My Twice Broken Tibia
or
My Orthopedic Odyssey
through Pennsylvania, Wilmington and finally Baltimore
-Roy Timpe
November 14, 2001
While riding my motorcycle home from work I encountered gravel at an intersection, and went down on my left side. As I went down, I remember thinking that there was nothing I could do to keep the bike from going down, so I would just ride the bike down. There was a sharp pain in my left leg as the bike went over. I do not know if I instinctively put my foot down, or if something in the pavement caught my left toe. Once down I started to roll. I put my arms out to prevent a roll, so I would have a non-bruised side to lay on in the hospital. I slid for what seemed like a long time. My chief concern was that I would encounter something like a sign post or large rock to abruptly stop my slide. Once I came to a stop, I realized the black leather that served me so well protecting me from road rash during the slide had now become a serious liability laying on black asphalt in the dark. The bike had slid clear of the intersection. I crawled to it, to be near the lights. I then took inventory of my body. Everything worked except my left leg. I could move my toes, but I could not move my foot laterally. A woman who worked at a nearby restaurant called for an ambulance, and I waited. At the Pennsylvania E.R. I learned I had sustained a spiral fracture of my tibia and fibula.
November 16, 2001
After waiting quite a while, I was scheduled for surgery to set the tibia. The doctor is to put an IM nail ( 10 mm diameter stainless steel rod ) to stabilize the break. I will not dwell on this aspect here except to say that I received less than optimum orthopedic care. I awoke from the operation to a leg set one half inch short ( 13 mm) and 30 degrees rotated to the outside. There did not seem to be nerve damage after the accident, but after surgery I had numbness at the top of my big toe. The peroneal nerve was quite unhappy about the 30 degree rotation.
April 3, 2002
I saw Dr. Paul Kupcha of Wilmington Delaware. At this point the Pennsylvania physician had me concerned about a non-union. I had come to believe the quickest way for me to get off crutches is to have the leg set properly. Dr. Kupcha examined the leg, and agreed to take me as a patient. He stated that he believed the leg had already healed, but x-ray tomography would give the necessary 3-D information near the IM nail to confirm healing.
April 18, 2002
The X-ray tomography is done. This is a clever way of doing a long x-ray exposure while moving the x-ray source and the film about a fulcrum during the exposure. The result is that bone in the plane of the fulcrum is in focus, while bone above and below the plain of the fulcrum is blurred and smeared on the film.
April 24, 2002
Follow up with Dr. Kupcha: He tells me the bone is healed, although the foot is crooked, and the leg is short. At this point Dr. Kupcha said that I might as well try the leg the way it is. If it does not work he will refer me to someone who can mend the deformity. On this day I got my first prescription for physical therapy.
Physical Therapy:
Despite the best efforts of the therapists, the geometry of my tibia would not allow proper function of the ankle and knee. Having the knee positioned properly caused the ankle to hurt. Positioning the ankle properly caused the knee to hurt. The 30 degree rotation was much more annoying than the length discrepancy. Climbing steps hurt the knee. Riding a bike caused the left foot to hit the crank. Rotating to avoid hitting the crank, caused the knee to go out of alignment. Riding a bike up hill was like climbing steps. Walking was painful. Running was out of the question. Cross country skiing was just a dream. Swelling was a perpetual problem since the misalignment of the foot did not work the calf muscles to promote fluid returning to the torso.
