believed in and trusted!!!! I finally found 1 and I am having surgery and bone grafting that will also come from my hip, then when that heals and I can weight bare again I have to have my left leg done as it hasnt healed either....your story helped me a lot as I am SCARED!!!!!
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replied February 27th, 2013
Terrible injuries, broke_bones! e-mail me if you want to chat.
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replied February 28th, 2013
UPDATE:

Hi Gaelic and others. I had another follow-up yesterday, February 27th. The bones are finally healing and the grafts are taking nicely.

My ongoing concern is my ankle. It's stiff and painful, mainly right at the front of the ankle. It feels like there's a shooter marble in there Smile Also, the distal screw is backing its way out now. The head and a few mm's of the screw are out and it's driving me nuts. It will come out next Friday, March 8th.

I'm working out on a stationary bike and some light weight training as well as daily dog walks. I am mostly hobbling around without aid of a cane, but I do take it with me when outdoors. Not a step is taken without pain, but at least I am walking. It's been a terribly long road, but I think I can see the light at the end of the tunnel.

I'll keep posting updates. Chin up, everyone who's going through this. You'll get through it, because you have no choice Smile
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replied March 1st, 2013
Especially eHealthy
Glad you are finally getting to the end of the tunnel. I used to say that I hope it is not the light of an oncoming train. But, you are probably going to finally beat this thing.


It is very common to have a very stiff ankle joint after being immobilized for a long period of time. Often there is a build up a scar tissue around the joint and it gets "socked in". All you can do at this point is continue to do range of motion exercises and see how things go.

Scar tissue will sometimes soften and stretch out as it matures, but this can often take many months to a year.

If you just cannot get the ankle motion you need, and there is a lot of scar in the front of the ankle, sometimes the surgeon will so an arthroscopy and clean out some of the build up of fibrous tissue from the front of the joint. But, that is way down the road, now it is just rehab and hard work. Which, it sounds, like you are used to now.


Hope you continue to get better. Keep up the hard work.

Wishing you the best.
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replied March 17th, 2013
distal tibia and fibia fracture
I broke both my tibia and fibia on my right leg last August. It is now 6.5 months since my accident.
Reading Pam's messages thread has been very helpful indeed! Thanks!

Prior to Dec17, there was no progress of growth at all.

Dec 17, 2012 : shows 20% weight bearing and physiotherapist had asked me to use weighing scale to determine what is 20% vs my weight. At this point, I was still using crutchers with my left leg supporting 100%. Only use the weighingscale as an 'exercise' guide.

Jan 30, 2013 (x rays only done every 6 weeks), it shows 50% improvement. Physiotherapist taught me how to use the crutchers while my injured foot allowed to touch the ground (weight is still borne mainly by my arm/crutchers).

March 13, 2013 (6 weeks after last x ray), x ray shows no improvement at all.
My OS is now asking me to consider doing a graft procedure. In fact, he first suggested the graft procedure in oct/nov time frame but I had wanted to see if my fracture can be healed naturally.

Now looks like I don't have a choice but to do grafting.

My fear now is whether after the graft procedure, is my condition better than after my 1st surgery?
And how different from my current condition?
This is my main concern for now as I am staying on my own.
Right now, in my home, I am using a computer chair to move around if I need to move stuff from one place to another. If I just need to move, I use the crutchers.

I will be seeking 2nd opinion thus Thursday, 21 March.

Hopefully, someone can address my fear as raised above.
Thanks in advance!


Regards,
Mabel
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replied March 17th, 2013
Especially eHealthy
Mabel,

Sorry about your problems.


You do not say how your fracture was treated: was it with a plate/screw or an IM nail)?

It probably does not really matter at this point.

If a fracture is not united after six months, it is considered to be a nonunion. Usually, once a nonunion is established, the bone will not unite on its own, without some help.


If the tibia had been fixed with an IM nail, with proximal and distal interlocking screws, it is sometimes possible to get the bone to heal by dynamizing the nail. This is where the interlocking screws are taken out at one end. By doing this, the construct of the IM nail goes from a load-shielding one, to a load-sharing one. Thus, before the nail took almost all of the stress through the leg, while in the later, the bone mostly takes the stress.

So, sometimes the nail can be dynamized, the patient placed on weight bearing status, and the fracture will heal. Sometimes.


If a plate and screws was used, this is a moot point.


Occasionally, a bone stimulator can be used to get the bone to heal. But, the data on these devices is mixed. The studies funded by the device companies themselves show good results. But, those done by independent factions, do not show results any better than chance.



