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Archive for the ‘pelvis’ Category

Today I went to see another orthopedist, just to be sure about the weird tear drop shaped spots on my previous pelvic X-ray (here). Mind you that those previous radiographs were taken about 20 minutes apart, so I figured it couldn’t be merely a fluke of the equipment or film. I was surprised I could actually get an appointment the same day. I told the schedular person that I had possible radiolucency in my pelvic radiographs and told her about my situation. I’m sure she didn’t quite expect that.

And the doctor looked at my radiographs and immediately knew what it was.

“Bowel gas”, he said.

At first, I really wasn’t buying this. I mean, if you took a ballon and put it in front of a concrete wall, you couldn’t see through the wall. Photons visible to us don’t behave this way, so why should higher energy X-rays? They are after all just photons. And it’s not like there’s some weird quantum tunneling going on here. And it’s not back-scattering either, as the emitter has no imaging film in it.

I was hoping to get a CT scan of my pelvis out of this, just to make sure everything was ok. I told him that maybe I asked the other guy so many questions that he didn’t notice this. After all, it is very subtle. He showed me a few test radiographs where there was pronounced bowel gas and they had similar “dark ghosts” throughout the pelvis, roughly where the colon would have lied. Some larger, some more dark, etc.

We talked about it some more and I agreed that if there were no spots in the same place, all was probably ok. He offerred to take another radiograph:

This radiograph was different, in that I stood up this time instead of laying down. The radiographer told me to touch my toes, but point my ankles out. At first, I thought she said feet together, so I asked. I told her that’s what the previous tech had me do. She was baffled why anybody would do that. So I asked her why and she said that when you stand that way, you get a better visualization of the trochanters (I think it was the trochanters).

And as you can see, about 6 days out that the spot is not there, but there is another spot further up on my pelvis. It too is bowel gas. He said that my pelvis looked perfectly healthy, that the arches at the top of my leg bone were well defined and nicely curved. He said I shouldn’t worry about this and go and get my jaw tumor fixed.

And that was re-assuring.

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Tonight, I updated the Wikipedia Bone Graft article to add information on risks and complications, with references.

Somehow, I didn’t get the impression that any of the major symptoms were issues from my orthopedist. Were these issues which were reported in the journals careless usage of tools during surgery? What gives?

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Today I went to the orthopedist (as I mentioned earlier). These are my pelvic X-rays (you can click on the images for a full-size image):

In this first one, the tech got the X-ray a little too low, you can’t see my iliac crest:

So they redid it:

One thing you will notice that’s common to both is the subtle radiolucent area on the left ilium. Down and right from where they want to take the donor bone.

This is subtle, just like the tumor in my jaw was. Not very apparent unless you stare at it a bit. I’ve highlighted it here:

Is this another spot of ameloblastoma that’s decided to grow elsewhere? If so, did it migrate or was it always there? And if I donate with it there, will I fracture my pelvis?

I will try to call the orthopedist tomorrow. The Dr. said to talk to his assistant and she’d call me back.

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Today I went to see the orthopedist. I was quite early, but it didn’t matter, as the oral surgeon’s office staff gave me the wrong address. At least they gave me the correct phone number. I showed up, went into the lobby of the building but couldn’t find the orthopedist or the group he was associated with.

So I called them. The lady who answered the phone gave me the correct address, which was next to the address I was told (but on a different street). I asked her how long when they were at the previous address and she said, “We haven’t been at the old address for about 5 years now”.

I was told he used this orthopedist all the time.  Right about now, I’m starting to doubt this. This seems kind of sloppy.

The building they are in is divided into two halves, with a receptionist (more like a “greeter” or director) at the front. Approximately half of the doctors are on one side, half on the other. The waiting room was long and narrow and felt really busy and quite drafty. My feet were quite cold, even though I was indoors and it was only about 50 deg F outside. The place seems like it’s setup for high patient volume, with (normally) two receptionists there.

The lady in front of me was complaining that she didn’t get a “call”. Was this a follow up care call? Or was this a reminder call? That part was not clear. The receptionist checked with the staff in the back (nursing staff, assistants, I don’t know?) and they said that they called all of her numbers. This also struck me as odd.

The paperwork I filled out asked me about every possible thing that could have been wrong with me. I appreciate the “holistic” or rather whole person approach … doctors sometimes get short-sighted and fail to notice a issue in another body system which has an impact on what they’re trying to do. This form also looked familiar. I’m thinking ADC clinic maybe is where I’ve seen this before? So I tried to fill it out in its entirety.

