Hi gaelic i broke my right tibia on nov. 6 2012 in a motorcycle accident (open fracture type 3a or 3b not really sure) note with bone loss and a gap of 1 or 1.5 inch. My 1st surgery was on nov 7 were they put ex fix. I've been on ex fix for 2 months and on 6th of jan. 2nd surgery IM nail and bone graft which my OS took bones at both of my hips.. my first xray was at 5 weeks (feb 11, 2013) my OS told me that the fracture was now consolidating he told me to come back after 45 days.my 2nd xray (march 23 2013) looks not much different from my previous one i didn't notice any callus formation but my OS is not worried at all he said there are little positive changes at my my xray but less than what he is expecting..I ask my OS if im on a delayed union he said no..Im afraid im not healing its been 5 months since the accident..how long it will take for my bone grafted fracture to unite?my next appt is on april 30...13 weeks of no weightbearing is so frustrating.Im totally disappointed that i didn't see any callus formation..how long it will take to see a callus?I thought the bone graft will jump start the healing process?I don't have any pain at the fracture site even at my hips i don't have any pain..thank u in advance
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replied June 19th, 2013
Compound fracture Tib/Fib, getting bone graft
I had a Tibia and Fibula compound fracture on May2, 2013. I was struck by a vehicle in a single lane striking the left side of my bike with the right front side of his suv, my leg was hit at approx 40mph. I had emergency surgery that night with a rod and 4 screws. I spent five days in the hospital. During the surgery they had to take a large amount of the tibia out because it was shattered. The bone came out a few inches above the ankle. I'm at 7 weeks and the Ortho said their is no bone growth and that I need a bone graft. He is not taking bone from because of the amount needed. I still have swelling in my entire foot and ankle. My foot will turn purple if I have it down for a few minutes. Sometime my leg hurt but I can handle it, other times it is in extreme pain. When the inserted the nail they tried twice to put it in but it was to narrow about half way down so they put a smaller one in. I am 32 I have had a non displaced fracture of right ankle and torn ligaments that required surgery in 2011. I also had neck surgery in Jan of 2013. This fracture was the worst pain I ever had, I was begging for stronger pain meds but the staff wouldn't give it to me. I wanted to know if anyone just had a bone graft done, not during the rod being put it and if so how bad was the pain? I have a strong tolerance to pain meds because I was on it for a few months because of neck surgery so the meds in hospital did nothing. I also wanted to know if you just had bone graft how long it took to union, how soon did you know bone was growing after bone graft. I am worried about the pain being extreme and even worse that the bone doesn't union. Since a larger rod can't be put in I don't know what they would do if this doesn't work. I don't know if I can handle the rod removed and then put back in. Thanks for any experience you had.
Mike
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replied June 19th, 2013
Mike3505,

Open fractures of the tibial shaft are significant injuries. When these injuries occur, there is significant disruption of the veins and lymphatic channels in the leg, thus you get the purple discoloration when the limb in held in a dependent position (hanging down).

To get the venous blood, lymphatic fluid, and edema back to the body core, it requires muscle action in the calf and thigh. So, ankle and knee range of motion will help with the swelling.

Gravity helps to return these fluids to the body, so elevating the foot above the heart level will help a lot.

You might also get some compression stockings/support hose, to help with the circulation problem. There are several types of these: fashionable (department store support hose), medical type (TED hose, Jobst stockings), and the athletic type (compression garments, often made out of neoprene). Select the type that you want to use and get a couple. ACE wraps do not work very well, they tend to bunch up and then cause problems with compression.



As to the bone graft, if you have a significant segmental loss of cortical bone, usually a cadaver graft and BMP (bone morphogenic protein) are used. This provides the structural support needed (the cadaver graft) and the osteoprogenitor cells needed to jump start the healing process. These are usually obtained from the patient, but again, if you have a significant segment lost, that would probably not be feasible.

When a bone graft is done, it starts the healing process all over once again. Before the graft is placed, the ends of the bones have to be "freshened up". This requires that all of the fibrous tissue (sort of like scar tissue) that is in the fracture site has to be removed, back to the point that the ends of the bone are bleeding. The bleeding will help to bring in the blood cells needed to help stimulate the body to heal the bone. The problem with the cadaver graft is that it is a piece of dead bone. So, the body will have to incorporate this chunk of dead bone into the living bone, which will require the formation of new blood vessels around and through the graft. Again, this takes a long time. It is not uncommon for Grade 3B and 3C open tibia fractures to take as much as 30-50 weeks to consolidate and unite.



As to what can be done, if an IM nail cannot be placed, well, every case is unique, but a common treatment method is to use an external fixator. This can be a linear bar placed with four pins into the tibia (two an each side of the fracture) or with the use of a ring fixator (like an Ilizarov frame). The external fixator holds the bone in place while it is healing, but also allows for wound care and mobilization of the patient. The last resort would be to place the patient in traction for several weeks, followed by long leg casting. But, this is something that you would have to discuss with your surgeon.



