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Elaine : spiral comminuted fracture of distal tibia and fibula Part 2
Diary entry posted Thu 5:34pm 25 July 2002

Part 2

I am a science teacher and have done a lot of research into this subject over the last year. What I have found is that IM rodding is the currently favored way to treat distal tibia fractures, but apparently most orthopedic surgeons do not try real hard to get the fragments properly realigned. There is a technique to do that without doing a full-scale open reduction, but most of the O.S.'s I've talked to are unaware of it. It involves inserting a half-pin through the skin and into the bone fragment and using the pin as a "joy-stick" to move the fragment into position. Then the pin can be removed and the tiny incision closed.

The next thing I learned is that distal tibia fractures are often spiral fractures and that the spiral break causes the break surface to be steeply angulated from horizontal. Mine is at least 60 degrees and in some places as high as 75 degrees above horizontal. Weight bearing in a horizontal fracture causes compression of the fracture and micromotion perpendicular to the break surface as you weight/unweight. This does stimulate healing. Unfortunately, when the break surface is tilted, the weight force vector needs to be resolved into a compressive component and a shear component. Only the compressive component helps the healing. Above 45 degrees of tilt, the shear component becomes larger than the compressive one and any healing that the bone is trying to do is sheared off by each weight/unweight cycle. In my case, the shear component is at least 1.5 times as large as the compressive one. What that led to with me was first, the lower screws bent with partial weight bearing and then, the screws broke with full weight, because the bone was not supporting the weight, only the rod and screws were. When the screws broke, the upper section slid down the "ski slopes" of my break surfaces until the rod bottomed out on the bottom of my tibia. If there had been any healing, at that point it was sheared off and the spiral CT scan with 1 mm slices and MRI confirmed a complete non-union with swelling of the bottom of the tibia from the pressure of the rod. I was told that I was at risk of driving the rod through my ankle, destroying it.

Another aspect of a spiral fracture is that of rotation. Several of the notes on this site made mention of foot not being lined up with the knee and I also had that, about 15 degrees. Besides the strain on the knee and the ankle if the leg heals that way, this causes additional problems in the healing. The two broken surfaces are not lined up by however many degrees the foot is rotated out. That can cause the break surfaces to actually be juxtaposed with unbroken cortical bone on the opposite fragment. Cortical bone is the hard outer part of the bone and it will not heal to the broken surfaces.
If that all wasn't enough, the small lower section of my tibia was angulated (crooked) compared to the main part of the tibia. Besides leaving me unable to balance on that foot because it put the weight force vector too far back in the heel, it caused the break surfaces to diverge so that they were close together on one side, but wide apart on the other side.

During this time I interviewed over a half-dozen orthopedic surgeons. Several wanted to do an exchange nailing, reaming out the bone (great, a thinner tibia) and putting in a larger rod. Most would do only minimal effort to fix the angulation, rotation, and half-inch length loss from the break sliding. They said don't listen to anyone who suggests an open reduction with plates and screws. Most of the rest of the orthopedic surgeons wanted to do an open reduction with plates and screws, again with only minimal concern about correcting what I felt were the causes of the non-union to begin with, and with restoring biomechanical function so I don't end up as a 46-year-old cripple. They also said don't listen to the doctors who wanted to do rodding.

Via a referral by my cousin who is a podiatrist, I found a podiatrist/surgeon who is a biomechanical expert and who uses external fixators a lot. In all fairness to orthopedic surgeons, there are some who specialize in external fixators and who could have done this, but they seem to be located in major cities that were not convenient for me.
This is his plan. My IM rod is to be removed because it is in the way of lining up the bone sections. My partially healed and incorrectly aligned fibula is also blocking proper alignment and will probably have to be re-broken and plated in the correct position. Any scar tissue and fibrous tissue that has formed in the break will have to be removed. If the bone ends have "sealed off", they will have to be pared back. They will coat the ends with my concentrated growth factors from my blood and then use donor bone grafting material. A Technetium Bone Scan indicated good bone growth and activity, or I would have had to have bone taken from my hip. The doctor will line all the pieces back up where they belong. (He thinks getting the bones in contact and where they're supposed to be gives you the best chance of healing. My contention exactly, and why I had wanted an open reduction a year ago. When I had an open reduction on a very bad ankle break 15 years ago, you couldn't even see where the break had been just 4 weeks after surgery.)

The leg length will be restored by sliding the segments back up the break to where they belong. The steeply angulated break surfaces will be brought into compression by using "skinny wires". This is done in a way that resembles hand sewing using thread with a knot on the end. The wires are "sewn" through the bone from opposite sides, pulling the pieces together, and the ends of the wires are anchored to the external fixator. In my case, my break is so complicated, that he may have to "sew" in multiple directions. (Getting all the wires to pull in the right directions and with the right force reminds me of a force table in Physics.) The upper and lower segments are each attached to the external fixator using half-pins that go through the skin and screw into the bone. He plans to have two rings above the break and two below. The rings are anchored to each other by long rods. This whole contraption is so stable and self-supporting that you're supposed to be able to start walking on it in 4 weeks or less. Total recovery is supposed to be 3 to 4 months. Physical therapy is planned to start in 7 to 10 days and continue throughout the recovery.

There is some greater risk of infection because of the pins going through your skin, but with proper care, they seal themselves off. These fixators were invented in Russia and are widely used all over the world, but for some reason, not so widely here in the U.S. They seem to be used as a last resort to recover from the disasters caused by not properly lining up the broken bone pieces so they can heal easily, instead of just relying on bone remodeling IF it heals. I'll report back post-surgery and let you know how it went.

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 Thu 5:34pm 25 July 2002
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