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Old 09-30-2011, 07:32 PM   #1
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Non-union - What are the options??

Hello all!

I'm hoping to gain some comfort or possible solutions from this experienced group...!

I had my first metatarsal lengthened and repositioned after a previous break. Bone graft was done with cadaver bone (April, 2011) and my body resorped the boned. Had the surgery done again early July with bone from the iliac crest. My doctor utilized bone morphogenic protien as well as blood platelets. I was also able to get an OrthoFix bone growth stimulator that I have been using for easily twice the amount of time recommended (6 to 9 hours instead of the recommended 3). I've pretty good about taking Calcium, D, Magnesium and Strontium... Have followed doctor's orders about weight bearing.

So...at the 11 week mark, my CT scan shows "suspected small foci of osseous bridging across the osteotomy site, but the majority of the osteotomy remains unfused with prominent osteotomy lucency". In other words, I guess very little healing.

For now, I am instructed to stay off of the foot for *another* six weeks. I actually have two really good doctors, one is away for a week or two, so when he returns I'll get his thoughts as well...

Does anyone have any thoughts about this? In my life time, this bone has been broken four times. I know that each time it's broken, there's less chance of healing, so I'm not sure if a *third* bone graft is going to be the answer. I don't think that I will be asymptomatic, as even the strap of the cast boot hurts the area around the osteotomy. I think there's surgical type of "punching" they can do were they insert bone marrow, or inject more BMP to hopefully stimulate bridging.

Just anxious to hear what my options might be or what else I can be doing on my part...as well as the experience of people on this board. Crutches since April, now until November...I'm not seeing the light at the end of the tunnel...

 
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Old 09-30-2011, 08:12 PM   #2
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Re: Non-union - What are the options??

sydney44,

Sorry to hear about your difficulties with your surgeries. When faced with multiple non-unions, the options become limited. A third bone grafting is an option, but the surgeons wouldn't necessarily do anything different. It would be almost the same procedure again.

Here are some suggestions:
1) Try a different bone stimulator. The one you are using is a electromagnetic type of stimulator. There is a different bone stimulator that uses ultrasound (Exogen by Smith & Nephew)

2) Hyperbaric oxygen. Although there isn't a lot of data on its improvement on healing rates, it is something that you can try.

3) Use a different bone graft. Probably one of the most effective bone graft substitutes on the market is called INFUSE. It is recombinant human bone morphogenetic protein-2, but it is only approved for use in certain spinal fusions, acute distal tibial fractures and a few oral maxillofacial surgeries. It is very, very expensive and there for is only approved for use in difficult fractures like the ones I just listed. I am 99.9% sure this type was not used in your second surgery.

4) Check and double check anything that may inhibit bone growth. That mean no smoking, no anti-inflammatories (NSAIDs, etc). Other things must be looked at as well like infection and blood supply. If an osteotomy site does not heal, the #1 thing to consider is infection.

5) More strict non-weight bearing

Ultimately if something is not healing and continues to limit your lifestyle, some patients have an amputation. It sounds extreme, but for some patients it is a viable options. I have faith that you will heal and will not need to consider this.

 
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Old 09-30-2011, 09:59 PM   #3
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Re: Non-union - What are the options??

Thank you! Some really good information. I have thought about the Exogen...not sure if the insurance company will pay for another bone stim, although if successful it would be less expensive than another surgery...

Do you have any idea of why some patients experience resorption of bone graft? I'm a little concerned that I might have some genetic make up that resorp this graft as well, later on (if it starts to take...)

I've gotten some slight conflict of opinion about the weight bearing. One doc has ok'd heel weight bearing only, the other would prefer *strict* non weight bearing. I do have two plates and about 12 screws in there holding it together. I've read where some weight bearing helps to induce bone formation, and yet it seems to be standard thinking to be strict non weight bearing.

Would the CT scan have picked up an infection? And what tests are done to examine blood supply?

You've been super informative - thank you!!

 
Old 10-03-2011, 08:30 AM   #4
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Re: Non-union - What are the options??

Even if the Exogen bone stimulator is not covered by your insurance, the company (Smith & Nephew) can work on getting it for you cheap or even free. There are income brackets that if not met, can qualify you for a bone stimulator at no expense. You will have to discuss this with your physician and the Smith & Nephew rep.

There are many reasons a bone graft would be resorbed, especially if it is not your own bowe. Infection and rejection of the graft are a possibility. In an injury or post-surgical setting, bone is broken down and formed. In your case, the bone wasn't forming as fast and the end result is a breakdown or resorption of the graft.

An infection wouldn't necessarily be picked up by a CT or MRI in your case. The best way to assess infection is to take a biopsy or culture of the bone. Blood work can be performed to look at WBC (white blood cell count), CRP, Sed rate to get a general assessment of infection as well. As far as evaluating blood flow, it would be a test such as an aterial doppler or angiogram.

Bone follows Wolf Law, which says form follows function. When you are not using bone, like in a wheel chair bound patient, the bone will become osteopenic and weaker. When you are walking, it stays strong because it is being used. It is good to have some weight bearing in many cases, but it is a fine line when dealing with surgery. Weight bearing too early can cause shifting of the fracture, osteotomy or hardware. Ultimately it doesn't matter what another doc says. It matters what the surgeon says. Unless you plan on changing doctors there is no reason to take advice about weight bearing from outside sources.