As to your pain management, you need to discuss the situation with your surgeon. Unfortunately, when spatient have had to use significant amounts of opioids as outpatients, when they then sustain a significant injury/surgery, the “usual” amounts of pain medications are not “enough”. Thus, if you know that you are going to have to have more surgery, you need to discuss the situation with your surgeon and anesthesiologist. If the problem is known about ahead of time, the anesthesiologist can make arrangements for “alternative” methods of pain management, such as the use of epidural or regional anesthesia. This type of anesthesia can be continued post-op, to provide the patient with better pain management. But, you are going to have some pain, there is no way around that. So, besides discussing the situation with your surgeon and anesthesia provider, you need to find “things” that you can do for yourself, to help with your pain. Eveyone’s pain level in unique and individual to them.

For the same injury/surgery, some patients do not need a lot of pain medication, as they can take care of the situation with meditation and relaxation techniques. While others need pretty significant amounts of pain medication. There is no real correlation with how much or how high of a “pain tolerance” a patient has, it is just the way that particular patient handles discomfort.


So, again, you are going to have pain. But, knowing that going into the surgery, steps can be taken. Unfortunately, again, if the patient has a signficant amount of “tolerance” to opiods already built up, he/she is going to be between that proverbial rock and a hard place. While there is no “theoritical” maximum amount of opioids that can be given, there is a limit on how high a physician feels comfortable in prescribing. Usually, they just will not go above that level. So, that is where the alternative types of anesthesia and pain management have to come in.

You may need to see a pain management specialist before you have the next surgery. While there is no way to take all of your pain away (short of putting you into a “narcotic coma”, which has a whole list of problems associated with it), hopefully, the pain management specialist, along with your surgeon and anesthesia provider can keep you “comfortable”. There really isn’t a “pain free” state.


So, you are looking at some more pretty significant surgery and a very long road in terms of rehabilitation ahead of you. Recovery does not “just happen”, it has to really be worked at. The more you put into your recovery, the more you will get out of it.

Also, if you feel that you may be becoming clinically depressed, that needs to be addressed, and soon. Depression makes pain significantly worse, and pain makes depression worse. Then, you are in the vicious cycle. So, again, if you are sinking into the throws of depression, get it treated before it gets out of hand.


Wishing you the best. Good luck.
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replied June 19th, 2013
Especially eHealthy
Mike3505,

Open fractures of the tibial shaft are significant injuries. When these injuries occur, there is significant disruption of the veins and lymphatic channels in the leg, thus you get the purple discoloration when the limb in held in a dependent position (hanging down).

To get the venous blood, lymphatic fluid, and edema back to the body core, it requires muscle action in the calf and thigh. So, ankle and knee range of motion will help with the swelling.

Gravity helps to return these fluids to the body, so elevating the foot above the heart level will help a lot.

You might also get some compression stockings/support hose, to help with the circulation problem. There are several types of these: fashionable (department store support hose), medical type (TED hose, Jobst stockings), and the athletic type (compression garments, often made out of neoprene). Select the type that you want to use and get a couple. ACE wraps do not work very well, they tend to bunch up and then cause problems with compression.



As to the bone graft, if you have a significant segmental loss of cortical bone, usually a cadaver graft and BMP (bone morphogenic protein) are used. This provides the structural support needed (the cadaver graft) and the osteoprogenitor cells needed to jump start the healing process. These are usually obtained from the patient, but again, if you have a significant segment lost, that would probably not be feasible.

When a bone graft is done, it starts the healing process all over once again. Before the graft is placed, the ends of the bones have to be "freshened up". This requires that all of the fibrous tissue (sort of like scar tissue) that is in the fracture site has to be removed, back to the point that the ends of the bone are bleeding. The bleeding will help to bring in the blood cells needed to help stimulate the body to heal the bone. The problem with the cadaver graft is that it is a piece of dead bone. So, the body will have to incorporate this chunk of dead bone into the living bone, which will require the formation of new blood vessels around and through the graft. Again, this takes a long time. It is not uncommon for Grade 3B and 3C open tibia fractures to take as much as 30-50 weeks to consolidate and unite.



As to what can be done, if an IM nail cannot be placed, well, every case is unique, but a common treatment method is to use an external fixator. This can be a linear bar placed with four pins into the tibia (two an each side of the fracture) or with the use of a ring fixator (like an Ilizarov frame). The external fixator holds the bone in place while it is healing, but also allows for wound care and mobilization of the patient. The last resort would be to place the patient in traction for several weeks, followed by long leg casting. But, this is something that you would have to discuss with your surgeon.



