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photonez
Big Wall climber
San Jose, Armpit of the Bay!
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Hello Ammon,
I'm nine months out from destroying my ankle while up high in Yos. I have to say, for me, the recovery has been awesome. There's been plenty of time to get stoked about my next adventure and plenty of good people to ease the way. My injury often feels like having a new ankle. It's like a pup, it's growing and getting stronger every day, and I get to teach it all sorts of new tricks. Also, I was able to start bicycling before I could walk, and that helped the recover tremendously.
Thanks for keeping people like me stoked.
Good luck with this adventure.
Ezra
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willm
Social climber
Oakland
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Hey Ezra, what happened that caused such a bad break?
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Clint Cummins
Trad climber
SF Bay area, CA
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Ezra took an aid lead fall on Washington Column - see Josh's post below.
Other folks (John Roe?) have broken ankles there, too.
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climbski2
Mountain climber
Anchorage AK, Reno NV
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Yeah no sh#t. Something is missing there... lol
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mucci
Trad climber
The pitch of Bagalaar above you
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Ezra was leading the 6th pitch of a super obscure, and sandbagged 3rd ascent attempt on Washington column.
For such a bad break, he kept it together just like Ammon and let kevin and myself execute the steepest self rescue I hope I/we never have to do again.
Then they shot him full of dope on the deck and the real adventure began.
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David Nelson
climber
San Francisco
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Bone is a living tissue, just like skin and muscle. The main difference is that it is hard, not squishy, and the majority of it is not cells. Our body is made up of cells, right? That might make us think that it is all cells, and most tissues are. Skin, muscle, liver, kidney: all cells. Bone, cartilage, and tendon are about 5% cells and the rest is called the "matrix", all the stuff between the cells. In bone, the matrix is a calcium-phosphate mineral component strengthened by fibers of collagen. Think of fiberglass and you have the right concept: the matrix is the resin, the collagen fibers are the fiberglass. Got it?
Bone can regenerate, unlike teeth or cartilage. However, bone has a hard time filling voids (there are some approximations going on here). If the void is too big to fill or heal, it is called a "critical size defect." Different bones, and each part of each bone, has its own unique critical size defect threshold.
The fibula is not very good at bridging gaps at that level. The bone at that level has only a little cancellous (spongy) bone and is most cortical (hard outside) bone. This limits its healing potential.
Almost certainly, the surgeon placed some material into the gap to assist the body in bridging that gap. We call the material "bone graft" or "bone graft substitute". The material may not be very heavily calcified, so it may not show up well on that xray. The xray parameters (how many milliamps of current, how many kilovolts of voltage) were set by the xray tech to give a good image of the native bone, and these settings almost certainly underestimates the amount of the bone graft material.
If there is no bone graft material, that gap will not close, which it appearently did, because the owner of that leg is walking.
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David Nelson
climber
San Francisco
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The body does all the healing, the surgeon just helps out the body, cleaning out the dirt, aligning the bone, and keeping it aligned with the hardware. The surgeon gets all the credit, but that is not fair: the body is doing all the work.
Humility is a good attribute for a surgeon. Or a climber.
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Vegasclimber
Trad climber
Las Vegas, NV.
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Awesome post Dr. David, thanks for a good Everyman level explanation.
My understanding from Dr. Gammon was that they were going to use some donor material when they put the tib plate in. My understanding os that they use corpse bone material for this but the Doc knows better then I do. The advances of the last 10 years in ortho have come at a terrible price as the wars have advanced medical ability a long way in a short time. That and the body's stunning ability to overcome injury have made for some truly amazing recoveries. The advances that I have seen here the last few years are part of what got me interested in the medical field again - I'm hoping to have my EMT-B next year. Not so much to do it as a job, but just because I find the practice fascinating.
Healing thoughts and prayers to Ammon as always!
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ElCapPirate
Big Wall climber
Reno, Nevada
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Got the wound vac and dressing cleaned today. Last surgery scheduled for Saturday and discharge planned next Thursday. They do plan on doing some skin grafting on both sides where it is still open:
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WBraun
climber
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Frankenstein .......
