Long Overdue Update #2

I had my second appointment of the year with my orthopedic surgeon on Friday, February 5th. As you may recall from my previous post, my surgeon had increased the amount of time in-between my appointments. This was both a blessing and the source of some anxiety. While making the drive up to Hamilton less often, especially in the winter (Canada and all that snow.!) and being on crutches is a good thing, more time in between visits is not exactly favorable when you are waiting to hear if your body parts are re-growing nicely. By the time the three week mark came around, I was starting to get pretty antsy. I didn't just want to know how my leg was doing. I needed to know. While logic and reasoning, plus my previous x-rays and the words of my surgeon tell me that my bone, or at least the precursor to that is growing, it is slightly implausible when you are sitting at home with a metal contraption screwed to your body, adjusting a tiny knob on the frame with a wrench twice a day thinking "will doing this really result in bone growth?" So you can imagine that I was quite ready to get some new x-rays by the time my appointment came along.

So, without further ado, here are my latest x-rays!

As you can see, things are moving along nicely!
The fixator itself is still working properly, moving the loose chunk of bone downwards and, more importantly, there is a nice white cloud forming at the top end of by tibia (or at least what is left of it!), just below my knee. If you look closely, we can make out a tiny white line around the edges of the empty space. These lines trace how the loose chunk of bone move downwards. They are the edges of my new bone! This does mean that the overall outline of the bone will not be nice and straight and smooth, but this is okay; the bone will remodel itself over time. What is important is that the entire bone in general will be straight which, thanks to the IM nail, will be the case!

Before I get to the next bit, it is important to understand that growing bone and the whole distraction osteogenesis/lengthening progressive process is, well, a process. It is not something that happens overnight and it is not something that is an exact science. While the concept is the same for everyone, each person's body grows and heals at a certain rate. This means that it is very difficult for doctor's to give precise dates or determine when certain medical procedures need to and therefore will occur.

When I started adjusting my fixator, my surgeon said it should take about ninety-five days to regrow the missing 6.5 cm/66 mm of my tibia. I did not know if this included time to turn the slack out of the frame before things would actually start moving. It was, however, easy to do the math. With 6.5 cm/65mm to regrow and a growth rate of 0.75mm a day, it would technically take 87 days to regrow my bone. The 95 days my surgeon quoted minus 87 days of growth means there are 8 days of turning out the slack. I started turning on December. Dec. 3 plus eight days of turning (including the third) puts us at Dec. 10th. Then add the number of days between then and my appointment on Feb. 5th. We get 55 days. 55 days times 0.75 mm would equal just less than 42mm or 4.2 cm of bone growth. According to this, and given the fact that I need to regrow 6.5 cm or 65mm, I should be two thirds of the way done. Looking at my x-rays, however, it is clear that at the time I had not gown 4.2cm of bone. If I had, the gap at the top of my leg would have been twice as big as the gap at the bottom, which it is not. My surgeon believes I have about another 3cm/30mm left to grow, which means we have only grown 3.5cm/35mm instead of 4.2 cm. Don't get me wrong here - I say only 3.5 and that makes it sound like I am displeased or that 3.5cm of bone growth isn't something to be proud of. But I am and it is. What it does mean, however, is that the rate at which I am adjusting my fixator is not the rate at which my tibia is actually re-growing itself. Why is this? I am not sure. My surgeon did not offer an explanation. What I do know though it that he is extremely pleased with what he sees so far. And if he is happy, I am happy.

Given the rough estimation my surgeon gave me (3cm/30mm more to go) after roughly calibrating the x-rays (drawing lines between the gap at the bottom og my leg and the ruler placed beside my leg in the x-ray), he thinks I have about 40 more days of lengthening/adjustments to go. 30mm times 0.75mm per day = 40 days. This however, assumes that the fixator is allowing for 0.75mm of bone growth per day, which given the latest x-rays, it probably isn't quite doing. So, when will I actually be done adjusting my fixator? I don't actually know. Given  1) the originally information I was given, and under the assumption that is would take 8 days to turn out the slack and 87 to regrow the bone, I would have been done turning on March 6th 2) what my surgeon told me at this appointment, I will be done turning on March 16th or 3) the possibility that the lengthening is not going at a rate of 0.75mm a day, it could take longer than March 16th (on the other hand, I think I might have a bit less then 3cm to grow, despite my surgeon's rough estimate, so depending on how fast the bone grows longer, it could be done a bit before March 16th).