As to your pain management, you need to discuss the situation with your surgeon. Unfortunately, when spatient have had to use significant amounts of opioids as outpatients, when they then sustain a significant injury/surgery, the “usual” amounts of pain medications are not “enough”. Thus, if you know that you are going to have to have more surgery, you need to discuss the situation with your surgeon and anesthesiologist. If the problem is known about ahead of time, the anesthesiologist can make arrangements for “alternative” methods of pain management, such as the use of epidural or regional anesthesia. This type of anesthesia can be continued post-op, to provide the patient with better pain management. But, you are going to have some pain, there is no way around that. So, besides discussing the situation with your surgeon and anesthesia provider, you need to find “things” that you can do for yourself, to help with your pain. Eveyone’s pain level in unique and individual to them.

For the same injury/surgery, some patients do not need a lot of pain medication, as they can take care of the situation with meditation and relaxation techniques. While others need pretty significant amounts of pain medication. There is no real correlation with how much or how high of a “pain tolerance” a patient has, it is just the way that particular patient handles discomfort.


So, again, you are going to have pain. But, knowing that going into the surgery, steps can be taken. Unfortunately, again, if the patient has a signficant amount of “tolerance” to opiods already built up, he/she is going to be between that proverbial rock and a hard place. While there is no “theoritical” maximum amount of opioids that can be given, there is a limit on how high a physician feels comfortable in prescribing. Usually, they just will not go above that level. So, that is where the alternative types of anesthesia and pain management have to come in.

You may need to see a pain management specialist before you have the next surgery. While there is no way to take all of your pain away (short of putting you into a “narcotic coma”, which has a whole list of problems associated with it), hopefully, the pain management specialist, along with your surgeon and anesthesia provider can keep you “comfortable”. There really isn’t a “pain free” state.


So, you are looking at some more pretty significant surgery and a very long road in terms of rehabilitation ahead of you. Recovery does not “just happen”, it has to really be worked at. The more you put into your recovery, the more you will get out of it.

Also, if you feel that you may be becoming clinically depressed, that needs to be addressed, and soon. Depression makes pain significantly worse, and pain makes depression worse. Then, you are in the vicious cycle. So, again, if you are sinking into the throws of depression, get it treated before it gets out of hand.


Wishing you the best. Good luck.

Read more: Broken Bones Forum - tibia bone graft http://ehealthforum.com/health/tibia-bone- graft-t391407.html#ixzz2Wj2im4Oy
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replied June 20th, 2013
Compound fracture Tib/Fib, getting bone graft
Gielia, thanks so much for the info. Unfortunately I had neck surgery on Jan 28, 13 and was taking Oxycodone 15mg 3 to 4 times a day for a while, by March I was down to 10mg. I stop taking them in mid April. I have a very high tolerance to pain medications now. When I had the first surgery, I could not get any relief. The pain was so bad, I couldn't take it. I'd love to hear from anyone that just had a bone graft after the initial surgery and had it work. I don't know what the chances are that this will work and I need it to. I was suppose to get married here May 18th, we were then going to have the ceremony, in Punta Cana tomorrow so it's a bit depressing for my fiance and I. I'm just hoping in 6 months the bone will union. I don't mind doing physical therapy, though it may be difficult I just want the bone to grow back. My Fibula break on x ray shows the bones are not even close to each other. My Ortho isn't even worried about that, I don't know why. He said it may heal on it's own but I can't see how when their so separated. It just sucks and I need the Tibia to union with this bone graft. I'm trying to stay positive but if this doesn't work it will break me. My fiance is already depressed and I'm trying to be positive because this is making things hard. If this doesn't work she's going to me more depressed then me. I need a light at the end of the tunnel. Can anyone tell me that they had a bone graft and it worked? What is the % of this working and I'll be able to go on with my life. I can't imagine still being like this in 6 or 7 months.
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replied June 20th, 2013
Compound fracture Tib/Fib, getting bone graft
The other thing is my neck is now hurting like hell. I had a herniation in my back prior to this but that's also hurting more. I probably screwed up my getting hit and I can't even worry about that because of my leg. Has anyone seen growth when they used a bone stimulator? I asked my Ortho to get me one, I fig anything that will help. Also a friend of mine told me someone he knows that had a compound fracture in leg years ago was prescribe HGH to help bones heal. Has anyone been prescribed a type of steroid to promote bone growth? I had my primary this past Monday take blood to check HGH levels and test testosterone because a year ago my brother had his checked and it was low.
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replied June 21st, 2013
Especially eHealthy
Mike3505,

As to the bone stimulator, the data is mixed. The information put out by the companies which make the devices, always show positive results. Bu, if you look at more independent data, the results are not as good. Most surgeons will give a stimulator a chance, but, do not put all your hopes on having one work miracles. In most cases, the time period where the stimulator was used, was probably what actually got the bone to heal. By putting the stimulator on the fracture, it "forces" the patient to give the fracture more time to heal. Did the stimulator actually help the fracture heal, or was it just giving the bone more time to heal that did the trick??