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S.Leeper
Social climber
somewhere that doesnt have anything over 90'
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heal fast bro!
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S.Leeper
Social climber
somewhere that doesnt have anything over 90'
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Ammon, how many bones have you broken over the years?
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Largo
Sport climber
The Big Wide Open Face
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Looks pretty clean to me. Expect your foot to stay swollen for about five or six months because the circulation was so compromised from the soft tissue trauma. If they can close those wounds with no muscle grafts they must be using magic. I'm guessing that the hole left in my leg from the open fracture was about the same size, judging by the wound-vac in the pic below:
Then once they did the muscle graft, it looked like this:
Unless you're in one hell of a hospital they generally try and avoid the muscle graft work at all costs because it takes so long to do (mainly the vascular surgery part) and is extra tricky work, so I hope you can just get by with skin grafts, which are easy money. If you get out by next week you got out basically twice as fast as I did. You must be a Man of Steel after all.
And thanks to Doctor David for his sage commentary. Makes so much more sense with a true expert weighs in.
JL
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Kalimon
Social climber
Ridgway, CO
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Total gnar there . . . aaaaarrrrrggggg! Way to put it out there Ammon. You are the definition of positive thinking and as a result your body is responding accordingly.
Thanks for your most positive example in all things great and small.
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Rudder
Trad climber
Costa Mesa, CA
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Crazy amazing awesome, Ammon! Looks great!
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tooth
Trad climber
B.C.
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Bone can regenerate, unlike teeth or cartilage
The dentin in teeth regenerates - called tertiary dentin. Not the enamel. However, we are working on using dental lamina 'seeds' to regenerate teeth in the jawbone, almost there!
Ammon, keep up the great attitude. Glad to see you healing, it will be awesome to see you flying again!
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David Nelson
climber
San Francisco
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Nice clean granulation (new scar tissue) beds, should take a skin graft well. Good luck.
What do they use for bone graft? The gold standard is some of your own bone, but that stuff is expensive: you are generally already using it for something else! The best quality bone that you can spare is from the pelvis, where your belt hits it above your hip (iliac crest). If skillfully harvested, you cannot feel the defect created by removing the bone. The downsides are further surgery, limited supply, risk of injuring a nerve that is right there, and OR time.
Second choice: We often use donor bone from a bone bank, quite similar to blood from a blood bank, but the donor is dead and donated their body to help others (put that dot on your driver's license and be an organ donor; after you are dead, you really have no heed of it and someone like Ammon does). This does not have the living cells of your own bone, but has the calcium-phosphate crystal substrate that living bone cells love to form on ( kind of like oysters need a substrate to settle on and grow on). The bank bone also has the protein messengers (mesenchymal cytokines) that say to the proto-bone cells: hey guys! Come over here and make Ammon some new bone! So bone bank grafts have some virtues.
The final choice is the class of materials called bone graft substitutes: various formulations of calcium sulfate/ calcium phosphate or similar chemicals (there are many formulations on the market, prob 40 worldwide). Cheaper than bank bone, can make it in many forms, theoretical lack of rejection (no foreign proteins).
The surgeon makes the decision based on patient factors, site factors, and voodoo ( no good prospective studies on most of the products on the market). And voila! New tibia!
(Most of the time. The real world is much messier than the scientific fairy tale I just outlined. We still get nonunions, infections, and ((Amon, don't read this)) amputations, which is why so much research is going on in the trauma field. This is not my area, I do research in post op pain and in distal radius fractures.)
Keep your prayers and good vibes up for Ammon, he is not yet out of the woods and he will need some months and years yet to heal.
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Sierra Ledge Rat
Mountain climber
Old and Broken Down in Appalachia
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I am sick with sorrow... These damn injuries are such inconveniences! We have better things to do than lie around in hospital beds while cells go about their little biochemical industries.
Gell well soon, and without complications!!!!!
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