June 19, 2002
Follow up with Dr. Kupcha: the doctor examined me, saw me walk and diagnosed a mal-union of the tibia. Dr. Kupcha refered me to Dr. Paley of the Rubin Institute for Advanced Orthopedics (RIAO) in Baltimore
Limb Lengthening:
From what I understand, the lengthening of bones was pioneered by Dr. Ilizarov, working out of the Soviet Union, in the 1950s. The concept is to break the bone. Allow healing to start, and then tease the bone apart while the healing is underway. The bone is left to start healing for a week. While the healing area is plastic the bone segments are separated at a rate of about 1 mm per day. Ilizarov achieved his results with an external fixator. This method has nearly infinite flexibility, but has the distinct disadvantage of leaving patients to fight infections where the pins go through the skin to attach the external device to the bone. For more information see: Sinai Hospital
July 11, 2002
Dr. Paley's waiting room is quite the experience. He is well known for a long wait. Other doctors have magazines on the tables in their waiting room. Dr. Paley has novels. He tends to run late because he is absolutely dedicated to doing his best work, and just seems to take the time required with his patients. A look at the other patients tells me he is a specialist's specialist. There are people here with much more severe deformities than mine. I even began to wonder if he would take me. Will my 30 degree rotation, and 13 mm lengthening be a good use of his time? Will he refer me to another doctor, and leave these more severe cases to his expertise? Those thoughts were not very rational, but I did wonder as I waited. At this point I was expecting to be placed in a Ilizarov external fixator. From the reading I had done on the internet, I expeced the repair of my tibia to take about 4 months.
Dr. Paley examined me, and determined my foot was 30 degrees externally rotated, and my tibia was 12 to 13 mm short. Dr. Paley then asked, "Do you want rotation corrected, or length and rotation?"
Naturally, I wanted to go for length and rotation. Dr. Paley then explained that he would use an ( Inter Skeletal Kinetic Device ) ISKD made by Orthofix.
ISKD Device:
This device is like an IM nail, however, it telescopes. The ISKD has a clutch ( you can think of it as a ratchet ) that turns a lead screw. The screw has a magnet. A half turn of the screw causes about a third of a mili-meter bone distraction (separation). The patient can monitor the progress of the screw by using a device provided that determines the magnetic pole facing the front of the tibia. A change from North to South or South to North indicates another third of a milli-meter. If two pole changes occur, while the monitor is not being used the resulting 2/3 mm change will not be recorded. The ISKD device is activated by twisting the foot back and forth.
August 20, 2002
Surgery presents choices. I had a choice of three methods of anesthesia: General, spinal, or epidural. Each of these is a trade off. I decided on the epidural. The advantage is it is slightly safer than the general (although the general is quite safe) The advantage over a spinal is that more anesthesia can be added in the event the surgery takes longer than anticipated, also the epidural can be left in the first night to lessen the discomfort.
The surgery went well. The old IM nail was removed. My tibia and fibula were perforated with a drill and then broken. The ISKD was installed using a fixture to assist. The fixture gives the doctor six degrees of freedom ( x, y, z, rotation, pitch, and yaw) over the broken portion of the bone. The rotation was corrected immediately. A screw was installed between the lower portion of the fibula and the tibia so that as the tibia is lengthened the fibula follows.
During surgery 4 mm of bone was lost for the osteotomy. The ISKD was distracted 2 mm to verify function. Physical therapy started the next day after surgery. The chief goal of physical therapy was to maintain mobility and strength in the ankle. The magnetic monitor for the ISKD was pre-loaded with the 2 mm distraction done in the O.R.
One pleasant surprise was that in the recovery room my big toe was no longer a numb. Correcting the rotation seems to have made the peroneal nerve happy again.
August 22, 2002
I was fitted with a "moon boot" and leave Sinai Hospital. The purpose of the boot boot was to try to maintain as much dorsiflexion as possible as I was not weight bearing. The struggle with the boot was that as I was at rest my foot started to plantarflex. The straps across the top of my foot tried to keep my foot ant 90 degrees. Eventually my foot fell asleep. This happened during the car ride home, as well as during the night. Once my foot was asleep, the numbness returned to my big toe.
First Week:
The goal during this first week was to do the physical therapy and not have any adjustments of the ISKD. Some motions caused sharp pain in the leg. A check with the monitor revealed that there were spontaneous pole changes. It seems some of the PT exercises caused the ISKD to adjust. As the week progressed, I eliminated all motions that could cause a twisting motion in my leg. I got through the week with the monitor showing about 3 mm of unintended adjustment.