As to human growth hormone, again, there is mixed results with its use. Some research has shown good results when used in patients with osteoporosis or who already have low HGH levels. Others studies show no decreased healing with the use of HGH. This is something that you can discuss with your surgeon. Of note, unfortunately, long term use of opioids can cause low testosterone levels in men. So, if you took the oxycodone for an extended period of time, you may have low testosterone levels. That should be checked also.


About bone grafting, if you have a segmental loss of bone, the only way you are going to get the bone to unite, would be with the use of a bone graft. In fractures, the bone fragments have to be in contact, for them to heal. So, if you have a significant "gap", that has to be filled in with something (bone graft).

If your "gap" is pretty significant, with loss of the cortical bone (the hard outside bone), you will need to have that replaced. That is usually done with the use of a cadaver graft. To "jump start" the healing process, usually, some autologous cancellous bone graft will be harvested from the patient's body (usually from the iliac crest, the pelvic brim). The cancellous bone is where the bone marrow is located, which has newly formed blood cells as well as the precursor cells needed for new bone growth (osteoprogenitor cells).

So, the surgeon would "freshen up" the edges of the fracture, back to bleeding bone (remember that bone is alive, it is living tissue). Then, the cadaver graft is placed and held there with whatever type of internal fixation that the surgeon wants to use (or can use). The small gaps between the patient's bone and the cadaver graft are filled in with the cancellous bone graft.


In the vast majority of cases, the bone grafting procedure is allow for bone healing. If bone grafting did not work, it would not be used. It is a big procedure, but again, if you have a significant gap in your bone, it has to be filled in with something.


Also, again, it sounds like you are struggling with the stresses of having a significant injury, besides that of being a newlywed. If you need to talk to someone, do so. Depression can really make everything seem so much worse. Do get some help, if you are slipping into a clinical depression.


Wishing you the best. Good luck.
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replied June 21st, 2013
Compound fracture Tib/Fib, getting bone graft
Thanks for your help again, I wish I knew how to/ or if I could download a copy of my x rays. The Tibia a few inches above ankle is fractured. On the right side of the rod their is a space where only the rod is no bone. My surgeon said he wasn't using my bone so I'm not sure what he's doing. I also asked him about putting a plate in to hold the graft in place because I've read about it on here. He told me it's going to be pressed in and will stay in place and nothing else is needed. I was hoping a bone graft of this kind wouldn't be to painful. Doctor made it sound like he's just going to cut around the area the bone came out pack this stuff in and close it. He told me I should be able to go home that evening. I'm kind of worried now because you said i"t would not be used. It is a big procedure, but again".I thought this was the easiest thing that could be done. Is this going to hurt as bad as the nail being put in? Now I'm really worried about the pain as how high my tolerance is, I can't do something like this again. I did so much research on HGH and testosterone. I say my personal MD on Monday to get all that stuff tested. I also don't think my surgeon would give me either and I doubt my doc would without my agreeing. Do you know the chance of a bone graft without using your own bone is successful? If I'm low on testosterone, which my youngest brother was a year ago when he got checked, should I def get a script. If HGH levels are low should this Ortho give me something for it? I feel like if he doesn't he's increasing my chances of having more problems. He's an ok Ortho but doesn't explain anything to me. He told me from the first visit after surgery that I'd need a bone graft. He never told me not to drink coffee, take vitamins. When I asked him how painful it would be, he knows how bad it was in my first surgery. He said it won't be that bad, my surgery is Wed at 1:15pm. I was told I should be out the same day, then said maybe one night stay. I don't know if I like this Ortho because he looks at my leg and says looks good, not infected, bone isn't growing though. I'm glad I don't have an infection, wounds healed, I don't even care about all the scars I just want to move on with my life. Every time my fiance and I plan something or pick a new date I either have another surgery interfering or I get hurt again like this and this is the worst injury. Sorry for the rant, my fiance is so depressed she can't talk about weddings, anything really. She wants to delete her facebook because seeing everyone getting married, down the shore, having fun it's depressing her. Today would of been our ceremony at 6pm in Punta Cana. Instead she is working like everyday, she has to stop home after to let the dog out and can't go anywhere because I can't take dog out or get food. I have to put on a smile and pretend I know everything will be ok when I don't. She broke down again last night because she says she has nothing to look forward to. We have now planned a wedding twice and surgeries/ injures from accident in 2010 stopped one that, now this one. What can I say besides, this bone graft will work, I'll be walking around in 5 or 6 months it will be completely healed. That is all I can say, I can't tell her that I have no idea what will happen. If I'm not healed in 6 months I will probably break down, I can't sit here a year from now going in for another surgery that will start me back at square one, I don't think mentally I can handle that.

