Literally, figuratively, and orthopedically - An update

Hello everybody! I hope everyone is doing well and able to enjoy the the lovely summer weather. We've finally made it through the dog days of summer (read unbearably hot and humid) and gotten to those that, at least where I live, are cooler but still warm and sunny. Between graduating from college in June, passing the CPNRE exam that made me eligible to register as a nurse, actually getting my nursing registration, starting my first job as a nurse earlier this week, and celebrating my twenty-fifth birthday on Wednesday, I've had lots of fun and rewarding stuff going on in my life. My right leg has been quite painful recently, increasingly so over the last few months, but I've also had lots of positive things to distract me and keep me busy.

Unfortunately, I received some bad - albeit not entirely unexpected - news regarding my leg when I went in for my appointment with my orthopedic surgeon yesterday morning.

If you've been following my blog over the last few months, you know that not much has changed in regards to my leg recently. For those of you who are new to the blog, here is a quick summary of some of the more recent events: In 2015 I had six and a half centimeters of my tibia removed because of a chronic bone infection that kept recurring. Later that year I had an external fixator (big metal frame attached to my leg with big pins screwed into the bone) put on my leg in order to regrow the missing section of bone through a process called distraction osteogenesis via bone transport with a monolateral external fixator. A link to an earlier blog post that explains this process can be found here. In layman's terms, the medieval torture method of stretching a person's limbs (the rack) can be applied to bone to correct length discrepancies or defects. Two ends of bone are slowly pulled apart in order to tempt new bone cells to grow and bridge the gap. After a whole bunch of complications, the fixator was removed in May 2016, earlier than we hoped for, and I was left with a gap between the two ends of bone near the bottom of my right leg. The hope was that this gap would fill itself in. At the end of January 2017 I had minor surgery to remove one of the screws holding the IM nail (big metal rod) in place. The IM nail runs through my entire tibia, holding the ends of the bone together. It is this metal rod that allows me to walk despite having what is essentially a broken leg. This past May I had x-rays taken that showed that my tibia had failed to heal. My surgeon explained that I had landed in non-union territory (when the ends of a broken bone do not knit together). Surgical options to fix the problem were thrown around, but we opted for a wait-and-see approach. I originally scheduled my next appointment with my surgeon for September 29th but, after increasing amounts of a pain over the summer, decided to see him sooner. I am used to having quite a bit of pain in my leg - pain in my knee and ankle because all my weight is taken by the IM nail instead of my tibia and therefore no distributed properly, as well as bone pain from the non-union itself. My surgeon has reassured me that this pain, be it as painful as it is, is not a sign that bad things are happening. The IM nail cannot break; the pain I just described is normal and not dangerous. Depending on how much pain I am in on any given day, this may or may not be reassuring to know. I have, however, been experiencing a new pain. Sometime in the spring I started getting what I think is muscle pain running down the outer portion of my lower leg, starting about midway down the leg. The more I walked the more it would hurt. My surgeon told me to be concerned about new pain that only occurs in one place, hence my desire to see him sooner. And that brings us up to speed right up to yesterday's appointment.

So, yesterdays appointment. I will first give a bullet form summary of everything that's going on in my x-rays and, after that, I will do my best to clearly and accurately explain everything that I think needs further explanation and to describe where it leaves us now. I apologize in advance if it is confusing. I think the only reason I understood everything my surgeon said is because I've been dealing with this for so long. I've had time to catch onto the medical lingo. Plus, I'm a nurse. That helps too. Here we go:

• Let's start with the good news. As you can see in my latest set of x-rays, the section of bone I grew at the top of my tibia looks like normal healthy bone. My surgeon couldn't be more pleased with how well it looks. For the most part, it is completely indistinguishable from the rest of the bone. Yay!

• Now on to the bad news. Both the x-rays taken from the front and side of my leg show that the gap between the ends of the bone near the bottom of my tibia has not filled in.We had been waiting to see if this would fix itself since the fixator came off in May 2016. As of this point, my surgeons considers this a non-union. The bone has failed to heal. Usually, when a person goes through the bone transport/distraction osteogenesis process, the two ends of the bone collide and the ends knit and heal together just like a broken bone would. The bone can still heal even when there is a slight gap between the ends of the bone. When my fixator was removed, however, one piece of bone bounced back. As a result, the gap between the ends of bone was larger than is optimal. We really hoped that the osteoblasts (new bone cells) would search for the other end of the bone, thus bridging the gap and letting  it heal, but this  unfortunately did not happen.

• More bad news. The x-ray showing the side view of my leg also shows that the bigger section of missing bone in the gap at the front of my tibia has also failed to fill in. My surgeon said that it is clear from the x-rays that the bone is trying really really really hard to heal itself but, for whatever unknown reason, it just hasn't been able too. Why does this gap exist? When I had the external fixator and went through the bone transport/distraction osteogenesis process, one section of the ends of bone grew faster than the other. Sometimes it eventually fills itself in, sometimes it doesn't. I fall in the latter category.