The other thing that struck me is the emphasis in the paperwork on workers comp. I gathered from this that they received ALOT of worker’s comp claims to the point of it being a source of revenue for them.

The assistant called me, came and got me and showed me to my room. And she said, “So you’re here for the pelvic pain?”. I had mentioned that I had previously had pain in my lower left abdominal region a few years back. I told her, “No, I’m here to see the orthopedist about donation from my iliac crest to treat the ameloblastoma in my left mandible”. She said that she remembered talking to my dentist. So I asked her how many cases like mine she’s seen here. She said that she’s been there about 3 years and she has not seen any cases like mine. She left the room. There was a table (bed) with a vinyl mattress on top of it with a pillow. The first thing I noticed is that there were black marks and possibly crayon marks on the vinyl mat. There was no paper cover. This seemed kind of gross to me.

She brought in (or maybe it was the radiation tech who did it) some disposable blue shorts that I needed to change into. I dubbed these “magic shorts”. I put these on and the radiation tech walked me back and laid me on another table, above which was an articulated arm with a glass viewing window. I presume this was the source of X-rays. She felt around for my pelvis and moved the arm around until she thought it was in place. I asked her what I should do with my legs and she that I should put them together. So I touched my ankles together as closely as possible. I asked her how much radiation each one gave me and she didn’t know the exact figure, but she said that it wasn’t as much as a CT scan (which I had previously mentioned to her that I had), because there was only about 1ms of radiation. I’m also wondering now if they use traditional film or if it’s all digital.

So I go back to the appointment room and wait for the doctor to come in.

He comes in and we chat for a bit. The first thing I think I asked him about was the risk for pelvic fracture. I had two journal articles with me where this happened in patients who have iliac crest bone donation for grafts elsewhere on their bodies. I didn’t show him these, but did talk about them. He said that he’d never heard of this.

In one of those papers, I had read about a procedure where part of the iliac crest was removed, the cancellous bone was removed, then the cap pat was restored. I told him I read about this, but I gathered that they actually needed to take more. He said that was correct. They needed to take some of the cortical bone to form into my jaw, not just the soft cancellous part.

One of my big concerns was them having to go in through the muscle and tear everything apart. There are a lot of important nerves in that part of the body, namely those going to the intestines, genital area and legs, along with all of their support blood vessels (veins and arteries). Not to mention your intestines themselves. I didn’t want to hobble around on one leg the rest of my life, or worse, not be able to feel/move various and sundry parts of my body beneath my waist. He said these weren’t a concern. The ilium has a ridge of bone and all of the musculature and such attaches to the periosteum, which is like a piece of leather. They use a periosteal elavator to peel this back from the bone, take the graft, then cover the periosteum back over the bone and stitch it together.

The periosteum, he says, takes about 2 weeks to grow back together and it will start producing new bone to replace whats been removed. “Would it completely replace itself?”, I asked. He said it would grow back some, but not completely. It all depended on how much stress there was on my pelvis. If after it healed, I started putting more stress on it by exercising, I’d probably have a more complete grow back. I asked him if it was going to grow back like a knife-edge and then fracture in that section and he said it wouldn’t.

When you run, he said, you put 16x your body weight on your hip, when you walk, it is 4x (why did I randomly write this down?)

I asked him why he was using the iliac crest, instead of doing a fibular harvesting. He said a fibular harvest wouldn’t provide enough bone.

He said nerves, blood vessels are inside of the muscle, so the risk is minimal.

There would be a numb spot near the incision, with a high risk of hematoma.

The worst complication, though, is infection.

I asked him how often he did this sort of procedure and he said that he did it about twice a year.

When was the last time he worked with my oral surgeon? About 6 months ago.

I told him that ameloblastomas reoccur sometimes, so since I might need another graft in the future, would this leave enough bone for a potential future graft. He said that if they had to do another graft, they’d go over to the other side. So I said, “what about after that?”. He said that he could probably get three grafts out of each side if he needed to, but he’s never had to do this. I remarked, “I don’t guess I’d have much waist after that”. No comment.

