What Happened

On the evening of December 30, we were on our sailboat, moored in Avalon Harbor. We had heard that there would be some wind that night, and so we decided to stay on the boat that night for dinner. After dinner, we were watching movies, and drinking wine. Some waves started to kick up, and we were bouncing around a bit, but were not uncomfortable, and didn’t feel we were in any danger. At around 10:00 pm, we heard a loud noise on deck. We went out to take a look and discovered that our head sail had become unfurled. I was able to pull it back in using the furling line. It was a bit tough with such a large sail with winds that were 30 - 35 knots, but I got it in. After we got it sorted out, we looked around the harbor, and to our amazement, the harbor was filled with white caps, and several large boats were either on shore, or drifting toward shore. We turned on our VHF radio, and listened to the harbor partol channel. Many people were asking for assistance either getting off their boats, or securing their boats, as many mooring were letting go. We decided to stay out on deck in case another boat broke loose and began heading toward us. Througout the night, boat after boat got into trouble. The harbor patrol was somewhat overwhelmed. They called Long Beach Coast Guard on the radio asking for help, but to our knowledge, none ever came. 

At about 3:00 am on the morning of the 31st, the speed boat to our starboard side broke loose from its bow mooring line. When it did so, it whipped around and was slamming into us stern-to-stern. We would fall down off a wave, and our stern would literally land on the stern of the other boat. I was very concerned that our rudder bearing would get damaged. If that were to happen, we would likely have sunk, as the rudder bearing is beneath the water line. We called the harbor patrol, but they were busy with other life saving rescue operations, and could not help us. I was out on the stern fending off the other boat as best I could with a boat pole. 

At this point, approximately 6 boats had either sunk or washed ashore. By morning two people would have be dead. 

I can’t recall exactly what happened, but somehow my left leg got crushed between the two boats when they collided. It was a sucker punch. I totally didn’t see it coming, but there it was. My leg was clearly broken. The tibia had punched through the front of my shin, and my foot was kind of dangling. I was lying on my back holding my foot with my left hand, and hanging on to the railing with my right hand. I screemed to Pam to call the harbor patrol. The harbor partol was there in short order, and was trying to figure out a way to get me off the sailboat and into their boat. Two of the harbor patrolmen grabbed me, one under each arm, and pulled me into their boat. I pushed off with my good leg, and landed hard on my back in their boat. They took me ashore, and got me into an ambulence. They went back to get Pam, and she was sitting in the front seat. They took me to Avalon hospital, but they indicated that there wasn’t much they could do, and said I had to get to the mainland. The ambulance crew indicated that the helicopter from UCLA had turned down previous requests that evening due to the high winds, but they would give it a try. Fortunately, the helicopter agreed to come and get me. We drove out to the helipad that is to the southeast of Avalon. The sound of the helicopter in the distance coming to get me was one of the most comforting sounds I have ever heard. We were told that Pam would probably not be able to come with me in the helicopter due to the high winds (they didn’t want the liability of another passenger), but fortunately, they did allow her to fly with me. We took off and headed for Harbor UCLA. It was about a 25 minute flight, and when we landed, we were greeted by a team of about 8 doctors and nurses. 

They did a few tests, and determined that all blood flow to my foot had been completely cut off. They needed to get me into surgery immediately if the foot was to be saved. I went into what ended up being a 6 hour surgery, during which the only objective was to fix the vascular damage. They were able to restore blood flow to the foot by transplanting a vein from my right leg to my left. They were not able to close the wound from the compound fracture however, and reported to Pam that although they were able to restore adequate circulation, I would still lose my foot because of the nerve damage they thought I had. The surgeon also put a plate in my leg to temporarily hold the leg rigid, and protect the vascular work that had been done. 

In the hours and day following the initial surgery, a bunch of circulation and nerve tests were conducted. Much to everyone’s amazement, the nerves seemed to be fine. A foot is not viable unless there is feeling on the underside. I had complete feeling on the bottom of my foot, and over most of the foot, albeit somewhat dulled sensation. I was scheduled for surgery on January 2. Instead of being an amputation, this would be a surgery to further stabilize the bone, and attempt to close the wound. 

In this second surgery, the wound was successfully closed, and a simple external fixator was put in place to rigidly hold the tibia in place. Approximately 8 cm of bone had to be cut out of my tibia, as it was crushed and no longer viable. Removal of this crushed bone also aided in the closure of the wound. A “wound vac” was put on my leg to extract drainage from the wound and to use vacuum pressure to pull it together. 

A few days after the second surgery, I met Dr. Stuart Gold. Dr. Gold is a leader in the field of distraction osteogenesis. He has a tremendous reputation as a pioneer and educator in this field. Dr. Gold told me that the prospects for limb salvage were quite good, and that he recommended using an Ilizarov Apparatus to repair the damage that had been done to my tibia. Other alternatives, such as internal fixation, were not likely to be successful due to the vascular damage, and the amount of bone that had been damaged. He recommended waiting four weeks for surgery in order to give the wound time to heal and stabilize, and to allow the swelling to go down. I was released from the hospital on Janaury 8. I had the temporary external fixator on my leg, which was not designed for weight bearing.