• And even more bad news. This will be hard for anyone with an untrained eye in regard to reading x-rays to notice, but my fibula is actually starting to bend. In orthopedics, this is called bowing. In other words, the bone is curved and not straight as it ought to be. Hence the title of today's blog post. Life has literally thrown me a curve because, well, the bone is curved. Life has figuratively sent me a curve - we did not expect this to happen. And then orthopedically. This one seems obvious: orthopedically because we are dealing with bones.

Here are my new x-rays:

Front view

Side view

Hopefully everyone is still with me at this point. I'm sure you're all enthralled and sitting on the edge of your seat, desperate to hear more. Well, at least any medically trained people will be, especially those working in orthopedics. XD The rest of you are probably all thinking "But what does it all mean?" and I don't blame you. There are way to many long, unfamiliar words involved. Plus, no blood and gore like in Grey's Anatomy to make things interesting. No foreign objects protruding out of body parts either. Maybe that's why so many people were interested in the external fixator.

So where exactly does this leave me?

• There's no way around it - it's been fifteen months since my fixator came off and my leg has failed to heal. The new section of bone at the top of my leg looks amazing and pretty much indistinguishable from the bone on either side of it, but I also have a non-union. As my surgeon said yesterday, "You are no longer a bone transport patient. You are now a nonunion patient". In many ways this sucks, but it's actually not a bad thing. Chronic bone infections and bone transports are rare, but non-unions are relatively common. This means that there are established treatment options and fairly established expected results.The treatment options for non-unions are surgical.

• My surgeon's concern is that, because I have had so many surgeries,  going into the site of the actual non-union could put me at an increased risk of infection and/or other complications. There is just to much inflammation and swelling, along with problems with circulation. He doesn't want to come anywhere near the site of the nonunion; he does not want to interfere with what bone growth there has been. He is very hesitant to do anything surgical, but at this point admits that there are no other options. If he could avoid it, like we did in May by taking the wait-and-see approach, he would, be he can't, so surgery it is.

• But wait! There are more things to consider than the non-union itself. Remember that I said that my fibula is bowing? We need to address that as well. Basically, what is happening is that my fibula is currently longer than my tibia. This is no good. On top of that, my tibia is broken and all my weight is going through the IM nail holding it together. When I walk, all of my weight is being transferred from the bone onto my IM nail. Other than causing pain, this wouldn't be a problem if my tibia and fibula where the same lengths. But they are not. So this is what is happening; My tibia cannot support my weight. As a result, my weight is transferred to the IM nail. But the IM nail and my tibia are shorter than my fibula. This allows some of my weight to be transferred to by fibula. You might be wondering what the problem with this is, because a leg bone is a leg bone and should take weight, right? Not exactly. The fibula is actually a non weight-bearing bone. As a result of all the weight being put through it (because my fibula is longer than my tibia and my tibia is broken), my fibula is bowing, bending, curving. Whatever you want to call it. As my fibula is bowing/bending, it is pushing and therefore putting pressure on the muscles on the outside of my lower leg. This is what is causing all of the new pain I have been having. The muscles are inflamed, irritated, and stretched. This also explains why my foot slants inwards when my leg dangles from a chair or I am sitting in bed with my legs stretched out in front of me. I thought I might have some form of foot drop, which is common in patients who have been through the bone transport process, but it's actually caused by my fibula bowing/bending outwards. In order to address the nonunion in my tibia, we also have to address the difference in length between the two bones.

• So how do we fix it? We can't touch the site of the nonunion, there is a gap of missing bone in my tibia, and my fibula is longer than my tibia. My surgeon can fix the discrepancy in the lengths of my tibia and fibula by doing something called a fibular osteotomy. This sounds complicated but is actually really simple. My surgeon will make a small incision on the side of my leg so that he can cut out a small section of my fibula (I'm guessing maybe about one centimeter of bone, but I'm not sure. I will ask him the next time I see him). And how about the nonunion if he can't get near the actual site of the nonunion? There are two options for this, and they both end in the same way. The surgeon might be able to change the position of my IM nail or the screws holding it in place so that the two ends of my tibia can be compressed together, or he can switch my current IM nail for a shorter one. Regardless of what he does, the ends of the bone will be compressed together. Doing this will make my leg shorter. Regardless of my fibula already being longer than my tibia, the fibular osteotomy would have to be done anyways because you can't make the tibia shorter if the fibula doesn't become shorter with it. Once this is done in surgery, I will start walking right away in order to put as much pressure on my tibia as possible. Research has shown that weight bearing promotes bone growth, and therefore bone healing. This is a technique called compressive loading. As long as I can handle the pain, I will be able to weight-bear/walk straight away after surgery.