Sorry for bouncing all over, have no way of releasing this.
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replied June 21st, 2013
Especially eHealthy
Mike,

If your surgeon uses a cadaver graft, so you do not have a "harvest site", the procedure should not be quite as bad as the first surgery. But, it is not fair to the patient to tell them, "oh, it is just a simple little procedure, you will be able to go home the same night, it is no big deal...", and then the patient wakes up from anesthesia, and say, "Oh $h#%, that hurts...!". It is better to tell them ahead of time to expect some discomfort, and then if it turns out that it is not too bad, then great. But, at least the patient is not blind sided that way. Most patients would rather be told really what to expect.

It is not a great idea to scare the heck out of patients. But, unfortunately, now with "informed consent", and all of the malpractice lawyers out there, surgeons now have to tell the patient all the bad things that could possibly happen, even if the chances are really low (like a million in one). So, most consent forms now start off with, "you could die from this procedure", so everything after that does not seem too bad (lol).


But, since you already have the IM nail in place, that will help. Then, usually, all that needs to be done is to "freshen up" the bone (remove the fibrous tissue from the fracture site, because you really want the bone to bleed - that brings in the needed cells for the bone to heal), and place the graft. Again, if the surgeon uses a cadaver graft (or some type of artificial bone substitute, such as coral), then he/she "sculpts" the graft to fit in the "hole" in the bone. Many times the graft can be "keyed in", so no internal fixation is needed to hold it in place.

However, since the surgeon is not going to use your own bone (autologous graft), it will take some time for the "dead" bone, or the bone substitute, to be incorporated into the living bone. As the body incorporates in the graft, it will have blood vessels grow into it, and it will eventually become part of the living bone. Through creeping substitution, the bone will "absorb" the graft. Incorporating it into itself. With time (quite a bit of time, like a few years), you might be able to see where the fracture was at one time, but the bone will come to look the same.


But, again, any time you cut open the skin, dissect out the soft tissues, manipulate the bone a little, then close up the wound, it is going to hurt some. Again, it probably won't be as bad as when you had the initial injury/surgery, but it is going to be uncomfortable.

Speak with your anesthesia providers about your problems with post-op pain control. Be sure he/she knows that you were on oxycodone for a while, and that you have built up a tolerance to Schedule II opioids. Again, it may be possible for the anesthesiologist to do regional blocks, or to use an epidural, so that you have better post-op pain management. Sure, it is nice to be able to go home the same night as surgery (keeps costs down too), but you have to have adequate pain control before that can happen. Be honest with the anesthesiologist, disclose all of the opioids and other pain medicine that you have had to use in the past. That way he/she can provide you with the best "experience" possible.


As to the human growth hormone and testosterone, the orthopedic surgeon may not feel comfortable managing those replacements. He/she may actually refer you to an endocrinologist. Again, if you have low levels of these hormones, then you would probably benefit from some replacements. But, in patients with normal levels, they have not really shown any added benefit in getting fractures to heal.



Sorry your fianc is having such problems accepting YOUR injury. Come on, you are the one who is having to "suffer" through the pain of it all. However, if she is having that much trouble, it may be that SHE needs to see someone for depression. Or, you may need to go as a couple. But, again, you are already under enough stress, to let alone now having to deal with this problem. I understand that she is upset. And, just as I advised you to get help if you think you are developing clinical depression, she may need to see someone also. Oh well....


So, you have another good sized orthopedic surgery ahead of you. If should not be as bad as when you injured your leg and had surgery the first time. But, you are going to be sore.


Hang in there. You have gotten this far. You've come too far to give up now.


Wishing you the best. Good luck.
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replied June 21st, 2013
I got my blood work back just now in the mail from my primary, it states hgh is good however Testosterone level is extremely low and to make an appointment. I made one for Monday. I called Ortho to advise and faxed paperwork over, the girl told me he would not prescribe Testosterone but I should be able to get primary md to do it. I told them I read about it helping with bone growth and density. She told Ortho and said he never heard of that and would have to look into it. Is what I'm reading online correct? If it is I don't understand why the Ortho doesn't know this. Thanks I will have to tell them about the pain meds. When I had the emergency surgery after the accident when I woke up Ortho was gone. I spent 5 days in hospital and I was in the worst pain of my life. The were giving me two 2mg dilaudid every 4 hours, it did nothing. At one point I had to pee and I had a plastic thing to use but I could not even move to lean my self to the side a little. I told the doctor their I needed more pain meds and that I was in so much pain I can't pee. The guy was such a D!ck and so were the rest. They kept saying if your in that much pain they would have to cut my leg open due to pressure when they had already stuck and the pressure was fine. I can read people as I am a retired police officer due to the other injuries/surgeries I had prior. They new I didn't need it but thought they would scare me. The doctor had the nurse come in with a Valium, I flipped out. I told her I'm not taking that and I told her I don't want that doctor back in my room or I'll throw something at him. I had told them I was taking Oxycodone for months prior up until a few weeks prior I stopped, they didn't care. My surgery is at a different hospital now so hopefully they will help me so I'm not is so much pain. Thanks again for all your help. Can you tell me if the information about Testosterone is correct that I'm reading online. I don't understand why the Ortho doesn't know. Also being that it is so low why wouldn't he prescribe it to me if it helps promote bone growth and things it produces for bone growth?
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replied June 22nd, 2013
Especially eHealthy
Mike,

You might find the following abstract interesting. Again, the data on HGH and testosterone is not all consistent. Though there are some studies which show that HGH and testosterone may help in fracture healing (especially in elderly, osteoporotic patients, or in patients who have low levels), not all studies show a positive effect.