That is a lot of numbers, math and possibilities. Confused yet? I know that I am. What I can say for sure is that I am pleased with how things are going and that the process is done whenever it is done, whenever that might be. If the last decade has taught me anything, is that orthopedic problems take a lot of time to fix and therefore a whole lot of patience. That is what is required of me now. I came into this appointment hoping for two things. First, I wanted to see that the fixator had continued to move the chunk of bone downwards and that the cloud in between that space on the previous x-rays continued to grow and become more dense. Second, I wanted my surgeon to be happy with what he saw. Both of these things happened at this appointment, and for that I am extremely grateful. If the fixator lengthening process is not going as fast as I thought it would have, that is okay and I am not going to complain about it or mope when the news I got is actually very good. No use that complaining that lemonade is sour! It is what it is. I didn't go to see amazing things; I went to get confirmation that my body was still doing what it needs to do to get well, and that is exactly what I found out. No disappointments. This is a process and there is no point getting upset about how fast or quickly it goes, because my attitude about it won't change it anyways. On top of all that, the final adjustments do not mark the end of my time with the fixator. I do not merely have a matter of weeks before the ex fix comes off. Rather, once the adjustments are made and the two ends of bone meet at the bottom of my leg, the whole frame is compressed to help the bone heal. This will likely be the most difficult part of the entire process - both pain and worry wise. Compressing the bone will hurt way more than lengthening it; this will be the time we hope and pray that the ends of the bone successfully knit together, otherwise a bone graft may be needed. Once the compression stage, which will last two weeks, is done surgery itself has to be scheduled. That will likely place surgery about a month after the compression ends. So at the time that I got this news, I was still looking at almost three months with the ex fix - not a mere matter of weeks. My attitude has been "this is what my life is like now and what it will be like for the foreseeable future, no use worrying about things that won't happen for months or getting upset about one smaller part of this entire process". This is not to say that I don't worry, because I have lots of worries, but the reality is that I can't do anything about it anyways. And as Corrie ten Boom says "Worry does not empty tomorrow of its sorrow, it empties today of its strength".

On another note regarding my leg situation, as I adjust my fixator the pins are supposed to track neatly through the skin. For about a week and a half or so, the bottom top pin had not been tracking properly. I let my surgeon have a look at it and he was able to explain what is going on. With normal skin, the pins do track neatly through the skin. On my leg, however, there is a horizontal scar, maybe two centimeters long, where the bone pierced through the skin when I first broke my leg all those years ago. Pins do not track neatly through scar tissues - the scar tissue resists this because it cannot move as freely as healthy skin/tissue. As a result, as the pin moved closer to the scar, the skin started to bunch up between the scar and the pin, instead of tearing as it should. As the skin bunched up more and more (which makes sense because the pin kept tracking despite the skin not tearing), it started forcing the scar downwards so that it became crooked. The surgeon said that if it doesn't resolve itself in two weeks to come back and he would numb the area and make an incision to help the pin track properly. Obviously we all hoped that didn't need to happen. But even if it does, here is why my surgeon is amazing. Because I have an external fixator and how hard core and serious those things are, I can come to the fracture clinic at any time, even without an appointment, to see either him or one of his residents. If the skin indeed does not track properly, I was told to come back two weeks later, on a Thursday. This is a day my surgeon does a lot of surgeries. Not only can I show up on that day and expect to be seen, my surgeon will actually come down between surgeries and take the time to numb the area around my troublesome pin and make the incision. He said this would only take about ten minutes, but the fact that he is willing to do that is absolutely amazing. Not many surgeons would be willing to do that in between surgeries.

And finally, my pain medication was increased. Over the previous week I was beginning to experience quite a bit more pain, particularly at night. At the time I was on 3mg of hydromorph contin every twelve hours (8 am and 8 pm). My surgeon decided to up the dose at night to 6mg. This allows for more pain relief at night while simultaneously preventing me from being to groggy in to the day time. So far the increase at night has been working well.

After the appointment mum and I went to IKEA. You must be thinking we go there quite  bit by now. We actually don't buy stuff very often (although after Christmas I did get some nice ornaments for next to nothing and some pots and pans for 5$ each in the As Is section). We mainly go to de-stress after appointments and to grab a bite to eat before we make the drive back home. After the appointment I was ridiculously tired. My mum thought I was going to fall asleep at the cafeteria at IKEA. I ddin't even eat the piece of cake I got!

In the meantime, my next appointment was scheduled for March 4th, exactly four weeks later. Fingers crossed I am better able to cope with a four week gape between appointments after last time. For now everything in fixator land is going well. I just need to have faith in my body. Grow bone, grow!

Up to my last appointment, that is pretty much it. Congratulations if you made it through the whole post. I know that it was a long one! Besides a few little things I want to talk about, I am no caught up on medical stuff.

PS. Here are a few close ups my mum took of the x-rays when the where pulled up on the computer screen in the fracture clinic. Mum and I found the zoom button on the screen, so we tried to get a really could image of the new cartilage/soon to be bone.