If you are faced with a decision to have another surgery, a final option is to walk on it and see what happens. Worse case scenario the bone fractures and has to be repaired, which is what was going to happen with the next surgery anyways. Metal plates and screws are strong, but they will bend and break if they are supporting all of your weight in that one area. Your best hope is that the bone is healed enough that it is supporting some of the weight and the plate doesn't have to support 100% of the weight.

 
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Old 10-03-2011, 08:08 PM   #5
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Re: Non-union - What are the options??

Thank you J. You give great answers and some wonderful insight!!

I am going to investigate further if I can get the Exogen. Any perspective if you feel that that it is superior to the typical OrthoFix/EBI stims?

Off topic a bit...my earlier MRI has this statement:
"MRI of the left ankle demonstrates scar remodeling of a subacute partial tear of the deep fibers of the deltoid ligament".

Does that sound like a significant tear or just something minor? I know radiologists often reference any and every thing they see in the reports....and I understand that tears of ligaments can happen often and often are minor...but thought the deltoid was difficult to tear...??

 
Old 10-03-2011, 11:31 PM   #6
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Re: Non-union - What are the options??

Both types of bone stimulators have had good results. Each company will give you research on how theirs is better. I don't think one is necessarily better than the other however. Since you have been trying the OrthoFix, it may be a good time to try the Exogen since you are getting slow results.

Essentially, your previous MRI is saying your Deltoid ligament is thickened. It is hard to tear the deltoid ligament, but it can be thickened or have small tears from abnormal stress in the ankle during walking. Since it is far away from the area of concern for you right now, I wouldn't pay much attention to the findings of the deltoid ligament. As you pointed out, radiologists will try to find any abnormality and comment on it. There are many abnormalities in an MRI that have no correlation to pain. Take it with a grain of salt unless you have symptoms in that area.

 
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Old 10-05-2011, 02:00 AM   #7
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Re: Non-union - What are the options??

Well, my foot had a fracture, which healed in a slightly dorsiflexed position. I had a lot of strain on my ankle for quite some time...I guess it was caused by the dorsiflexion as well as the first met being overly shortened...It really threw off my gait. that is what brought me to this correction, which is having some difficulty in healing...this was a bone graft and lengthening to correct my ankle instability caused by the first met being too short and dorsiflexed. hence the questions about the MRI...

I never fully appreciated how all of the bones/ligaments really worked in concert with one another in the foot...till I got the initial fracture.

boy, after all of this, I *really* hope that when (positive thoughts) I do heal, I no longer have the ankle/deltoid stuff going on...

Thanks J! I'll try to update as I get info! But your help was really appreciated!

 
Old 10-06-2011, 12:48 PM   #8
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Re: Non-union - What are the options??

I agree with J9879. The Exogen is a great bone stimulator. It worked well for my 5th met fracture. I spent 6 weeks on crutches (not casted thankfully) and used the bone stimulator daily. It worked well! The company paid for at least half of it for me and my insurance picked up the other half so I got it at no charge and now I have it should I ever need it again, which I hope NEVER happens. I hope that you find something that works! I can't imagine 7 months on crutches! 2 was my longest and that was more than enough!

 
Old 10-07-2011, 09:47 PM   #9
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Re: Non-union - What are the options??

Hi Hollywood!

Well it's been six months, long enough!...and I just got good news from my surgeon. He sees 30% healing and wants me to start weight-bearing, backing off if I feel pain or swelling...

I'm just beside myself with relief! I know I'm a ways off from being all better, and I think I'm going to have some peroneal tendon issues to deal with...even being mostly non weight bearing I have had some pain above the inner ankle area...but am really happy that apparently I'm healing more than the radiologist report indicates. Had some concerns about necrosis...

So thanks all for your input!! fingers crossed about the future....!

 
Old 10-10-2011, 04:33 PM   #10
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Re: Non-union - What are the options??

That is great news!! You say you think you will have peroneal tendon issues and the pain is on the inner ankle. Usually pain with peroneals is on the outside of the ankle b/c they run along the outside of the ankle. The short one is commonly injured with 5th met fx's. If you are having pain on the inner ankle, did you mean your post-tib tendon?

 
Old 10-10-2011, 06:14 PM   #11
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Re: Non-union - What are the options??

Hi Hollywood!

Yes, pain is above the inner ankle and sometimes twists into the middle of the two long bones (fibula and the other one). Even now while I've been non weightbearing, I have felt the pain above the ankle. I guess it happened from the year plus of walking on a foot with first met in a dorsiflexed position...so yes, I guess the post-tib tendon....we wanted to wait and see what effect repositioning and lengthening the first met would have on this pain. This will be my next research assignment, depending on how I feel after weight bearing for a bit...

It's been such a long journey. Almost three years of my life not being able to do a fraction of what I once did. But I am going to focus on the positive for now that at least I can bear a little weight after 7 months of crutches!!

Thank you for the congrats!

 
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