So, again, once a nonunion is established, the fracture usually needs help to unite. Thus, the internal fixation is removed, the fibrous tissue within the fracture is removed (a type of scar) back to raw bleeding bone, another set of internal fixation is applied, and the defect in the bone is grafted.

It is usually best use autologous bone graft (graft taken from the patient's body). The usually place to harvest graft is from the anterior iliac spine (or crest), also called the pelvic brim. A trap door is made in the hard cortical bone and the spongy cancellous bone is removed with a currette (looks like a tiny ice cream scoop).

This cancellous bone provides two things: a scaffolding for the new bone to grow on and osteoprogenitor cells, to jump start the healing process.


The internal fixation that is currently in place will not hold up forever, in the face of a nonunion. It is always a race to see what happens first: the fracture healing or the hardware failing.

Internal hardware (orthopedic fixation devices) is not meant to hold up to the repeated stresses of weight bearing. It will eventually fail. Just like a paper clip which is bent over and over again.


So, once there is a nonunion, something has to be done.



There is not much you can do to help speed up the healing process, or even to encourage it. But, you can slow it down. Smoking is the single most detrimental thing there is to fracture healing. Nicotine constricts the tiny new blood vessels growing into the new bone. This causes lack of blood flow, and thus, lack of oxygen. The tissues become ischemic/hypoxic and fail to thrive. They just do not heal.

You need to eat a proper diet; with extra protein, calcium, vitamin D, and magnesium.

When the surgeon allows weight bearing try to do so. By placing stress across the fracture site, it can stimulate the body to lay down callus and heal the bone. This is known as Wolff's Law - bone will respond to the stresses applied to it. This is why weight lifters and manual laborers have strong, stout bones. And the reverse, those who do not stress their bones (age, injury, space flight, etc) will develop osteoporosis.


So, you most likely need to have a bone grafting done, to get this bone to heal.


Good luck.
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replied March 17th, 2013
Gaelic,

Thanks so much for your not only a detailed response but a speedy one at that too!

Extract from one of the initial x ray reports :

Comminuted and segmental fractures are seen over the distal third of right tibial shaft and also seen over distal third of the right fibular shaft. The tibial fractures have been internally fixed and immobilized with an intramedullary nail and interlocking screws.

In addition, chondromalacia patellar changes are seen as well.

(end of extract)

Question 1 : can you help explain what 'chondromalacia patellar changes are seen as well' means?


I had this surgery while in South Africa and followed up thereafter in Malaysia where I reside.

I was also asked to wear an Air Walker type of shoes where I change to the splint type when I go to sleep at night.

Question 2 : Instead of the surgery as described above, the doctor here says that he would have put a plate across the calf (diameter-wise not length of calf). Not sure what is the medical term or procedure for this. I know this is a moot question too but just curious to know. Of course, when I asked for this to be corrected, he said it would infect the wound as it was just operated on.


I started with physio sessions some time in November (2 months after operation). During physio sessions, ultrasound was done on parts that require circulation e.g. the toe areas, etc. and an annodi machine to stimulate bone growth using LED technology.
Physio started with twice a week and increased to 3 times a week.

The dr. recommended grating after 2 months but I had wanted to it to heal on its own. However, the option of dynamizing the nail was not raised.

In your response, you mentioned, "So, again, once a nonunion......Thus, the internal fixation is removed, the fibrous tissue within the fracture is removed (a type of scar) back to raw bleeding bone, another set of internal fixation is applied and the defect in the bone grafted"

Question 3 : Do you mean that the intramedllary nail and interlocking screws are replaced with another new set? If it is, then it's like re-doing the first operation?

If grafting is done using autologous bone graft, I read from the other message threads that this pain is more than the injured point.

Question 4 : Is this true? And how big is the wound of the pelvic area? Will I be able to move with my crutchers on the 2nd day after grafting?

Question 5 : My fear as outlined in my initial mail is whether after grafting, my condition or situation will be similar than my first operation?

As I am staying on my own, I need to know if I am able to move as what I am doing now i.e. moving using a computer chair if I need to carry stuff or using crutchers only if I need to move from one place to another.

Question 5a ; What are the stages of recovery I will experience after grafting and based on past trends of other patients, how long before I can start to walk (even slowly) without crutchers?


When i first came back from South Africa a week after surgery, I had rehabilitate with a couple of my friends (who happened to be retired nurses). I moved back to stay in my own home after 6 weeks as the dr already told me at that time that it will take at least 6 months for recovery.


Question 6 : As the orthopaedic fixation devices will eventually fail, at what point do you recommend having these removed from my leg after recovery?