I once again wrote in my notes “Muscles attach to the periosteum and nerves, blood vessels embedded in muscle, so risk to them is minimized”. I think I re-stated this and asked him, just to check my understanding. I also wrote in my notes,

  • “said he’s never heard of fracture”
  • “they don’t do the cap and take take cancellous bone and cap procedure – my oral surgeon needs too much bone
  • “he says he’s a personal and profession friend of my oral surgeon and his family uses him all of the time”
  • “separate anesthesiologist”

I asked him about the potential blood loss and whether or not I needed to pre-bank blood for the surgery. He said that he didn’t expect that I would lose more than about 50cc of blood, but I would ask [oral surgeon], because he didn’t know how much I’d lose from that part of the surgery.

I asked him how many of these were performed nationally per year and he said about 100K – 150K. They used to do many, many more but there are other alternatives now, like coral make it not as necessary.

I was trying to figure out the dynamics of how this worked. So the graft will be taken out here and will look like an upside-down “U” (cross-section wise):

But jawbones are surrounded by hard bone (with soft cancellous bone in the center). That’s what gives them their strength. So how do you get the bottom back? He said that the body will regrow this.

I asked him if they inject anything into either of the bone (harvested vs. graft target), such as rhBMP2 (recombinant human bome morphogenetic protein 2)? He said that on the donor site, they don’t. He’ll look at how I’m clotting up and if I need help, they spray this Gelfoam bloot clotting substance in before they close me up. He may or may not install a drain, depending on how much I bleed.

He said that I could be sore in the area for up to 1.5 years afterwards.

I will need 2-8 follow up visits, depending on how well I heal.

For a 2-3 weeks afterwards, I will need somebody to drive me around. I am not to drive until it heals.

I asked him if he had an email address I could email him at. He said they didn’t provide email there.

And if I have any further questions, I can call and ask for his medical assistant and she’ll take down questions and she’ll call me back.

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Tonight I stayed up till 6:15am researching journals about ameloblastoma, bone grafts, etc. I’m keeping notes here.

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This came in the mail today:


[Patient] is 31 years old and presented for evaluation of radiolucent area in his posterior left mandible on December 4, 2008, as referred by his dentist, [Dentist]. A multi-centimeter diameter lesion was noted in the left ramus and was not associated with pain or anesthesia. There was notable expansion of the mandibular ramus and external oblique region. An incisional biopsy of the area was performed under local anesthesia on December 8, 2008, and submitted to Baylor College of Dentistry Oral Pathology Services for evaluation. The pathology report revealed an ameloblastoma within his mandible. A cone-beam image CT scan was performed on December 12, 2008, and I have reviewed that scan today. The lesion is large and extends from the anterior portion of the mandible in the distal first molar region to the posterior extent of it in the mid ramus below the mandibular condyle. There is significant expansion of the mandible, thinning of the cortices and root resoprtion of tooth #18. There is a possible perforation to the soft tissues on some of the lingual areas. There inferior alveolar nerve appears to be within very thin bone and displaced to the inferior quarter of the mandible.

[Patient] enjoys excellent general health. He is GI intolerant to erythromycin. Otherwise, he received a tonsillectomy at 8 years old, wisdom teeth extraction at 18 and partial gingivectomy for periodontal maintenance during the past year.

IMPRESSION:

  1. Patient is a 31-year-old man in good general health
  2. Ameloblastoma, large, left posterior mandible.

TREATMENT RECOMMENDATIONS

  1. Inform patient regarding the clinical findings and nature of his lesion. We have discussed this prior and we will do so more in great detail in the near future.
  2. Obtain articulated study models for a reference guide for his dental occlusion. This may be performed by his dentist.
  3. Surgery, left mandible:
    1. Partial mandibulectomy with removal of tooth #19 and tissue distal with maintenance of the mandibular condyle
    2. Autologous, cortical cancellous bone graft from the iliac crest to mandible with rigid bone plate fixation
    3. These procedures will be performed in a hospital operating room while the patient receives general anesthesia. An orthopedic surgeon will be consulted for harvesting of the bone graft.

Aspects of the details of the surgery will be discussed with the patient in the near future. Such topics will include the expected permanent anesthesia of the inferior alveolar nerve due to its ablation as well as aspects of reconstruction, limitation of function and need for long term rehabilitation. In the long term, dental implants maybe be used to replace the #19 and #18. Complex vestibuloplasty as well as other bone graft augmentation may be performed after the patient has healed over 1 year following these surgeries. He will need follow up care and the discussion of possible recurrence of the ameloblastoma cannot be ruled out.

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