As to the surgeon not knowing a lot about the use of these hormones in fracture healing, it is not surprising. Orthopedic surgeons usually will learn some about this in their Basic Science lectures during residency, so that they can answer some questions on their “board exams”. But, most do not actually do the treatment of patients with low levels of HGH and testosterone. They will usually refer the patient to their primary care physician or an endocrinologist, for the actual treatment. It is the same with “little old ladies” with osteoporosis. Orthopedic surgeons know about osteoporosis, and how to diagnosis it (and how to treat the fractures which these patients sustain), but most do not actually treat the little old ladies with medication. They leave that up to the patient’s primary care physician.

The field of orthopedic surgery encompasses so much information, that it is just not possible for the surgeon’s to know it all. This is why most orthopedic surgeons will subspecialize nowadays. A couple of decades ago, most orthopedic surgeons were general orthopedists, they did a little bit of everything. But, again, nowadays, most will do a fellowship in one of the subspecialities (total joints, spine, sportsmedicine, pedi pod (pediatric orthopedic surgeon), hand surgery, ortho oncology, foot and ankle, trauma/reconstruction, and so forth).

Again, most orthopedic surgeons will learn about the basic sciences during residency, but once they have taken their board exams, most quickly “purge” that information. There is just so much that they have to know, just for the subspecialty that they do practice.


Again, the hormone data is still controversial. It is a lot like that of bone stimulators, PRP (platelets rich plasma injections), stem cell therapy, and so forth; there is data on both sides. You can find data to say whatever you want it to.


Hang in there. You still have a long ways to go. You do need to discuss your low testosterone level with your primary care provider. And, again, it IS well known that long term opioid usage can cause significantly low levels of testosterone in men. It is one of the endocrinopathies that is seen in long term opioid use. So, your primary care provider may need to do some more investigation to determine what is causing your low testosterone levels. Your family history will be important here.


Wishing you the best.





Z Orthop Unfall. 2008 Jan-Feb;146(1):59-63.

[Therapy effects of testosterone on the recovery of bone defects].

[Article in German]

Maus U, Andereya S, Schmidt H, Zombory G, Gravius S, Ohnsorge JA, Niedhart C.

Source: Klinik fr Orthopdie und Unfallchirurgie, Schwerpunkt Orthopdie, RWTH Aachen.

Abstract

AIM:
Androgens have proliferative effects on osteoblasts and increase fracture healing by systemic and local stimulation of bone formation. The aim of the present study was to evaluate if the systemic stimulation by androgens leads to increased bone-defect healing.

METHODS:
1.5-mm trepanation defects were created in the femoral diaphysis of 30 Sprague-Dawley rats. 10 animals were used as untreated controls and 10 animals per group were treated by intramuscular injection of 1 or 10 mg dihydrotestosterone two days prior to surgery. After 14 days the samples were explanted and examined by macroscopy, histology and histomorphometry.

RESULTS:
All animals were included into the study and were analysed. Clinical observation showed no complications. Macroscopic examination and histology showed no significant differences. All defects were filled with trabecular bone in direct contact to the surrounding bone. Histomorphometry showed a significantly decreased bone content in the controls in comparison to both therapy groups, while the therapy groups showed no significant differences between each other.