At my end, I don't smoke or drink. Generally, a health conscious person as I do exercise and try to eat a balanced diet. Have also completed marathon in my hay days Smile

The supplements that I have been taking as prescribed by the doctor :-

1. Bio enhanced calcium plus, vit d2 safflower oil and lecithin taken twice a day since I came back to malaysia.
2. Rocaltrol capsule 0.25 mg (calcitriol)taken once a day since I came back to Malaysia
3. Protaxos 2g taken every night at least 2 hours after meal/before bed time. Only started with this in the 2nd week of December.
4. Neobion taken only for one month in February as I felt numbness on my big toe and 2nd toe. Now they feel better but still some numbness. The degree of numbness has significantly reduced.
Question : Not sure if this will re-surface after grafting? I already have a permanent numbness feeling near the knee area.


Thanks in advance for you response.

Regards,
Mabel
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replied March 19th, 2013
Especially eHealthy
Mabel,

I hope I can answer all of your questions.

1. Chondromalacia patella

This is a term which is sort of overused, in that many physicians use it to mean that there are some degenerative changes around the patella (kneecap). Such as is seen with osteoarthritis (also called DJD - degenerative joint disease). In the patella, that would be narrowing of the "space" between the kneecap and the femoral groove (it really isn't a space, it just looks like it on x-ray. It is where there is cartilage, but since cartilage does not show up on x-rays, it looks like a "space".) There could also be osteophytes (bone spurs). The other two signs of DJD are subchondral sclerosis (hardening of the bone under the cartilage) and subchondral cysts.

However, in the purest sense, chondromalacia patella is a "surgical diagnosis". When an orthopedic surgeon does an arthroscopic surgery of the knee, and notes that the cartilage on the kneecap is soft to probing, then a diagnosis of chondromalacia patella can be made.

"Chondro-" means cartilage.
"-malacia" means softening.
"patella" is the kneecap.

So, you can see, that a radiologist cannot really make this diagnosis from an x-ray. But, again, it is often used sort of interchangeably with osteoarthritic changes.



2. Type of surgery.

The type of surgery selected is based on several things. One is where the fracture is located. If it is too close to the ankle or knee joint, then an intramedullary (IM) nail cannot be used. If the fracture actually goes into a joint, then an IM nail cannot be used. In these cases, special types of plates are used. There are custom made plates, just for the tibial plafond (just above the ankle) and tibial plateau (just below the knee).

In the midshaft, usually an IM nail, locked proximally and distally, is used.

However, a DCP can also be used in the midshaft. (DCP - dynamic compression plate). The plate is placed on the outside of the bone, up and down the bone. In the tibia, it is usually recommended that at least six cortices to “screwed”, above and below the fracture. So, that would require at least a six hole plate (three screws above and three screws below the fracture). If the fracture is oblique/spiral, then an interfragmentary screw (or more) would also have to be placed, in addition to the plate/screws. So, this takes a lot of dissection of the soft tissues to get to the bone, to place the plate. This is called on ORIF (open reduction and internal fixation).

In the US, if an IM nail can be used, it is the treatment of choice. It is felt that opening the fracture, to place a plate, causes higher risks of infection. Also, the extra dissection to get to the fracture, through all of the soft tissue can cause extensive scarring. So, the indirect reduction and placement of the nail is preferred.

But, in Germany, they will almost always place a plate.

So, it is up to the surgeon. He/she will make the decision based on location of the fracture, fracture characteristics, his/her training, and possibly patient preference.


(Now, this is for closed fractures. If the fracture is open (used to be called compound), then a different type of treatment is used. Frequently, in open fractures, an external fixator will be used, to stabilze the fracture, so that the wound can be managed.)




3. Bone grafting

It is the choice of the surgeon’s, as to what type of internal fixation he/she wants to use for the bone grafting procedure.


In some cases, if the fracture has an IM nail, and it just needs “a little help” in healing, the surgeon can elect to just remove the interlocking screws, to dynamize the nail. Then, with the patient bearing weight on the leg, it will sometimes stimulate the body to go ahead and finish healing the fracture.


If there is an IM nail, and the fracture has started to heal, but needs more help than just the dynamization would provide, then the surgeon can elect to just do a nail exchange, but no bone graft. In this case, the current nail and screws are removed and the IM canal is reamed again. By reaming the intrameduallary canal, it causes some bleeding around the fracture site, which can bring in some osteoprogenitor cells. Then a new, bigger nail is placed, but not locked.


But, if the surgeon feels that the fracture needs the full formal bone graft, then there is a couple of ways to do it.