Within a few days of discharge from the hospital, I had almost no pain. I was taking a 10-325 Hyrdocodone at night, but other than that, no pain medication. I returned to work on January 12. I was keeping my leg elevated as much as possible, as swelling was still considerable, and the foot felt like it was going to explode when it was hanging down. My company purchased an electric scooter for moving between the entrance and my office, and for going to meetings. By the end of January, the swelling had gone down considerably, and I was able to crutch fairly long distances without too much trouble. I was able to sit for an hour or so (at a restaurant for instance) without my leg elevated with little discomfort or additional swelling. I was sleeping quite well, and was able to sleep on my back, or either side quite comfortably. 

I went into the hospital for surgery to install the Ilyzarov Apparatus on February 2. The Ilyzarov Apparatus frame is shown to the right. The Ilyzarov Apparatus is designed to facilitate the healing of large amounts of destroyed bone. Since there was so much damage to the lower part of the tibia where blood flow was impaired, it was not likely that this bone would ever heal on its own. The Ilyzarov concept involves intentionally breaking the tibia just below the knee to create what is called a “regen” site. It is in this regen site, where blood flow is plentiful, where new bone tissue is formed. As the tissue is formed, the tibia is then “transported” down the length of the leg until it mates or “docks"with the other end of the broken bone. This transport is accomplished by turning four M6x10 nuts 2 - 4 times per day, which moves the bone down the leg at .25 mm per turn. 

It was an early morning surgery, and took about 2 hours. When I came out of the surgery, I had some pain, but nothing that the PCA (morphene drip) couldn’t take care of. Onto this frame, Dr. Gold installed 13 wires that went through skin, muscle and bone. The whole frame weighs about 7 pounds, and allows weight bearing. The weight bearing ability exerts a force on the bone that stimulates what is known as the “piezoelectric effect”, which is an important phenomenon for bone growth. The installed fixture is shown in the figure below.

I spent two nights in the hospital after the surgery. I returned to work the next day, and was actually weight bearing that day using a cane. I was still on pain meds at that point, taking up to 6 10—325 Hydrocodone tablets per day. The pin sites initially all had sponges covering them, but I removed most of them after a few days, as the drainage was negligible. Dr. Gold had prescribed Keflex, to be taken four times a day to prevent drainage and to actually reduce inflamation. Throughout the month of February, I continued to take the Hydrocodone at up to 6 per day.

The main complaint that I had at this point was difficulty sleeping. I could usually fall asleep fairly easily, but would wake up at 11:00 or midnight, and stay awake until 2:00 or 3:00 am. I tried all kinds of things including melatonin, Benadryl, Ambien, ZZZQuil, Sominex, Nytol, Hyrdoxyzine, Cyclobenzaprine, Tramadol, and Diazapam. None helped a bit. For the first three months, I could only sleep on my back, as sleeping on my side would exert a painful bending moment on the knee in the direction orthogonal to the direction in which it bends. 

About two weeks after the surgery, one of the nuts used for transport began to become difficult to turn. After discussion with Dr. Gold, I used some WD-40 and a triangular file to try to both lubricate and remove some possible thread damage. This worked for a time, but in early April, this nut competely seized, presumably due to a phenomenon that is common in stainless steel known as “galling”. Galling is the flow of material, much like a viscous liquid that changes the shape of the threads. The threaded rod and nut had to be replaced, which was straightforward. The old rod had to be cut out of the frame, for which we used a Dremmel tool. This is much less violent than a bolt cutter would be. 

We had to cancel a vcation in January, and needed to use the tickets by the end of March (this trip had already been cancelled once before.) We planned to take a long weekend trip to Hawaii during the second week of March. It was not clear how this would go, given the pain levels I had been experiencing, and the swelling that I was still seeing. We used some upgrade certificates to fly non-stop first class. On the way to Hawaii, we flew on a 767 with lie flat sleeper seats, which was pretty nice. When we got to Hawaii, I was pretty comfortable, but had a little bit of swelling. Throughout the 4 day trip, I tried to wein myself from the pain killers. By the end of the trip, I had reduced pain killers considerably. On the way back, we were in first class again, but not in lie flat sleeper seats. I was able to keep my leg elevated by sitting on the right side of the plane against the window and draping my leg over the center armrest into Pam’s lap. It was reasonably comfortable, and when I landed 6 hours later, I had very little swelling. 

Over the course of the next two months, the swelling continued to decline, and by the end of April I was once again able to sit at a table in a restaurant without having to elevate my leg. The original wound where the compound fracture occurred finally healed around the middle of April. It took a long time because of the reduced blood flow, and because of the fact that the skin was stretched pretty tight around the fracture site. I also had a blister on the top of my foot that formed after the February 2 surgery. Dr. Gold indicated that this was the result of circulation issues. This took a very very long time to heal, and is still not completely healed. 

