The series of x-ray images below show the distraction osteogenesis process. Because of the geometry of the break and the fact that blood flow at the bottom of the leg is impaired, it was the opinion of several surgeons that the break would not heal using internal fixation. The concept behind this technique is to make a clean break in the tibia at the top of the bone where blood flow is good, and use this break to grow bone tissue. As bone tissue is grown, the tibia is translated down the leg until it “docks” with the lower part of the bone. Because new bone tissue (“soft callus”) does not have calcium content, it is not visible in an x-ray for many weeks. I put these images here to show the process, as despite hours of digging, I was not able to find a series of images like this on the internet. 

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January 12, 2015

This image shows the injury after the second surgery. The tibia was cut at the top of the break, but the bottom part of the break was left as-is. At this point, the temporary x-fix was on the leg. The fibula is broken, and the leg is approximately 1 inch shorter than it had been before the break. 

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February 10, 2015

This is the first x-ray image taken after the Ilizarov apparatus was put in place on February 2. Transport had not yet begun. The gap at the top of the bone is the “regen site”, and is still in contact. I could feel the two ends of the bone sliding when I applied weight to the leg. 

February 26, 2015

This is the first image that shows the transport process. This is after two weeks of transport. At that time, I was directed to turn the M6x10 nuts four times a day, which would move the tibia down the leg at 1 mm per day. At this point there is soft callus forming in the regen site, but it is radiologically transparent, and as such it is not visible on an x-ray. 

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March 3, 2015

At this point in the treatment, Dr. Gold had directed me to reduce the number of turns from 4 per day to 2 - 3 per day. The rationale was that there would be less compression on the knee and the K-wires would cut through the tissue more slowly, reducing pain in both areas. Some tissue is beginning to be visible in the regen site at this point, but it is very faint. 

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March 17, 2015

Transport continues at . 5 - .75 mm per day. 

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March 30, 2015

At this point, transport is approximately 50% of the total required distance. 

Photo Apr 20, 5 17 24 PM

April 20, 2015

More identifiable calcified bone tissue is beginning to appear in the regen site. 

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April 30, 2015

Dr. Gold’s X-ray machine was inoperative, so this x-ray was taken at Torrance Memorial Hospital, which is why it looks different than the other images. In this photo docking is imminent, and a decision needed to be made with regard to whether or not a bone graft would be done. We elected to do the graft in order to gain some assurance that a union would be formed when the tibia docks. In this image, additional calcification can be seen in the regen site as well. 

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May 18, 2015

This is the first image taken after the bone graft. The docking has now begun, and the bone graft matter can also be seen in and around the docking site. Also, calcification is now becomming more pronounced. 

I used a simple graphics editor and Excel to analyze these images in order to project when the docking would begin. The result is shown in the figure below. The dotted line is the line trajectory that we would expect based on the prescribed number of turns per day. The actual gap is shown as the solid line. I also laid in a regression line to project docking based on actual measured transport. The actual measured gap lags the dotted line by a few millimeters. The reason for this is the fact that the wires are not perfectly rigid, and flex somewhat, espcially as force is applied to them, and as the transport process meets resistance as the tibia is moved through the scar tissue and the surrounding muscle, which had shrunk somewhat as a result of the injury and the fact that a bone had not been present for four months. As the equation of the black line indicates, the average change per day was about .62 mm per day throughout the transport process. 

x-ray 20150608

June 8, 2015

This is the image in which the outline of new bone is clearly visible in the regen area. While docking is complete, we continue to turn the bolts twice a day in order to increase compression on the docking site, which will facilitate bone growth. 

June 29, 2015

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These two images show the continued calcification of the regen site. 

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August 4, 2015

It had been 5 weeks since the last x-rays were taken. Calcification continues, albeit slowly. Dr. Gold suggested Vitamin D supplements to help with this. Initially, Dr. Gold thought November would the timeframe in which the x-fix would come off. Now he is saying 90% probability by Christmas. 

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September 1, 2015

Latest x-ray shows continued progress on calcification. Hoping for fixator removal in November or December of this year. 

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October 5, 2015

Calcification looks very good and we should be able to release tension on wires at the next visit.

The external fixator came off on November 25, 2015. Dr. Gold began to loosen tension on the x-fix on October 15. At that time, although the x-fix was still attached, it was not providing any structural support. We started by loosening the bottom first, and then the top. 

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November 30, 2015

This is the first x-ray taken a few days after x-fix removal. 

© Carl@nardell.net 2015