The surgeon can do a nail exchange, just like above, but also open the fracture site, clean the fracture up, removing any fibrous tissue which has formed in the fracture, and then packing the fracture with bone graft.

Or, the surgeon can remove the nail, open the fracture, and plate it. Then, during the plating, the fracture would be cleaned, reduced, fixed with the plate, and bone grafted.


Usually, the best bone graft is an autologous graft (taken from the patient’s body). The best place to harvest the graft from in the anterior iliac spine (crest), also called the pelvic brim. This cancellous bone provides both scaffolding for the new bone to grow upon, but also osteoprogenitor cells, to jump start the healing process.


So, there are a lot of ways to do a bone grafting. It is again basically up to the surgeon and patient.




4. Bone graft harvest site.


It is true that many patients feel that the bone graft harvest site is more painful than the fracture site. This is probably due to a couple of reasons: one - this is an uninjured part of the body, so it is not supposed to hurt (you expect a fracture to hurt); and two - the muscles of the trunk attach to the pelvic crest, so just about all movement or stabilization of the body causes the site to hurt.


Since there is no real need to harvest a large piece of cortical bone for a structural graft, the bone graft can usually be obtained through a small incision, maybe an inch or so long (depending upon how heavy the patient is; if the patient has quite a bit of adipose tissue, the incision may have to be a little bit bigger). The crest is approached and a “small trap door” is made in the cortical bone. Then, a curette (looks like a tiny ice cream scoop) is used to scoop out the cancellous bone from the ilium. The ilium is part of the pelvis and it has two “tables” of cortical bone (the hard compact outer bone). Between the two tables is the cancellous bone (spongy bone). This is where the bone marrow is, where the blood cells are made. That is the bone graft that is wanted.


Again, many patients feel that the bone graft harvest site is the most sore. But, usually, most patients do not have too much trouble using crutches or a walker. And, the soreness tends to go away pretty quickly.

However, every patient is unique and reacts to surgery in his/her own way.





5/5a. Bone graft vs initial surgery


Again, everyone reacts to surgery in their own way. Usually, most patients have a slightly easier time with the bone grafting procedure, because they sort of know what to expect. Also, though there is trauma from the surgery, the limb is not having to go through a big trauma again.


But, depending upon how extensive the grafting procedure has to be, the patient may be up and about really quickly, or may be laid up for several days.


This is something that you would really have to discuss with your surgeon. Find out what exactly is going to be done. And, just ask the surgeon what to expect. That way, you can make arrangements for any help that you might need.

Again, it really depends upon exactly what is going to be done in the grafting procedure.





6. To remove or not to remove.


As to removing hardware once the fracture is healed, is basically up to you. In the US, there is no medical reason to remove internal fixation, as long as the fracture is healed, and the hardware is not causing any problems. However, in some countries, all hardware is routinely removed, once the bone is healed (as in Germany).

Once the fracture is healed, the hardware will not fail. The bone will support the limb and the hardware is no longer stressed.


So, once the bone is healed, if you want to have another surgery to remove the hardware, that is a possibility. But, if it is not causing any problems, there is really no need to undergo another operation.





7. Numbness


If you still have an area of numbness, just to the side of the incision at the knee, that is permanent. There is a tiny nerve that goes across the upper leg, just below the knee (the infrapatellar branch of the saphenous nerve), that gets transected when the incision is made, to place the IM nail. This nerve supplies the sensation to the area just lateral to the incision.

That spot will be numb forever, usually. In some cases, the patient may get a little sensation back, but usually, if that is going to occur, it will do so within the first 4-6 weeks after the surgery. So, if the area is still numb, it will probably be that way forever.






You need to really discuss all of this with your surgeon. Write down any questions that you have, that way, you won’t forget to ask them when you are with the surgeon.


Good luck.
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replied March 19th, 2013
Gaelic,


Thanks so much for your patience and detailed response. My understanding of the condition I am in is so much clearer now.

I have few more questions to add....

Q1. Have you come across any patient declared as non-union, but able to heal on its own without grafting procedure? If so, how long did it take till patient can walk without crutchers?

Q2a. Typically, how much blood is lost on the grafting site since tourniquet cannot be used?

Q2b. And how much blood lost working on the injured leg itself?

3. Typically, how long after grafting, patient can walk with some weight bearing (2 feet on the ground but still with crutchers) and without crutchers?

Q4. In the first surgery to addresss tibia fracture, why does the OS not do a proximal tibial bone graft harvest at that time especially for patients who are of a certain age? That would then save another surgery being done, won't it?