Pain had pretty much gone away between the beginning of March and the middle of April. However, in mid-April, the pain level around the pin sites began to increase, as did the inflammation. There was also a noticable indentation (ring) around my leg where the gap was at the site of the injury. Dr. Gold explained that the pain was most likely caused by the bone beginning to move through the site where the injury occurred, and was displacing scar tissue, and stretching tissue that had shrunk in the absence of bone tissue. I began taking pain killers again, primarily at night, as the pain was keeping me from sleeping. Two 5-325 Hydrocodones had no effect. Dr. Gold prescribed 5-325 oxycodone, and that did not have a noticibly better impact. I did find that a cocktail in the evening took the edge off, be it good or bad. At this point, I was getting anywhere between an hour and a half and three hours of sleep every night, and was not really tired during the day, which was surprising. 

At the end of April, the transport was nearing completion, and we had to decide whether we would elect to do a bone graft or not. The alignment of the transport was very good, and there were no other motivations to do a surgery at this point. The main benefit of the bone graft would be to ensure that the docking site would form a union. If the bone graft were not conducted, and the union did not form later, a plate would have to be inserted, which is a more significant operation, and would result in hardware being permanently left in my leg. We elected to go forward with the bone graft. The surgery involved removal of some bone tissue from my hip, and mixed with some tissue from a cadaver, which would then be inserted into the docking site. The surgery was conducted on May 4, and generally went as expected. The main issue was that Dr. Gold had to make the incision at the site of the original compound fracture wound, as opposed to going in through pristine tissue, as he had planned to do. This meant that the incision was somewhat more fragile that it otherwise would have been. As a result, I stayed out of the office for a few weeks to give the incision a better opportunity to heal. 

After the bone graft surgery, the pain was pretty much gone right after I was discharged from the hospital. I suspect that the incision that Dr. Gold made relieved some of the resistance to the transport process. The indentation around the would site is gone, and as of May 18, the docking process has begun. I have been taking a combination of Gabapentin and oxycontin (30 mg) right before bed. This has allowed significantly better sleep. I now am getting 6 or 7 hours a night, which has made me feel a lot better. Getting up in the morning can sometimes be a little challenging, but the good sleep is very much worth it. At this point, I was also able to lie on my side, which was a great thing, and also helped my sleep. Not sure why the knee was more tolerant to the bending moment at this point. It is probably simply a case of the overall inflammation being lower over time. 

Dr. Gold has indicated that the removal of the x-fix will be paced by the calcification of the regen site. This is expected to take until the end of October. I am greatly looking forward to this. In the meantime, I am trying to get as much back to normal as possible. Simple things like being able to sit at a table without keeping my leg up, walking across a room without a cane (which I started doing in June), or being able to hang out in the pool are all things that bring back some semblance of normal. Dr. Gold indicated I could go swimming in our own pool, but we didn’t want to risk getting the leg wet with pool water. We had purchased every device on Amazon designed to keep casts (and external fixators) dry, but none of them would fit over the 180 mm diameter rings that the frame is made from. So, Pam found a very large tube that would allow some part of me to be in the pool while my leg stays out. It was a little tricky getting into, but worked really well! 

In July 2015, I was walking down the hall at work, when I heard a snapping sound, and felt a sharp pain. I initially thought I had been shot, but then quickly realized what happened. One of the wires that goes through the tibia had snapped. These wires are loaded to about 100 kN, and when the wire snapped, all of that strain energy was released into the bone. It hurt for about a minute, and then I felt fine. When I next saw Dr. Gold, he removed the wire. Removal of the wire actually hurt more than the wire snapping. The reason is that the wire has a small sphere on it that prevents the bone from sliding along the wire. That ball broke through the skin when Dr. Gold pulled the wire out. Again, the pain didn’t last very long, but it stung momentarily. 

In the last month (August 2015), I have been getting more and more back to normal. I now swim in the pool without the inner tube, have been out saiiling, and have even been paddleboarding. The pain is now mostly non-existent. I did have some tendonitis, and was back on crutches for about a week. I simply took it easy, and it calmed down. The paddleboarding was scary at first. Balancing on a board requires some muscles that have not been used much lately. I was very shaky at first, but once I got going I was fine. I did not fall in!

A couple of weeks after trying paddleboarding, I started to have significant soreness around the docking site. It was sufficiently painful that I had to go back to crutches. Dr. Gold indicated that it is part of the healing process as the soft tissue heals. 

We sailed to Catalina Island on October 1st, eventhough I was on crutches. Our friends, Steve and Christina sailed with us, and enabled the trip. During this trip, we made it a point to meet with the harbor patrol rescuers and the paramedics who rescued us. In the photo below, JJ, to my right, is the man who lifted me off the boat into the harbor patrol boat. Curt, to my left is the one who drove the harbor patrol boat. This was a fantastic meeting, in which there were many hugs, and more than a few teary eyes. 

i am happy to say that the external fixator was removed on November 25, 2015. Early on, there was a noticable limp, and I was a bit timid. As of early March, 2016, I am running, lifting full weights, and walking without a perceptible limp. Although the left leg is about 1 cm shorter than the right, there is no noticable impact of this. I had two physical therapy sessions, and did a bunch of exercises at home every day, but other than that have had no other therapy after frame removal. 

© Carl@nardell.net 2015