CONCLUSION:
The stimulation of healing of bone defects with androgens leads to a significantly higher bone content inside the defects. In clinical application, androgens may be a possibility to increase bone formation, especially in elderly patients. Furthermore, it may be possible to shorten postoperative rehabilitation because of the effects of androgens on muscles.
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replied June 30th, 2013
Well I had the bone graft done on the 26th, was able to go home the same day. I told the ortho about my tolerance to pain meds. I was able to get nerve block injections which worked great, my leg was numb for almost 24 hours. The Ortho said he is getting me a bone stimulator so hopefully when I see him on the 2nd he will have it. I'm not sure what kind he will have. I've been doing a lot of research and it seems like this (Exogen 4000) studies done that shows really high rates not just healing but also treating non unions. I read forums where some had a different kind and had a non union and then were given this kind and it worked. I ended up buying a used one (used 11 times) on ebay for 300 dollars. I don't know if I'm given a different one by Ortho can I use both of them, one after another? I also saw my primary my total Test was 49, extremely low. He gave me a 30 day supply of Test but said I need to see a endocrinologist. Their were 3 total hormones all produced by the same gland and all were very low. I'm going to try to make an appointment soon with one and ask if I can get HGH. The lab paperwork is confusing, it says Growth Hormone, Serum 0.1 ng/ml. Their an area next to it where it says Reference interval, which I'm guessing mean the average but it goes from 0.0-2.9. Where should I fit in that, 0.1 seems low to me. The Test is 49 and says low, where it should be is between 348-1197.
Being that I've been able to find a lot of research and the results look good for Exogen stimulator I am hoping I can use both in the same day. I need to get this healed and I can't wait 6 months and have to start over with another surgery. A good friend of mine told me someone he knows had the same injury and his Ortho prescribed him HGH to help it heal. My Ortho will not prescribe any of it and my primary didn't even want to prescribe the Test due to levels so low he wants me to see a specialist. If my levels are normal for my age, 32, if the HGH will make my bone grow I am hoping they would at least prescribe it to me just for two months. My fiance is already yelling at me for ordering the Exogen because she said it may not be safe to use both. I tried to look for information online but can't find anything about it. Since the both seem to work the same way I can't see why it would cause damage if I did. Any advice or knowledge is appreciated.
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replied June 30th, 2013
Especially eHealthy
Mike,

It probably wouldn't hurt to use both, but it most likely won't help much either. Theoretically, you can overuse the ultrasound devices. There is a fine line between the ultrasound being therapeutic, helping to stimulate a bone to heal, and having the sound waves actually interfere with the healing process.

Healing fractures are a relative contraindication to the use of deep healing ultrasound machines. Many physical therapists will not use ultrasound over fresh fractures.

The Exogen stimulator does use ultrasound, but the intensity and wave length are much different than the deep heating ultrasound modality. So, the manufacturers of the Exogen state that it should be used exactly as the physician prescribes it.

Remember, just because something may work, does not mean that overdoing it works better.


I have mixed results with stimulators. If the bone heals when a stimulator has been employed, great. But, I have basically found that it is the bone grafting that actually causes the fracture to unite, along with the extra time.


As to the HGH, again, it has mixed results. And, most of the positive results have been in patients with osteoporotic bone. You do not want to use excessive amounts of HGH, because that will cause irreversible acromegaly. Its use must be regulator and managed by someone well versed in its effects (ie an endocrinologist).

You should probably be under the care of an endocrinologist, since your testosterone level is so low. That really needs to be worked up, as to why it is so low.


Good luck. Glad that your surgery was not too much of an ordeal this time (with the use of blocks).
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replied June 30th, 2013
Thank you so much for your replies, I really appreciate it. My Ortho made it seem like the bone graft was a breeze and if I hadn't received the information from you I may not have even been offered the nerve blocks. I am going to make an appointment with an endocrinologist as my primary stated I need to. I did some research on Test and I saw it helps with bone density, does it also help with bone growth? My primary wanted to wait and have an endocrinologist give me the Testim 1% but I told him I didn't know how soon I could get in to see one. I saw him two days before my surgery. I was concerned that these low levels may have something to do with my bone not growing and just want every advantage I can get. I am now in a soft cast, prior I was in a walking boot, I guess that's what it would be called. When I get my next x rays done I'd like to be able to post them on here so maybe you could tell me if it is healing. I don't know how to download them to this site though. If anyone knows how could you let me know. Again thank you so much for all your help. My Ortho doesn't really explain much and when I try to ask he still doesn't explain much, he just says it will work out.
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replied July 1st, 2013
Especially eHealthy
Mike,

Everyone needs a certain amount of testosterone, even women. While it should not keep a fracture from healing, as you state, it may lead to problems with overall bone density.

Osteoporosis is a problem with bone density, but the mineralization of the bone is normal (there is just less of it). Osteoporotic bone will heal if the patient sustains a fracture. The problem is that they may sustain another fracture from the loss of bone density. Men can get osteoporosis just like women. But, theirs is called senile osteoporosis, mainly just from aging. Women develop post-menopausal osteoporosis, from the lack of estrogen.


The post-op dressing you are in is probably just the usual bulky compressive dressing, meant to keep swelling to a minimum. Yes, I am glad that you had the nerve block done, it makes the procedure much easier to deal with.


Good luck.
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replied July 2nd, 2013
I went to Ortho today and he said the wound looks good. Where the bone graft was put in the area is raised which he said is normal. Going back next week to have stitches taken out. He said it would be hard to see on x ray if it's healing due to having the bone graft done. He made it sound like it's hard to tell the difference between the graft and bone growth, is this true? He also told me before surgery he would have a bone stimulator for me as I have been asking for one for a while. I left forgetting to ask about it. I called up as soon as I got home and the lady said she has to ask the doctor. Why hasn't he got me one yet? It's starting to bother me the way he acts, lack of answering questions and explaining things to me. Now I'm frustrated because he didn't get the bone stimulator. I ordered one online but it's going to be a week before I get that one.
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replied July 2nd, 2013
Especially eHealthy
Mike,

Sorry you are having problems.

