Stability Questions, LeFort I--Life with a delayed Union

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#31 Post by **phil** » Wed Aug 22, 2007 3:38 am

OK, so here's my ammunition to take to the surgeon:

http://ortho.smith-nephew.com/us/Standa ... odeId=2865

Sounds like a miracle. I had never even heard of healing fractures with ultrasound before, but I guess one can always learn something new!

#32 Post by **WhiteLurcher** » Wed Aug 22, 2007 4:39 am

Hey Phil sorry to hear about your latest setback, trust you to make it into that unique 1-2% pity it wasn't the lottery jackpot!

Joking aside though you must be pretty worried, but if your surgeon wants to give it another two weeks, there must still be hope that it will work out ok!

I sympathise with you about the bite going to pots that must be very frustrating after all your progress so far!

I see my OS on Monday and will try and ask for you, although I haven't had much luck getting satisfactory answers of my own out of him yet!

All the best!

#33 Post by **dubnobass** » Wed Aug 22, 2007 4:54 am

It may not come to that - a month without elastics on no-chew may sort the problem out.
I've done some digging and have found a couple of articles of interest, but unfortunately they involve coughing up money to access them online, or would need to be obtained from a large central library (the British Library can get hold of any paper for a fee, maybe there's a similar library in the States that does the same?):

Van Sickels JE, Tucker MR. Management of delayed union and nonunion of maxillary osteotomies. J Oral Maxillofac Surg. 1990 Oct;48(10):1039-44. Review. ($30 for 24 hour access)

D'Agostino A, Toffanetti G, Scala R, Trevisiol L, Spam F. Maxillary post-traumatic outcome correction literature review and our experience. Part I: maxillary bone non-unions-"poor bone positioning". Minerva Stomatol. 2004 Apr;53(4):151-64.

I also found a vaguely useful reference in the article below:
http://www.emedicine.com/plastic/topic481.htm:

Malunion and resultant malocclusion and deformity occur if reduction is not precise or if loosening of fixation occurs during the postoperative period. This can be avoided with meticulous surgical technique and adequate fixation, preferably with carefully placed miniplates. Patient noncompliance with maxillomandibular fixation (MMF) and early mastication may result in micromotion, which leads to poor bone healing.

If malunion is discovered early, attempts to optimize reduction may be made by loosening the MMF tension and adjusting the wire closure forces or elastics in order to normalize occlusion. If this fails, rigid fixation (wires or plates) must be removed and replaced for better stabilization.

For delayed presentations in which the bones have healed into malposition, osteotomies must be performed through or near the original fracture sites and the bones must be repositioned with rigid fixation. In rare instances, bone resorbs as a result of malunion and motion, and osseous interposition grafts or overlay grafts may be required. Split calvarial grafts are well suited for midface work, but rib grafts may be used as an alternative.

Total nonunion is less common than malunion. In most cases, maintaining an extended period of fixation and immobility results in eventual healing. For persistent nonunion, fracture sites must be reexplored, freshened, and refixated. Again, areas of gaps may need to be addressed with osseous grafts.

I will be seeing my orthodontist tomorrow, but I'm not sure if any of the surgical team will be around. I need to find up when my followup appointments are, so I will see if there's anyone I can ask about your problem.

#34 Post by **phil** » Wed Aug 22, 2007 5:04 am

Thanks again, everyone, for all your responses.

dubnobass, thank you so much for the helpful information. I think as much as I can get in this stage is a good thing! How in the world did you find all that, by the way?

The link on your post comes up dead, though. Hmmm...

I've got calls into both my surgeon and orthodontist today. Hopefully they'll call back soon.

The very bright silver lining to this massive cloud is that we are all learning from this, and perhaps this information will be of use to someone else in the future. In some way, what I'm going through is not quite as bad, for that reason.

#35 Post by **dubnobass** » Wed Aug 22, 2007 5:13 am

The magic of PubMed:
http://www.ncbi.nlm.nih.gov/sites/entrez

You just need to flexible with search terms, e.g. fibrous union = delayed union, nonunion, non union, pseudoarthrosis.. and then there's lefort, le fort, maxilla, maxillary, bimaxillary

The link above should work if you crop the colon off the end of it.

If it's was me, I'd be running through worst-case scenarios. I think that would involve re-doing the LeFort and possibly being wired. If you think you could cope with those, you can cope with the worst-case scenarios! I really hope it doesn't come to that, though. There are so many variables here that it would be difficult to pin in down to one, but your surgeon seems to be recommending the things that can be done now, and which are likely to having an effect - i.e. removing any forces which would prevet the bones having a chance to rest and heal.

Fingers crossed!

#36 Post by **phil** » Wed Aug 22, 2007 5:39 am

dubnobass,

You're a gem!

I've already ordered the article from the British Library. Do you know how I go about getting a copy of the PubMed article by Van Sickels and Tucker? I couldn't figure out how to order it!

#37 Post by **Mikatgeo** » Wed Aug 22, 2007 8:06 am

Phil,

I've been following your journey and first I have to say how sorry I am for you that it hasn't been an easy one. I really admire the way you've taken charge of your care. The medical profession can be very intimidating.