Q5. If grafting is required in my case, is there still an option to do a proximal tibial bone graft harvest?

Q6. Can I say that all grafting requires
(a) re ream of canal; and
(b) exchange of all the hardware from the 1st surgery?

Thanks again! I'll need all the luck! Going for my 2nd opinion tomorrow.

Will look out for your response before I go if possible.


Regards,
Mabel
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replied July 8th, 2013
Car vs bike
On the 5/4/2012 i was hit by a car while riding a motor bike suffering a fractured tib/fib , the tibia was plated & screwed & i had a vac dressing put on the wound they did not repair the fibular & told me that it would heal itself in time even though it almost had a s shape to it , after the vac dressing was removed & the stitches taken out the wound started to brake down & small pieces of metal from the plate started to become visible , the surgeon told me that if it got infected that they would have to remove my leg below the knee at this point i told them that i was going to get a second opinion , when i presented myself to another hospital the took one look at it & admitted me i was operated on the next day , they removed the plate & screws & ran a wire from my knee down to my ankle along the fibular to straighten it & help it heal properly they also put a vac dressing back on the wound site , after they were happy with how it was looking they put on external fixations & did a flap dressing , i had the external fixations on for 10 months before they decided it was not working the bone just wasn't showing any signs of growth so they decided that a bone graft would be the best way to go from there , i have had a cement spacer put in my leg to try & clean up the small infection that is still in there , at the moment i am awaiting a call from the surgeons to tell me to come in for the bone graft , it has been a year & a half since my accident & i have had over 20 operations on my leg . What amount of time would i be looking at in hospital for this procedure & how much longer will it be before i can expect to be able to walk again , i feel so frustrated as i just want my life back instead of just laying around in bed because thats all i can do at this point , i have been living at my sisters since i got out of hospital & without her help i would be lost . My avatar is of the x-rays after the first lot of surgery when they pinned & plated the fracture , i look forward to hearing your opinion of my case .
Thankfully Nihilist 73
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replied July 8th, 2013
Especially eHealthy
nihilist73,

Open fractures of the tibia are still a significant injury, even in the 21st century. They still carry a high rate of amputation, even with all of the technology available.


A bone grafting procedure usually does not take very long. However, it is all of the associated procedures that will take the surgeon's time. Such as cleaning up the wound (debridement) and stabilizing the fracture. Most likely, the surgeon will just continue with the external fixation, if all of the pin track sites are clean.

The bone has to be "freshened" up. The ends of the tibia have to be taken back to raw bleeding bone.

There has to be adequate soft tissue coverage for the bone graft to succeed. It is important to have a very good vascular bed for the bone to heal.

If you have a large segmental defect, that is usually replaced with one of several types of bone grafts. A cadaver graft can be used. Or a cortical graft from the pelvis can be fashioned to key into the defect. In some cases, a vascularized fibular graft can be taken from the opposite leg (the midshaft of the fibular can be sacrificed without any functional problems, as the fibula is a nonweight bearing bone).

The cortical bone graft has to be fixated in some manner. This can be with internal fixation, or the graft can be fashioned to just fit tightly into the defect (keyed in).

Then, cancellous bone (spongy bone) is harvested from the pelvic brim and is pressed into the small holes and crevices around the cortical bone graft. The cancellous bone is where the bone marrow is. So, it contains the cells needed to "jump start" the healing process. The osteoprogenitor cells.


So, in all, it can be a fairly big operation. You will most likely stay in the hospital for a few days.

Then, all you can do is wait and see if the graft takes.


All this time since your injury, hopefully, you have been lifting weights and using an arm ergometer (for cardio conditioning). You need to be in as good of a condition as your can be. Your injured leg is going to be extremely weak, as the muscles have atrophied.

Again, hopefully, you have been doing therapy to maintain range of motion of all of the joints in that limb.

If you have not, now is a good time to start.


You also need to be eating a proper diet, with extra protein (for the "building blocks" needed for tissue repair). You also need to be taking in extra calcium, vitamin D, and magnesium.

If you are smoking, you really need to quit. Nicotine is probably the single most detrimental thing there is to healing bones and wounds.


And, you need to get your head in the right place. You have to get through this next round of surgery.

You now know why many patients opt for an amputation. In many cases, patients have their amputation and are immediately fitted with a prosthesis. They can start walking almost immediately and get back to work. A BKA does not increase the "metabolic output" needed to walk but just a little. But, an amputation is a big decision, especially now that you have invested over a year and a half, and twenty surgeries.


Wishing you the best.

Good luck.
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