Here is a comparison of one of my x-rays taken in sometime in Summer 2016 and one taken yesterday. On the left is the one from 2016; on the right is the most recent one. You can really tell how much the fibula has bowed in the last year. The bowing is most apparent when you look at the outer curve of the fibula (left part of the thin long bone on each x-ray).

• There are several drawbacks to the surgical solution: Firstly, is means another surgery and there are always risks that accompany surgery (e.g., general anesthesia, infection). Secondly, the fibular osteotomy requires the surgeon to open my leg from the side instead of from the front as was done in all my previous surgeries. This kind of sucks, but my leg doesn't look that great to begin with after all the years of infection, the external fixator, and all the surgeries. In reality though, an extra scar is small change for what I get in return, a bone that will heal. The risk of an infection or complications is really my concern. At my appointment in May, we had talked about the possibility of doing a bone graft , but my surgeon doesn't want to do it anymore. He is more concerned that I will end up with an infection and be right back where I started off before I had all the infected bone removed from my leg. When he explained the surgery he proposed to me, he said "This is the main solution I propose to patients we present with a non-union after a broken leg doesn't heal, but you've had way more going on than that". He proposed the surgery, but it's clear he is only going to do it because we have no other available options. If he could avoid it altogether, he would.

• The positives, however, far outweigh the drawbacks. Theoretically, this surgery should allow my tibia to heal. I say theoretically because theoretically everything else that we have done so far should have resulted in my leg healing as well, but that obviously hasn't happened. We just don't know, given everything that my leg has been through, if it will really work or not. But we have hope, and optimism, and that, in my opinion, is quite something to have. So, aside from having no other options, I am deciding to go ahead with the surgery. This will be the tenth and hopefully final trip to the operating room to solve this problem.

I really hope that all of that made sense. Please let me know if you think anything needs further explanation or clarification. I feel like every time I post an update that things get a little bit more complicated. The story gets a little bit longer and I fall into the 1% of patient who have something go wrong again. I'm really hoping that this surgery will be the final one. Even my surgeon commented on how this is starting to get a bit crazy and outrageous. At some point, things have to go right for me, right?

Even though the proposed surgery is my only option, I still wanted time to think things through before signing any consent forms. You don't go through as much as I have regarding medical decisions without first taking the time to think about them first. In addition, I just started a new job and would like to get through the probation period before requesting time off for surgery. I've been hired as a casual registered practical nurse, so this could take a while. I'm hoping to have the hours done by the end of the year. I also need to get through the rest of the training sessions and actually start on the unit in order to see if I can manage the twelve hour shifts. If I can grin and bare the pain, I will definitely wait until the probation period is done before I have surgery. If not... well, we will see. I also have had a vacation planned for October since sometime in April and I am determined to do (with my cane as my trusty companion, of course, so that I can survive all the walking). If all of that works out, I hope to have surgery in January or February. I go back to see my surgeon on September 29th in order to ask any questions about the surgery that I come up with in the meantime and to sign the consent forms. And that's about it. Given the amount of pain I have been in, I was expecting that the bone would still be broken and to hear that surgery would be my only option. I'm still disappointed, of course, that the bone healed as little as it did and that I do need more surgery. And I was not expecting what we heard is happening to my fibula at all. And I am sad and disheartened that something has prevented me from moving on from this part of me life again. At this point, I think anything that could go wrong to my leg has happened: compound fracture, non-union, malunion,  bone infection went diagnosed for five year, finally diagnosed and received treatment, relapse of chronic osteomyeltis, external fixation, heterotopic ossification, another nonunion... It's been such a long, unfortunate story over the last eleven and a half year. But I am choosing to remain positive and hopeful. That's the only way I can get through this and still continue to enjoy the other aspects of my life in the meantime. And that's it really. We haven't gotten any further in terms of healing, but at least we now have a solid plan. I always feel much better when we have a plan to guide us. This broken leg saga has been the ultimate in uncertainties and it will be a welcome change in my life when it is finally over.

Just to give you an idea of how things have/haven't changes over the previous months, here are both my x-rays from last May and this week. On the left are the x-rays from May, and on the right are the new ones. If you compare the first two pictures, you can see that my fibula is bending.

Every time we see the surgeon and get bad or unexpected news, my mum and I need some time to process it. After all, these appointments are understandably very stressful. After Friday's appointment, we first went to Cafe 541. I wanted the grilled cheese sandwich they sell there instead of the one the hospital cafeteria serves. After that we went to Dundurn Castle to take a walk through their fruit/vegetable garden. This was followed by a trip to Ikea - we had a snack in the restaurant and then I found some lovely finds in the As Is section. XD We then stopped by the Dutch Shop in Grimbsy to get some goodies (and tea! Always stop to get tea!), follwod by taking the scenic route along the Niagara Escarpment in order to get home (and avoid highway traffic).