Since I'm on the upper end age-wise for this kind of surgery I'm particularly concerned with the healing process. I will be having a very similar procedure, about 5mm upper advancement and about 4mm lower reduction. I have my pre-op on Tuesday and I've added fibrous union to my list of questions and if I learn anything new I will certainly report back to you.

I do have to say though that I like your OS's conservative approach. Eight weeks isn't that long at all. I totally understand your impatience though. I think I would also be beside myself about the whole thing. If it were me, I would do everything possible to promote healing.. lots of rest, good diet and think good, positive thoughts!

Hope it's just a little bump in the ride and things will get much better for you.

#38 Post by **phil** » Wed Aug 22, 2007 8:35 am

Mikatgeo,

Thank you for your response.

I am glad that my issue will cause you to bring this up to your surgeon for your pre-op! I never in a million years would have forseen this complication--I had SARPE last summer with no issues whatsoever, and lots of new bone growth, so hopefully this is an anomaly.

The orthodontist has called me back, and is putting in a call to the surgeon, who is off today. That should get the ball rolling! It was a good thing that I made those phone calls this morning, because the surgeon hadn't even bothered to call the orthodontist yet!

ASK YOUR PHYSICIANS LOTS OF QUESTIONS! I am learning more and more to not be afraid of them, and not back down until somebody gives me an answer. After all, it's my face they're messin' with!

Good luck with your pre-op, and once again, thank you for contributing to this thread. We can all learn from each other. That is a big part of what ArchWired is all about!

#39 Post by **dubnobass** » Wed Aug 22, 2007 8:38 am

phil wrote:dubnobass,
I've already ordered the article from the British Library. Do you know how I go about getting a copy of the PubMed article by Van Sickels and Tucker? I couldn't figure out how to order it!

If the British Library hold this title, they should be able to copy it for you (and if not, they can usually contact one of their fellow libraries for it) - I think the ordering process is much the same.

Have you considered hitting a local University bookshop for a bit of browsing research? I'm quite spoiled here because we have a lot of teaching hospitals and such in London, so we have have entire basements devoted to medical textbooks. I may use this as an excuse to find a good book on Lefort and bisaggital split osteotomies - I'll see what I can find out and let you know.

#40 Post by **phil** » Wed Aug 22, 2007 8:41 am

dubnobass,

I JUST received the electronic link for the article from the British Library, and I downloaded it. When I read it, I'll let everyone know what I find.

My local public library (which has won national awards) is getting me the other article through interlibrary loan. Gotta love those public libraries! So helpful.

Thanks again for your help. Things are in motion now, and undoubtedly the collective brain power will help to solve my problem.

#41 Post by **phil** » Wed Aug 22, 2007 9:18 am

HERE'S WHAT I KNOW:

I just got off the phone with the orthodontist. He had a conversation with the surgeon. The surgeon doesn't believe that this is going to be an issue, and that I should experience significant stabilization in the next month or so. The orthodontist said that out of the 800 surgical cases in his career, he had only seen TWO cases of delayed union, and both resolved. I don't find this terribly comforting--it makes me statistically part of a group that is smaller than ONE PERCENT! YIKES!

No elastics for quite a while, though.

I'm going to continue to gather information, and pursue a second opinion about my case, just to be sure.

Onward and upward!

#42 Post by **HighandLo** » Wed Aug 22, 2007 10:39 am

Wow, you are special, Phil

! The news sounds encouraging that your Dr.s aren't worrying yet, since you still have time before you are considered to be "nonunion" (according to the World Ortho Website below). It is labeled "delayed union" when bones don't heal after 4 months. Thanks for keeping us updated. We know more than we did last week!

These descriptions are from an Adult Bone Trauma website. It looks like they don't call it "nonunion" for several months after trauma (surgery).

http://www.worldortho.med.usyd.edu.au/d ... -bone.html

I looked at the BONE HEALING ABNORMALITIES section.

My OS appt. was re-scheduled for tomorrow, so I'll post when I find out anything.

Lo

#43 Post by **phil** » Wed Aug 22, 2007 11:09 am

Thanks, LO! You're a friend!

Wed Aug 22, 2007 3:32 pm

Sometime in the next few weeks I will be talking over the phone with my OMS. Will ask him about fibrous unions. Must say, tho, it does sound like it might just be slower than normal fusing.

Phil, how soon after your surgery do you think you would have been okay to fly on an airplane--let's say one four hour flight with a change, a coupla hours in the airport, then another three hour flight?

Trying to figure out how early I can leave CR after my operation. I'll be 47, and you're 42, so I figure your experience might be kinda comparable.

#45 Post by **phil** » Wed Aug 22, 2007 3:43 pm

4beauty4symmetry,

Personally speaking, I would not have felt up to it until at least ten days post-op. I would have been physically able, but the trauma of going through surgery does tax the body pretty severely. I was just always worn out all the time for the first two weeks.

Good luck with your surgery!