Who knows why the bone stimulator was not ordered. But, if the surgeon told you he was going to get one, that probably should have been done. Unfortunately, some surgeons tend to sort of "think" out loud, "discussing" options mainly with themselves, the patient is present to hear this, but later the surgeon feels that a different course is best (but the patient is no longer there to hear this). Not to say this is correct, just that this does occur.

Again, as to the bone stimulator, the results are very mixed, and many surgeons feel that they do not do anything (but get the patient to give the fracture more time to heal). Almost all of the positive results reported with the use of stimulators comes from the companies who make the devices. So, it is subject to extreme bias.


I sorry, did you state what type of bone graft you had placed? Was it cadaver, bone substitute, or autograft (taken usually from the pelvic brim)?

As to the healing, it depends upon the type of graft used, as to how it will look during the healing process.


Hope you are getting your testosterone level taken care of, and finding out why it is so low.


Good luck.
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replied July 2nd, 2013
The bone graft was a Cadaver bone, I believe. It was taken from someone who donated it after their passing. I attempted to reach a specialist who my primary recommended due to the hormone levels being low. One is no longer in business, the other doesn't take my insurance. I contacted the third who told me the doctor will not see anyone under the age of 50, what is that about. Why would you not see me because I'm not 50 or over, ugh. My leg where the bone graft was done is raised a bit, which of course he said is normal. He didn't say when it would go down. I asked him when he takes an x ray in a month or so should he be able to tell if it's healing. He told me that it's hard to tell the difference between the graft and bone healing, this I don't understand. When will he be able to tell if it's healing or if it's just the graft between the break? He doesn't really explain things and I don't understand. When he says he won't be able to tell the difference, well how do I know if it's healing? When will my leg go back down to normal? It's not a minor bump it's a pretty large bump where the graft was placed. I'm going to figure out how to post my x ray and the next one he does I'm going to post it.
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replied July 2nd, 2013
The bone graft was a Cadaver bone, I believe. It was taken from someone who donated it after their passing. I attempted to reach a specialist who my primary recommended due to the hormone levels being low. One is no longer in business, the other doesn't take my insurance. I contacted the third who told me the doctor will not see anyone under the age of 50, what is that about. Why would you not see me because I'm not 50 or over, ugh. My leg where the bone graft was done is raised a bit, which of course he said is normal. He didn't say when it would go down. I asked him when he takes an x ray in a month or so should he be able to tell if it's healing. He told me that it's hard to tell the difference between the graft and bone healing, this I don't understand. When will he be able to tell if it's healing or if it's just the graft between the break? He doesn't really explain things and I don't understand. When he says he won't be able to tell the difference, well how do I know if it's healing? When will my leg go back down to normal? It's not a minor bump it's a pretty large bump where the graft was placed. I'm going to figure out how to post my x ray and the next one he does I'm going to post it.
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replied July 2nd, 2013
http://i43.[image removed]/v3136e.jpg

This is my last x ray before surgery
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replied July 2nd, 2013
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Mike,

From your x-ray, it looks like you may have been forming a synostosis between the tibia and fibula, just above the fracture site. It is not possible to know from sure from just one x-ray, you really need two views taken at 90 degrees to each other (ie an AP and lateral). A synostosis is a bone bridge between two bones.


Cadaver graft has to be incorporated into the living bone. That can take quite a while, as the living bone "creeps" into the dead cadaver bone, and "absorbs" it. Usually, there will be a change in the density and the way the graft looks as the consolidation progresses. But, it does not look the same as a fresh healing fracture.


The swelling is going to take a while to go down. You have had some pretty significant insults to the soft tissues around the fracture (from the injury and surgeries). Once you are out of any surgical dressings, if the swelling continues, you may need to get some compressive stockings (support hose) to help with it. There are several types: fashion (you can get these at department stores), medical (such as TED hose or Jobst stockings), or the athletic type. You would probably do best with either the TED hose or the athletic compressive garments. These actually do help a lot with soft tissue edema and swelling.


It is strange that the endocrinologist does not take patients under the age of 50. But, there are some physicians who do specialize in the "geriatric" population (just like pediatricians take care of kids).

If you cannot find an endocrinologist, some urologists also take care of men with low testosterone levels.


Good luck. Looking forward to your new x-rays.
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replied July 14th, 2013
I had my bone graft done and have just started PT. My range of motion is horrible, I have had a lot of swelling in foot/ankle since first injury 5/2/13. The swelling has finally gone down, it's still there but it was really bad for months. I'm including my x ray that was just taken. Ortho said wound looks good, it looks like my fibula is starting to heal but he didn't say the Tibia was doing anything. I have a large bump where the bone graft was placed. I have just started putting about 20lbs on my leg, it does hurt but I'm hoping this helps it heal.
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