August 27, 2002
The first followup x-ray showed much healing activity. It also showed that there were about 2 mm of adjustment that were not on the monitor. That means that I missed about 6 pole rotations. I think some of this happened during the car ride, and during the night. In the car I sat with my leg across the back seat. As the car stopped and started in traffic the mass of the boot would occasionally encourage a torsional motion in my lower leg. I remember some sharp pains during the car ride home.
The good news was that there was much healing activity, and the unintended distractions had no ill effect on my leg. The 8/27/02 x-ray is below:
Note the telescoping portion of the ISKD on the left side of the x-ray. You can see the osteotomy for both the tibia and fibula.
Intentional Adjustment:
With the unintentional adjustments, and the initial adjustment during surgery, I had only about 7 mm of adjustment to go to achieve the 12 - 13 mm necessary. The adjustment is achieved by vigorously rocking the foot back and forth about 20 times and then checking for a pole rotation. Alternatively you can cross your leg, and grab your foot and manually rock it back and forth. Yet another method is to lie on your belly, bend your knee and have someone you trust rotate your foot. I was concerned about pain during these adjustments. Thankfully, only the first 2 mm or so were painful. Once the bone pieces got a little further apart, the adjustments went well with no pain.
About ten days after the adjustments were done, I started experiencing little sharp pains in my tibia in the area of the osteotemy. I believe this was the telescoping rod wiggling as my bone began to calcify. The telescoping rod had perhaps 25 to 50 microns of play between the inner and outer tube. I think the rod allowed a little wiggling. This did not hurt when the bone was plastic. As the bone calcified I believe this wiggle room between the rods allowed for the pain. These sharp pains only lasted about two weeks.
September 9, 2002
A follow up visit with Dr. Paley. At this time Dr. Paley surprised me by telling me to get to 50% weight bearing as soon as possible, and then in two weeks go to 75%. After four weeks he expected me to be able to do 100%. I was totally amazed that 7 weeks after the break I could begin walking. Dr. Paley smiled a little and indicated that although this was a big thing for me, rotational correction and 13 mm of length was very straight forward for him and his team. I had no difficulty believing this, having seen the other patients in the waiting room.
October 7, 2002
The 10/7/2002 x-ray is below:
Note the larger gap because of the completed lengthening. Also the tibia was fused well on the back and the sides. The front was filling in a little slower. The bone was healing roughly in proportion to the amount of flesh on the bone. Dr. Paley told me to go to 100% weight bearing. He watched me walk, and said my limp had two components: the muscles that are responsible for the foot push off were weak, and my hip muscles were weak as well. I can believe the muscle weakness. My muscles doing the push off had not worked since 11/14/2001.
I was given a prescription for three months of physical therapy, and told to return at the end of that period.
Learning to Walk:
As soon as I started to use my newly aligned foot I noticed all the things I had been doing to compensate for the crooked foot. For example, as I used the clutch in the car I would have to rotate my foot clockwise as I depressed the clutch. Otherwise my crooked foot would not clear the fender well, and my heel would tend to cover the brake. Now that the foot was straight again I needed to retrain myself not to do this motion. I had also trained my muscles to compensate for the crooked foot as I walk. Walking properly required concentration. Physical therapy had me doing what I call narcissistic walking; I would walk on a tread mill in front of a full length mirror, and work on keeping my gate natural
November 9, 2002
I actually played 9 holes of golf today. Granted I used a cart, but I'm sure I will be able to walk the course in the spring. One novelty I never had before was walking through sand traps and looking at my foot prints. It was a kick to see my left footprint straight.
February, 2003
I had the telescoping hardware removed from my tibia this month. I was required to be on crutches for some 6 weeks post surgery.
January 2004
Since my last entry I have walked 18 holes of Golf several times, and gone cross country and downhill skiing several times. I intentionally waited until the hardware was removed before trying skiing, since the last thing I need in my life is a broken tibia with a bent rod inside it.
