New Techniques Spell Hope for Shattered Limbs

On a morning shrouded with fog, emergency medical technician Merrill McColl hurried to help a stricken woman. But it was McColl who ended up in the hospital.

The ambulance carrying the volunteer EMT worker never reached the woman’s house. It collided with a truck in the predawn gloom. McColl’s right arm and pelvis were broken. His legs were shattered--flesh torn apart, bones splintered. The right tibia, or shinbone, was in bits below the knee.

“The first recollection I have is of the doctor saying I might lose both legs,” said McColl, a retired biology teacher with an engaging smile. Six months later, there still was talk of amputation. No one dared hope he would ever stand on those mangled limbs.

But today, a little more than a year after his accident, McColl is walking with crutches and taking some steps without them. His right leg is nearly two inches shorter than the left, and the skin looks like a relief map of the Grand Canyon, but the bones have healed.

Not long ago, such traumatic fractures surely would have led to amputation. But advanced techniques for putting bones back together are allowing orthopedic surgeons to save limbs that might otherwise be lost, as well as getting patients back on their feet faster with fewer complications.

Dr. Richard Uhl, an orthopedic surgeon at Albany Medical Center, the regional trauma center for Upstate New York and nearby states, said there is a growing need for extensive bone repairs because doctors are seeing more high-energy fractures resulting from major car wrecks.

Such cases rarely made it to the operating room in the past because the victim died of head or chest injuries, Uhl said.

“Now, with air bags, they’re surviving. But their legs, their feet, or their pelvis are completely destroyed,” said Dr. Paul Hospodar, another Albany Medical Center trauma surgeon.

While simple fractures are repaired with a cast, severe breaks require fixation, Uhl said. That is, the bone fragments are held together with pins, rods, plates, screws, wires and other hardware.

“Orthopedics has progressed fairly slowly,” Hospodar said. “But in the past five years, there’s been an exponential growth in technology.”

Uhl and Hospodar are pioneers in the use of hybrid external repairs of complex fractures of the tibia, the large bone of the lower leg. That’s the repair technique used on McColl’s legs.

“This was a 3-B open fracture. That’s about the worst you can get,” Hospodar said, looking at an X-ray of McColl’s right tibia. “The soft tissue and muscle were almost completely destroyed.”

“The old way would have been to put two plates on it,” Hospodar said. “That has an infection rate of 50% and an amputation rate of 50% at least. With his injury, we couldn’t even put a plate on.”

In McColl’s case, Hospodar said, he used a framework of rings and clamps encircling the leg. Pins were inserted through the fragmented bone and attached to the frame. The technique doesn’t require surgery or a cast.

Two bone grafts failed to replace a missing section of McColl’s tibia, so Hospodar turned screws on the fixator to force the upper and lower pieces of the bone together. That shortened the leg by an inch and a half.

“One thing that’s very exciting is that we can actually lengthen bones, regenerate bones,” Hospodar said. It’s called a bone segment transport.

Say a three-inch piece was broken out of someone’s shinbone. Surgeons saw through the healthy upper part of the bone and use wires above and below the cut to secure the bone to an external frame. The patient turns screws on the frame daily to move the middle piece of bone downward gradually over a period of months.

In about a year, the transported piece has “docked” with the bottom and new bone has grown and hardened in the space left when the upper section was slowly pulled apart.

Virtually the entire length of the tibia can be regenerated this way. It works more reliably than a bone graft taken from the hip, Hospodar said. But, because the procedure can cost $40,000 to $60,000 and keep the patient out of work for many months, he said amputation is sometimes preferred.

Besides allowing otherwise irreparable bones to heal, the procedure has certain other advantages over casting. The most important is that it allows patients greater mobility. That stimulates bones to heal more strongly, Hospodar said, and reduces the risk of pneumonia and other complications of bed rest.

“A person with a femur [thigh bone] fracture 20 years ago would have been in the hospital eight to 12 weeks, flat on their back in traction, then in a body cast for another two months,” Hospodar said. “We still weren’t assured of good results.”

Now, the same patient can have a rod inserted inside the bone and return to work on crutches within a week, or perhaps even a day, he said.

Sue Harrington, an occupational therapist, said she couldn’t work after a car accident left her with a full arm cast. Because the bone wasn’t healing properly, Uhl made a four-inch incision in Harrington’s forearm and screwed a titanium plate to the broken bone.

She started arm exercises the next day and returned to work two days later with a removable splint. “Being able to exercise your arm during that time is the greatest advantage,” she said.

Harrington said she’ll have the plate removed eventually because it hurts when she bumps it. But some patients elect to leave rods or plates in place when they’re not uncomfortable, rather than undergo surgery again.

McColl had the right leg ring fixator and the last of 48 pins removed from his body a year after his accident. Soon after that, with a brace on his leg, he went with his wife on a vacation to the Bahamas and walked in the surf.